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MINNESOTA MEDICINE
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association,
Northern Minnesota Medical Association, Minnesota Academy of Medicine, and
Minneapolis Surgical Society
Owned and Published by
THE MINNESOTA STATE MEDICAL ASSOCIATION
Under the Direction of Its
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, M.D., Chairman, St. Paul
T. A. Peppard, M.D., Secretary, Minneapolis
A. H. Wells, M.D., Duluth
H. A. Roust, M.D., Montevideo
C. L. Oppegaard, M.D., Crookston
Philip F. Donohue, M.D., St. Paul
Henry L. Ulrich, M.D., Minneapolis
O. W. Rowe, M.D., Duluth
H. W. Meyerding, M.D., Rochester
B. O. Mork, Jr., M.D., Worthington
EDITOR
Carl B. Drake, M.D., Saint Paul
ASSOCIATE EDITORS
George Earl, M.D., Saint Paul
Henry L. Ulrich, M.D., Minneapolis
VOLUME 30
JANUARY — DECEMBER, 1947
EDITORIAL AND BUSINESS OFFICES
2642 University Avenue ---------- Saint Paul 4, Minn.
BUSINESS MANAGER
J. R. Bruce
Copyrighted, 1947, by the
Minnesota State Medical Association
Index to Volume 30
A
Acute intussusception in infancy and childhood, 257
Acute isolated myocarditis (Fiedler’s myocarditis), 54
Acute perforated gastric and duodenal ulcer, 1253
Acute poliomyelitis in pregnancy, 729
Adenocarcinoma of the sweat glands with metastases
(case report), 286
Alimentary diverticula, 1284
Amebic abscess of the liver with bronchohepatic fistula,
1161
Amino acid therapy, Protein and, 493
Anderson, U. Schuyler : Exteriorization procedures for
colon injuries, 200
Anesthesia for transthoracic gastrectomy, 88
Anesthesia in obstetrics, The general problem of, 953
Angina pectoris due to coronary sclerosis, Further ob-
servations on the prognosis in, 162
Anuria, Postoperative, 195
Appendix, Epithelial neoplasms of the, 176
Arthus phenomenon induced by the local application of
penicillin (case report), 517
Ascaris, Intestinal, diagnosed roentgenographically in
Minnesota (case report), 410
Asthma, bronchial, The treatment of persons who have,
386
B
Baker, Milton E., and Baker, Ilene Godfrey : Acute
poliomyelitis in pregnancy, 729
Beek, Harvey O. : Educational management in psycho-
somatic medicine, with special reference to the gas-
trointestinal tract, 884
Benjamin, A. E. : Adenocarcinoma of the sweat glands
with metastases (case report), 286
Bile duct, extrahepatic, Reconstruction of the, 759
Bleeding, rectal, A plan for the detection of the source
of, 503
Blumenthal, J. S., and Peterson, Herbert W. : Metastatic
carcinoma of the heart, 860
Boies, Lawrence R. : Meniere’s disease : endolymphatic
hydrops, 427
Boman, P. G. : Medical therapy in ulcerative colitis, 956
Borg, Joseph F. : Peripheral arterial embolism, 432
Borgerson, A. H. : Office proctology, 272
Bradley, William F., Small, John T., Wilson, James W.,
Walters, Waltman, and Neibling, Harold A. : Vag-
otomy in peptic ulcer, 965
Bronchiogenic carcinoma, Roentgen therapy of, 975
Buckley, R. P., Wells, A. H., and Litman, S. N. : Influen-
zal meningitis, 647
Buie, Louis A.: “Eor manners are not idle” (President’s
Address), 841
Buie, Louis A.: Veterinary medicine, 512
Buie, Louis A. : Voluntary prepayment medical care and
its rural aspects, 382
Book Reviews
Adams, H. S. : Milk and food sanitation practice, 1012
Albrecht, Frederick K. : Modern management, 454
American Hospital Association : Hospital care in the
United States, 1013
American Pharmaceutical Association : National formu-
lary, 117
Beck, Alfred C. : Obstetrical practice, 1220
Campbell, John D. : Everyday psychiatry, 589
Children’s Bureau : Children in the community, 219
Davison, Wilburt C. : The compleat pediatrician, 454
December, 1947
Doggart, James Hamilton : Diseases of children’s eyes,
1221
Hodges, F. J., Lampe, I., and Holt, J. F. : Radiology
for medical students, 589
Kalinowsky, L. B., and Hoch, Paul H. : Shock treat-
ments and other somatic procedures in psychiatry, 340
Litzenberg, Jennings C. : Synopsis of obstetrics, 1221
McCord, Cary P. : A blind hog’s acorns, 454
Potter, Edith L. : Rh ; . its relation to congenital hemo-
lytic disease and to intragroup transfusion reactions,
910
Rigler, Leo G. : The chest, 117
U. S. Pharmacopoeial Convention, Inc. : Pharmacopoeia
of the United States of America, No. XIII, 1012
U. S. Public Health Service, Division of Hospital Fa-
cilities: The hospital act and your community, 1110
Walch, J. Weston : Check and double check on sickness
insurance, 219
C
Cabot, Verne S., and Clay, Lyman B. : Unusually large
ovarian cyst in an elderly woman (case report), 60
Cancer, A review of 174 cases of, with necropsies, 735
Carcinoma, bronchiogenic, Roentgen therapy of, 975
Carcinoma, Metastatic, of the heart, 860
Carcinoma of the papilla of Vater, 1174
Carcinoma of the right part of the colon, The surgical
treatment of, 1197
Carcinoma, prostatic, Orchiectomy and hormones in, 403
Cardiac findings due to sternal depression. 1265
Cardiovascular roentgenology, A physiologic approach to,
1041
Case for diagnosis (thrombosis of left renal artery with
acute infarction of left kidney, renal arteriosclerosis
of right kidney, uremia, etc.), 766
Centenarian, The surgical history of a (case report), 767
Chest x-ray surveys, Community-wide, and the general
practitioner, 625
Chest x-ray surveys, mass. Follow-up of abnormal pul-
monary findings observed in, 1251
Choledochostomy tube removal, Criteria for, 315
Chordoma, 863
Chronic mastoiditis with cholesteatoma and stenosis of
the external auditory meatus, 161
Chronic ulcers of the leg associated with congenital
hemolytic jaundice (case report), 651
Chylothorax ; pregnancy in an arrested case, 47
Circulation, A short commentary on the history of the,
264
Clay, Lyman B., and Cabot, Verne S. : Unusually large
ovarian cyst in an elderly woman (case report), 60
Clinical use of folic acid, 1167
Colitis, ulcerative, Medical therapy in, 956
Collins, Arthur N. : Duodenal diverticulum, 268
Colon injuries, Exteriorization procedures for, 200
Colon, carcinoma of the right part of the. The surgical
treatment of, 1197
Community-wide chest x-ray surveys and the general
practitioner, 625
Congenital diaphragm of the duodenum (summary), 539;
(complete paper), 745
Congenital dislocation and congenital subluxation of the
hip, 889
Congenital urethral valve, 56
Constrictive fibrino-pleurisy, 1293
Cooney, Marion, and Kabler, Paul : Toxoplasmosis, 637
Coronary sclerosis, Further observations on the prognosis
in angina pectoris due to, 162
Cor pulmonale, 514
Country medicine — past, present and future, 37
Coventry, Mark B. : Internal derangement of the knee, 42
1325
71020
INDEX TO VOLUME 30
Creevy, C. D. : Ectopic kidney with hydronephrosis, 89
Criteria for choledochostomy tube removal, 315
Cruveilhier-Baumgarten syndrome, The, 506
Clinical-Pathological Conferences
Acute isolated myocarditis (Fiedler’s myocarditis), 54
Carcinoma of the papilla of Vater, 1174
Chordoma, 863
Congenital urethral valve, 56
Cor pulmonale, 514
Epithelial neoplasms of the appendix, 176
Influenzal meningitis, 647
Kimmelstiel-Wilson syndrome, 280
Parathyroid adenoma, 760
Primary carcinoma of the pancreas, metastatic carci-
nomatous lymphangitis of the lungs, etc., 981
Rhabdomyosarcoma of the right interauricular septum,
282
Thrombosis of left renal artery, renal arteriosclerosis of
right kidney, uremia, diabetes mellitus, 766
Communications
Ikeda, Kano, 1011
Ulrich, Henry L., 1094
Van Brussel, Martha: Our forgotten children, 210
D
Danielson, Earl A. : The Meeker County tuberculosis
control project, 635
Deafness, a therapeutic problem, 642
Diverticula, Alimentary, 1284
Diverticulum, Duodenal, 268
Donohue, Philip F. : Orchiectomy and hormones in pro-
static carcinoma, 403
Dry, Thomas J., Gage, Robert P., and Montgomery,
George E. : Further observations on the prognosis
in angina pectoris due to coronary sclerosis, 162
Duodenal diverticulum, 268
Duodenal ulcer, gastric and, Acute perforated, 1253
Duodenum, Congenital diaphragm of the (summary),
539; (complete paper), 745
E
Ear, nose and throat problems, Recent advances in the
management of, 1156
Ectopic kidney with hydronephrosis, 89
Edlund, Gus : Chylothorax : pregnancy in an arrested
case, 47
Education, Postgraduate medical, in a private hospital,
845
Educational management in psychosomatic medicine,
with special reference to the gastrointestinal tract,
884
Eginton, C. T. : Rectal impalement, 45
Elman, Robert: Protein and amino acid therapy, 493
Emanuel, Karl W., Gillespie, Malcolm, and Wells, Ar-
thur H. : Carcinoma of the papilla of Vater (diag-
nostic case report), 1174
Embolism, Peripheral arterial, 432
Emerson, Haven : A sound public health program, 1050
Endocrine therapy, 33
Enuresis, 91
Epidemiology and recent developments in poliomyelitis,
1145
Epilepsy, Observations on a mild form of, 49
Epithelial neoplasms of the appendix, 176
Evert, J. A., Jr., and Meyerding, Henry W. : Mycetoma
or Madura foot, 407
Experiences in the treatment of hydrocephalus in in-
fants, 790
Exteriorization procedures for colon injuries, 200
Editorial
AM A Directory information card, 1190
AMA Fellows, 1081
Acres of diamonds, 1080
Associated medical care plans, 878
Bell lectureship and the Minneapolis x-ray survey, The,
661
Bond-a-month plan, 779
Calorie intake and industrial output, 296
Cancer, 990
CARE, 528
Community chest, 879
Comparative costs of medical care, 1280
Consumers co-operative medical care, 188
Demerol, 528
Fading ink, 420
Fluids in heart disease, 187
Folic acid in pernicious anemia, 778
Heart disease, 73
If you were told — , 878
Intravenous ether — an aid to collateral circulation, 422
Laboratory abuse, 777
Lemon juice and teeth, 778
Life insurance for State Association members, 991
Mayo memorial, The, 779
Medical ethics in veterans program, 663
Memorial to Doctor O’Brien, A, 1278
Minnesota Cancer Society, 420
Minnesota Medical Service, 72, 661, 1277
Mobile speech clinic undertakes survey, 189
More CARE, 1277
More nurses needed, 188
Mortality in diabetes, 72
National Foundation for Infantile Paralysis, The, 777
Nursing problem, The, 298
O’Brien, William A., 1278
O’Brien, William A., A tribute, 1279
Pertussis immunity and mixed antigens, 990
Research professorship in rheumatic fever, 662
Schools for practical nurses, 527
Shortage of nurses, 1276
Socialism or free enterprise?, 1188
State meeting, 661
State meeting a success, 777
Streptomycin, 187
Streptomycin and tuberculosis, 1276
Topical sulfa N. G., 1190
Trimethadione (tridione) in petit mal, 528
Tuberculosis surveys in Minnesota, 421
Tuberculosis and Christmas seals, 1190
Typhoid in Minnesota, 1189
Use of dimercaprol (BAL), 296
Vagotomy for peptic ulcer, 297
F
Falk, Abraham : Water-borne tularemia, 849
Farkas, John V., and Moos, Daniel J. : The surgical
history of a centenarian (case report), 767
Feldman, F. M. : Tuberculosis among residents of Olm-
sted County over the age of sixty-five, 856
Fenestration operation for otosclerosis, The, 1249
Fibrino-pleurisy, Constrictive, 1293
Financing the establishment of a small hospital, 261
Finley, K. H., Richards, T. W., and Jessico, C. M. : Ob-
servations on a mild form of epilepsy, 49
Fistulas, chronic, of the rectum following penetrating
wounds, Surgical management of, 310
Flink, Edmund B. : The use of chemical agents in the
treatment of hyperthyroidism, 198
1326
Minnesota Medicine
INDEX TO VOLUME 30
Folic acid, Clinical use of, 1167
Follow-up of abnormal pulmonary findings observed in
mass chest x-ray surveys, 1251
“For manners are not idle,” 841
Fricke, Robert E. : Uses of radon ointment, 52
Further observations on the prognosis in angina pec-
toris due to coronary sclerosis, 162
G
Gage, Robert P., Montgomery, George E., and Dry,
Thomas J. : Further observations on the prognosis
in angina pectoris due to coronary sclerosis, 162
Ganglioneuroma, Lumbar retroperitoneal (summary),
539; (complete paper), 969
Gastrectomy, Transthoracic, 84
Gastrectomy, transthoracic, Anesthesia for, 88
Gastric and duodenal ulcer, Acute perforated, 1253
Gastric hemorrhage, Massive, due to hemorrhagic gas-
tritis necessitating gastric resection, 317
Gastrointestinal tract, Educational management in psy-
chosomatic medicine, with special reference to the,
884
General principles in the treatment of peptic ulcer, 742
General problem of anesthesia in obstetrics, The, 953
Getting the most from a pathologist, 276
Gillespie, Malcolm, Wells, Arthur H., and Emanuel, Karl
W. : Carcinoma of the papilla of Vater (diagnostic
case report), 1174
Glomus tumors, 159
Granulocytopenia, Sulfadiazine, and thrombocytopenia
complicating pregnancy with survival, 509
H
Hall, G. H. : Massive gastric hemorrhage due to hem-
orrhagic gastritis necessitating gastric resection, 317
Hallberg, Olav E. : Recent advances in the management
of ear, nose and throat problems, 1156
Hamilton, James A. : Financing the establishment of a
small hospital, 261
Hannah, Hewitt B. : The treatment of hysteria by narco-
hypnosis, 305
Hansen, Robert E., and Tuohy, Edward L. : Nitrogen
balance and its clinical application, 394
Harper, H. P. : Pulmonary decortication for infected
organized hemothorax, 312
Hart, Vernon L. : Congenital dislocation and congen-
ital subluxation of the hip, 889
Hatch, W. E., Wells, Arthur H., and Joffe, Harold H. :
Congenital urethral valve, 56
Hawley, Paul R. : Medical service program in the Vet-
erans Administration hospitals, 377
Hayford, W. D., and Hertzog, A. J. : Acute isolated
myocarditis (Fiedler’s myocarditis), 54
Hayford, W. D., and Hertzog, A. J. : Kimmelstiel-Wil-
son syndrome, 280
Health program, A sound public, 1050
Health program in rural schools, The, 1054
Heart, Metastatic carcinoma of the, 860
Hein, Fred V. : Physical education in rural schools, 1057
Heller, B. I., and Jacobson, W. E. : Amebic abscess of
the liver with bronchohepatic fistula, 1161
Hemorrhage, postpartum, Prolonged labor, with special
reference to, 945
Hemothorax, infected organized, Pulmonarjr decortica-
tion for, 312
Hertzog, A. J., and Hayford, W. D. : Acute isolated
myocarditis (Fiedler’s myocarditis), 54
Hertzog, A. J., and Hayford, W. D. : Kimmelstiel-
Wilson syndrome, 280
Hertzog, A. J., and McCarthy, A. M. : Cor pulmonale,
514
Hertzog, A. J., and Sether, Julian: Case for diagnosis
(thrombosis of left renal artery with acute infarc-
tion of left kidney, renal arteriosclerosis of right
kidney, uremia, etc.), 766
Hilding, A. C. : Deafness, a therapeutic problem, 642
Hilleboe, Herman E. : Community-wide chest x-ray
surveys and the general practitioner, 625
Hip, Congenital dislocation and congenital subluxation of
the, 889
Hirschboeck, Frank J. : Rural medical service, 1065
Hospital facilities for all, 1060
Hospital, small, Financing the establishment of a, 261
Hullsiek, Harold E. : A plan for the detection of the
source of rectal bleeding, 503
Hydrocephalus in infants, Experiences in the treatment
of, 790
Hydronephrosis, Ectopic kidney with, 89
Hyperthyroidism, Newer methods in the treatment of, 39
Hyperthyroidism, Present-day concepts in the treatment
of, 786
Hyperthyroidism, The use of chemical agents in the
treatment of, 198
Hysteria, The treatment of, by narco-hypnosis, 305
History
Notes on the history of medicine in Fillmore County
prior to 1900, 62, 179, 289, 412, 519, 652, 769, 867,
982, 1071, 1178, 1268
I
Impalement, Rectal, 45
Industrial integration, 174
Infants, Experiences in the treatment of hydrocephalus
in, 790
Infection of the neck after tonsillectomy, 851
Influenzal meningitis, 647
Insulin mixtures, The use of, 153
Internal derangement of the knee, 42
Intestinal ascaris diagnosed roentgenographically in
Minnesota (case report), 410
Intussusception, Acute, in infancy and childhood, 257
In Memoriam
Abramovich, Joseph H., 903
Adams, James Linn, 576
Allen, Harry Winslow, 207
Andersen, Arnt G., 1302
Ayres, George T., 1000
Benesh, Norbert George, 1000
Bessesen, Alfred N., 1000
Blakely, Clement Campbell, 576
Christie, George Ralph, 207, 798
Conner, H. Milton, 1302
Crewe, John E., 1001
D’Arms, Harry Lee, 1302
Davis, William, 903
DeCourcy, Donald Michael, 207
Dempsey, Domnick Patrick, 208, 446
Dittman, George Claude, 577
Duffalo, John A., Jr., 1092
Dunlap, Harold F., 1092
Ederer, John Joseph, 208
Gamble, Joseph William, 1001
Gamble, Paul W., 1302
Gendron, Julius F., 1092
Gilles, Floyd Lester, 577
Ginsberg, William, 1092
Grana, Alfonso, 1304
Green, Robert K., 1092
Grimes, Henry B., 208
Harrington, Francis E., 680
December, 1947
1327
INDEX TO VOLUME 30
Hill, Eleanor Jane, 209
Holl, Peter M., 680
Jackson, Clarence Martin, 326
Johnson, Carl M., 578
Johnson, Howard Elmer, 1304
Jonasson, Kristian, 1002
Joshie, Nielamber C., 1304
Joyce, Thomas M., 681
Kepler, Edwin John, 1304
Kistler, Charles Milton, 903
Knauff, Muhlenburg Keller, 1305
Larson, Winford Porter, 446
Lillie, Walter L., 446
Macbeth, Jesse Lynn, 209
Manley, James Rollin, 1305
Marsh, Harold E., 1002
Monahan, Robert Hugh, 905
More, Charles Wesley, 904
Morris, Robert E., 1307
O’Brien, William Austin, 1306
Olson, Reinhart Gilbert, 1002
Peck, Llewellington D., 905
Plankers, Arnold, 209
Pollock, Lee W„ 579
Reiter, Henry W., 1306
Remy, Charles E., 209
Robitshek, Emil C., 905
Salt, Clifford G., 447
Shastid, Thomas Hall, 580
Smith, Benjamin F., 1094
Stinnette, Shelby E., 581
Verne, Victor E., 210
Vogel, Joseph H„ 1003
Wright, Charles D’Arcy, 1003
Wunder, Henry Edward, 1307
J
Jackson, Arnold S. : Newer methods in the treatment of
hyperthyroidism, 39
Jacobson, W. E., and Heller, B. I. : Amebic abscess of
the liver with bronchohepatic fistula, 1161
Jaundice, congenital hemolytic, Chronic ulcers of the
leg associated with (case report), 651
Jaundice, infectious and serum, The relationship of, 498
Jensen, N. K. : Constrictive fibrino-pleurisy, 1293
Jessico, C. M., Finley, K. H., and Richards, T. W. : Ob-
servations on a mild form of epilepsy, 49
Joffe, Harold H. Hatch, W. E., and Wells, Arthur H. :
Congenital urethral valve, 56
Joffe, Harold H., Magney, F. H., and Wells, Arthur H.,
Parathyroid adenoma, 760
Joffe, Harold H., Terrell, Bernard J., and Wells, Arthur
H. : Primary carcinoma of the pancreas, metastatic
carcinomatous lymphangitis of the lungs, etc. (diag-
nostic case study), 978
Joffe, Harold H., and Wells, Arthur H. : A review of
174 cases of cancer with necropsies, 735
Joffe, Harold H., and Wells, Arthur H. : Epithelial
neoplasms of the appendix, 176
Joffe, Harold H., Wells, Arthur H., and Rowe, 01 in
W. : Diagnostic case study (rhabdomyosarcoma of
the interauricular septum), 282
Joffe, Harold H., Wells, Arthur H., and Swenson, Ar-
nold O. : Chordoma, 863
K
Kabler, Paul, and Cooney, Marion: Toxoplasmosis, 637
Keil, Marcus A.: Clinical use of folic acid, 1167
Kidney, Ectopic, with hydronephrosis, 89
Kimmelstiel-Wilson syndrome, 280
Knapp, Miland E. : The treatment of the muscular af-
ter-effects of poliomyelitis, 1152
Knee, Internal derangement of the, 42
Knight, Ralph T. : Anesthesia for transthoracic gas-
trectomy, 88
L
Labor, Prolonged, with special reference to postpartum
hemorrhage, 945
Laird, Arthur T. : The treatment of persons who have
bronchial asthma, 386
Lake, Clifford F. : Infection of the neck after tonsil-
lectomy, 851
larson, Lawrence M. : Lumbar retroperitoneal ganglio-
neuroma (summary), 539; (complete paper), 969
Leddy, Eugene T. : Roentgen therapy of bronchiogenic
carcinoma, 975
Leighton, R. S., and Weisberg, R. J. : Intestinal ascaris
diagnosed roentgenographically in Minnesota (case
report), 410
Lillie, H. I., and McBean, James B. : Chronic mastoid-
itis with cholesteatoma and stenosis of the external
auditory meatus, 161
Litman, S. N., Buckley, R. P., and Wells, A. H. : In-
fluenzal meningitis, 647
Liver, Amebic abscess of the, with bronchohepatic fistula,
1161
Lumbar retroperitoneal ganglioneuroma (summary),
539; (complete paper), 969
Me
McBean, James B. : Observations on the management
of vasomotor rhinitis, 399
McBean, James B., and Lillie, H. I. : Chronic mastoid-
itis with cholesteatoma and stenosis of the external
auditory meatus, 161
McCarthy, A. M., and Hertzog, A. J. : Cor pulmonale,
514
McKaig, Carle B. : The present Southern Minnesota
Medical Association, 157
M
MacKinnon, Donald C. : Acute perforated gastric and
duodenal ulcer, 1253
Madden, John F. : Sporotrichosis in Minnesota, 854
Madura foot, Mycetoma or, 407
Magney, F. H. : Acute intussusception in infancy and
childhood, 257
Magney, F. H., Wells, Arthur H., and Joffe, Harold H. :
Parathyroid adenoma, 760
Management of obstetric emergencies, The, 949
Manners are not idle, For, 841
Mark, Hilbert : Follow-up of abnormal pulmonary find-
ings observed in mass chest x-ray surveys, 1251
Massive gastric hemorrhage due to hemorrhagic gas-
tritis necessitating gastric resection, 317
Mastoiditis, Chronic, with cholesteatoma and stenosis
of the external auditory meatus, 161
Maxeiner, Stanley R. : Transthoracic gastrectomy, 84
Mayo, Charles W. : The surgical treatment of carcinoma
of the right part of the colon, 1197
Mears, F. B., and State, David : Arthus phenomenon
induced by the local application of penicillin (case
report), 517
Medical care. Voluntary prepayment, and its rural as-
pects, 382
Medical service program in the Veterans Administra-
tion hospitals, 377
Medical therapy in ulcerative colitis, 956
Medical treatment of peptic ulcer, 960
Meeker County tuberculosis control project, The, 635
Meniere’s disease : endolymphatic hydrops, 427
Meningitis, Influenzal, 647
Metastatic carcinoma of the heart, 860
Meyerding, Henry W., and Evert, J. A., Jr. : Mycetoma
or Madura foot, 407
1328
Minnesota Medicine
INDEX TO VOLUME 30
Meyerding, Henry W., and Varney, James H. : Glomus
tumors, 159
Michelson, H. E. : Minnesota serological evaluation
study, 972
Minnesota multiphasic personality inventory, The, 753
Minnesota serological evaluation study, 972
Moe, Allan E. : Cardiac findings due to sternal depres-
sion, 1265
Molner, Joseph G. : Epidemiology and recent develop-
ments in poliomyelitis, 1145
Montgomery, George E., Dry, Thomas J., and Gage,
Robert P. : Further observations on the prognosis
in angina pectoris due to coronary sclerosis, 162
Moos, Daniel J., and Farkas, John V. : The surgical
history of a centenarian (case report), 767
Mycetoma or Madura foot, 407
Myocarditis, Acute isolated (Fiedler’s myocarditis), 54
Medical Economics
1947 National Health Bill, 299
$3,000,000 Mayo memorial virtually assured, 665
AMA “grass roots conference” hailed as decided success,
1083
AMA House of Delegates agenda indicate Association’s
growth, 190
Advisory committee formed to tackle nurse shortage,
783
Border state doctors must heed narcotic regulations,
533
Cancer fight intensified, 301
Conference studies national school health program, 1193
Council approves additional orthopedic clinics, 664
County officers hear progress reports on MSMA pro-
grams, 424, 531
County Society officers plan national conference, 664
Delegates discuss health questions at Duluth meet, 881
Delegates hear plea for establishment of practical nurse
training schools, 76
Dual approach speeds prepayment medical care program,
74
Emergency maternal and infant care program to end
gradually, 993
Federal funds used to promote compulsory health in-
surance, 994
Hearings being held on National Health Bill, 784
Minnesota health legislation, 300
Minnesota State Board of Medical Examiners :
Physicians licensed February 8, May 3, July 12, No-
vember 8, 77
State of Minnesota vs.
Richard Almsted, 996
Clara Olga Anderson, Irene E. McFarland and
Isadore Abramovich, 194
Jacob S. Balzer, 1283
David Bush, 533
Herman V. Feenstra, 1085
Harry Gilbert, 666
W. A. Groebner, 666, 996
Thomas F. Jackamore, 534
Raymond E. Older, 666
Alida Toivonen, 1195
Asunda (Sue) Willner, 1195
Mower County to organize state’s first health council,
1283
North Central Conference meets in Saint Paul, Novem-
ber 23, 1192
Personal debts peril patients’ budgets, 665
Prepaid medical and surgical care for Minnesota people,
992
Prepayment medical care termed “jig-saw puzzle,” 1281
Risks of administering blood plasma, 1082
Social security mission to Japan questioned, 1082
State Division rehabilitates 590 handicapped persons, 1192
University receives grant for mental health studies, 995
Veterans medical service, 302
December, 1947
Miscellaneous
Doctor Chesley honored, 780
Metopon hydrochloride, 781
Report of the House of Delegates — American Medical
Association, December 9-11, 1946, 423
Report of Minnesota AMA delegates, 880
State meeting, The, 529
N
Neck, Infection of the, after tonsillectomy, 851
Neibling, Harold A., Bradley, William F., Small, John
T., Wilson, James W., and Walters, Waltman : Vag-
otomy in peptic ulcer, 965
Nelson, C. B. : Trichinosis in Minnesota, 640
Nelson, Wallace I. : Congenital diaphragm of the duode-
num (summary), 539; (complete paper), 745
Nelson, Wallace I. : Congenital diaphragm of the duo-
denum, 745
Newer methods in the treatment of hyperthyroidism, 39
Nichols, Donald R. : Streptomycin : its present uses,
1263
Nitrogen balance and its clinical application, 394
O
Observations on a mild form of epilepsy, 49
Observations on the management of vasomotor rhinitis,
399
Obstetric emergencies, The management of, 949
Obstetrics, The general problem of anesthesia in, 953
Office proctology, 272
Orchiectomy and hormones in prostatic carcinoma, 403
Otosclerosis, The fenestration operation for, 1249
Ovarian cyst, Unusually large, in an elderly woman,
(case report), 60
P
Parathyroid adenoma, 760
Pathologist, Getting the most from a, 276
Penicillin, Arthus phenomenon induced by the local ap-
plication of (case report), 517
Penicillin in the treatment of syphilis, 535
Periarteritis nodosum — treatment with penicillin, 303
Peripheral arterial embolism, 432
Personality inventory, The Minnesota multiphasic, 753
Peterson, Herbert W., and Blumenthal, J. S. : Metastatic
carcinoma of the heart, 860
Physical education in rural schools, 1057
Physiologic approach to cardiovascular roentgenology,
A, 1041
Plan for the detection of the source of rectal bleeding,
A, 503
Plan of action for farm communities, The, 1049
Platou, Erling S. : The sick child in poliomyelitis, 1149
Poliomyelitis, Acute, in pregnancy, 729
Poliomyelitis, Epidemiology and recent developments
in, 1145
Poliomyelitis, Remarks on, 91
Poliomyelitis, The sick child in, 1149
Poliomyelitis, The treatment of the muscular after-ef-
fects of, 1152
Polyneuritis, 166
Postgraduate medical education in a private hospital, 845
Postoperative anuria, 195
Pregnancy, Acute poliomyelitis in, 729
Present-day concepts in the treatment of hyperthyroidism,
786
Present Southern Minnesota Medical Association, The,
157
Primary carcinoma of the pancreas, metastatic carci-
nomatous lymphangitis of the lungs, etc., 981
1329
INDEX TO VOLUME 30
Proctology, Office, 272
Prolonged labor, with special reference to postpartum
hemorrhage, 945
Prostatic carcinoma, Orchiectomy and hormones in, 403
Protein and amino acid therapy, 493
Psychosomatic medicine, Educational management in,
with special reference to the gastrointestinal tract,
m
Public health program, A sound, 1050
Pulmonary decortication for infected organized hemo-
thorax, 312
Pulmonary findings observed in mass chest x-ray sur-
veys, abnormal. Follow-up of, 1251
President's Letter
Annual meeting, The, 660
General practitioner, The, 877
Local heart associations, 1078
Medical benevolence, 419
Medical service area is key to physician distribution, 526
Minnesota Medical Service, Inc., to begin operation
shortly, 295
National Physicians’ Committee calls conference of the
professions, 1186
Physicians obligated to remedy conditions in state insti-
tutions, 185
Physicians of today reject “peaceful mediocritv” of past,
' 71
Socialized medicine, 988
Tuberculosis in Minnesota, 776
R
Radon ointment, Uses of, 52
Rea, Charles E. : Present-day concepts in the treatment
of hyperthyroidism, 786
Rea, Charles E. : Reconstruction of the extrahepatic
bile duct, 759
Recent advances in the management of ear, nose and
throat problems, 1156
Reconstruction of the extrahepatic bile duct, 759
Rectal bleeding, A plan for the detection of the source
of, 503
Rectal impalement, 45
Rectum, chronic fistulas of the, following penetrating
wounds, Surgical management of, 310
Relationship of infectious and serum jaundice, The, 498
Remarks on poliomyelitis, 91
Renal and other retroperitoneal tumors, The surgical
approach to, 84
Retroperitoneal tumors, The surgical approach to renal
and other, 84
Review of 174 cases of cancer with necropsies, A, 735
Rhabdomvosarcoma of the right interauricular septum,
282
Rhinitis, vasomotor, Observations on the management of,
399
Richards, T. W., Jessico, C. M., and Finley, K. H. : Ob-
servations on a mild form of epilepsy, 49
Ritchie, Wallace P. : Experiences in the treatment of
hydrocephalus in infants, 790
Ritt, Albert E. : Industrial integration, 174
Robb, Edwin F. : Enuresis, 91
Roentgen therapy of bronchiogenic carcinoma, 975
Rowe, Olin W., Joffe, Harold H., and Wells, Arthur H. :
Diagnostic case study (Rhabdomyosarcoma of the
right interauricular septum), 282
Rukavina, John G., and Tuohy, Edward L. : The re-
lationship of infectious and serum jaundice, 498
Rural medical service, 1065
Rural schools, Physical education in, 1057
Rural schools, The health program in, 1054
Ryan, Joseph M. : General principles in the treatment of
peptic ulcer, 742
Rynearson, Edward H. : Endocrine therapy, 33
1330
Reports and Announcements
AMA centennial, 570
American Academy of Allergy, 1086
American Academy of Arts and Sciences offers Francis
Amory prize, 98
American Association for the Study of Goiter, 898
American Association on Mental Deficiency, 442
American Board of Orthopaedic Surgery, 676
American College of Allergists — instructional course,
898, 998
American College of Chest Physicians, 320, 899
American College of Physicians, 570, 899
American College of Physicians and Surgeons, 442, 676,
796
American College of Surgeons, 899, 1086, 1308
American Congress on Obstetrics and Gynecolgy, 204
American Congress of Physical Medicine, 570, 677
American Radium Society, 677
American Society for the Study of Sterility, 320
Annual county officers meeting, 98
Army internships and residencies, 1308
Central Association of Obstetricians and Gynecologists,
570
Chicago Medical Society, 98, 1308
Chicago Ophthalmological Society — refresher course, 900
Christian, George Chase, lecture, 1210
Civil service examinations for physicians, 901
College of American Pathologists, 677
Crippled children’s clinics, 442
Dakota County Society, 322
Examinations for appointment to regular corps, USPHS,
204
Fiftieth anniversary celebration (Ramsey County Medi-
cal Society), 900
Goodhue County Society, 100
Grants for scientific research, 998
Hearing aid firm offers fellowship, 678
Hennepin County Society, 322, 678
Hennepin-Ramsey County Societies, 796
Industrial health meetings, 320
International College of Surgeons, 796, 1210
Interurban Academy of Medicine, 100
Johnson, Herman, memorial lecture, 444
Judd, E. Starr, lecture, 320
McLeod County Society, 322
Markle Foundation post-fellowship grants, 1086
Medical broadcast for January, 98
March, 320
July, 796
August, 898
Medical social service, 1308
Medico-legal conference and seminar (Harvard Medical
School), 900
Michigan Postgraduate Clinical Institute, 1309
Minneapolis Surgical Society:
Election of officers, 572
Meeting of October 3, 1946, 84
Meeting of November 7, 1946, 195
Meeting of December 5, 1946, 310
Meeting of March 6, 1947, 459
Meeting of May 1, 1947, 1284
Minnesota Academy of Medicine :
Meeting of October 9, 1946, 89
Meeting of November 13, 1946, 303
Meeting of December 11, 1946, 427
Meeting of January 8, 1947, 535
Meeting of February 12, 1947, 786
Meeting of March 12, 1947, 884
Meeting of April 9, 1947, 1197
Minnesota Medical Service, 98
Minnesota Pathological Society, 100, 206, 442, 572
Minnesota Society of Anesthesiologists, 1088, 1310
Minnesota Society of Clinical Pathologists, 1210
Minnesota Society of Neurology and Psychiatry, 442,
572, 998, 1310
Minnesota Medicine
INDEX TO VOLUME 30
Minnesota State Medical Association :
Ninety-fourth annual session —
Announcements and program, 667
Summary of proceedings, 1202
Roster, 541
State meeting, The, 529
Minnesota Surgical Society, 322
Mississippi Valley Medical Society, 796, 901, 1309
National Gastroenterological Association, 570
National conference on medical service, 98
Northern Minnesota Medical Association, 796
Omaha Mid-west Clinical Society, 1088
Philadelphia seminar in radiology, 98
Prize contest announced (American Association of Ob-
stetricians, Gynecologists and Abdominal Surgeons),
320
Ramsey County Society, 100
Red River Valley Society, 678
Redwood-Renville County Society, 100
Research fellowships, 1086
St. Louis County Society, 102, 1211
Second South American Congress of Neurosurgery, 204
Society of Clinical Surgery, 678
Southern Minnesota Medical Association, 902, 1088
Southwestern Minnesota Society, 796, 1088, 1310
Steams-Benton County Society, 322
University graduates available for assistantships, 206
Upper Mississippi Society, 797
Urology award, 1086
Van Meter Prize award, 998
Wabash County Society, 1211
Waseca County Society, 322
Washington County Society, 102, 206, 322, 572, 681, 797,
1088
Woman’s Auxiliary, 96, 206, 324, 444, 574, 679, 1090,
1208, 1311
Wright County Society, 1310
S
Schade, F. L. : The management of obstetric emer-
gencies, 949
Schneider, Robert A., and Walch, A. E. : The Minne-
sota multiphasic personality inventory, 753
Scott, Horace G. : Alimentary diverticula, 1284
Serological evaluation study, Minnesota, 972
Sether, Julian, and Hertzog, A. J. : Case for diagnosis
(thrombosis of left renal artery with acute infarction
of left kidney, renal arteriosclerosis of right kidney,
uremia, etc.), 766
Sewell, Mrs. Charles W. : The plan of action for farm
communities, 1049
Shambaugh, George E. : The fenestration operation for
otosclerosis, 1249
Sherwood, George E. : Country medicine — past, present
and future, 37
Short commentary on the history of the circulation, A,
264
Sicher, William D. : The Cruveilhier-Baumgarten syn-
drome, 506
Sick child in poliomyelitis, The, 1149
Skinner, H. 0. : Chronic ulcers of the leg associated with
congenital hemolytic jaundice (case report), 651
Small, John T., Wilson, James W., Walters, Waltman,
Neibling, Harold A., and Bradley, William F. :
Vagotomy in peptic ulcer, 965
Smiley, D. F. : The health program in rural schools,
1054
Sound public health program, A, 1050
Southern Minnesota Medical Association, The present,
157
Sporotrichosis in Minnesota, 854
Sprague, Randall G., and Underdahl, Laurentius 0. :
The use of insulin mixtures, 153
December, 1947
State, David, and Mears, F. B. : Arthus phenomenon in-
duced by the local application of penicillin (case
report), 517
Stetler, L. A. : Postoperative anuria, 195
Strandjord, Nels M., and Sukman, Robert: Sulfadiazine
granulocytopenia and thrombocytopenia complicat-
ing pregnancy with survival, 509
Streptomycin:' its present uses, 1263
Sukman, Robert, and Strandjord, Nels M. : Sulfadiazine
granulocytopenia and thrombocytopenia complicating
pregnancy with survival, 509
Sulfadiazine granulocytopenia and thrombocytopenia
complicating pregnancy with survival, 509
Surgical approach to renal and other retroperitoneal tu-
mors, The, 84
Surgical history of a centenarian, The (case report),
767
Surgical management of chronic fistulas of the rectum
following penetrating wounds, 310
Surgical treatment of carcinoma of the right part of the
colon, The, 1197
Sussman, Marcy L. : A physiologic approach to cardio-
vascular roentgenology, 1041
Sweat glands, Adenocarcinoma of the, with metastases
(case report), 286
Sweetser, Theodore H. : The surgical approach to renal
and other retroperitoneal tumors, 84
Sweitzer, S. E. : Penicillin in the treatment of syphilis,
535
Swenson, Arnold O., Joffe, Harold H., and Wells, Ar-
thur H. : Chordoma, 863
Syphilis, Penicillin in the treatment of, 535
T
Tenner, Robert J. : Surgical management of chronic
fistulas of the rectum following penetrating wounds,
310
Terrell, Bernard J., Wells, Arthur H., and Joffe, Harold
H. : Primary carcinoma of the pancreas, metastatic
carcinomatous lymphangitis of the lungs, etc. (diag-
nostic case study), 978
Thrombocytopenia, Sulfadiazine granulocytopenia and,
complicating pregnancy with survival, 509
Tonsillectomy, Infection of the neck after, 851
Toxoplasmosis, 637
Transthoracic gastrectomy, 84
Transthoracic gastrectomy, Anesthesia for, 88
Treatment of hysteria by narco-hypnosis, The, 305
Treatment of persons who have bronchial asthma, The,
386
Treatment of the muscular after-effects of poliomyelitis,
The, 1152
Trichinosis in Minnesota, 640
Tuberculosis among residents of Olmsted County over
the age of sixty-five, 856
Tuberculosis control project, The Meeker County, 635
Tularemia, Water-borne, 849
Tumors, Glomus, 159
Tumors, renal and other retroperitoneal, The surgical
approach to, 84
Tuohy, Edward B. : The general problem of anesthesia
in obstetrics, 953
Tuohy, Edward L., and Hansen, Robert E. : Nitrogen
balance and its clinical application, 394
Tuohy, Edward L., and Rukavina, John G. : The rela-
tionship of infectious and serum jaundice, 498
U
Ulcer, Acute perforated gastric and duodenal, 1253
Ulcer, peptic, General principles in the treatment of, 742
Ulcer, peptic, Medical treatment of, 960
Ulcer, peptic, Vagotomy in, 965
1331
INDEX TO VOLUME 30
Ulcers, Chronic, of the leg associated with congenital
hemolytic jaundice (case report), 651
Underdahl, Laurentius O., and Sprague, Randall G. :
The use of insulin mixtures, 153
Unusually large ovarian cyst in an elderly woman (case
report), 60
Urethral valve, Congenital, 56
Use of chemical agents in the treatment of hyperthy-
roidism, The, 198
Use of insulin mixtures, The, 153
Uses of radon ointment, 52
Utendorfer, R. W. : Criteria for choledochostomy tube
removal, 315
V
Vagotomy in peptic ulcer, 965
Vandersluis, Charles W. : Getting the most from a pa-
thologist, 276
Varney, James H., and Meyerding, Henry W. : Glomus
tumors, 159
Veterans Administration hospitals, Medical service pro-
gram in the, 377
Veterinary medicine, 512
Visscher, Maurice B. : Remarks on poliomyelitis, 91
Voluntary prepayment medical care and its rural aspects,
382
W
Walch, A. E., and Schneider, Robert A. : The Minne-
sota multiphasic personality inventory, 753
Walters, Waltman, Neibling, Harold A., Bradley, Wil-
liam F., Small, John T., and Wilson, Tames W. :
Vagotomy in peptic ulcer, 965
Water-borne tularemia, 849
Watson, Alexander M. : Prolonged labor, with special
reference to postpartum hemorrhage, 945
Weisberg, R. J., and Leighton, R. S. : Intestinal as-
caris diagnosed roentgenographically in Minnesota
(case report), 410
Wells, Arthur H. : Postgraduate medical education in a
private hospital, 845
Wells, Arthur H., Emanuel, Karl W., and Gillespie,
Malcolm: Carcinoma of the papilla of Vater (diag-
nostic case report), 1174
Wells, Arthur H., and Joffe, Harold H. : A review
of 174 cases of cancer with necropsies, 735
Wells, Arthur H., and Joffe, Harold H. : Epithelial
neoplasms of the appendix, 176
Wells, Arthur H., Joffe, Harold H., and Hatch, W. E. :
Congenital urethral valve, 56
Wells, Arthur H., Joffe, Harold H., and Magney, F. H. :
Parathyroid adenoma, 760
Wells, Arthur H., Joffe, Harold H., and Terrell, Bernard
J. : Primary carcinoma of the pancreas, metastatic
carcinomatous lymphangitis of the lungs, etc. (diag-
nostic case study), 978
Wells, A. H., Litman, S. N., and Buckley, R. P. : In-
fluenzal meningitis, 647
Wells, Arthur H., Rowe, Olin W., and Joffe, Harold H. :
Diagnostic case study (Rhabdomyosarcoma of the
right interauricular septum), 282
Wells, Arthur H., Swenson, Arnold O., and Joffe, Har-
old H. : Chordoma, 863
White, S. Marx : Periarteritis nodosum — treatment with
penicillin, 303
Willius, F. A. : A short commentary on the history of
the circulation, 264
Wilson, J. Allen: Medical treatment of peptic ulcer, 960
Wilson, James W'., Walters, Waltman, Neibling, Har-
old A., Bradley, William F., and Small, John T. :
Vagotomy in peptic ulcer, 965
Wilson, Viktor O. : Hospital facilities for all, 1060
Y
Yeager, Charles L. : Polyneuritis, 166
1332
Minnesota Medicine
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2
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30
January, 1947
No. 1
Contents
Endocrine Therapy.
Edward H. Rynearson, M.D., Rochester, Minnesota 33
Country Medicine — Past, Present and Future.
George E. Sherwood, M.D., Kimball, Minnesota.. 37
Newer Methods in the Treatment of Hyper-
thyroidism.
Arnold S. Jackson, M.D., Madison, Wisconsin... 39
Internal Derangement of the Knee.
Mark B. Coventry, M.D., Rochester, Minnesota.. 42
Rectal Impalement.
C. T. Eginton, M.D., M.S. (Surg.), Saint Paul,
Minnesota , 45
Chylothorax : Pregnancy in an Arrested Case.
Gits Edlund, M.D., Saint Paul, Minnesota 47
Observations on a Mild Form of Epilepsy.
Lt. C. M. Jessico, MC, USNR, Lt. Comdr. K. H.
Finley, MC, USNR, and Lt. Comdr. T. IV. Rich-
ards, HS, USNR 49
Uses of Radon Ointment.
Robert E. Fricke, M.D., Rochester, Minnesota.... 52
Clinical-Pathological Conferences :
Acute Isolated Myocarditis (Fiedler’s Myocar-
ditis)
A. J. Hertzog, M.D., and W. D. Hayford, M.D.,
Minneapolis, Minnesota 54
Congenital Urethral Valve.
Harold H. Joffe, M.D., W. E. Hatch, M.D., and
Arthur H. Wells, M.D., Duluth, Minnesota.. 56
Case Report:
Unusually Large Ovarian Cyst in an Elderly
Woman.
Lyman B. Clay, M.D., and Verne S. Cabot, M.D.,
F.A.C.S., Minneapolis, Minnesota 60
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900 (Continued) .
Nora H. Guthrey, Rochester, Minnesota 62
Photograph — Louis A. Buie, M.D., President,
Minnesota State Medical Association 70
Contents of Minnesota Medicine copyrighted
President’s Letter:
Physicians of Today Reject “Peaceful Mediocrity”
of Past 71
Editorial :
Minnesota Medical Service 72
Mortality and Diabetes 72
Heart Disease 73
Medical Economics :
Dual Approach Speeds Prepayment Medical Care
Program 74
Delegates Hear Plea for Establishment of Practical
Nurse Training Schools 76
Minnesota State Board of Medical Examiners —
Physicians Licensed in 1946. 77
Minneapolis Surgical Society :
Meeting of October 3. 1946 84
The Surgical Approach to Renal and Other Retro-
peritoneal Tumors. (Abstract.)
Theodore H. Sweetser, M.D., Minneapolis, Min-
nesota 84
Transthoracic Gastrectomy.
Stanley R. Maxeiner, M.D., F.A.C.S., Minne-
apolis, Minnesota 84
Anesthesia for Transthoracic Gastrectomy.
Ralph T. Knight, M.D., Minneapolis, Minnesota.. 88
Minnesota Academy of Medicine :
Meeting of October 9, 1946 89
Ectopic Kidney with Hydronephrosis.
C. D. Creevy, M.D., Minneapolis, Minnesota.... 89
Remarks on Poliomyelitis.
Maurice B. Visscher, M.D., Minneapolis, Min-
nesota 91
Enuresis.
Edwin F. Robb, M.D., Minneapolis, Minnesota.. 91
Woman’s Auxiliary 96
Reports and Announcements 98
Of General Interest 106
Book Reviews 117
by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918.
January, 1947
3
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
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Office of Minnesota State Medical Association,
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EDITING AND PUBLISHING COMMITTEE
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B. O. Mork, Jr., Worthington
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O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
C. L. Oppegaard, Crookston
EDITORIAL STAFF
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BUSINESS MANAGER
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Minnesota Medicine
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Minnesota State Medical Association
OFFICERS
Louis A. Buie, M.D. ..
C. B. Drake, M.D
L. R. Gowan, M.D
B. B. Souster, M.D
W. H. Condit, M.D....
E. J. Simons, M.D
W. A. Coventry, M.D.
C. G. Sheppard, M.D...
R. R. Rosell
President
First Vice President
Second Vice President
Secretary
T reasurer
Past President
. .Speaker, House of Delegates. .
Vice Speaker, House of Delegates
Executive Secretary
Rochester
... St. Paul
... Duluth
. . .St. Paul
Minneapolis
. Swanville
. . . Duluth
Hutchinson
... St. Paul
COUNCILORS*
First District
R. L. J. Kennedy, M.D. (1947) Rochester
Second District
L. L. Sogge, M.D. (1947) Windom
Third District
C. M. Johnson, M.D. (1949) Dawson
Fourth District
A. E. Sohmer, M.D. (1948) Mankato
Fifth District
E. M. Hammes, M.D. (1949) St. Paul
Sixth District
A. E. Cardle, M.D. (1948) Minneapolis
Seventh District
W. W. Will, M.D. (1949) Bertha
Eighth District
W. L. Burnap, M.D. (1948) Fergus Falls
Ninth District
F. J. Elias, M.D. (1947) (Chairman) Duluth
HOUSE OF DELEGATES, AMERICAN MEDICAL
ASSOCIATION*
. Minneapolis
Fergus Falls
Bertha
.... St. Paul
Members Alternates
A. W. Adson, M.D. (1948) Rochester J. C. Hultkrans, M.D. (1948)
W. A. Coventry, M.D. (1948) Duluth W. L. Burnap, M.D. (1948)..
E. W. Hansen, M.D. (1947) Minneapolis W. W. Will, M.D. (1947)....
F. J. Savage, M.D. (1947) St. Paul George Earl, M.D. (1947)...
SCIENTIFIC COMMITTEES
COMMITTEE OlV SCIENTIFIC ASSEMBLY
Louis A. Buie, M.D., General Chairman Rochester
E. J. Simons. M.D Swanville
R. R. Rosell Saint Paul
Section on Medicine
W. W. Spink, M.D Minneapolis
S. H. Boyer, Tr. M.D Duluth
Section on Specialties
Paul F Dwan, M.D Minneapolis
F. W. Lynch, M.D Saint Paul
Section on Surgery
O. J. Campbell, M.D Minneapolis
J. T. Priestley, M.D Rochester
Local Arrangements
R. P. Buckley, M.D Duluth
•Terms expire December 31 of year indicated.
COMMITTEE OlV CANCER*
A. H. Wells, M.D. (1947) Duluth
D. P. Anderson, Jr., M.D, (1949) Austin
Herbert Boysen, M.D. (1949) Madelia
E. C. Hartley, M.D. (1949) Saint Paul
J. A. Johnson, M.D. (1948) Minneapolis
J F. Karn, M.D. (1949) Ortonville
F. H. Magney, M.D. (1948) Duluth
W. C. McCarty, Sr., M.D. (1947) Rochester
Martin Nordland, M.D. (1948) Minneapolis
Wm. A. O’Brien, M.D. (1947) Minneapolis
W. T. Peyton, M.D. (1947) Minneapolis
COMMITTEE ON CHILD HEALTH
G. B. Logan, M.D Rochester
S. L. Arey, M.D Minneapolis
F. G. Hedenstrom, M.D Saint Paul
R. J. Josewski, M.D Stillwater
R. L. j. Kennedy, M.D Rochester
E. E. Novak, M.D New Prague
R. E. Nutting, M.D Duluth
E. S. Platou, M.D Minneapolis
W. B. Richards, M.D Saint Cloud
L. F. Richdorf, M.D Mirmeapolins'
C. H. Schroeder, M.D Duluth
V. O. Wilson, M.D Minneapolis
Irvine McQuarrie, M.D. (ex officio) Minneapolis
•Terms expire December 31 of year indicated.
6
Minnesota Medicine
COMMITTEE ON CONSERVATION OF HEARING
L. R. Boies, M.D Minneapolis
A. G. Athens, M.D Duluth
W. L. Burnap, M.D Fergus Falls
C. E. Connor, M.D .....Saint Paul
J. B. Gaida, M.D Saint Cloud
A. V. Garlock, M.D Bemidji
B. E. Hempstead, M.D Rochester
Anderson Hilding, M.D Duluth
H. \V. Lee, M.D Brainerd
E. A. Loomis, M.D Minneapolis
H, A. Roust, M.D Montevideo
J. T. Schlesselman, M.D Mankato
Andrew Sinamark, M.D Hibbing
Tj. E. Strate, M.D Saint Paul
COMMITTEE ON DIABETES
J. R. Meade, M.D Saint Paul
C. N. Harris, M.D , Hibbing
J. K. MoEN, Jr., M.D Minneapolis
W. S. Netf, M.D Virginia
Harry Oerting, M.D Saint Paul
B. F. Pearson, M.D Shakopee
R. H. Puumala, M.D Cloquet
E. H. Rynearson, M.D Rochester
R. V. Sherman, M.D Red Wing
C. J. Watson, M.D Minneapolis
COMMITTEE ON FIRST AID AND RED CROSS
J. S. Lundy, M.D Rochester
G. I. Badeaux, M.D Brainerd
Charles Bagley, M.D Duluth
Paul F. Dwan, M.D Minneapolis
J. W. Edwards, M.D Saint Paul
B. A. Flesche, M.D Lake City
A. F. Giesen, M.D Starbuck
G. H. Goehrs, M.D Saint Cloud
W. W. RiekE, M.D Wayzata
COMMITTEE ON FRACTURES
V. P. Hauser, M.D Saint Paul
N. H. Baker, M.D Fergus Falls
W. H. Cole, M.D Saint Paul
E. T. Evans, M.D Minneapolis
B. C. Ford, M.D Marshall
R. K. Ghormley, M.D Rochester
J. H. Moe, M.D Minneapolis
M. J'. Nydahl, M.D Minneapolis
L. J. Rigler, M.D Minneapolis
J. A. Thabes, Jr.. M.D Duluth
M. H. Tibbetts, M.D Duluth
Nels Westby, M.D Madison
COMMITTEE ON GENERAL, PRACTICE
Ralph H. Creighton, M.D Minneapolis
E. C. Bayley, M.D Lake City
R. M. Burns, M.D Saint Paul
C. S. Donaldson, M.D Foley
R. J. Eckman, M.D Duluth
HEART COMMITTEE*
F. J. Hirschboeck, M.D. (1948) Duluth
O. K. Behr, M.D. (1947) Crookston
H. E. Binet, M.D. (1949) Grand Rapids
C. A. Boline, M.D. (1949) Battle Lake
P. G. Boman, M.D. (1948) Duluth
J. F. Borg, M.D. (1948) Saint Paul
C. N. Hensel, M.D. (1949) Saint Paul
Charles Koenigsberger, M.D. (1947) Mankato
M. J. Shapiro, M.D. (1947) Minneapolis
H. L. Smith, M.D. (1948) Rochester
S. M. White, M.D. (1949) Minneapolis
HISTORICAL COMMITTEE
M. C. Piper, M.D Rochester
Richard Bardon, M.D Duluth
Olga Hansen, M.D Minneapolis
F. R. Huxley, M.D Faribault
A. G. Liedloff, M.D Mankato
Robert Rosenthal, M.D Saint Paul
C. L. Scofield, M.D Benson
G. E. Sherwood, M.D Kimball
F. P. Strathern, M.D Saint Peter
J. A. Thabes, Sr., M.D Brainerd
W. F. Wilson, M.D Lake City
COMMITTEE ON HOSPITALS AND MEDICAL
EDUCATION
H. S. Diehl, M.D Minneapolis
A. R. Barnes, M.D Rochester
T. E. Broadie, M.D Saint Paul
E. W. Humphrey, M.D Moorhead
R. C. Hunt, M.D Fairmont
C. C. Kennedy, M.D Minneapolis
W. A. O’Brien, M.D Minneapolis
P. S. Rudie, M.D Duluth
H. L. Ulrich, M.D Minneapolis
W. H. Valentine, M.D Tracy
H. B. Zimmermann, M.D Saint Paul
"Terms expire December 31 of year indicated.
January, 1947
COMMITTEE ON INDUSTRIAL HEALTH
A. E. Wilcox, M.D. Minneapolis
H. B. Allen, M.D Austin
L. S. Arling, M.D Minneapolis
Martin Aune, M.D Minneapolis
N. W. Barker, M.D Rochester
C. C. Bell, M.D Saint Paul
T. H. Dickson, M.D Saint Paul
L. W. Foker, M.D Minneapolis
Clarence Jacobson, M.D Chisholm
O. L. McHaFfie, M.D Duluth
J. L. McLeod, M.D Grand Rapids
J. R. McNutt, M.D Duluth
J. A. Thabes, Sr., M.D Brainerd
COMMITTEE ON MATERNAL HEALTH
J. J. Swendson, M.D Saint Paul
R. N. Andrews, M.D Mankato
C. J. Ehrenberg, M.D Minneapolis
A. D. Hoidale, M.D Tracy
A. B. Hunt, M.D Rochester
J. C. Litzenberg, M.D Minneapolis
J. L. McKelvey, M.D Minneapolis
R. J. Moe, M.D Duluth
D. E. Morehead, M.D Owatonna
F. J. Schatz, M.D Saint Cloud
A. M. Watson, M.D Royalton
V. O. Wilson, M.D Minneapolis
W. W. Yaeger, M.D. Marshall
COMMITTEE ON MEDICAL TESTIMONY
E. M. Hammes, M.D Saint Paul
B. S. Adams, M.D Hibbing
L. A. Barney, M.D Duluth
H. Z. Giffin, M.D Rochester
S. R. Maxeiner, M.D ....Minneapolis
J. F. Norman, M.D Crookston
W. G. Workman, M.D Tracy
COMMITTEE ON MILITARY AFFAIRS
R. B. Hullsiek, M.D Minneapolis
M. S. Belzer, M.D Minneapolis
E. G. Benjamin, M.D Minneapolis
J. J. Catlin, M.D Buffalo
R. V. Fait, M.D Little Falls
M. G. Gillespif, M.D Duluth
Karl Johnson, M.D Duluth
G. C. MacRaE, M.D Duluth
W. P. Ritchie, M.D Saint Paul
A. K. Stratte, M.D Pine City
COMMITTEE ON NERVOUS AND MENTAL DISEASES
W. P. Gardner, M.D Saint Paul
S. A. Challman, M.D Minneapolis
G. IT. Freeman, M.D Saint Peter
L. R. Gowan, M.D Duluth
R. C. Gray, M.D Minneapolis
E. M. JTammes, M.D Saint Paul
P. H. Heersema, M.D Rochester
W. H. Hengstler, M.D Saint Paul
W. L. Patterson, M.D Fergus Falls
COMMITTEE ON OPHTHALMOLOGY
T. R. Fritsche, M.D New Ulm
W. L. Benedict, M.D Rochester
L. J. Dack, M.D Saint Paul
F. P. Frisch, M.D Willmar
H. W. Grant, M.D -..Saint Paul
E. W. Hansen, M.D Minneapolis
F. N. Knapp, M.D Duluth
V. I. Miller, M.D Mankato
L. W. Morsman, M.D Hibbing
C. L. Oppegaard, M.D Crookston
C. E. Stanford, M.D Minneapolis
W. T. Wenner, M.D Saint Cloud
COMMITTEE ON PUBLIC HEALTH NURSING
M. Me. Fischer, M.D Duluth
L. V. Berghs, M.D Owatonna
W. C. Chambers, M.D Blue Earth
L. F. Davis, M.D ■ Wadena
T. F. Hammermeister, M.D New Ulm
E. J. HuEnekens, M.D Minneapolis
J. N. Libert, M.D Saint Cloud
COMMITTEE ON SYPHILIS AND SOCIAL DISEASES
P. A. O’Leary, M.D Rochester
C. D. Freeman, M.D Saint Paul
W. E. Hatch, M.D Duluth
H. G. Irvine, M.D Minneapolis
P. E. Kierland, M.D Alexandria
F. W. Lynch, M.D Saint Paul
H. E. Michelson, M.D... Minneapolis
H. J. Nilson, M.D North Mankato
S. E. SweitzER, M.D Minneapolis
COMMITTEE ON VACCINATION AND
IMMUNIZATION
E. J. HuenEkens, M.D Minneapolis
R. N. Barr, M.D. Minneapolis
E. E. Barrett, M.D .Duluth
A. J. Chesley, M.D Saint Paul
F. M. Feldman, M.D Rochester
W. W. Higgs, M.D Park Rapids
C. O. Kohlbry, M.D Duluth
C. E. Merkert, M.D Minneapolis
R. B. J. Schoch, M.D Saint Paul
C. S. Strathern, M.D Saint Peter
7
COMMITTEE OlV TUBERCULOSIS
J. A. Myers, M.D Minneapolis
R. N. Barr, M.D Minneapolis
Ruth E. Boynton, M.D Minneapolis
John Briggs, M.D Saint Paul
H. A. Burns, M.D Saint Paul
F. F. Callahan, M.D Saint Paul
S. S. Cohen, M.D Oak Terrace
K. A. Danielson, M.D Litchfield
W. H. Feldman, M.D Rochester
E. K. Geer, M.D Saint Paul
G. A. Hedberg, M.D Nopeming
H. C. Hinshaw, M.D Rochester
T. J. Kinsella, M.D Minneapolis
L. S. Jordan, M.D Granite rails
Hilbert Mark, M.D Minneapolis
E. A. Meyerding, M.D Saint Paul
K. H. Pfuetze, M.D Cannon Falls
C. G. Sheppard, M.D Hutchinson
S. A. Slater, M.D Worthington
W. H. Ude, M.D Minneapolis
NON-SCIENTIFIC COMMITTEES
EDITING AND PUBLISHING COMMITTEE*
E. M. Hammes, M.D. (1951) Saint Paul
P. F. Donohue, M.D. (1948) Saint Paul
H. W. Meyerding, M.D. (1949) Rochester
B. O. Mork, M.D. (1951) Worthington
C. L. OppEgaard, M.D. (1950) Crookston
T. A. Peppard, M.D. (1947) Minneapolis
H. A. Roust, M.D. (1948) Montevideo
O. W. Rowe, M.D. (1947) Duluth
H. L. Ulrich, M.D. (1950) Minneapolis
A. H. Wells, M.D. (1949) Duluth
COMMITTEE ON INTERPROFESSIONAL RELATIONS
W. P. Gardner, M.D Saint Paul
M. J. Anderson. M.D Rochester
J_. J. Catlin, M.D Buffalo
E. E. Christenson, M.D Winona
K. A. Danielson, M.D Litchfield
P. F. Eckman, M.D Duluth
C. O. Estrem, M.D Fergus Falls
J. M. Hayes, M.D Minneapolis
R. F. Hedin, M.D Red Wing
F. J. Savage, M.D Saint Paul
J. T. Schlesselman, M.D Mankato
L. G. Smith, M.D Montevideo
W. H. Valentine, M.D Tracy
COMMITTEE ON MEDICAL ECONOMICS
George Earl, M.D., General Chairman Saint Paul
Executive
George Earl, M.D Saint Paul
A. W. Adson, M.D Rochester
S. H. Baxter, M.D Minneapolis
W. H. Hengstler, M.D Saint Paul
R. D. Mussey, M.D Rochester
L. L. Sogge, M.D Windom
T. H. Sweetser, M.D Minneapolis
Editorial
George Earl, M.D Saint Paul
L. R. Boies, M.D Minneapolis
W. F. Braasch, M.D Rochester
W. L. Patterson, M.D Fergus Falls
D. W. Wheeler, M.D Duluth
Medical Advisory
B. J. Branton, M.D Willmar
W. H. Hengstler, M.D Saint Paul
Ivar Sivertsen, M.D Minneapolis
Medieal Ethics
B. S. Adams, M.D Hibbing
H. S. Diehl, M.D Minneapolis
R. D. Mussey, M.D Rochester
COMMITTEE ON PUBLIC HEALTH EDUCATION
S. H. Baxter, M.D., General Chairman Minneapolis
Executive
S. H. Baxter, M.D Minneapolis
R. M. Burns, M.D Saint Paul
R. M. Hewitt, M.D Rochester
F. J. Heck, M.D Rochester
(Chairmen of all Scientific Committees)
Editorial
R. M. Hewitt, M.D Rochester
R. P. Buckley, M.D Duluth
G. W. Clifford, M.D Alexandria
T. J. Edwards Saint Paul
WT W. Spink, M.D Minneapolis
Itnriio
R. M. Burns, M.D Saint Paul
J. K. Anderson, M.D Minneapolis
R. N. Andrews, M.D Mankato
Elizabeth C. Bagley, M.D Duluth
N. W. Barker, M.D Rochester
P. M. Gamble, M.D Albert Lea
C. N. Harris, M.D Hibbing
E. A. Heiberg, M.D Fergus Falls
R. N. Jones, M.D Saint Cloud
F. R. Kotchevar, M.D Eveleth
R. H. Wilson, M.D Winona
Medical Service
A. W. Adson, M.D Rochester
J. A. BargEn, M.D Rochester
J. F. Borg, M.D Saint Paul
R. R. Cranmer, M.D Minneapolis
J. A. Malmstrom, M.D Virginia
C. B. McKaig, M.D Pine Island
C. A. McKinlay, M.D Minneapolis
J. F. Nop.man, M.D Crookston
O. I. Sohlberg, M.D Saint Paul
A. O. Swenson, M.D Duluth
H. B. Troost, M.D Mankato
W. W. Will, M.D Bertha
State Health Relations
T. H. Sweetser, M.D Minneapolis
R. B. Bray, M.D Biwabik
J. N. Dunn, M.D Saint Paul
John Earl, M.D Saint Paul
R. R. Heim, M.D Minneapolis
C. M. Johnson, M.D Dawson
Harry Klein, M.D Duluth
A. G. Liedloff, M.D Mankato
J. P. McDowell, M.D Saint Cloud
Carl Simison, M.D Barnesville
S. A. Slater, M.D Worthington
COMMITTEE ON RURAL MEHICAL SERVICE
Speakers’ Bureau ,
F. J. Heck, M.D Rochester
L W. Duncan, M.D Moorhead
P. J. Hiniker, M.D Le Sueur
P. A. Lommen, M.D Austin
Gordon MacRae, M.D Duluth
J. L. McLeod, M.D Grand Rapids
J. F. Norman, M.D Crookston
Charles E. Rea, M.D Saint Paul
M. M. Weaver, M.D Minneapolis
COMMITTEE ON PUBLIC POLICY
L. L. Sogge, M.D Windom
G. I. Badeaux, M.D Brainerd
L. A. Barney, M.D Duluth
J. F. DuBois, M.D Sauk Center
E. A. Eberlin, M.D Glenwood
Reuben F. Erickson, M.D Minneapolis
W. A. Fansler, M.D Minneapolis
R. C. Gray, M.D Minneapolis
H. C. Habein, M.D Rochester
V. M. Tohnson, M.D Dawson
B. O. Mork, Jr., M.D Worthington
M. O. OppEgaard, M.D Crookston
W. C. Rutherford, M.D Nisswa
H. R. TrEgilgas, M.D South St. Paul
MINNESOTA STATE CERTIFICATION BOARD ON
PUBLIC HEALTH NURSING
F. J. Savage, M.D Saint Paul
•Terms expire December 31 of year indicated.
First District
Paul Leck, M.D., Chairman Austin
Second District
V. W. Doman, M.D Lakefield
Third District
Magnus Westby, M.D Madison
Fourth District
J. F. Traxler, M.D Henderson
Fifth District
A. K. Stratte, M.D Pine City
Sixth District
W. E. Hart, M.D Monticello
Seventh District
A. J. Lenarz, M.D Browerville
Eighth District
C. W. Jacobson, M.D Breckenridge
Ninth District
J. K. Butler,, M.D Carlton
COMMITTEE ON UNIVERSITY RELATIONS
Edwin J. Simons, M.D Swanville
E. L. Tuohy, M.D Duluth
E. M. Jones, M.D Saint Paul
S. H. Baxter, M.D Minneapolis
H. Z. Giffin, M.D Rochester
COMMITTEE ON VETERANS MEDICAL SERVICE
R. H. Creighton, M.D Minneapolis
S. H. Boyer, Jr., M.D Duluth
C. J. Fritsche, M.D New Ulm
W. P. Ritchie, M.D Saint Paul
C. A. Wilmot, M.D Litchfield
8
Minnesota Medicine
R>
SPEED
WITH ACCURACY
These units meet the
most rigorous demands
and have proved out-
standing in transure-
thral prostatic resection.
BIRTCHER
ELECTROSURGICAL
UNITS
are precision-built for
flawless service:
Jr Cutting speed to satisfy the most
critical requirements whether dry
field or under water.
Jr Control is easy and perfect, in
cutting and hemostasis, sepa-
rately or blended together.
Jr Performance is unfailingly exact.
Accurate calibration of control
dials insures precise repetition of
proved technics.
Jr Dependability is assured.
AMERICAN MEDICAL ASSOCIATION ACCEPTED
C. F. ANDERSON CO., INC.
Surgical and Hospital Equipment
901 Marquette Minneapolis 2, Minn.
•) A Mi !
January, 1947
9
Jn the Sarly Recognition
of Protein "Deficiency
Unsupervised dietary curtailment and self-imposed food restric-
tions, not infrequently observed in elderly patients and in those
desirous of preventing weight gain or losing weight, are apt to
lead to multiple nutritional derangements. Not the least im-
portant among these, and often overlooked, is protein deficiency.
The early symptoms of chronic protein deficiency are vague
and lack specificity. Thus they escape detection unless pointedly
looked for. Easy fatigability, loss of weight, anorexia, malaise,
and a slight pallor due to underlying secondary anemia consti-
tute the most common complaints. A careful history of eating
habits usually discloses the true significance of these symptoms.
Detection of the earliest objective sign of protein deficiency —
negative nitrogen balance — requires hospitalization for several
days, in order that nitrogen intake and excretion can be accu-
rately determined.
Prolonged protein deficiency leads to hvpoproteinemia, and is
readily recognized by generalized edema and by a serum protein
level below the normal 7 to 8 Gm. per 100 cc.
The most dependable and effective means of preventing and
correcting protein deficiency is through proper organization of
the diet. The recommended intake of 1 Gm. of protein per Kg.
of body weight insures nitrogen balance in normal persons. For
correction of frank protein deficiency, at least 2. Gm. per Kg. of
body weight — and frequently considerably more — is required.
Among the protein foods of man, meat ranks high, not only
because of the generous supply of protein it provides, but also
because its protein is biologically complete, applicable for the
satisfaction of every protein need.
The Seal of Acceptance denotes that the nutri-
tional statements made in this advertisement
are acceptable to the Council on Foods and
Nutrition of the American Medical Association.
AMERICAN MEAT INSTITUTE
MAIN OFFICE. CHICAGO... MEMBERS THROUGHOUT THE UNITED STATES
10
Minnesota Medicine
<MwC. . .
A strong foundation saved the Cathedral of Cologne in
ground-shaking bombing assaults of World War II . . .
and a strong nutritional foundation laid down in infancy
will likewise help to protect health and strength in
years to follow, against health-destroying assaults of
disease. • BIOLAC furnishes among other essential nutri-
ents the valuable proteins of milk, an outstanding source
of all the indispensable amino acids . . . the prerequisite
building blocks of strong tissues. • BIOLAC is bacterio-
logically safe . . . convenient. . .economical. . .readily available.
BORDEN'S PRESCRIPTION PRODUCTS DIVISION
350 MADISON AVENUE, NEW YORK 17, N. Y.
Biolac ■
7^e fintoidaXtovi
Biolac is a liquid modified milk, prepared from whole and skim
milk with added lactose, and fortified with thiamine, concentrate of
vitamins A and D from cod liver oil, and iron citrate; only ascorbic
acid supplementation is necessary. Evaporated, homogenized mid
sterilized. Biolac is available in 13 fi. oz. tins at all drug stores.
Quickly prepared . . . easily cal-
culated: 1 fi. oz. Biolac to 1 V2 fi-
oz. water per lb. of body weight.
January, 1947
11
. . a<z+c Se
Sy 7*^4 l*£fA4t(ucf?(nO 0^-
Tunxrirptes,
/VfrtirfUnCdtALC^^, /QxccJu <xJ
. . . 4****^ \ t
Russell. H.G.B.. abstracted, Proc. Roy. Soc. Med. 36:401.
Smith. Kline & French Laboratories. Philadelphia, Pa*
/
Benzedrine Inhaler
a fotfoo 4*£att4
To
relieve
the
discomfort
of
sinusitis
The vasoconstrictive vapor of Benzedrine Inhaler, N.N.R., diffuses evenly
throughout the upper respiratory tract, opening sinal ostia and
ducts which are frequently inaccessible to liquid vasoconstrictors. The
sinuses drain. Headache, pressure pain, "stuffiness” and other
unpleasant sinusitis symptoms are relieved.
Each Benzedrine Inhaler is packed with racemic amphetamine, S. K. F. , 250 me. ; menthol. 12.5 mg. ; and aromatics.
12
Minnesota Medicine
’*Reg. U. S. Pal- Oft
Control of menopausal
symptoms can be established
promptly, in the majority
of cases, by ORAL therapy
alone. The extensive bibliography
of "PREMARIN" offers convincing
evidence that this highly potent,’
orally active, natural estrogen is a
most effective therapeutic measure for
treating the menopausal patient.
Essentially Safe, Naturally Occurring,.
jt, Orally Effective,
Water SofiMf* ijf f^erated,
i " '■
Imparts a feelin
TABtETS of 1.25 mg.
TABlETS IHalf-Slrengthl of 0.625 mg.
LIQUID, containing 0.626 mg. per-4 cc
AYERST,
McKENNA &
HARRISON Ltd
22 East 40th Street. New York 16, N. Y.
t
January, 1947
13
"What are the
MAGIC WORDS?”
ic words, no magic wand can improve a cigarette.
g more tangible is needed.
P MORRIS superiority is due to a different method
facture, which produces a cigarette proved* definitely
iting to the smoker’s nose and throat.
ps you prefer to make your own test. Many doctors
re is no better way to prove to your own satisfac-
superiority of PHILIP MORRIS.
Philip morris
TO PHYSICIANS WHO SMOKE A PIPE: We suggest an unusually fine new blend -COUNTRY DOCTOR
PIPE MIXTURE. Made by the same process as used in the manufacture of Philip Morris Cigarettes.
* Laryngoscope, Feb. 1935, Vol. XLV, No. 2. 149-154
Laryngoscope. Jan. 1937,- Vol. XLVII, No. 1, 58-60
Philip morris a c co., ltd., Inc.
H9 Fifth Avenue, N. Y.
14
Minnesota Medicine
FINE PHARMACEUTICALS SINCE 1886
1. New England J. Med. 228:1 18
(Jan. 28) 1943.
2. J.A.M.A. 129:613 (Oct. 27) 1945.
Nine physicians were among 225 upper income patients
found guilty of diets wanting in one or more vitamins.
Low-vitamin diets are not restricted by income or by
intelligence.2 Greater assurance of adequate vitamin main-
tenance is available in potent, easy to take, and reasonably
priced Upjohn vitamin preparations.
Upjohn
January, 1947
15
Coi-gMBOS, INDIANA, U.S.A.
OKt PINT
»rboKyJutu, Syrup !or Supplements ^
infant feedi^g
,*s Directed by Phy>^'3"
CONTAINING
V,tAMin b comp1'*
852-5 — MALTOSE —
(r°m pure starch providing
‘bwrption, uniform compos'"15
•w, h..°m !rom irritating impurities
L “GUI irruacing “
"'"nthc Mai of high vacuum.
“•,“i>l«ipoonr.V°T or.. fluid
*20 ttalorioj per fluid ounc»-
FLEXIBILITY
Pediatricians recognize the advantages of flexibility
in prescribing infant feeding formulas, as the pro-
tein, fat, and carbohydrate requirement may vary
with the individual baby. Formula preparation with
CARTOSE* is simple, rapid, and accurate.
CARTOSE supplies carefully balanced propor-
tions of nonfermentable dextrins in association with
maltose and dextrose. Due to the time required for
hydrolysis of the higher sugars, absorption is spaced.
This lessens the likelihood of distress attributable to
the presence of excessive amounts of readily fer-
mentable sugars in the intestinal tract at one time.
When supplementation with vitamins of the B com-
plex is indicated, KINNEY'S YEAST
EXTRACT* is suggested for routine incorpora-
tion in the daily feeding. The full daily dose is simply
added to the twenty-four-hour formula.
KINNEY’S YEAST EXTRACT is prepared from a specially
cultured yeast and contains all the known factors of
the B complex in natural, palatable form.
CARTOSE and KINNEY'S YEAST EXTRACT are offered
for use under the guidance of physicians. They are
available only at drugstores.
*The words CARTOSE and KINNEY'S YEAST EXTRACT are
registered trademarks of H. W. Kinney & Sons, Inc,
H. W. KINNEY & SONS, INC..
COLUMBUS, INDIANA
16
Minnesota Medicine
His diet is balanced, yet he is a borderline vitamin defi-
ciency case. Like many others whose occupations are
sedentary and who take little exercise otherwise, his
caloric requirements and appetite are so small that he
simply does not eat enough food to supply adequate
quantities of the protective factors. As a result his case
record has taken its place in his physician’s file along
with those of all of the other varieties of dietary delin-
quents: the ignorant and indifferent, patients too
busy” to eat properly, those on self-imposed and badly
balanced reducing diets, excessive smokers, alcoholics,
and food faddists, to name but a few. First thought in
such cases is dietary reform, of course. But this is often
more easily advised than accomplished. Because of this,
an ever-growing number of physicians prescribe a vita-
min supplement in every case of deficiency. If you re
one of these physicians— or if you prescribe vitamins
only rarely— consider the advantages of specifying an
Abbott vitamin product: Quality— Certainty of potency
—A line which includes a product for almost every vita-
min need-And easy availability through pharmacies
everywhere. Abbott Laboratories, North Chicago, 111.
January, 1947
17
PYOKTANIN SURGICAL GUT
Plain and 'Jcrtnalijetf
Manufactured Since 1099 by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia.
I • •
Price iiit
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE G NONBOILABLE
Sizes 000 — 00 — 0 — 1 — 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
• • •
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FOR SALE BY SURGICAL DEALERS AND DRUGGISTS
18
Minnesota Medicine
ESTINVi ,
For menopausal patients one ESTINYL Tablet of 0.05 mg. daily
is usually sufficient, but two or three tablets daily may be pre-
scribed in the presence of severe symptoms.
There are sound medictd reasons for ESTINYL, an oral
estrogen closely related to the primary follicular
hormone, alpha-estradiol:
it is the most potent oral estrogen
known today,
it controls hormonal deficiency
symptoms rapidly,
it is virtually free from side
effects in therapeutic dosage,
it induces the sense of well-being
characteristic of the estrogenic
hormone.
it is economical— within the means of
almost all patients.
ESTINYL (ethinyl estradiol) Tablets are best administered at
bedtime.
Available in two strengths— 0.05 ( five-hundredths ) mg. (pink) and 0.02 ((wo-
hundredths) mg. (buff) tablets. Bottles of 100, 250 and 1,000.
Trade-Mark ESTINYL-— Reg. U.S.Pat.Off.
CORPORATION • BLOOMFIELD, N. J.
IN CANADA, SCHERINC CORPORATION LIMITED, MONTREAL
'Tor what avail the plough or sail,
or land or life , if freedom fail?”
. . . EMERSON
★ A doctor told us, the other day, that he thinks of American freedom
as a breathing organism. It can exhale benefits for our people no faster
than it inhales contributions from our people.
He said :
"Take Medical Protective, for example. It wouldn’t be able to offer
doctors its fine service and protection against malpractice suits except
for a freedom of enterprise which enabled it, first, to pioneer this
specialized field — and then to broaden and perfect its service as its
resources grew.”
But, he added, companies like yours — and we doctors, too — are
the makers of freedom as well as its recipients ; for a government is less
likely to encroach upon the liberties of a people who do not abuse them.”
Through 1947, which will mark our 48th anniversary (a year for every
star in the flag), our conviction that "there is no substitute for America”
will remain firm.
THE
Fort Wayne 2, Indiana
Professional Protection exclusively. . . since 1899
MINNEAPOLIS Office: Robert L. McFerran, Manager, 816 Medical Arts Building, Telephone Atlantic 5724
20
Minnesota Medicine
Tonsillectomy first in the series: "FACIAL EXPRESSIONS OF SICKNESS
In the lirst stage of therapy, prophylaxis, the establishment of a moderate blood level ol penicillin has been shown
lo be effective in reducing postoperative infections. This is particularly Irue in tonsillectomies. Here, a tablet ol
buffered penicillin every two hours, day and night, for 24 huurs before the operation is a -simple, yet effective means
of avoiding secondary inflammation due to penicillin-sensitive organisms. For such prophylaxis, tablets of calcium
penicillin, 50,000 units each, are available in bottles of 12.
PENICILLIN TABLETS OBAL by
LABORATORIES INC.
ACUSE 1, NEW YORK
January, 1947
21
43 -ACRE REMEDY
FOR GROWING PAINS
We think it s a healthy sign when a 51-year-old organization has grow-
ing pains. And our remedy is the purchase of a new 43-acre plant
located in Milwaukee. It includes adequate provision for expanding
production and accelerating engineering research and development of
radiographic and therapeutic apparatus.
Important to you is the fact that the move from Chicago to Milwaukee
will mean no interruption of the production schedules established to
meet present delivery promises.
Our Chicago plant will continue to run at full capacity. The Mil-
waukee plant, already in operation, will gradually assume an increasing
share of the manufacturing load.
Here, in this modern manufacturing facility, is concrete evidence of
our plans to meet present and future demands of your profession. And
your demands will be met without sacrificing the high quality and
efficiency that have always characterized the products of this organiza-
tion. General Electric X-Ray Corporation, 175 West Jackson Blvd.,
Chicago 4, Illinois.
22
GENERAL ELECTRIC
X-RAY CORPORATION
Minnesota Medicine
Big Game Hunters
» He hunts the “biggest game” of all . . .
the microscopic and mysterious enemies
of mankind.
He hunts not with a rifle, but with a
microscope.
He is the doctor out to effect a cure
by finding the cause— and combating it.
No place in the world, not even the
remotest jungle, is too far, too danger-
ous, or too difficult for him to penetrate
when the needs of medical science say,
“This must be done.”
R. J. Reynolds Tobacco Company , Winston-Salem. North Carolina
According to a
recent independent
nationwide survey:
More Doctors
Smoke Camels
than any other cigarette
January, 1947
This is the battle banner of the National Foun-
dation for Infantile Paralysis. The slim, sword-
like torch is the stern symbol of a tireless war
on a dreaded disease.
The finest of doctors and scientists have given
of their time and skill and knowledge to fight
poliomyelitis. And annually since its inception
in 1938, the National Foundation for Infantile
Paralysis has conducted the March of Dimes,
in a nation-wide appeal for funds to carry on
the work.
The familiar blue and white symbol above your
neighborhood drug store tells you that he is a
Rexall druggist. More than 10,000 Rexall Drug
Stores throughout the nation are proud to join
with the American people in support of the
1947 March of Dimes, from January 14 to
January 31.
UNITED-REXALL DRUG CO.
LOS ANGELES, CALIFORNIA
PHARMACEUTICAL CHEMISTS FOR MORE THAN 44 YEARS
DO
YOU
KNOW
WHAT
THESE
SYMBOLS
STAND
FOR?
24
Minnesota Medicine
: ;
V--
if-
if
jfe
L:
Why do Tom , Disk and Harry
u m f
need Vitamin D ?
•>
UKIOUkJL in propylene glycol
MILK DIFFUSIBLE VITAMIN D PREPARATION
ODORLESS • TASTELESS • ECONOMICAL
i
Growing children require vitamin D
mainly to prevent rickets. They also need
vitamin D, though to a lesser degree,
to insure optimal development of muscles
and other soft tissues containing
considerable amounts of phosphorus.
Milk is the logical menstruum for \
administering vitamin D to growing
children, as well as to infants, pregnant
women and lactating mothers. This
suggests the use of Drisdol in Propylene
Glycol, which diffuses uniformly
in milk, fruit juices and other fluids.
Average daily dose for infants
2 drops, for children and adults
4 to 6 drops, in milk.
Bottles of 5, 10 and 50 cc.
DRISDOL, trademark Reg.
U. S. Pat. Off. & Canada,
Brand of Crystalline Vitamin D2
(calciferol) from ergosterol
CHEMICAL 9 COMPANY, INC.
Windsor, Ont,
January, 1947
25
DEPENDABILITY.. .the most important quality in a contraceptive
CLINICAL
ACTIVE INGREDIENTS: Boric acid 2.0%, oxyquinolin benzoate
0.02% and phenylmercuric acetate 0.02% in a base of glycerin,
gum tragacanth, gum acacia, perfume and de-ionized water,
write for literature
HOLLAND RANTOS CO., Inc.
551 FIFTH AVENUE • NEW YORK 17. N. Y.
c0oF"Jc,'Ce
26
Minnesota Medicine
Vt^ith infant mortality at its highest during the first month of
life, the fewer the burdens on the baby’s endurance, the firmer
will be his grip on life. And gastro- intestinal upset, colic and
diarrhea can be heavy burdens for an infant.
'Dexin' has proved an excellent "first carbohydrate." Because
of its high dextrin content, it (1) resists fermentation by the
usual intestinal organisms; (2) tends to hold gas formation, dis-
tention and diarrhea to a minimum, and (3) promotes the for-
mation of soft, flocculent, easily digested curds.
'Dexin' brand High Dextrin Carbohydrate is simply prepared
in hot or cold milk and is readily adaptable to increasing for-
mula needs. 'Dexin' doe S make a difference. -Dexin’ Reg. Trademark
HIGH DEXTRIN CARBOHYDRATE
Composition— Dextrins 75 % • Maltose 24% • Mineral Ash 0.25% • Moisture
0.75% • Available carbohydrate 99% • 115 calories per ounce • 6 level packed
tablespoonfuls equal 1 ounce • Containers of twelve ounces and three pounds •
Accepted by the Council on Foods and Nutrition. American Medical Association.
Literature on request
BRAND
BURROUGHS WELLCOME & CO. (U.S.A.) INC., 9 & 11 East 41st St., New York 17, N. Y.
A good grip on life
January, 1947
27
Whenever mother’s milk is unavailable or of insufficient quan-
tity S-M-A can be relied on to replace it.
S-M-A has the same percentage of protein, fat and carbo-
hydrate as human milk. This similaritv of S-M-A to mother’s
milk is largely responsible for the successful nutritional his-
tory of S-M-A babies. *REG. U.S. PAT. OFF.
S-M-A is derived from the milk of tuberculin-tested cows. Part of the
butter fat of this milk is replaced with animal and vegetable fats in-
cluding biologically assayed cod liver oil. Milk sugar, vitamin A and D
concentrate, carotene, thiamine hydrochloride, potassium chloride and
iron are added.
Supplied: 1 lb. tins with measuring cup.
S. M. A. DIVISION • WYETH INCORPORATED • PHILADELPHIA 3 • PA.
28
Minnesota Medicine
in Schenley Laboratories’ continuing
summary of penicillin therapy.
treatment with
PENICILLIN SCHENLEY
SCHtNLtf
L*BORtf°WtS
services-
1. penicill'n ^jgaling
for J°nuorJ; hosbeen
WiS*o°''^siCianS'
a ^7raegh:nrart
P^f'he moiled »?.
will be
physic«ans
req'
iuest.
give enough-soon enough-long enough
snt: Penicillin solution
ITeural cavity after aspiration
_ "sterile isotonic salt solution, if
necessary. Penicillin should not be used for irrigation.
The optimum dose for each injection is 50,000 to 200,000
units in a volume of solution less than the amount of
fluid or pus aspirated. The frequency of injections
depends on the extent, type, and severity of the infection,
and the response to therapy. Treatment should be
continued until after the fluid becomes sterile.
Surgical intervention is necessary if fibrin masses or
loculation prevent adequate aspiration or if penicillin
therapy is ineffective, as indicated by persistence of
positive cultures after one week.
SYSTEMIC THERAPY. Systemic use of penicillin is
indicated as a supplement to intrapleural therapy par-
ticularly where there exists an underlying active
pulmonary infection or a bronchopleural fistula.
SCHENLEY LABORATORIES, INC.
EXECUTIVE OFFICES: 350 FIFTH AVENUE, NEW YORK CITY
© Schenley Laboratories, Inc.
January, 1947
29
1
I
Anmimcement
George W. Borg Corporation, manufactur-
ers of postwar X-ray equipment, has ap-
pointed the Mithun X-Ray Company, 3601
Glenhurst Avenue, Minneapolis, Minnesota
as exclusive distributors of its products in the
states of Minnesota, North Dakota and South
Dakota.
Mjthun X-Ray Company is completely
equipped to render technical and electrical
service to the profession.
Mr. Mithun has been active in the X-ray
equipment field for more than twenty years
and is well known to medical men in this
area.
IMMEDIATE DELIVERY
ON ALL TYPES
• X-Ray Diagnostic Equipment • Vertical Controlled Boards
• Motor Drive Tables • Mobile and Bedside Units
SHOWROOM LOCATED AT
1424 W. 28TH STREET MINNEAPOLIS, MINNESOTA
TELEPHONE KENWOOD 4422
i
i
GEORGE W. BORG CORPORATION
I
i
Delavan, Wisconsin
MANUFACTURERS OF X-RAY EQUIPMENT
!
30
Minnesota Medicine
STREPTOMYCIN NOW IS AVAILABLE
Physicians now may obtain adequate supplies of this remarkable new antibac-
terial agent, without restriction, from their local pharmacists and hospitals.
j
four s equivalent to ■ .63 1
1 Gram Streptomycin Base
(Hydrochloride)
LOT NO, 481
Consult aecomptxnving circular,
St^ioinycm should be administered me it
of a physician.
be low 1 5 ° C. (53° f.)
Upiration Date ; July 18, 1947
WKfeCO^tNC. * 8AHWAYJ.I
CLINICAL INDICATIONS
Streptomycin is effective in1 the treat-
ment of: Urinary Tract Infections, Bac-
teremia, and Meningitis doe to suscep-
tible strains of the following organisms:
Esch. co li B. laetis aerogenes
Proteus vulgaris Ps. aeruginosa
<B. pyocyanous)
Klebsiella pneumoniae
(Friid&ndor’s bacillus)
TULAREMIA
All H. influenzae infections
Streptomycin is a helpful agent also in the treatment
of the following diseases, but its position
has not been clearly defined :
*
Tuberculosis.
Peritonitis due to susceptible organisms.
Pneumonia due to Klebsiella pneumoniae
( Friedlander's bacillus).
Liver abscesses due to streptomycin-sensitive
bacilli.
Cholangitis due to susceptible pathogens.
Endocarditis caused by penicillin-resistant,
streptomycin-sensitive organisms.
Chronic pulmonary infections predominantly
due to streptomycin-sensitive flora.
Empyema due to susceptible organisms.
STREPTOMYCIN
(HYDROCHLORIDE)
Courier/ |V1 E R C K ^cceMed
MERCK & CO-, Inc. RAHWAY, N. J.
January, 1947
31
BEGINNING
REMOVING INTRODUCER
COMPLETING INSERTION
SEATING DIAPHRAGM
These illustrations, showing the simplicity of use of “RAMSES” Gyne-
cological Products, are reproduced from the booklet Instructions for
Patients. For the physician’s convenience, a supply of these booklets is
available, upon request, for distribution to patients.
Determination of indications for control of conception,
and advice on the proper method of providing pro-
tection, are the exclusive province of the physician.
“RAMSES”* Gynecological Products are designed for
use under the guidance of the physician only.
*The word "RAMSES” is a registered trademark of Julius Schmid, Inc.
FLEXIBLE CUSHIONED DIAPHRAGM
gynecological division
JULIUS SCHMID, INC.
Quality First Since 1883
423 West 55 Street • New York 19, N. Y.
32
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 January, 1947
ENDOCRINE THERAPY
EDWARD H. RYNEARSON, M.D.
Rochester, Minnesota
SINCE this paper was presented at the
meeting of the Minnesota State Medical As-
sociation, there has appeared a booklet Exhibit on
Endocrine Products, published under the auspices
of the Council on Pharmacy and Chemistry of
the American Medical Association. It was pre-
pared by Drs. Austin Smith and Walton Van
Winkle, Jr., and can be obtained by writing to
the office at 535 North Dearborn Street, Chi-
cago, Illinois. It supplies in one small booklet a
much larger amount of information than was
contained in my original remarks or will be
written here.
What are some of the products of the endo-
crine glands which we physicians have found
useful ?
Thyroid
Desiccated thyroid is the most widely used
(and misused) of all the hormones. It has sev-
eral advantages : it is inexpensive, it is effective
by mouth, and when properly used it is not toxic.
It is so satisfactory that I know of no reason
for the routine use of thyroxin, which is expen-
sive and which belongs in the research laboratory.
The most common use for thyroid is to elevate
the basal metabolic rate. In cases of myxedema
it constitutes complete replacement therapy. I
have rarely seen a patient with myxedema who
received more than 2 grains (0.13 gm.) daily as
a maintenance dose, and in most instances there
is a difference in response to variation of as
little as yi grain (0.016 gm.). A patient may feel
From the Division of Medicine, Mayo Clinic, Rochester, Minn.
Read at the annual meeting of the Minnesota State Medical
Association, Saint Paul, Minnesota, May 22, 1946.
“low” with 1 grain (0.065 gm.), “too nervous”
with 1 J4 grains (0.1 gm.), “just right” with
iy4 grains (0.08 gm.). This is quite a contrast
to the patient who has a low basal metabolic rate
without myxedema and who can take 3, 4 or 5
grains (0.2, 0.26 or 0.3 gm.) a day without any
untoward symptoms. Having taken such an
amount for some weeks, her basal metabolic rate
is found to have risen dramatically from — 18 per
cent to — 17 per cent ! In these cases, the low rate
is part of the general picture rather than the
cause of the trouble, and justification for the
use of thyroid depends on the patient’s response
rather than any changes in the basal metabolic
rate. The use of thyroid in certain cases of men-
strual disorders, sterility, and so forth, is also
often empiric. Almost every obese patient receives
thyroid at one time or another ; very rarely is it
of any help (unless “accompanied by a diet”).
It is unfortunate that some obese patients are giv-
en prescriptions for excessive amounts of thyroid ;
one such patient was taking 32 grains (2.1 gm.)
a day. She was reducing all right, and so were
her chances for life. Thyroid is also very gen-
erously prescribed for “glandular imbalance,”
Mongolian idiocy, too much or too little hair,
too thick or too thin fingernails and a host of
other poorly defined conditions.
Parathyroid Hormone
I have never prescribed a single injection of
parathyroid hormone for the treatment of acute
or chronic parathyroid insufficiency. It is a very
valuable hormone for research studies, but pa-
tients can be treated easily and inexpensively by
January, 1947
33
ENDOCRINE THERAPY — RYNEARSON
the administration of calcium by mouth with
vitamin D for absorption. The calcium, whether
as lactate or as gluconate, should be dissolved in
very hot water; unless a clear solution is ad-
ministered it is very poorly absorbed. I am not
prepared to say that there is no absorption from
all the calcium powders and tablets which are
administered, but I can say that I have never
seen these help any patient who had true hypo-
parathyroidism. The amount of calcium required
to control a patient’s symptoms and elevate the
serum calcium to normal varies in each case.
Some patients require only 2 or 3 teaspoonfuls
(8 or 12 gms.) of the powder daily; others, in
cases of acute insufficiency, may require 16 or
20 teaspoonfuls (64 or 80 gms.). Vitamin D may
be given as cod liver oil or one of the many
preparations in concentrated forms. Calciferol
and dihydrotachysterol (A.T. 10) are often of
great value. One cubic centimeter of A.T. 10
taken daily by mouth every day or every other
day will control the hypoparathyroidism of many
patients. Parathyroid hormone can be used for
such patients, but in addition to the expense there
is always the risk of overtreatment, which pro-
duces the clinical picture of hyperparathyroidism.
Adrenal Cortex
Adrenal cortical extract is prepared by several
linns. Its primary use is in the treatment of Ad-
dison’s disease. The only synthetic fraction avail-
able for use is desoxycorticosterone acetate.
Neither one satisfies most physicians. The extract
is often too weak, and if sufficient amounts are
given the cost is often prohibitive. The synthetic
fraction is often unsatisfactory because its effect
is incomplete, causing only a retention of salt and
water. What we physicians hope for is either a
more potent, less expensive, whole adrenal cortical
extract or other synthetic fractions which will
help with the other deficiencies present in Ad-
dison’s disease, such as hypoglycemia. The syn-
thetic fraction is usually prepared in oil and ad-
ministered hypodermically. It can also be im-
planted as pellets. Preparations for oral or sub-
lingual use are more wasteful than preparations
for parenteral use. Some oral preparations, such
as cortalex tablets, are too weak to be of any
value in the treatment of Addison’s disease; they
are usually prescribed for “hypo-adrenia,” what-
ever that might be.
.14
Adrenal Medulla
Physicians are well acquainted with the indica-
tions and uses of epinephrine. Its vasoconstrictive
effect has made it valuable in certain cardiovascu-
lar conditions, in asthma, in shock, and so forth.
Pancreas
Space does not permit a discussion of the
various types of insulin and their use.
Estrogenic Substances
In the booklet mentioned at the beginning of
this article, more than two pages are required
simply for the listing of the commercial forms
of estrogens. The booklet lists both the naturally
occurring estrogens and all the varied synthetic
fractions. It states:
Estrogens may be 'administered by injection, by in-
unction with a suitable base, or by mouth. Estrone and
estradiol lose considerable activity when taken orally.
When estrone is administered in the form of its sul-
fate, it appears to retain a greater amount of its potency.
Several estrogenic compounds have been prepared
which lose relatively little potency when administered
orally.
Besides crystalline estrogens, preparations of highly
purified but noncrystalline estrogens are available. These
are usually extracted from the urine of pregnant women
or pregnant mares ; the estrogenic activity of such ex-
tracts is due almost entirely to estrone. The Council
has coined the term Solution of Estrogens for such prep-
arations.
1’here has been an enormous amount of clinical re-
search with estrogenic substances. Claims for thera-
peutic results have been often exaggerated and confus-
ing. Definite and consistently reliable results have been
obtained in only a relatively small number of conditions.
These include treatment of the symptoms of the meno-
pause syndrome, natural or artificial, senile vaginitis,
kraurosis vulvae, pruritus vulvae, gonorrheal vaginitis
of children, hypogenitalism in the female, relief of en-
gorgement of the breasts, interruption of excessive flow-
ing in ‘ functional bleeding," palliation of local discom-
forts from prostatic carcinoma and its metastases. All
oilier indications should be considered unscientific or in
the experimental stage of therapy.
Estrogens are carcinogenic when administered experi-
mentally to animals which have an inherited sensitivity
to the development of mammary carcinoma. Many clini-
cians believe that estrogens are therefore contraindicated
in the treatment of women who have a familial or per-
sonal history of mammary or genital malignancy.
Progestins
The hormone of the corpus luteum is most im-
portant in normal female physiologic processes.
Tt is essential for the inception of pregnancy and
Minnesota Medicine
ENDOCRINE THERAPY— RYNEARSON
for its successful completion. My experience in
female endocrinology is limited, and again I refer
to this booklet :
Commercial preparations of progesterone are either
extracts of animal ovaries, or the pure compound pre-
pared synthetically. At one time, there was considerable
enthusiasm over the therapeutic use of such prepara-
tions in dysmenorrhea, menorrhagia and habitual abor-
tion, but the volume of satisfactory evidence is too small
to warrant dependence on progesterone for treatment of
these conditions.
Androgens
Castration in the male produces the clinical
picture recognized since the days of antiquity.
For all these years, physicians have attempted to
treat male gonadal deficiency in a variety of ways,
including the widely publicized transplantation of
“goat glands.” In more recent years there have
been available testosterone propionate (in oil.
ointment or pellets) and methyl testosterone for
oral or sublingual use or for administration in an
ointment. These substances constitute adequate
replacement therapy for those patients whose
symptoms are caused by a lack of this hormone.
Androgens also have other effects, such as a
marked nitrogen-sparing effect, and encouraging
reports have been published of their use in cases
of inoperable carcinoma of the breast. There are
conflicting opinions regarding their use in cases
of gynecologic disorders and angina pectoris.
Without any facts to support the statement,
I feel safe in saying that the largest amount of
androgens is prescribed for nonspecific conditions.
I refer particularly to such conditions as impo-
tence and “male climacteric.” Undoubtedly there
are cases in which both conditions are real and
respond to treatment. Again without facts to
support me, I state my conviction that most men
who are impotent are suffering from a psychic
disturbance and that most men diagnosed as hav-
ing “the male climacteric” are simply exhausted,
frustrated, middle-aged men. Many of these men
are helped by androgens, but in my opinion this
is psychosomatic medicine in most instances.
When controls were run, as they were at the
University of Minnesota and at Johns Hopkins
Hospital, for example, the men could not tell
when they were getting the hormone and when
they were receiving a placebo.
Anterior Pituitary
The anterior lobe of the pituitary is a most
important gland. We are all familiar with pitui-
tary dwarfism and the deficiency secondary to a
chromophobe adenoma. We are equally familiar
with the syndromes produced by over function,
such as gigantism, acromegaly and Cushing’s dis-
ease. We are all thrilled with the dramatic reports
published by our friends in the laboratory where-
in they recount their ability to isolate separate
hormones or fractions which when injected into
animals cause such startling changes.
But we are equally aware of our disappoint-
ment when we attempt to use commercially pre-
pared anterior pituitary extracts in the treatment
of patients. To my knowledge there has not been
a single instance in which any patient suffering
from postoperative pituitary insufficiency has
been helped in any way by the injection of any
anterior pituitary extract. This statement is al-
most equally applicable to the use of growth hor-
mone in the treatment of dwarfism. Prolactin
has been advised for the treatment of severe
menstrual bleeding, but in general it may be said
that the results of the injection of anterior pitui-
tary hormones have been very disappointing.
There is, of course, no evidence that any oral
preparation is worth anything.
Posterior Pituitary
Surgeons and obstetricians have found im-
portant uses for pitressin and pitocin. We physi-
cians are interested in the use of pitressin in the
treatment of diabetes insipidus. It can be admin-
istered hypodermically in an aqueous solution
or, for a prolonged effect, as pitressin tannate in
oil. It can be administered in a jelly or on pledg-
ets in the nose. The easiest, cheapest and usually
most satisfactory method is to prescribe the pos-
terior pituitary powder, which the patient intro-
duces into the nose. The least wasteful method is
to blow a small amount into the nose with an
atomizer bulb and glass tube. Ordinarily a small
amount of powder (easily measured on the tip
of a small blade) insufflated in the morning and
at night will control the symptoms.
Gonadotropic Substances
These are obtained (1) directly from the an-
terior pituitary gland, (2) from the serum of
pregnant mares and (3) from the urine or placen-
ta of pregnant women. They differ somewhat
physiologically. For example, chorionic gonado-
tropin (2 and 3 in the preceding list) does not
markedly stimulate the ovaries of monkeys or hu-
man beings. It may cause degenerative changes.
January, 1947
35
ENDOCRINE THERAPY— RYNEARSON
Chorionic goiiadotropin has had wide use in the
treatment of gynecologic disorders related to a
real or supposed ovarian disturbance, particularly
various abnormalities of menstruation, and in an
attempt to overcome female infertility. It has
been used alone and in various combinations with
other hormones, particularly with the estrogens
and progestins, in an effort to simulate the nor-
mal cyclic hormonal effects.
In both male and female patients chorionic
gonadotropin has been used to stimulate gonadal
development and often to produce generalized
growth. Its primary use in male patients has been
in the treatment of cryptorchidism. Astounding
successes were listed in early reports but it be-
came obvious that many of these patients did not
have true cryptorchidism ; with patience and
warmth the testes would descend. There is now
general agreement that this treatment will affect
the descent of the testes of those boys whose
testes will descend spontaneously when the de-
layed maturity is complete. There is no objection
to hastening maturity and descent ; many observ-
ers feel that there are good reasons for hasten-
ing them. These same observers feel that if de-
scent does not occur after six to eight weeks of
treatment, surgical intervention should follow,
since the tissues are at that time most susceptible
of repair. Other competent observers, however,
are of the opinion that most of these testes will
descend of their own accord and that the delayed
descent is a manifestation only of delayed puber-
ty. They recommend simply observation and pa-
tience. If testes do not descend when puberty is
complete, then surgeons are fairly well in agree-
ment that an effort should be made to bring the
testes down surgically if both are undescended
and that if one is undescended, it should either
be brought down or removed. This conviction is
based on the fact that testes cannot function
normally unless they are in the scrotum and there
is a higher incidence of carcinoma in intra-abdo-
minal than in intrascrotal testes, although the in-
cidence of carcinoma in either is rare.
Conclusions
Endocrinology continues to be a most fascinat-
ing study. Its reputation is enhanced by the bril-
liant advances from the laboratory and their care-
ful application in the treatment of patients. Those
who indiscriminately inject hormones into patients
who have poorly defined conditions, and then re-
port good results with never a control, are hurt-
ing rather than helping endocrinology. Physicians
who regard these enthusiastic, unscientific papers
with skepticism and criticism are labeled “nihi-
lists.” They would prefer to be called “realists,”
for they make an effort to determine what is real
and to suspect that “10,000 patients suffering
from crud ; report of 100 per cent cures” may
not represent a very scientific study.
FELLOWSHIPS FOR PHYSICIANS AND ENGINEERS
Announcement is made by Surgeon General Thomas
Parran of the U. S. Public Health Service that appli-
cations for Fellowships in postgraduate public health
training for physicians and engineers for the school year
beginning in the fall of 1947 will be received at any time
prior to May 1, 1947.
The Fellowships are made possible by a grant of
$228,400 from the National Foundation for Infantile
Paralysis through funds contributed to its March of
Dimes. Fifty-three students were awarded Fellowships
for the school year beginning in September, 1946.
The Fellowships provide an academic year’s graduate
training of approximately nine months in an accredited
school of public health or an acceptable school of sani-
tary engineering followed by three months of field train-
ing, and are open to men and women, citizens of the
United States, under forty-five years of age. Physi-
cian applicants must have completed at least a year's
internship.
The specific purpose of the Fellowships is to aid in
the recruitment of trained health officers, directors of
special services, and engineers to help fill hundreds of
vacancies existing in State and local health departments
throughout the country. The Fellowships are intended
for newcomers to the public health field, and are not
open to employees of State and local health depart-
ments, for whom Federal grant-in-aid funds are al-
ready available to the States.
Applicants for Fellowships may secure further de-
tails by writing to the Surgeon General, U. S. Public
Health Service, 19th and Constitution Avenue, N. W.,
Washington 25, D. C., Attention Public Health Train-
ing.
36
Minnesota Medicine
COUNTRY MEDICINE— PAST, PRESENT AND FUTURE
GEORGE E SHERWOOD. M.D.
Kimball, Minnesota
IT has been customary for the presiding officer
of the Northern Minnesota Medical Associa-
tion to contribute to the annual program by giving
a presidential address. I wish to state at this time
that I feel wholly inadequate for the occasion, as
both my literary and oratorical ability are very
limited. In fact, I feel a good deal like the man
who, being of some prominence in his locality,
had spent his summer vacation in making an ex-
tended European tour, and upon his return, as he
left the palatial liner at New York, was ap-
proached by a representative of the Atlantic
Monthly and asked if he would not contribute
something to the next issue of that noted maga-
zine. His answer was very brief and much to the
point. He said that it would be impossible, as he
had suffered from mol de mer ever since he board-
ed the ship and had been forced to contribute to
the Atlantic daily.
It was some poet or philosopher, I believe, who
said that brevity is the soul of wit. So I will take
his advice, undoubtedly much to your gratifica-
tion, and my part of the program will be very
brief. We have such an unusual array of talent
at the toastmaster’s table that any remarks that
I could make would be more or less superfluous
and would add little to the eloquence of the occa-
sion.
First, I wish to thank the members of this so-
ciety for the honor of presiding over this organi-
zation for the past year. It has been my pleasure
to have been affiliated with the Northern Minne-
sota Medical Association for a number of years
and to have become quite well acquainted with a
goodly share of its members. I assure you that its
membership as a whole is composed of a high type
of medical men, both as to character and profes-
sional attainments.
A few months ago there was held in Saint Paul
the ninety-third annual meeting of the Minnesota
State Medical Association. As the years have
rolled by, the membership of that fine organiza-
tion has become so large that it is almost un-
wieldy, and it has been found necessary to divide
the meeting into different sections that meet si-
President’s Address before the Northern Minnesota Medical
Association, Crookston, Minnesota, August 24, 1946.
January, 1947
multaneously. Therefore, it is almost impossible
for any ordinary member of the medical profes-
sion to contact and become acquainted with more
than a small portion of its membership. Hence
such sectional organizations as the Northern
Minnesota Medical Association have a proper
place in the economy of organized medicine. Hav-
ing a much smaller membership and attendance
at its meetings, it affords a better opportunity for
its members to become acquainted with each other,
and it should receive the encouragement and sup-
port of all medical men residing within its terri-
tory. This is especially true at this time, when
the bureaucrats are doing their utmost to destroy
the private practice of medicine and to regiment
the medical profession under the guise of social-
ized medicine. If we do not stand together and
put up a united front in opposition, they will very
likely succeed.
It is now more than fifty years since your
speaker located in a country town to practice his
profession. Since that time there have been great
changes in the conduct and administration of a
country practice, as well as in the general practice
of medicine and surgery, so that a physician who
locates in the country today has little conception
of the hardships and trials of a country doctor of
half a century ago. Just as the airplane has de-
stroyed the isolation of the world at large, so have
the automobile, good roads, rural telephones and
radio destroyed the isolation of country life. At
the beginning of this century the roads as a rule
were simply trails through the forests and over
the prairies and for transportation we had to de-
pend on horse-drawn vehicles. Hospitals were
few and far between ; consultation was difficult to
procure, and laboratory diagnosis was hard to
obtain, so that the country doctor of those days
had of necessity to be more resourceful and self-
sufficient and had to depend on his own observa-
tions and experience in the treatment of his pa-
tients. I can assure you from actual experience
that it was far from romantic to be called out on
a winter’s night, during a raging snow storm in
subzero weather, over roads covered with drifting
snow, to minister to the ills of a rural patient
often many miles away. Compared to that, the
country doctor of today has a a very easy task.
„ 37
COUNTRY MEDICINE — SHERWOOD
When he receives a country call, he can step into
his high-powered automobile and with very little
discomfort speed over highways cleared of snow
in the winter time to his patient’s bedside, and
make the round trip in one quarter of the time
and with none of the hazards and discomforts re-
quired during the horse and buggy days. Or he
can drive to a well-equipped modern hospital not
many miles away, and arrive there as rapidly as
some of the city surgeons, whose homes are in the
fashionable suburbs, can reach the hospital with
which they are affiliated.
Not only have there been great changes in the
administration of a country practice since the
dawn of the century, but there have also been
great changes in the character of the human af-
flictions that the country physicians are called to
treat. Some of the diseases that were common
at that time are now very rare. Epidemics of
small pox, diphtheria and typhoid fever were
usually an annual event, and often took a great
toll of humanity. Pulmonary tuberculosis was
not considered contagious at that time, but was
thought to be hereditary ; and due to the poor
housing conditions under which the early settlers
had to live, frequently decimated entire families.
Tuberculous disease of the bones and lymphatic
glands, due to the bovine germ and transmitted to
humans through infected milk, was very preva-
lent. Now, through the pasteurization of milk and
the tuberculin testing of cattle that type of tuber-
culosis has been almost entirely obliterated. Thus
through the progress of medical science and the
discovery and use of vaccines and antitoxins to
prevent and treat disease, many of the maladies of
former days are almost non-existent.
In spite of the elimination of the hazard, hard-
ships and inconveniences of country practice, the
average graduate in medicine today does not
choose to locate in the country, but usually pre-
fers to establish himself in the larger and more
populous centers where the profession is often
overcrowded but hospital and facilities are near
at hand. This migration to the cities has resulted
in a real scarcity of physicians in the villages and
rural communities. In fact, there are counties in
some states without a single resident phvsician.
Dr. Simons, our esteemed president of the Minne-
sota State Medical Association, in a recent issue
of Minnesota Medicine, covered this situation
very ably and very thoroughly. He stated that the
lack of proper medical care in some parts of the
country is not due to an actual shortage of physi-
cians but to a lack of proper distribution of
physicians.
This tendency of medical graduates to establish
themselves in the larger centers is not only evident
in our country but in other lands as well. In our
neighboring country south of the border this tend-
ency has been evident for a number of years — so
much so, in fact, that Mexico City with its popu-
lation of about two million has a large oversupply
of physicians, while many parts of the republic
lack adequate medical care. The government of
Mexico has recognized this deplorable condition
and has attempted to ameliorate it by appropriate
legislation. Every graduate of a medical school
in Mexico is now required to locate for six
months to a year in a locality needing a physician
before he receives his diploma, and during this
period of probationary practice, the government
assists him financially.
Another reason advanced by some as a factor
in the cause of this mal-distribution of physicians
in the country is the great increase of specializa-
tion. Tt is claimed that a number of medical col-
leges are devoting so much time to turning out
specialists that the education of general practi-
tioners is neglected. Years ago, when a doctor
wished to become a specialist in medicine or sur-
gery, he was advised to engage first in general
practice for a few years so he could ascertain
what line of practice he preferred and was best
fitted for. Then, through personal experience he
could better appreciate the problems and difficul-
ties of a general practitioner.
In conclusion, T wish to say that the inadequate
distribution of medical care in this country of
ours is one of the chief arguments advanced by
advocates of state medicine. It, therefore, be-
hooves organized medicine to use its very best ef-
forts to meet this problem and to see that this mal-
distribution of doctors is corrected, so that all
parts of our country are provided with proper
medical care. In that way the time-honored rela-
tion between the doctor and his patient will be
preserved, and the country doctor will not become
a relic of the past and a forgotten man.
38
Minnesota Medicine
NEWER METHODS IN THE TREATMENT OF HYPERTHYROIDISM
ARNOLD S. JACKSON, M.D.
Madison, Wisconsin
WHILE thyroidectomy has long been con-
sidered a satisfactory method of treating
adenomatous goiter, the surgical removal of the
hyperplastic type has not afforded equally good
results. Those interested in the study of goiter
have long sought other means of overcoming hy-
perthyroidism in exophthalmic goiter. In the
early part of this century, various solutions in-
cluding weak phenol and boiling water were in-
jected into the goiter in an attempt to destroy it;
quinine, urea, and x-ray therapy had their day;
and then in 1922 when Plummer proposed the
pre-operative use of Lugol’s solution, some advo-
cated iodine as a curative measure, and unfortu-
nately a few still continue to do so. Then George
Crile suggested denervation of the adrenal glands,
and others irradiation of the pituitary. In time
all these methods were discarded, and thyroidec-
tomy again returned to favor.
Still, thyroidectomy, even when performed by
the most experienced thyroid surgeons, occasion-
ally proves to be disappointing. Probably the in-
cidence of recurrence for all surgeons performing
thyroidectomy has been at least 10 per cent. In
some patients two or even three recurrences have
developed. I performed a thyroidectomy upon one
patient with exophalmic goiter upon whom three
subtotal resections of the gland had been per-
formed previously by skillful surgeons.
As a consequence, because of these occasionally
unsatisfactory results and because recurrences
sometimes develop after many years of good
health, the discover)' of a real antithyroid drug
was eagerly anticipated. Such a discovery seemed
apparent when Astwood and others demonstrated
in 1943 the effectiveness of thiouracil in treating
hyperthyroidism.
Three years have now elapsed since Astwood’s
report, and thiouracil has been tried in many
thousands of cases. At first the drug was re-
leased only to institutions prepared to conduct
careful clinical research studies on its effect in
hyperthyroidism. Despite these careful investi-
gations, thirty or more deaths as a result of
agranulocytosis are known to have occurred.
From the Frieda Meyers Nishan Foundation for the Study of
Goiter of the Jackson Clinic, Madison, Wis.
Read before the meeting of the Interurban Society of Duluth
and Superior at Superior, Sept. 19, 1946.
January, 1947
Since the drug has been generally released, a cer-
tain number of unpublished deaths have undoubt-
edly occurred from its use. One of the most re-
cent about which I have learned was a patient
with neurocirculatory asthenia that had been in-
correctly diagnosed as hyperplastic goiter.
Despite its unfortunate toxic effects, thiouracil
has proved a valuable adjunct to surgery in the
treatment of certain types of toxic goiter. Three
years’ experience in a series of fifty cases has led
me to the following conclusions regarding the
advantages and dangers of this antithyroid agent.
There are advantages in its use in the following
types of cases :
1. In advanced multiple toxic adenoma in
which there is no response to iodine.
2. In toxic adenoma complicated by such con-
ditions as myocarditis, fibrillation, hypertension,
diabetes, and decompensation.
3. In severe exophthalmic goiter, in the very
young and in the aged and in the debilitated and
decompensated.
4. In exophthalmic goiter in which because of
pregnancy, previous nerve injury, infections, or
other diseases it may be desirable to delay opera-
tion and yet not continue on iodine.
5. In “iodine-fast” exophthalmic goiter.
6. In recurrent or persistent hyperthyroidism.
Thiouracil has supplemented but not supplanted
thyroidectomy in the treatment of toxic goiter.
Because it in no way tends to reduce or eradicate
the nodular adenomatous goiter, it cannot replace
operation. The toxicity may be reduced and even
controlled, but the goiter may still continue to
grow and cause pressure symptoms or even be-
come malignant. The fact that I have seen five
adenomatous goiters in recent months that have
undergone malignant changes has made me more
cognizant than ever of this possibility. The expe-
rience of numerous other surgeons interested in
this field indicates that malignancy of the thyroid
is apparently on the increase.
The experience of a large number of investiga-
tors has been that, sooner or later, most of the
patients with exophthalmic goiter who have been
on treatment with thiouracil tend to have recur-
39
TREATMENT OF HYPERTHYROIDISM— JACKSON
rences. My own experience is negligible since I
have preferred to use the drug largely as a pre-
operative measure in certain selected cases. Be-
cause of the danger of the development of agran-
Five months ago I discontinued the use of thi-
ouracil and began substituting a less toxic anti-
thyroid agent, propylthiouracil. There is every
indication that this new preparation will prove
Fig. 1. Recurrent exophthalmic goiter with nerve paralysis controlled and apparently cured by thiouracil.
ulocytosis, because of the necessity of having pa-
tients travel a considerable distance at weekly in-
tervals to have a check of the white blood count,
and because of the comparatively long period of
treatment and observation required, thyroidec-
tomy has remained the treatment of choice for
most patients. One patient with a mild case of
exophthalmic goiter is now well eight months
after the drug was stopped. Three patients suf-
fering from a recurrence likewise appear cured
after a similar interval. Ten suffered a relapse
after the drug was stopped.
In such types of cases as have been previously
mentioned, thiouracil has proved a most useful
agent, and in my own experience it has occasioned
no serious consequences. However, two mild skin
reactions and one gastro-intestinal upset have oc-
curred. Few reactions to the drug have occurred,
I believe, because all patients have been schooled
to watch for toxic manifestations and have been
observed at short intervals and especially because
the drug has not been used in large doses. Pa-
tients are usually started on a dose of 0.1 gm.
three times a day, and this amount is seldom
doubled. As soon as indicated by the metabolic
rate and clinical study, the dosage is reduced to a
maintenance amount of 0.2 gm. daily.
equally as effective as thiouracil in the treatment
of hyperthyroidism and will be devoid of its dan-
ger. All patients who were receiving thiouracil
have now been changed over to this drug, and
their clinical status and metabolic rates remain
equally satisfactory. On the other hand, there is
little indication that propylthiouracil will prove of
any greater curative value. For example, two
children, aged nine and thirteen, both of whom
have exophthalmic goiter, have been receiving
these drugs for a year and both continue to show
signs of hyperthyroidism, although the disease is
held in check.
Propylthiouracil is still on a research basis, but
there is every indication that it will shortly be re-
leased and will largely supplant thiouracil. It is
my belief that thiouracil should never have been
released for general distribution, and I believe it
should now be withdrawn in favor of its less
dangerous successor. However, the same precau-
tions must be observed in using propylthiouracil,
and frequent observation and checking of the leu-
kocyte count should be continued until greater
data is accumulated. It is dispensed in 25 mg.
tablets, and the average dose is one before meals
and one at bedtime. Some investigators have
been using up to 150 mg. or more a day with no
40
Minnesota Medicine
TREATMENT OF HYPERTHYROIDISM— JACKSON
unfavorable reactions. One case of clinical
agranulocytosis without serious consequences has
been recorded. This report was by Dr. Bartels
.of the Lahey Clinic and was presented at the
young investigators presented at the Chicago
meeting of the goiter society aroused the keen
interest of all the members. The possible effect
of radioactive iodine on carcinoma of the thyroid
Fig. 2. A severe case of “iodine-fast” goiter responding well to thiouracil.
June meeting of the American Association for the
Study of Goiter. This discussion concerned a
study of 165 cases of hyperthyroidism treated by
propylthiouracil. A study of eighty cases was
reported by the Cleveland Clinic. The results
achieved at these institutions and at the Jackson
Clinic indicate that propylthiouracil will prove
more effective than Lugol’s solution in the pre-
operative preparation of patients having toxic
adenomatous goiter. As with thiouracil, the poor
risk patient may be so improved that a one-stage
thyroidectomy may be performed with little dan-
ger. There is no indication as yet that this drug
will do other than this in exophthalmic goiter. It
may effect a cure without surgery in mild and in-
cipient cases and possibly in a small percentage
of the remainder.
Preliminary reports by Drs. Hertz and Chap-
man of Boston on the use of radioactive iodine
are interesting but inconclusive. In a small series
of twenty-five cases of hyperthyroidism, satisfac-
tory results were obtained in twenty, and in the
remainder it was necessary to perform thyroidec-
tomy to effect a cure. Reports by these brilliant
January, 1947
was discussed, but little was brought out to justify
the exaggerated reports that have appeared in the
press and which did not receive the approval of
the investigators.
At the meeting of the goiter society, my brain
became somewhat confused after two days of
atomic bombing with isotopes, radioactive iodine
and other new ideas in relation to goiter, but I
finally gathered courage to present a nearly for-
gotten subject, the treatment of hyperthyroidism
by thyroidectomy. A study of 100 cases of ex-
ophthalmic goiter operated upon twenty or more
years ago was presented, and slides of several of
these patients as they appeared in the early twen-
ties and as they appear today were shown. Only
one of these patients is suffering from the disease
today, and in this case the symptoms are mild and
under control. Ten of the patients are now over
seventy-five years of age and are still in good
health.
Newer methods in the treatment of hyperthy-
roidism are proving a valuable adjunct to the sur-
geon in treating hyperthyroidism, but as yet noth-
(Continued on Page 118)
41
INTERNAL DERANGEMENT OF THE KNEE
MARK B. COVENTRY. M.D.
Rochester, Minnesota
r | 'HE TERM "internal derangement” has been
employed since Heys first introduced it in
1784 to include a large group of intra-articular
conditions of joints. Infections of joints and dif-
ferent types of arthritis per sc are excluded from
the group but most other lesions of the knee joint
are included. The athlete who has a "trick knee”
and the patient who says, "Doctor, my knee goes
out of joint,” are suffering from internal derange-
ment of the knee. The patient usually contributes
information which reveals that rather sudden me-
chanical locking, slipping or giving way of the
joint occurred and that the subsequent reaction of
the synovium was characterized by swelling. Aft-
er a period, the condition usually becomes asymp-
tomatic only to recur after subsequent trauma. A
high percentage of patients who have internal de-
rangement of the knee are young men because
they are more likely to be subjected to trauma
than are others.
Approximately twenty-five separate conditions
may cause mechanical derangement of the knee.
The two most common are tears in the semilunar
cartilage and loose bodies in the knee. According
to figures recently compiled by Henderson and
Lipscomb,3 1,079 arthrotomies were performed in
1,031 cases at the Mayo Clinic before 1944, for
treatment of conditions arising from tears in the
semilunar cartilage or from loose bodies. Six hun-
dred fifty-nine tears were found, and in 420 cases
derangement was due to the presence of a loose
body. The correct diagnosis was made pre-oper-
atively in 79 per cent of the cases. In this unse-
lected group, patients of all ages w-ere included.
The diagnosis of internal derangement depends
on the history, physical examination with special
attention to the knee, roentgenographic exami-
nation and, in some cases, surgical exploration.
Most important among these is the history. From
the history it can be decided whether conserv-
ative or surgical treatment should be instituted. In
taking the history, attention should be given to
the type of attack — whether true locking has oc-
curred, or whether simply a little catch or a giving
way is responsible — to the number of attacks and
From the Section on Orthopedic Surgery, Mayo Clinic, Roch-
ester, Minnesota.
Read at the annual meeting of the Northern Minnesota Med-
ical Association, Crookston, Minnesota, August 24, 1946.
to whether these attacks are getting more or less
frequent. The triad of symptoms usually associat-
ed with internal derangement is pain, catching or
locking, and swelling. According to Henderson
and Lipscomb’s statistics, 70 per cent of all of
these patients had this triad. However, one or
more of the symptoms may be lacking and it is
important that the patient not be dismissed simply
because locking has not occurred. In cases of
tears in the posterior part of the cartilage or dis-
ruption of a ligament locking does not, as a rule,
occur.
For examination after the general evaluation,
the patient’s lower extremities should be un-
clothed. The patient should first be asked to walk,
so the presence or absence of swelling, of atrophy
of the quadriceps femoris and of limping, and the
range of motion, can be observed. The patient sits
down for the rest of the examination. It is easier
for me if I sit at a right angle to the patient. The
patient is asked to point with one finger to the
location of most of the pain. Then the knee
should be palpated for warmth or tenderness.
Sometimes loose bodies or the semilunar cartilage
itself can be felt. The range of motion is ob-
served, and at the same time the examiner can
determine whether crepitus is present by placing
his hand on the knee. Lateral and anteroposterior
stability is then determined.
Following this roentgenograms should be taken
and examined. The roentgenographic findings are
of only negative significance in many cases. Tears
in cartilage and injury to soft tissue will not be
manifested in a routine roentgenogram. How-
ever, calcified menisci, loose osteocartilaginous
bodies, osteochondritis dissecans and fractures of
the tibial spine can all be seen by roentgenogram.
Besides the conventional anteroposterior and lat-
eral views, two- special views are of great help in
the diagnosis and localization of lesions of the
bones of the knee.2 ( 1 ) The intercondylar notch
view taken with the patient’s knee flexed reveals
at times the presence of osteochondritis dissecans.
Evidence of this condition cannot always be seen
in other roentgenograms. This type of roentgeno-
gram will also reveal loose bodies which may be
caught in this region and injuries to the tibial
42
Minnesota Medicine
INTERNAL DERANGEMENT OF THE KNEE— COVENTRY
spines. (2) A vertical patellar view often will
show evidence of osteochondritis and other ab-
normalities of the patella and the femoral con-
dyles.
Diagnosis and Treatment of Specific
Internal Derangements
An outline somewhat similar to the one present-
ed by Badgley1 follows. It is used for a brief de-
scription of diagnosis and treatment of specific
internal derangements.
I. Semilunar cartilage.
(a) Tears.
(b) Cysts.
(c) Congenital abnormalities.
(d) Calcified meniscus.
(e) Hypermobility or recurrent dislocation.
II. Lateral ligaments.
(a) Rupture.
(b) Cysts and adventitious bursae.
III. Injury to cruciate ligaments.
IV. Loose bodies.
(a) Of synovial origin.
(b) Of articular origin.
(1) Osteochondritis dissecans.
(2) Osteochondral fractures.
V. Soft tissue.
(a) Adhesions.
(b) Hypertrophic infrapatellar fat pads.
VI. Recurrent dislocation of the patella.
VII. Fractures of the tibial spine.
Semilunar cartilage. — The tear of the cartilage
may be in the anterior, medial or posterior third,
or may be of the so-called bucket-handle type. In
the bucket-handle type the most severe locking
occurs, and reduction with the patient under anes-
thesia sometimes is required for treatment. Diag-
nosis is based on a history of injury, locking,
swelling and pain, and on physical examination
either at the time of injury or later. Tenderness
is almost always present over the injured cartilage
and sometimes a definite click can be felt on flex-
ion and rotation of the tibia on the femur. Treat-
ment consists of excision of the cartilage. In my
opinion, the entire cartilage should be removed,
preferably through two incisions.
Cysts are probably congenital. They almost in-
variably occur on the lateral meniscus, and the
swelling can be seen cephalad and slightly anterior
to the fibular head. Catching and pain are often
present and treatment is excision.
The “discoid” meniscus is the most common
congenital abnormality. It usually involves the
January, 1947
lateral meniscus. Diagnosis is made chiefly by
means of the history. Patients who have this
congenital abnormality have had “snapping knee”
since childhood and pain in the region of the lat-
eral meniscus. It is treated by surgical excision
of the meniscus.
Calcified meniscus is found fairly commonly in
older patients, and, as a rule, produces a few symp-
toms. Only occasionally do swelling and catching
occur. I have encountered one case of true lock-
ing. If locking does occur, the meniscus should be
excised ; otherwise, conservative measures, includ-
ing diathermy, should be used.
While hypermobility or dislocation without tear
may be found, it exists less commonly than is gen-
erally thought. Usually it can be demonstrated at
the time of operation that the anterior third of
the cartilage is hypermobile. If the condition
which arises in cases of hypermobile cartilage is
severe enough to cause locking and swelling, the
cartilage should be excised.
Lateral ligaments. — Either the tibial or the fib-
ular collateral ligaments may become ruptured.
The history of injury is always given. If the re-
laxation is only mild, the best treatment is to
build up the quadriceps muscle. If the entire liga-
ment is definitely disrupted, the defect should be
repaired surgically.
Cysts and adventitious bursae occur with some
frequency, and the diagnosis is often made only at
the time of operation because the condition which
arises in these cases resembles that in cases of
torn cartilage or cyst of the cartilage. If a cyst
is present it should be removed. Roentgen therapy
or diathermy and injection of procaine hydro-
chloride should be used for treatment of adven-
titious bursae, and surgical treatment should be
carried out only as a last resort.
Injury to cruciate ligaments. — Both the ante-
rior and the posterior cruciate ligaments may be
injured. Injuries of this type commonly occur in
automobile accidents in which the patient’s knees
are bumped against the dashboard. While surgi-
cal procedures have been devised to repair the
injuries, if the quadriceps femoris is strong and
the collateral ligaments intact, tears in the ante-
rior and posterior cruciate ligaments are not par-
ticularly disabling. Treatment should be directed
toward restoration of strength in the quadriceps
muscle which is invariably weakened.
43
INTERNAL DERANGEMENT OF THE KNEE— COVENTRY
Loose Bodies. — Cure in cases of osteochon-
dromatosis in which loose bodies are derived from
synovia, can be accomplished only by complete
synovectomy. If but one or two loose bodies are
present, however, these can often be removed and
the patient will experience a good deal of per-
manent relief. Loose bodies should be removed,
for their presence tends to traumatize the articu-
lar cartilage, and irreversible changes in the hya-
line cartilage occur.
Osteochondritis dissecans, in which loose bod-
ies are derived from the articular cartilage, is
found most frequently in young men. In its early
stage it is diagnosed when pain and swelling oc-
cur. Later when the dead fragment of cartilage
and bone separates and becomes a loose body,
locking frequently occurs. It is treated by remov-
al of the loose body. The bed from which the
loose body separates is usually curetted down to
bleeding bone at the same time, although there is
some reason to think that this may not be neces-
sary.
Osteochondral fractures may occur as the re-
sult of a direct blow to the patella which trans-
mits the blow to the femoral condyles, or of a
direct blow to the femoral condyle itself. In cases
of osteochondral fracture, patients must be ob-
served carefully for evidence of necrosis of bone
and cartilage.
Traumatic and hypertrophic arthritis with de-
tached osteophytes is encountered frequently in
elderly patients and, when locking occurs, the
best treatment is surgical excision of the loose
bodies.
Soft tissue. — Adhesions may occur after an in-
tra-articular fracture with hemarthrosis. They
prevent full range of motion and the adhesions
usually must be cut surgically as they often are
extremely strong and cannot be broken by manip-
ulation carried out with the patient under anes-
thesia.
Hypertrophic infrapatellar fat pads will be
found occasionally. The pads become pinched
between the femur and tibia and cause catching,
pain and effusion. If the symptoms warrant, sur-
gical removal of the fat pads should be carried
out.
Recurrent dislocation of the patella. — Diagno-
sis of this condition is often missed because an
inadequate history has been taken. The patient
should be questioned carefully as to whether he
has seen his knee when it “goes out of joint.”
Sometimes it is so painful the patient does not
think about how the knee looks, but as most dis-
locations of the patella are lateral and are ob-
served easily even by the untrained eye, informa-
tion concerning the episodes usually will help the
physician make the diagnosis. In other cases, the
physician sees the dislocation, for frequently it
must be reduced with the patient under anes-
thesia. Treatment should be carried out early to
prevent the occurrence of secondary arthritic
changes in the knee and is directed toward reat-
taching the patellar tendon medially and distally.
This treatment is satisfactory in most cases al-
though occasionally fascial slings must be used
in addition. In cases in which the lateral femoral
condyle has flattened it must be raised by means
of a wedge osteotomy.
Fractures of tibial spine. — These occasionally
occur because of either anterior or posterior
strain. The tibial spines are avulsed because of
the pull of the cruciate ligaments. For treatment
a cast is applied and usually patients recover sat-
isfactorily. Careful observation is necessary so
non-union or avascular necrosis of the spines may
be found when it occurs.
Comment
In conclusion I would like to emphasize three
points :
1. The main disability in all internal derange-
ments of the knee is weakness of the quadriceps
femoris and nothing in the way of a cure can be
achieved unless the quadriceps is brought back to
normal. This cannot be done simply by having
the patient walk, but a systematic program of ex-
ercises against weight must be carried out pre-
operatively and postoperatively or, if surgical
treatment is not undertaken, during the conva-
lescence from the injury.
2. In cases in which removal of semilunar car-
tilage is necessary, the entire semilunar cartilage
should be removed, not just the anterior two
thirds. It has been my experience that catching
and pain are produced occasionally by the poste-
rior third of the cartilage when it is left.
3. In any case in which it is necessary to per-
form arthotomy the patient should be assured
(Continned on Page 83)
44
Minnesota Medicine
RECTAL IMPALEMENT
Report of an Unusual Case
C. T. EGINTON. M.D., M.S. (Surg.)
Saint Paul, Minnesota
TT T OUNDS of the rectum by impalement are of
* * infrequent occurrence ; however, they are of
interest because of the frequently bizarre acci-
dents from which these injuries are sustained, the
extensive damage often done to contiguous tis-
sues, and the serious danger of peritoneal contam-
ination.
During the past few years there have been re-
ports of an occasional case or small series of cases
of traumatic perforations of the rectum, most of
these being due to instrumentation, enemata or
air pressure. Reports of injury by impalement
have been quite rare. This particular trauma is
apparently primarily a haying hazard, most of
the reported cases occurring in farmers who have
fallen from hay stacks onto pitchforks, rakes, or
other farming implements. However, miners,
well-drillers, and, in fact, nearly all industrial
workers are occasionally subject to this type of
injury.
I wish to report a case of rectal impalement un-
usual in respect to etiology as well as involvement
of adjacent structures.
Case Report
H.M., a twenty-year-old Thlingit Indian, male, was
brought to the Whitehorse General Hospital, White-
horse, Yukon Territory, Canada, at 11 :30 p.m., December
13, 1945, complaining of intense abdominal pain and
bleeding from the rectum.. At 2:30 p.m. that day, re-
turning from his trap line near Teslin Lake, Y.T., he
was standing on a toboggan type sleigh behind his dog
team. As the descent to the lake down a steep bank
commenced, the dogs got out of control and left the
trail. When the patient noted that the sled was headed
for a clump of bushes, he attempted to sit on the
sleigh and control its course by dragging his feet in the
snow. As the toboggan tipped to one side he was
thrown clear and landed on a branch of wood about
two feet long and about one inch in diameter. At the
time of this accident the dog team was travelling at
high speed, probably about twenty miles per hour. He
was impaled on this piece of wood with very great
force. The branch penetrated his rectum and the pa-
tient thought it broke off as he heard a distinct snapping
sound. He lost consciousness, however, immediately
afterward. When he regained consciousness, the dog
team was over half way across Lake Teslin, which
would take between eight and ten minutes with the team
travelling at twenty miles per hour. The patient ex-
tracted the stick from his rectum and began to walk to
January, 1947
his camp, a distance of two miles. This walk was through
deep snow and required great effort. He arrived at his
camp about 4 :30 p.m. and remained there until 6 p.m.
when the Royal Canadian Mounted Police car arrived
and transported him to Whitehorse, a distance of 114
miles. He was admitted to the Whitehorse General
Hospital at 11 :30 p.m., nine hours after the injury.
There had occurred a moderate amount of bleeding
from the rectum during this period. The pain in the
rectum had intensified and had now become associated
with severe abdominal pain, most marked in the supra-
pubic area. Shortly after admission to the hospital, he
passed about 200 c.c. of bloody urine. There was no
dysuria, and no gas was noted in the urine.
Physical examination at the time of admission re-
vealed a well-developed, well-nourished Thlingit Indian
male, in acute distress, conscious and rational, lying
in supine position. Blood pressure was 100/70, heart
rate 84, oral temperature 103°F. The entire abdomen
was rigid and tender, most markedly below the um-
bilicus. There was no distention, but the abdomen, was
silent to auscultation. There was a ragged superficial
abrasion in the anterior part of the anal skin extend-
ing into the mucosa. Digital examination revealed a
perforation in the anterior wall of the rectum about
9 or 10 cm. from the anus. There was a small amount
of semi-solid fecal material in the rectal ampulla.
Ten hours after the injury, the patient was taken to
the operating room. With the patient in the Sims posi-
tion, a proctoscopic examination under spinal anesthesia
showed a ragged rent in the anterior rectum about 10
cm. from the anal margin. It was about 4.5 cm. long
and gaped about 2 cm. Through this could be seen a
loop of small bowel surrounded by fecal material. The
perforation extended through the rectovesical pouch of
Douglas into the posterior wall of the bladder (Fig. 1).
There was no leakage of urine apparent at this time
and it could not be determined if the bladder mucosa
was intact. Several large fecal masses were removed
from the pouch of Douglas with sponge forceps and
suction ; the rectal perforation was closed with four
interrupted No. 0 plain catgut sutures. The patient was
then placed on his back. A left paramedian incision was
made below the umbilicus, splitting the rectus muscle.
Upon incising the peritoneum, a moderate amount of
sanguineous stercoraceous material was encountered.
As much as possible of this was removed by suction
and sponging. The pelvis was explored and the peri-
toneal tear was closed and anchored above the ecchymotic
area on the posterior wall of the bladder. Perforation
of the bladder was not demonstrable at this time, so
no sutures were placed in the bladder. However, the
damaged area was covered with peritoneum from the cul
de sac. A loop of sigmoid colon was brought into the
abdominal incision ; the two pillars were sutured to-
gether for a distance of 8 cm. and were anchored
45
RECTAL IMPALEMENT— EGINTON
laterally to avoid fenestration, and the abdomen was
closed.
On December 15, 1945, the colostomy was opened
with the cautery. Borborygmi were audible on that day.
The patient’s general condition improved rapidly; how-
ever there occurred frequent watery stools with a
uriniferous odor through the rectum and colostomy.
Cystoscopy was performed on December 27, 1945,
when it was deemed that the patient’s general condi-
tion warranted such a procedure. No obstruction to the
insertion of the cystoscope was encountered. The bladder
was filled with cloudy urine containing flecks of mu-
copurulent material. The mucosa over the entire pos-
terior wall and trigone W'as uniformly reddened and
edematous. The ureteral orifices appeared normal.
There was a large ragged perforation, 2 by 1 cm.,
triangular in shape, in the retroureteral pouch, about 2
cm. above the trigone ridge. The edges of this tear
appeared necrotic. Fluid could be seen to run directly
into the rectum and cloudy fluid return. It was pos-
sible, while clear fluid was running into the bladder, to
visualize the lumen of the rectum through the fistula
(Fig. 2).
On January 4, 1946, the patient was again taken to the
operating room where spinal anesthesia was induced.
He was placed in an exaggerated lithotomy position,
and a transverse, curved incisioij was made 2 cm.
anterior to the anus. This was carried down through
the perineal body; and the rectourethralis muscle was
transected. Denonvilliers’ fascia was dissected, exposing
the fistula above the prostate. The rectum was mobilized
well above this area. The fistula was then excised and
the edges of the bladder defect freshened with the scalpel,
and the muscular layer of the bladder was united with
chromic No. 00 catgut continuous suture, avoiding the
mucosa. Denonvilliers’ fascia was approximated over
the bladder suture line with another row of interrupted
sutures. The levator ani leaves were pulled together in
front of the rectum with three interrupted sutures of
chromic No. 1 catgut. The mobilized rectum wras pulled
toward the anus as far as possible, the first, most su-
perior suture, being carried into the anal sphincter to
anchor the rectum in its anal position. The redundant
rectal mucosa was excised and the remaining defect
dosed with a continuous suture of No. 00 chromic
catgut. The perineal muscles were reunited with plain
No. 0 catgut interrupted sutures and the skin was closed
with subcuticular plain No. 0 catgyit. An urethral cathe-
ter was left inlying.
No leakage occurred at the site of repair, the wound
healed primarily, and the patient recovered without in-
cident from this operation. On January 19, 1946, a
clamp was applied to the colostomy spur. On January
26, 1946, the inlying catheter w7as removed and the pa-
tient began voiding spontaneously four to five times
each day. The bladder apparently had normal capacity.
The colostomy spur was completely obliterated by Jan-
uary 28, 1946. Urinalysis on February 4, 1946, was
negative. On February 5, 1946, cystoscopy was again
performed. There was no cystitis ; the urine was clear.
At the site of the previous fistula, there was only a
dimple in the mucosa, completely healed. Four hun-
dred c.c. of 12 per cent sodium iodide solution were
instilled into the bladder and a cystogram taken. This
showed no leakage into the rectum. The bladder out-
line was normal except for a very slight denting at the
site of the former fistula. Digital examination of the
rectum showed firm non-tender scar tissue. On March
8, 1946, the patient was returned to the operating room.
Under intravenous sodium pentothal anesthesia, the
colostomy was closed extraperitoneally. The peritoneum,
however, was undermined and pulled over the suture
line in such a manner that a sling for the sigmoid loop
was formed. Thus it was possible to close the abdomen
firmly in layers, including the peritoneal folds. Recov-
ery was uneventful, and the patient began having normal
bowel movements in four days.
( Continued on Page 61)
Fistulous opeming
Fig. 1. Sagittal section shows path of impalement.
Fig. 2. Posterior wall of bladder.
46
Minnesota Medicine
CHYLOTHORAX: PREGNANCY IN AN ARRESTED CASE
GUS EDLUND, M.D.
Saint Paul, Minnesota
/^HYLOTHORAX is an effusian of chyle in
the pleural cavity due to lesions of the tho-
racic duct or of its radicals. It is a relatively rare
condition and often of obscure etiology. Thirty
per cent of the cases are said to be due to trauma,
18 per cent to cancer of the pleura, 15 per cent
to occlusion of the left subclavian vein, 7 per cent
to compression of the thoracic duct, 7 per cent to
sclerosis of lymph vessels, 7 per cent to lymphan-
giectasia, and 16 per cent to malignant lymphoma
and blood parasites (probably filaria).5 Mortality
is high, being somewhat less than 50 per cent.4
This is readily understood when the etiology is
taken into consideration. According to Brescia,1
Bartolet first described this entity in 1633. H oy-
er2 reported the eighty-fifth case in 1938, and in
1944 Jahsman3 reported three cases, bringing the
total number up to 105.
Case Report
The case I wish to report, the first pregnancy in
an arrested case, is that of C.E.D., a white woman, aged
thirty-one, first seen on January 18, 1943, when she com-
plained of gastric distress, anorexia, menorrhagia and
malaise.
She had had lobar pneumonia in 1933 and said she
had not felt well since. She also had an unco|mplicated
appendectomy in 1937. Physical examination at that time
revealed a normal chest. There was some tenderness in
the right mid-abdomen, and the uterus was fixed in the
right pelvis. The hemoglobin was 70 per cent. No defi-
nite diagnosis was made but she was put on a tonic
regime and responded so well she was discharged Feb-
ruary 9, 1943.
On June 1, 1943, I was called to her home and found
her confined to her bed with a history of having had a
“cold” for a week or so. She looked very sick, and
casual examination revealed lungs full of moist rales
with the left chest half full of fluid. She was sent to
Midway Hospital by ambulance and was admitted with
a temperature of 101.8° which rapidly went up to 104°,
and then quickly subsided under sulfathiazole.
On admittance, urine showed 2 plus albumin, hemo-
globin 58 per cent, Wassermann negative, RBC 4,240,000,
WBC 10,600 with normal smear and differential count.
X-ray of the chest showed considerable increased den-
sity in the left base due to effusion, and the heart was
displaced to the right. There was no evidence of lung
or mediastinal infiltration. On Tune 3, 1943, a re-ray
with horizontal and vertical left lateral views of the
chest showed a freely shifting effusion.
Presented at the meeting of the general staff of Midway Hos-
pital, Saint Paul, Minnesota, June 5, 1946.
On June 4, I aspirated 700 c.c. of milky fluid which
was alkaline in reaction and had a specific gravity of
1.014. Culture showed a few Gram-positive diplococci.
Guinea pig inoculations were reported negative on July
17 and July 30. Re-ray of the chest showed consider-
ably less effusion in the left basal area than on the pre-
vious study, with considerably less displacement of the
heart to the right. A moderate degree of effusion still
remained basally on the left. No definite lung infiltration
was demonstrated.
Fluid gradually re-formed in the left chest, and on
June 12 respirations were again embarrassed and 800
c.c. of milky fluid were aspirated. Re-ray showed no
change except possibly a slight decrease in the fluid
densities in the left base.
Feeling that we were accomplishing nothing by aspira-
tion and were only wasting previous body fluid, we pur-
sued an expectant course, but had to aspirate her again
on June 18 because of marked respiratory embarrass-
ment. Fluid became less and less and finally was en-
tirely absorbed as verified by x-ray examinations which
revealed the heart normal in size and configuration, the
lungs entirely normal with evidence of adhesive pleurisy
in both costo-phrenic angles.
On June 20, 1945, two years .after the last aspiration,
she returned to my office feeling fine but thought she
might be pregnant, her last menstrual period having been
on May 5, 1945. Examination at this time revealed a
normal chest and abdomen, blood pressure 130/80, hemo-
globin 84 per cent, urine 2 plus albumin, and a positive
Friedmann test. The question then arose as to what ad-
vice to give her. She was very anxious to have a baby
and her husband felt the same way. A search of the
literature revealed no record of pregnancy following
chylothorax. I finally decided to adopt expectant treat-
ment, feeling that if we could bring the fetus to via-
bility without too seriously endangering the mother we
could do an elective cesarean section and avoid the
strain of labor.
Dr. McKelvey, head of the department of obstetrics at
the University of Minnesota, became interested in the
patient, and in October, 1945, I sent her to the University
Hospital at his request for observation and study with
particular reference to vital capacity studies.
His report of October 20, 1945, was as follows :
blood pressure on admittance 156/98, on the following
day 134/76 and on the day of discharge 138/90. A
catheterized urine specimen showed 2 plus albumin and
occasional white blood cells, and hemolytic streptococcus
was cultured from it. Uric acid was 4.6 mg. Other
chemistry reports were normal. The venous pressure
was 11.5 cm. of saline. Circulation time was, arm to
tongue, 15 seconds, arm to lung 5 seconds. An electro-
cardiogram was normal. An accurately measured vital
capacity was 2.88 liters. Chest x-ray showed an old ad-
hesive pleurisy. The blood cholesterol was 390 mg. per
cent.
January, 1947
-'7
CHLYOTHORAX— EDLUND
Dr. McKelvey’s conclusions were : “The patient has
a mild pregnancy toxemia. There is no evidence of
active chylothorax at present and no evidence of dis-
turbance of pulmonary circulation or of the heart as a
result of the previous episode. I have not been able to
find any case report in the literature of a pregnancy as-
sociation with chylothorax. However, in my opinion,
there is no good reason to believe that there should be
any change from the present state as a result of the
pregnancy.”
Her course from here on was uneventful except for
varying rises and falls in blood pressure and varying
amounts of albumin in the urine, until December 7, 1945,
when her blood pressure was 150/90, albumin 4 plus,
hemoglobin 70 per cent, and she did not feel very well.
I ordered her home to bed. On December 14 she com-
plained of severe epigastric pains and felt miserable. I
had her admitted to Midway Hospital on that day and
administered morphine for relief of pain. We were then
in a position to weigh her every day and check her in-
take and output, blood pressure, fetal heart tones, and
urine, hoping to delay a cesarean section as long as
possible, as she was still two months from term. Her
blood pressure ran fairly constant, about 150/90, and
urine specific gravity was 1.012 to 1.016, with a constant
4 plus albumin and occasional white blood cells. Hemo-
globin was 9.9 gm., Rh factor positive, urea nitrogen 26.5
mg., and uric acid 7.5 mg.
On December 18, Dr. Louis Freidman, who had been in-
strumental in interesting Dr. McKelvey, saw her and his
impression was that she was suffering from a toxemia
of pregancy, pre-eclampsia and secondary anemia, and
advised continuance of conservative treatment in an ef-
fort to increase the viability of the fetus.
On December 27, 1945 (due February 12, 1946), her
condition not having improved, I did a classical cesarean
section, incising the abdomen under novocaine infiltra-
tion and the uterus under sodium pentothal anesthesia.
The placenta was found attached to the anterior uterine
wall. A male child weighing 4 pounds 8 ounces was
delivered, the placenta extracted, uterus closed, tubes
ligated and abdomen closed without drainage.
Before operation her blood pressure was 158/104, with
fetal heart tones 136, urine 4 plus albumin, hemoglobin
10.4 gm. The pre-operative diagnosis was pre-eclampsia
with arteriosclerosis. Postoperatively she was given 500
c.c. of whole blood, and this was repeated on January 3,
1946. Her postoperative course was uneventful and she
was discharged from the hospital on January 10 with a
blood pressure of 146/84; urine was alkaline, amber
colored, specific gravity 1.016, 4 plus albumin, 3 to 5
R.B.C., 15 to 25 W.B.C. ; hemoglobin was 12.4 gm. ;
temperature was 98.4°, pulse 88, and respirations 18.
The baby, weighing 4 pounds 8 ounces at birth lost 3J4
ounces during the first three days and then gradually
gained, until on discharge from the hospital January 31,
he weighed 6 pounds 9 ounces. Six months following
birth he was perfectly normal and steadily gaining in
weight. The mother has been perfectly happpy, feels
well, does all her own work but still has a blood pres-
sure of 140/90, 4 plus albumin and 70 per cent
hemoglobin.
Summary
1. In this case we were unable to establish an
etiological factor for the chylothorax.
2. The relative rarity of the condition is em-
phasized by the fact that this is the 106th case
reported and the first of pregnancy in an arrested
case.
3. Diagnosis is dependent on aspiration of
chylous fluid.
4. In this case we achieved arrest of the chy-
lothorax by rest and supportive measures and by
discontinuing aspiration. Pregnancy was treated
conservatively and by elective cesarean section.
5. Evidently the pregnancy had no effect on
the chylothorax nor the chylothorax on the preg-
nancy in this case.
References
1. Brescia, M. A.: Chylothorax: report of case in infant.
Arch. Pediat., 8:345, 1941.
2. Hoyer, A. : Chylothorax. Nord. med. (Norsk mag. f.
Laegevidensk), 9:40, 1941.
3. Jahsman, W. E-: Chylothorax: brief review of literature:
report of three non-traumatic cases. Ann. Int. Med., 26:669,
1944.
4. Shipley, A. M.: Injuries of the chest. In Lewis, Dean:
Practice of Surgery. Vol. 4, chap. 10, p. 14.
5. Tice, Frederich: Practice of Medicine: Chylothorax. Vol.
5, p. 649.
Discussion
Dr. L. L. Freidman : This case is a most interesting
one, and apparently very rare. A thorough search of the
literature did not reveal a single case of pregnancy with
chylothorax.
No specific conclusions from an obstetrical standpoint
can be drawn from this case. Certainly the pregnancy
did not influence the chylothorax, and I don’t believe the
chylothorax influenced the pregnancy, except from an
increase in respiratory embarrassment during the last
few weeks. Unfortunately, the patient developed a pre-
eclampsia. She was put to bed and not only did not im-
prove, but her diastolic blood pressure increased and
urinary findings persisted on absolute bed rest.
Dr. Edlund sectioned this patient at viability. Un-
doubtedly without the toxemia she could have been al-
lowed to deliver normally.
The toxemia may be classified as an arteriosclerotic
superimposed with pre-eclampsia. We have no direct
evidence cf this, except a persistent albuminuria prior
to pregnancy and a resultant hypertension and albumi-
nuria three months postpartum.
This is a most interesting case, and so rare that it
may be called an academic curiosity. I have urged Dr.
Edlund to prepare the case report for publication, which
he has so ably done.
48
Minnesota Medicine
OBSERVATIONS ON A MILD FORM OF EPILEPSY
LT. C. M. JESSICO, MC, USNR. IT. COMDR. K. H. FINLEY, MC. USNR, and
LT. COMDR. T. W. RICHARDS. HS, USNR
This is a report of studies made in the U. S.
Naval Hospital, San Leandro, California, on
patients who were returned to the United States
from the Pacific area because of a history in
which convulsive seizures were described or sug-
gested. Though a large proportion of naval and
marine patients suspected of having epilepsy
while overseas were sent to this particular hospi-
tal, it was necessary to restrict the present report
to a relatively small number.
For the most part, the studies made can be
divided into four groups: (1) physical, neuro-
logical, psychiatric and laboratory examinations
plus observation on the ward; (2) the water-pi-
tressin test (as introduced by McQuarrie7’8) ;
(3) psychological examination, and (4) electro-
encephalography.
Obviously, an epileptic history and a record of
a previous diagnosis of epilepsy were important
criteria in making the final diagnosis. However,
we felt that without confirmation by means of
at least one of these four methods of study, the
final diagnosis of epilepsy should not be made.
Of the four approaches to the patient men-
tioned, the first — that of physical examination, et
cetera — needs no further description. It might be
well to discuss briefly each of the remaining pro-
cedures.
The water-pitressin test involves hydration with
fluids by mouth, and antidiuresis by the use of pi-
tressin parenteraSly. It has been shown that a
convulsion can thus be induced frequently in an
epileptic but not in a non-epileptic.8 The mode of
action is not understood but may be an alteration
in intracellular and extracellular electrolytes
since sodium chloride inhibits a convulsion.8 The
test, as standardized at this hospital, includes the
oral intake of 500 c.c. of fluid every hour for
eleven hours or a total of 6,000 c.c., and then
every two hours for ten hours making an addi-
tional 2,500 c.c. Pitressin, 0.5 c.c., is given par-
enterally every two hours for a total of ten in-
jections. If a grand mal seizure occurs at any
time, the test is discontinued.
Psychological examination consisted of the fol-
Dr. Jessico is now associated with the Duluth Clinic, Depart-
ment of Neuropsychiatry, Duluth, Minnesota.
lowing tests: Thematic Apperception Test,
Rorschach, Minnesota Multiphasic Inventory,
parts of the Bellevue-Wechsler Scale and the
Cornell Selectee questionnaire. We were inter-
ested in the personality pattern and in detecting
signs of psychological deficit which might be as-
sociated with deterioration.
Electroencephalograms were obtained on all
the patients and were classified as normal, border-
line* or abnormal. A six-channel Grass electro-
encephalograph was used. Eight electrode place-
ments (four over each hemisphere: frontal, post-
frontal, parietal and occipital) constituted the
routine procedure used. The bipolar method of
recording was employed. When the clinical his-
tory or other laboratory findings indicated, ten
to sixteen electrode placements were applied. A
two to three minute period of hyperventilation
was employed in every instance, and a glass of
fruit juice was given the patient one-half hour
before the test.
This report covers seventy-three consecutive
cases admitted to the neurology ward with a diag-
nosis of epilepsy. Except for the case of one
man on whom the water-pitressin test was not
made, each was subjected to the four methods of
study described above.
The final diagnoses established for the group
of seventy-three patients were :
Epilepsy ; 57
Psychoneurosis, otherwise unclassified 6
Hysteria 3
Personality disorder 3
Mental deficiency! 1
Narcolepsy 1
Migraine ,'. 1
No disease 1
Though not typical because of the great number
of seizures, the manner in which the patients were
*Borderline is used for the types of EEG patterns which can-
not be readily grouped as either definitely normal or abnormal.
These borderline tracings include, for the most part, the following
types of patterns: (1) low amplitude records which show no
definite frequency at the standard rate of amplification (i.e.,
50 microvolts when equivalent to a vertical deflection of the needle
a distance of one-half centimeter) ; (2) tracings which show oc-
casional random, medium or high voltage, slow cycles through-
out; (3) records with the more than average number of low
amplitude (less than 25 microvolts) 18 to 30 per second cycles,
and (4) tracings containing an abundance of high voltage (over
25 microvolts) IS to 30 per second cycles, usually occuring in
random distribution rather than in paroxysmal bursts of rapid
activity, which latter are included under the abnormal group.
flf a patient had mental deficiency and epilepsy, the final
diagnosis was epilepsy.
January, 1947
49
EPILEPSY— JESSICO, ET AL
studied is exemplified by the following summary
of a case :
M. R., twenty years of age, was on active duty for
one year and seven months before he was admitted to
the sick list. He was overseas for one year and had
combat experience.
He was admitted to the hospital in May, 1945, with
the complaint of “spells of blackout” two or three times
a year since about thirteen years of age. In some spells,
he bit his tongue. Usually he had a sufficiently long
warning so that he could hide before he lost conscious-
ness. In April, 1945, he had a spell in the presence of
naval personnel and awoke to find himself in sick bay.
In this hospital, he gave a further history of “blank”
episodes of a few seconds’ duration once or twice a week
since January, 1945, and intermittent left-sided head-
aches during the past year.
In the family history, it was learned that the mother
was nervous and the father had trouble with his back.
The patient had one sibling, a sister, who died of a
mastoid complication at the age of twenty-three years.
A maternal grandmother probably had epileptic seizures
and later died of cancer of the breast. Two cousins had
had convulsions.
The patient gave a history of a normal birth and the
usual childhood diseases, including scarlet fever. He con-
sidered himself well except for the “spells.” He bit his
nails until shortly before admission. His home environ-
ment was unsatisfactory because his parents did not get
along well together and there was a “funny atmosphere
around home.” He was expelled from high school once
and quit school at the age of seventeen years. He has
not married. Before enlistment, he worked in garages
and traveled with a carnival. He drank considerable
liquor overseas.
The physical and neurological examinations were es-
sentially negative. Psychiatric examination revealed a
restless, apprehensive, mildly depressed young man who
worried over what people would think of him because of
his spells. Psychological tests showed the man to have
average mental capacity. The Rorschach revealed con-
siderable anxiety and suggested a strongly traumatic
background. The electroencephalogram was abnormal by
virtue of the ease with which the pattern broke down to
over-breathing and by a suggestive spike and wave con-
tour of some of the slow cycles. Roentgenograms of the
skull were negative. Routine laboratory examinations,
which included a urinalysis, complete blood count and a
blood Kahn, were negative.
On June 2, the patient had a grand mal convulsion wit-
nessed by a nurse. On June 13, a grand mal convulsion
was induced by the water-pitressin test after four in-
jections of pitressin. Dilantin sodium, 1 gm. twice daily,
was prescribed.
The age of the entire group ranged from seven-
teen years to forty-two years. A history of sei-
zures prior to enlistment was elicited in those with
a final diagnosis of epilepsy in thirty-four cases
(60 per cent), and of these, eight said they had
had only one attack. Of the twenty-three cases
with a history of no seizures prior to enlistment,
six had only one attack prior to admission to this
hospital. Three of the established cases had only
petit mal attacks, and the rest had grand mal sei-
zures either alone or in combination with other
forms. (It is not unlikely many petit mal cases
have been unrecognized in the service.) The age
of the first spell ranged from infancy to forty-two
years. All but two had the first seizure before the
age of thirty years.
Fourteen of the entire group had had actual
combat experience, and twelve of these had had
an established diagnosis of epilepsy. Nine had
combat experience before the first seizure but no
relationship could be determined. No individual
in this series had seizures which suggested very
strongly a relationship to head trauma. One pa-
tient had his first seizure one month after he was
dazed by a blow to the head. Of the entire group,
forty-three gave a history of head trauma of vary-
ing severity, and of those with the final diagnosis
of epilepsy, thirty-two gave such a history, so that
a larger percentage of the established cases of epi-
lepsy gave such a history than those of the entire
group. A few inconclusive abnormal neurological
signs in several patients were discounted because
of lack of supporting evidence of an organic lesion.
Pneumoencephalograms on three patients were
normal. It was impossible to make a worthwhile
estimate of the effect of alcohol on the epileptic
seizures. However, three claimed they had sei-
zures only after heavy drinking. Of the entire
group, a history of what might be termed a se-
vere illness was elicited in sixteen, which included
two cases of dengue fever. There appeared to be
no relationship, except possibly for the two pa-
tients who had dengue fever and had their first
seizure within a year of that illness. A family
history of fainting spells or epilepsy was elicited
in 39 per cent of the entire group and in
37 per cent of those with the final diagnosis of
epilepsy. The figures were reversed slightly when
only the terms epilepsy or convulsions had been
used, and then 22 per cent of the entire group and
23 per cent of the definite epileptics had a positive
family history.
In 40 per cent of those finally diagnosed as epi-
leptic, a routine psychiatric examination had re-
vealed evidence of mental deficiency or a person-
ality disorder of sufficient degree to disqualify the
individual for an early return to duty in the serv-
50
Minnesota Medicine
EPILEPSY— JESSICO, ET AL
ice. Results of the psychological tests suggested
that of this group of fifty-seven men, forty-two
gave evidence of appreciable maladjustment.
Eight patients showed signs of psychological defi-
cit. Six were mentally deficient. In fourteen
cases, trends in the direction of possible psychotic
development were in evidence. It must be pointed
out that these men had been under the stress of
overseas duty during the war. A relationship be-
tween the epileptic seizures and personality diffi-
culties was not obvious, but a direct study of that
problem was not made.
Electroencephalograms on the group of estab-
lished epileptics were definitely abnormal in only
54 per cent of the cases. Another twenty-eight
per cent were borderline. The following table
gives the percentage of normal, borderline and
abnormal records in this group of epileptics as
compared with a larger group studied in civilian
life.4
Normal
Military Group:
1. Admission diagnosis of
epilepsy (73 patients) . . . 30%
2. Final diagnosis of epilepsy 18%
(57 patients)
Civilian Group:
1. Final diagnosis of epilepsy 15%
(626 patients)
Borderline Abnormal
26% 44%
28% 54%
10% 75%
In the military group, the seventy-three indi-
viduals admitted to the hospital with a question
of epilepsy had a lower percentage of abnormal
EEGs than the fifty-seven where such a diagnosis
was later established. However, the military
group of established epileptics had a lower per-
centage of abnormal EEGs than the civilian
group, which implies that the convulsive states
of the military group were of a milder character.
There was nothing consistent in the character
of the abnormal EEGs. Most of them contained
slow cycles of varying frequencies and about one-
fourth had organized rapid cycles (frequencies
between 18 to 30 cycles per second) usually with
slow activity. In only one of the seventy-three
cases was a typical spike and wave pattern ob-
tained. Yet, several of the patients had petit mal
attacks, although all but three had grand mal seiz-
ures also.
It is important to note that almost 50 per cent
of the cases given a final diagnosis of epilepsy
had normal or borderline EEGs. This demon-
strates that a diagnosis of epilepsy is not ruled out
by a normal EEG. Also a few questionable cases,
in which the diagnosis of epilepsy was ruled out,
had abnormal EEGs, confirming the fact that
an abnormal EEG is not in itself proof of epi-
lepsy. Like most laboratory tests, the EEG
should only be evaluated when considered in the
light of other clinical and laboratory findings.
Seventy-two out of the seventy-three cases had
a water-pitressin test. The test was not completed
in six cases. In thirteen, a grand mal convulsion
was induced. Not excluding the incomplete tests,
twenty-three per cent of the patients with the
final diagnosis of epilepsy had a positive test.
Twitching movements of the extremities occurred
in four more. The diagnosis of epilepsy was made
in three of these. In a previous group, which in-
cluded forty-four cases with the final diagnosis
of epilepsy, 55 per cent had positive tests. It may
be assumed, therefore, 'that the potential for sei-
zures is less in the present group than in the pre-
vious group. In the present group, one patient
had a seizure after the second injection of pitres-
sin. All others had seizures only after at least
four injections of pitressin were given. One pa-
tient, an officer, had no seizure until eight hours
after the tenth injection of pitressin. Two pa-
tients had hysterical seizures and a third a prob-
able hysterical reaction.
Summary
A final diagnosis of epilepsy was made in fifty-
seven cases out of a total of seventy-three sus-
pected of epilepsy. Of these, 60 per cent gave a
history of seizures prior to enlistment.
There was no apparent close relationship be-
tween the onset of seizures and combat experi-
ence, head trauma, or serious illness in this group,
except for the possibility of two cases of dengue
fever, following which seizures occurred. A defi-
nite family history of convulsions was elicited in
23 per cent of the patients with the final diagnosis
of epilepsy. Evidence of a personality disorder or
mental deficiency was found in 40 per cent of the
established epileptics. Psychological tests gave
evidence of appreciable maladjustment in forty-
two cases of this group of fifty-seven epileptics.
The significance of these findings was not deter-
mined. The electroencephalogram was definitely
abnormal in only 54 per cent of the cases in which
the diagnosis of epilepsy was considered justified.
A comparison of this military group of estab-
lished epileptics with a civilian group revealed a
lower percentage of abnormal electroencephalo-
grams in the former, which implies that the con-
(Continued on Page 61)
January, 1947
51
USES OF RADON OINTMENT
ROBERT E. FRICKE. M.D.,
Rochester, Minnesota
QINCE the inception, of roentgen and radium
^ therapy and their widespread and effective
use in treatment of cancer, ulceration due to in-
jury to the skin has presented a serious problem.
The cutaneous damage may have resulted from
the repeated treatments required to destroy a
malignant lesion or from some individual idiosyn-
cracy, as the tissues of some people will not
tolerate an amount of irradiation harmless to most.
In either case, the radiodermatitis may not ap-
pear for some years after the exposures. It often
appears as a telangiectasis which is permanent ;
subsequent trauma may produce a chronic ulcer.
The ulceration differs from most inflammatory
ulcers in that the poor blood supply, due to
sclerosis of the vessels, nullifies any tendency to
heal spontaneously or following the administration
of stimulating ointments. This damaged vascular-
ization also discourages attempts to excise the
ulcer and graft successfully. The indolent ulcer
refuses to heal and eventually a malignant lesion
is prone to develop.
These indolent ulcers have presented a serious
problem to radiologists and dermatologists for
many years, and many ointments and medicinal
preparations have had their vogue. However,
these preparations fail to afford complete satis-
faction. Preparations of the leaves of Aloe vera,
ointments containing sulfonamide compounds,
gramicidin ointments, aluminum subacetate wash-
es, petrolatum irradiated with ultraviolet rays, and
so forth, have shown some promise in the past
but have not been absolutely satisfactory.
The type of therapy discussed in this study
is the use of alpha particles provided by radon
absorbed in petrolatum or lanolin. Alpha particle
treatment was described by Fabry1'3 in 1925 and
1926. He used thorium X in petrolatum with
encouraging results. Since 1930, Uhlmann®’7 has
continued this form of treatment, employing ra-
don in petrolatum or lanolin.
The alpha particle is the nucleus of the helium
atom with two positive charges and is emitted by
radium in its disintegration to form radon, and
From the Section on Therapeutic Radiology, Mayo Clinic,
Rochester, Minnesota.
Read at the annual meeting of the American Therapeutic
Society, Atlantic City, New Jersey, May 11 and 12, 1946.
52
by radon in its decay to become the elements of
lighter atomic weight known as the active deposit.
The radiations producing the ulceration of the
skin are beta rays, gamma rays and roentgen
rays. The alpha particle is never used in cancer
therapy. Its range is limited to a few centimeters
in air and it is stopped by the thinnest glass wall
or by a piece of paper. As all radium and radon
used in cancer therapy are enclosed in metal,
alpha particles are not utilized.
Hence, while alpha particles are a component
of the irradiations given off by radium and its
decay products, they had no part in producing
the injury but are a formerly unused portion of
the irradiations.
Preparation
In cancer therapy, radium salt or radon is
utilized. After radium bromide or chloride has
been dissolved in water, the gas radon is collected
and purified. Radon decays rapidly; its half-
value is 3.85 days. Any clinic using a radon plant
for cancer therapy can readily manufacture radon
ointment. The gas is absorbed readily in petro-
latum or lanolin ; it is sixteen times as absorbable
in petrolatum as in water at room temperature.
Extremely weak preparations are used ; in can-
cer therapy 50 mg. of radium sulfate or 50 mil-
licuries of radon are common units of treatment.
Radon ointment is commonly used in the
strength of 40 to 100 microcuries (0.04 to 0.1
millicurie) to the cubic centimeter or gram of
petrolatum. Metal seeds containing radon are
broken into a jar of petrolatum and the strength
of the preparation is measured by its gamma
radiation.
The range of the alpha particle is only 0.1
mm. in tissue but penetration of the petrolatum
favors a deeper absorption. Experiments quoted
by Low-Beer and Stone5 indicate that radon may
be absorbed even through intact skin.
Technique
The treatment of the ulceration with radon
ointment usually is patterned after that suggested
by Uhlmann. Radon ointment is freshly prepared
in the strength of 30 to 100 microcuries per cubic
AIinnesota Medicine
USES OF RADON OINTMENT— FRICKE
centimeter of petrolatum. It is spread over the
surface of the ulcer in a layer 4 to 5 mm. thick
and immediately covered with a piece of rubber,
oilcloth or other material, sealed in place with
overlapping strips of adhesive. This is done to
retard the escape of radon from the petrolatum.
The ointment is left in place for eight hours and
then removed. The application is made once a
week for eight or ten weeks with freshly prepared
ointment each time. Usually, by the end of the
third application healing becomes evident. If
there is no evidence of healing, a malignant lesion
is probably present and the radon ointment treat-
ment may be discontinued. It is important to
know that radon ointment therapy is valueless in
the face of malignant change.7
Williams and I4 previously reported the ex-
perience with the first two patients treated at the
Mayo Clinic with radon ointment; these were
treated in 1943. These two cases provided the
sternest test possible, as both chronic indolent
ulcers had already undergone malignant change.
Radium therapy was employed to control the
cancer and radon ointment to stimulate healing
of the ulcer. The' first patient, a woman present-
ing an ulcer in the right groin, which had not
healed completely for twenty-four years, obtained
palliation and partial healing over the next two
years, but the malignant process could not be
controlled entirely. The second patient, a man,
had a huge perianal ulcer of seven years’ dura-
tion following roentgen treatment for pruritus
ani in 1925. Biopsy from several regions showed
low grade carcinoma. The cancer was arrested
by radium therapy and the huge ulcer healed
completely with the application of radon ointment.
Since 1943, several patients who had chronic
ulcers have been treated. The ulcers treated had
not undergone malignant change. Definite heal-
ing appeared in six of ten of the ulcers treated ;
of the four failures three appeared due to insuf-
ficient treatment, the patients neglecting to return
after only one or two applications.
Other Uses
Besides chronic ulcers due to roentgen or
radium irradiation, treatment with radon oint-
ment has shown promise in two other conditions.
Cavities and ulcers of the vaginal wall with foul
necrotic slough, which appear in some people
following radium therapy for carcinoma of the
uterine cervix, seem to represent delayed heal-
January, 1947
ing. The tissues of these patients do not seem
to react normally to radiation and do not heal in
the usual manner.
These ulcers of the vaginal wall are as re-
sistant to ordinary stimulating medications as
roentgen ulcers of the skin. During the past two
years, seven patients who had this condition were
treated with radon ointment ; four showed ex-
cellent response. The three not apparently help-
ed abandoned treatment after one or two appli-
cations.
Another use made of radon ointment in 1945
was an attempt to stimulate epithelization follow-
ing operation to construct a vagina in cases of
congenital absence of that structure. Grafting
of the newly formed vaginal cavity appeared has-
tened and even the deeper tissues appeared more
flexible and resilient after radon ointment therapy
than when it was not used. The surgeon per-
forming these operations was pleased with the
results and referred all his patients, following this
rare operation, for postoperative treatment. The
radon ointment was spread over the plastic mold
used to maintain patency of the newly formed
vagina. Treatments were eight hours long and
were given once a week for eight or ten weeks.
Twelve patients were treated in 1945 with marked
benefit to all.
Conclusions
Radon absorbed in petrolatum or lanolin has
so far shown promise in the treatment of chronic
indolent ulcers with poor blood supply, occurring
usually many years after irradiation therapy. This
type of ulcer has proved exceedingly refractory
to other forms of treatment. In the future these
ulcers may become more common, as irradiation
is pushed to its limits in combating cancer.
Radon ointment therapy is tedious, extending
over several weeks’ time, and is not by any means
successful in every case. Some patients are not
helped. If malignant change has occurred, healing
will not ensue. It is important to remember that
radon ointment has no effect on malignant tissue.
Additional suggested uses are treatment of ne-
crotic ulcers of the vaginal wall, which occasion-
ally follow irradiation therapy of cancer of the
uterine cervix, and to stimulate growth of granula-
tion tissue after the operation for construction
of a vagina in patients who have had a congenital
absence of that structure.
(Continued on Page 59)
53
CLINICAL-PATHOLOGICAL CONFERENCES
ACUTE ISOLATED MYOCARDITIS (FIEDLER'S MYOCARDITIS)
A. J. HERTZOG. M.D., and W. D. HAYFORD, M.D.
Minneapolis, Minnesota
Dr. Hayford: This case (A-46-1626) is that of a
thirty-one-year-old white woman who was admitted to
the Minneapolis General Hospital on August 20, 1946.
She was complaining of a feeling of tightness across
the chest and of a very rapid heart beat. Her past
health had been good. She had had scarlet fever at
some time during her youth. She was the mother of
four children. There was no history of hypertension.
In May of 1946, she was confined to bed for one month
because of swelling of both legs. She had less severe
cardiac palpitation at this time. The details of this
illness are not known.
Physicial examination on admission to the hospital
showed a pulse rate of 220 per minute and regular.
The temperature was normal. The blood pressure was
94/80. She was a small, poorly nourished white female
in no acute distress. The point of maximal impulse of'
the heart was found in the fifth interspace about 8
cm. to the left of the midsternal line. The tones were
very forceful. There were no murmurs. The lungs were
clear. The liver was not palpable. There was no evi-
dence of congestive heart failure. The remaining ex-
amination showed nothing of note. An electrocardio-
gram showed a tachycardia with a rate of 220 and
slurring of the ST segment in all three leads (Fig. 1).
The tachycardia was thought to be supraventricular in
origin. The Kline and Rytz tests were negative for
syphilis. Blood chlorides were 638 mg. per cent. Urin-
alysis and leukocyte count were not completed, due to
her short stay in the hospital.
At 3:00 A.M. on August 21, she was given 4.0 c.c.
of cedilanid intravenously to begin rapid digitilization.
At 9:00 A.M., she stated that she felt somewhat better
althought her heart rate was still as rapid as it had
been upon admission. Carotid pressure or pressure on
the eyeballs did not affect the heart rate. Forced vomit-
ing by irritating the throat and forced-held inspiration
also had no effect on the heart rate. She was given a
second dose of 4.0 c.c. cedilanid. A second electrocar-
diogram at 9 :20 A.M. showed a tachycardia over 200
per minute and some ST depression. At 10:00 A.M., the
patient suddenly stiffened in bed and developed a marked
opisthotonus. She suddenly became cyanotic. Respira-
tions became very slow. Artificial respiration was in-
stituted and oxygen was given. She failed to respond
and died at 10 :02 A.M., on August 21, 1946.
From the Minneapolis General Hospital, A. J. Hertzog, M.D.,
pathologist.
Fig. 1. Electrocardiogram showing marked tachycardia.
Dr. Donald H. Peterson : X-ray films of her chest
do not contribute much. The heart appears normal in
size with nothing unusual about the contours of the
cardiac silhouette. The pulmonary markings are in-
distinct because the patient moved somewhat at the time
of exposure.
Dr. Hertzog : I think we should have a discussion of
this case before we give the autopsy findings. Does
any one wish to ask any questions or make a diagnosis?
54
Minnesota Medicine
CLINICAL-PATHOLOGICAL CONFERENCES
Intern : She was confined to bed in May of this year
with a tachycardia and swelling of her legs. I would
guess that she had acute rheumatic heart disease with an
endocarditis and possibly a myocarditis.
Dr. Hayford: The story that we were able to gather
from her and her family made a very poor one for
rheumatic fever in May. We were not impressed.
Student : How long can a severe tachycardia persist
without resulting in heart failure?
Dr. Herman Koschnitzke : In general, a tachycardia
of 240 or more if continuous for five days or longer
becomes incompatible with life. Such a tachycardia re-
duces the blood flow through the coronary arteries by
reducing the diastolic interval. Systolic contractions oc-
cur so fast that the heart is not properly filled with
blood during diastole. This embarrasses the coronary
circulation. Coronary sclerosis in older patients further
reduces the margin of safety.
Student : Why was she given digitalis instead of
quinidine?
Dr. Hayford : Cedilanid was given because the tachy-
cardia was first thought to be supraventricular in ori-
gin. Further study of the electrocardiograms showed
it to be ventricular in origin. Quinidine would then be
the treatment of choice.
Student: Ts it possible to have a ventricular tachy-
cardia as severe as this without the presence of or-
ganic heart disease?
Dr. Hertzog : Occasionally, it may happen. However,
we always think first of an anatomical basis for the
tachycardia, particularly coronary sclerosis in older peo-
ple. Dr. Sether will give the autopsy findings.
Autopsy
Dr. Julian Sether: The body was that of a small
poorly nourished female weighing approximately 105
pounds. There was no peripheral edema or signs of
congestive heart failure. The transverse cardiac diam-
eter was 12 cm. as compared to a transverse thoracic
diameter of 24 cm. The heart weighed only 270 grams.
The epicardial surfaces were smooth. The left ven-
tricular wall measured 1 cm. in thickness. The right
ventricle appeared dilated and measured 0.4 cm. in
thickness. The musculature of the heart was soft and
flabby. The valves and chordae tendineae were normal.
The circumferences of the valves were as follows:
aortic 6 cm., pulmonic 6 cm., mitral 8 cm., and tri-
cuspid 12 cm. There was no evidence of any endocar-
ditis. The musculature of the left ventricular wall and
interventricular septum contained irregular yellowish-
grey patches measuring up to 3 cm. in size. They
somewhat resembled areas of fatty metamorphosis. The
right lung weighed 180 grams and the left, 160 grams.
They appeared crepitant and were not edematous. The
liver weighed 1,240 grams and appeared normal. The
spleen, kidneys, gastrointestinal tract, and remaining
organs appeared normal.
Dr. Hertzog : We had to wait for the microscopic sec-
tions of the heart muscle to he sure as to what we were
dealing with in this case. I will show you on the screen
a section of the myocardium. There is a very severe
diffuse myocarditis. The myocardium is infiltrated with
Fig. 2. Photomicrograph of myocardium showing severe dif-
fuse inflammation and degenerating muscle fibers.
large numbers of mononuclear cells, eosinophiles, and
clumps of neutrophiles. There is extensive degenera-
tion of the muscle fibers. The large multinuclear giant
cells you see represent degenerating muscle fibers (Fig.
2). Nothing resembling Aschoff nodules is seen. Sec-
tions of the valves showed no evidence of any en-
docarditis. The epicardium appeared normal. The
pathology is hence essentially a severe diffuse idiopathic
myocarditis. A gram stain was negative for bacteria.
Sections of the remaining organs showed nothing of
note except slight patchy atelectasis of the lungs and pas-
sive congestion of the liver.
This case is then one of diffuse isolated acute myo-
carditis. We use the term isolated to mean that it is
confined to the myocardium and there is no evidence of
any disease in other parts of the heart or body. This
type of heart disease is well recognized as Fiedler’s
myocarditis. It does not resemble a rheumatic myocar-
ditis. However, I do not think we can completely elim-
inate rheumatic fever as an etiological factor from the
histology. The reported cases of myocarditis due to
sulfa sensitivity that I am familiar with have never
shown any muscle degeneration such as one sees in this
case. Furthermore we have no history of any sulfa
therapy. Dr. Hayford will give us a short review of
the literature of myocarditis with special reference to
Fiedler’s myocarditis.
Discussion
Dr. Hayford: The term, myocarditis, is one .that has
been badly abused. It should be limited to true inflam-
mations of the myocardium. Many physicians in the
past used the name loosely to describe myocardial ex-
haustion and changes in the myocardium secondary to
coronary disease. It is hence difficult to evaluate the
older reports on the incidence, of myocarditis in autopsy
January, 1947
55
CLINICAL-PATHOLOGICAL CONFERENCES
material. One of the best reviews of the subject in
recent years is'fh&t of Saphir.8 Saphir classifies myo-
carditis as follovits'y fetal; specific, due to such diseases
as rheumatic fever, tuberculosis, or syphilis, et cetera ;
myocarditis in infectious -disease with or without endo-
carditis ; and isolated or Fiedler’s myocarditis. He
found 240 cases of myocarditis in 5,626 autopsies. This
is an incidence of 4.26 per cent. In this series, there
were fifteen cases listed as isolated or Fiedler’s myocar-
ditis. Dr. Clawson1 found only one questionable case
of the granulomatous type in his series of 6,283 hearts
in the files of the pathology department of the Uni-
versity of Minnesota. Fiedler4 in 1899 described the
condition as follows : “There is an acute, rapidly occur-
ring inflammation of the myocardium which most likely
is due to micro-organisms. This same occurs, as a rule,
in young people with or without fever. The pulse rate
is markedly increased, and uncommonly decreased ; the
heart is dilated to the right and left ; heart action is
irregular ; dyspnea, cyanosis, congestive phenomena in
both greater and lesser circulation occur ; and there is
a marked tendency to cardiac weakness. The disease is
localized mainly in the myocardium and causes there
an interstitial myocarditis, the remaining organs being
uninvolved or having only a secondary inflammation.”
Isolated myocarditis is commonly a disease of young
people, the most common age period of reported cases
being twenty to fifty years of age. The onset is often
sudden, accompanied by a chill. Dyspnea, precordial dis-
tress, tachycardia, and weakness are common symptoms.
Sudden death occurs frequently. A review of the litera-
ture shows that two distinct histological types have
been described. One is characterized by the presence
of granulomatous lesions and the other by a more dif-
fuse type of inflammation. A form of myocarditis due
to sulfonamide therapy has become well known to
pathologists in the last three or four years. Such
cases have been reported by Weller and French9 and
Lederer and Rosenblatt.6 Most of these cases have been
interstitial myocarditis with little or no muscle degenera-
tion. Cases very similar to our case have been reported
in the last few years by Coulter and Marcuse2; Mal-
lory7 ; Hansmann and Schenken5 ; and Covey.3 The
disease known as isolated myocarditis probably has a
variety of undiscovered causes.
Bibliography
1. Clawson, R T. : Personal communication.
2. Coulter, W. W., and Marcuse, Peter: Acute isolated myo-
carditis. Am. T- Clin. Path., 14:399-404, 1942.
3. Covey, G. W. : Acute isolated myocarditis (Fiedler’s myo-
carditis). Am. T. Clin. Path., 12:160-165. 1942.
4. Fiedler: Ueher aknte interstitielle Myocarditis. Festschrift
des Sladtkrankenhauses, Dresden-Friedrichstadt, 1899.
5. Hansmann, G. H., and Schenken, J. R. : Acute isolated myo-
carditis. Am. Heart T.. 15:749. 1938.
6. Lederer, M., and Rosenblatt, P. : Death during sulfathiazole
therapy; pathologic and clinical observations on four cases
with autopsies. T.A-M.A , 119:8-18. 1942.
7. Mallory, Tracy: Case reports of Massachusetts General
Hospital. Case number 32122. New England J. Med.,
234:420-423, 1946.
8. Saphir, Otto: Myocarditis, a general review. Arch. Path.,
32:1,000-1.051. 1941 and 33:88-137, 1942.
9. Weller, C. V., and French, A. J. : Interstitial myocarditis
following the clinical and experimental use of sulfonamide
drugs. Am T. Path.. 18:109-121. 1942.
CONGENITAL URETHRAL VALVE
A Report of Two Cases
HAROLD H. JOFFE, M.D.. W. E. HATCH. M.D., and ARTHUR H. WELLS, M.D.
Duluth, Minnesota
Dr. A. H. Wells : We wish to present two cases of
urinary obstruction due to congenital valves in the pro-
static urethra. They illustrate some of the difficult
diagnostic features of this lesion found in widely
separated age groups.
Dr. R. E. Nutting: This three-and-a-half-month-old
white male infant was admitted on September 13, 1946,
weighing 13 pounds 10 ounces. He had been adopted
by his present parents at the age of six days, at which
time he was apparently normal and healthy. The mother
complained that for the past three or four weeks the
infant had been having noisy and heavy breathing. I
found him in apparent good health on August 17, 1946.
However, since that time she noticed that her child
had become rather pale. His diet was changed about
one month prior because of some “digestive disturbance.”
On September 12, 1946, the evening before admission,
the child vomited once and refused all food. The fol-
lowing day we found a hemoglobin of 50 per cent as-
From the Department of Pathology of St. Luke’s Hosoital,
Duluth, Minnesota, Arthur H. Wells, M.D., Pathologist. Cleri-
cal assistance by Miss Faith Gugler.
sociated with rapid, heavy respirations, enlarged heart,
possible palpable spleen, and an enlarged bladder. The
infant was brought to the hospital for immediate trans-
fusion.
In the hospital, a preliminary examination revealed
rapid and heavy breathing associated with expiratory
rasping but no evidence of any respiratory obstruction.
There was a mass in the left upper quadrant, thought to
be an enlarged spleen. The heart rate was 150 per
minute and regular. The hemoglobin was 9.5 grams
with a red blood cell count of 3,700,000, a white blood
cell count of 13,600 and a normal differential count.
During the preliminary examination while in the
oxygen tent, the child had a generalized convulsion as-
sociated with involuntary passage of stool and urine.
He expired approximately three hours after admission
without the blood transfusion.
Dr. A. H. Wells : This fairly well developed and
nourished 3k2-month-old white male infant was found to
have a valve like fold of mucous membrane sweeping
down from the verumontanum to the left and protruding
into the prostatic urethra to a sufficient degree to almost
56
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CLINICAL-PATHOLOGICAL CONFERENCES
completely obstruct this passageway (Fig. 1). There
was a similar fold passing down from the verumontanum
and swinging over to the left lateral wall. However,
this structure was small in comparison and apparently
played very little part in the obstruction. The prostatic
micturition and the observation of a gradual reduction
in the size of an already small stream of urine. He had
had a dull low backache for several years and for the
past year had noticed an accentuation of this pain in
the right flank. He was extremely nervous and ap-
Fig. 1. Arrow points to curved shelf-like
valve obstructing prostatic urethra. See dilated
prostatic urethra, also dilated and trabeculated
bladder.
urethra above the valve on the left was severely dilated
and cone shaped. The urethral orifice gaped widely.
The urinary bladder had severely hypertrophied and
thickened walls. It contained approximately 50 c.c. of
clear amber-colored fluid, and its fundus extended half
way up between the symphysis pubis and the umbilicus.
Its mucosal surface was rather severely trabeculated.
The ureters were bilaterally severely dilated and tor-
tuous. Both kidney pelvi had extreme dilatations, and
there was severe atrophy of the parenchymal tissue of
both kidneys. The kidneys weighed 30 and 32 grams
respectively and measured approximately 3x3. 5x6 cm.
Their thin shell-like walls had no grossly normal ap-
pearing kidney tissue. The blood urea nitrogen was
214.4 mg. per cent and the creatinine 5.25 mg. per cent.
Incidental findings were cardiac hypertrophy (60
grams) due primarily to hypertrophy of the left ven-
tricle and mild dilatation of all cardiac cavities. There
were toxic changes of moderate grade in the myocar-
dium, liver, and spleen.
Final diagnosis — Congenital urethral valves (a) dila-
tation -of posterior urethra, (b) hypertrophy and dila-
tation of bladder, (c) bilateral hydroureter (severe),
(d) bilateral hydronephrosis (severe), (e) uremia (im-
mediate cause of death), (f) cardiac hypertrophy and
dilatation of cavities, (g) toxic changes in myocardium,
liver, and spleen.
Dr. W. E. Hatch : I wish to present the case of a
young white man of twenty-one years who gave a his-
tory of persistent bed-wetting up until the age of six-
teen, also the constant necessity of much straining with
January, 1947
Fig. 2. Proximal urethra filled with opaque
media revealing site of obstruction in posterior
urethra.
prehensive and had given up the idea of going to col-
lege. The effort necessary for micturition was quite
noticeable. He had a residual of 60 c.c. of cloudy urine
with 30 to 40 pus cells per high-power field. The urine
had a normal specific gravity. There were 5,500,000
red blood cells, a hemoglobin of 17 grams, and 12,650
white blood cells.
The cystoscope was passed into the bladder only
after overcoming considerable resistance -in the poste-
rior urethra, where much manipulation was necessary.
Mild cystitis and early trabeculation was seen on the
bladder mucosa. Many pus cells were found in speci-
mens from both kidney pelvi. The pyelogram revealed
a uniform moderate dilatation of the pelvis on the
right side and a normal pelvis on the left. A urethro-
gram (Fig. 2) revealed a constriction in the posterior
urethra. A thorough inspection of the urethra using
the urethroscope and the McCarthy fore oblique cysto-
scope revealed congenital valves of the infra montanae
type. There was only a mild congestion of the mucous
membrane of the posterior urethra.
The congenital valves of the urethra were severed
using the McCarthy resectoscope with the cutting cur-
rent. An indwelling catheter with irrigation for a few
days was the only postoperative treatment used.
The patient immediately noticed marked improve-
ment in his freedom of urination. Various types of
cystoscopes were passed at different times since the
operation without meeting the former resistance and
urethrograms failed to reveal the obstruction found in
Figure 2. In six months he gained 26 pounds, his nerv-
ousness subsided, ambition and energy increased and
57
CLINICAL-PATHOLOGICAL CONFERENCES
he went to college. It is now almost ten years later
and he has had no further difficulty with urination.
Discussion
Dr. H. H. Joffe: Counseller and Menville2 reviewed
eighty-four cases with congenital urethral valves and
found that 75 per cent occurred before the age of ten
Fig. 3. Taken from Young and McKay.18 Three types of
congenital urethral obstruction.
and 52 per cent before the age of five. These figures
closely parallel the age incidence of other reports. 10>14>18
The ratio of males to females is about 3:1. 15 Stevens14
in 1936 found fourteen cases of obstruction of the fe-
male urethra by diaphragms or valves. There were ap-
proximately 130 cases reported in the literature up to
1945. 17
Etiology
The early anatomists regarded the congenital valves
as dilated lacunae, aberrant folds of mucosa or ad-
herent fibrin masses.10 At present there is no unanimity
of opinion as to their formation. Many explanations of
etiology have been advocated, none of which adequately
explain all types of the valves. The following are some
of the proposed theories :
1. Simple enlargement of normal prostatic urethral
folds.1'13
2. Developmental anomaly of the Wolffian and Mul-
lerian ducts.4'6
3. Anomalous attachment of the verumontanum to the
roof of the posterior urethra.10'13’16
4. Persistence of the fetal urogenital membrane.1’4’6’13
5. Remnant arising from the fusion of the entoderm
with the ectoderm.17
According to Watson16 valves of the prostatic ure-
thra may have their origin as early as the fourteenth
58
week of fetal life and occur at the time of marked
epithelial activity.
Davidsohn3 reported a case of identical congenital
valves in twins. The placenta and membranes were not
properly examined, therefore the monozygotic or dizy-
gotic nature of the twins were unknown.
Classification
The classification of Young1’3’4’17 is the most widely
accepted (Fig. 3). Here congenital valves of the pos-
terior urethra are divided into three types, with type I
being the most common.
Type I : A ridgelike fold extending distally from
the verumontanum and dividing into two membranous
sheets which are attached to the sides of the prostatic
urethra (Fig. 3).
Type II : A similar ridge and folds as in Type I
extending proximally towards the internal sphincter
where they are attached to the urethra (Fig. 3).
Type III : A diaphragmatic fold, iris type, incomplete
crescent or semicircular fold on either side of the
urethra which may occur in any portion of the prostatic
urethra with a small central or eccentric aperture
(Fig. 3).
Pathological Anatomy
The results of obstruction to the flow of urine are
those incident to any urethral obstruction1 and the de-
gree of pathology is proportional to the amount of
obstruction.17 An original hypertrophy of the bladder
musculature and trigone may in time fail to overcome
the resistance of the valves with a resultant dilatation
and residual urine. Dilatation of the posterior urethra
proximal to the valves, bilateral hydroureter and hydone-
phrosis usually follow with eventual death from uremia
in untreated cases. The resultant urinary stasis pre-
disposes to cystitis, ureteritis, pyelitis and pyelone-
phritis.
Symptoms
According to Whipple17 over half of the 130 cases
reported in the literature were not diagnosed during
life, which emphasizes the fact that this entity is not
as widely known as it should be. The symptoms are
those produced by the local obstruction, secondary in-
fection, and resultant uremia. The chief complaint is
usually some disorder of urination such as pain, reten-
tion, incontinence, frequency, eneuresis, and dribbling.
Difficulty in starting the stream and in voiding are
among the early manifestations and may date back to
birth.2 Frequency even in the absence of infection is
common in all except in the late stages because of the
reduced elasticity and working capacity of the hyper-
trophied bladder.10 Eneuresis may be the sole complaint
and in a series of forty cases reviewed in the literature
was reported in twenty-nine cases.6 All were between
the ages of five and fifteen. The symptoms of fretful-
ness, loss of weight or failure to gain weight, protuber-
ant abdomen, secondary to a distended bladder, chills,
fever, and pyuria of secondary infection and evidence of
renal damage are of paramount importance. With exten-
sive damage to the kidney, signs of renal insufficiency are
manifested by low renal function, anemia, retention of
Minnesota Medicine
CLINICAL-PATHOLOGICAL CONFERENCES
nitrogenous products in the blood, gastrointestinal dis-
turbances, such as nausea, vomiting and anorexia, also
neurological symptoms, and finally lethargy and
coma.1'2'5’6’8’9'10’13’18 The fallacy that the bladder is
always distended sufficiently to be seen or felt is shown
in the series of Campbell15 and Thompson.15 A history
of continuous difficulty in urination since birth is highly
suggestive of congenital valvular obstruction of the
posterior urethra.13
Diagnosis
Dr. W. E. Hatch : The following conditions should
be considered in a differential diagnosis : vesical or ure-
thral calculi, hypertrophied verumontanum, chronic
pyelonephritis, congenital polycystic kidney, congenital
strictures, new growths of the prostate or urethra, and
cord bladder with paralysis and those associated with
spina bifida.
It is of importance to keep in mind that valves while
obstructing the flow of urine may offer no resistance to
the passage of a sound into the bladder because the
valves fall back against the side of the prostatic urethra
during the passage only to return to their original ob-
structing position.
The most valuable diagnostic procedure is that of
cystoscopy and endoscopy with a carefully prepared
lateral x-ray view of the urethra filled with opaque
media. There should be a characteristic dilatation of
the bladder neck and posterior prostatic urethra above
a constricting point. An excretory urogram may well
indicate the degree of kidney and urethral damage. Blad-
der residual, urine cultures and blood chemical analyses
help complete the study. Great care and a diminutive
cystoscope are essential to the study of an infant bladder.
Treatment
Treatment is based on relief of urinary obstruction
and the method of choice is transurethral resec-
tion.1-2-11-13-15’18 There are advocates of perineal ure-
throtomy11 and suprapubic9-12 cystotomy approaches.
Special care must be exercised in handling the tiny
delicate structures in infants. A slow decompression ex-
tending over two or more days is essential in the more
severe cases at any age. A long period of urethral drain-
age of the bladder and chemotherapy may be advisable
before an attempt at destroying the obstructing lesion. In
cases with severe renal impairment the prognosis is
poor, especially if urinary tract infection is well estab-
lished.
While the true value of radon ointment is not
known and work with it is still experimental, suf-
ficient promise has been shown to encourage con-
tinuance of this form of therapy.
References
1. Fabry, J. : Behandlung einer schweren Rontgenverbrennung
der Hande mit Radium und Doramadsalbe. Med. Klin.,
2:1498, (Oct. 2) 1925.
2. Fabry, J.: Entstehung und Entfernung der oberflachlichen
Gefassektasien nach Rontgen — und Radium-Mesothorium-
bestrahlungen. Med. Klin., 2:1408-1409, (Sept. 10) 1926.
January, 1947
Summary
Two cases of congenital valves obstructing the ure-
thra have been reported. The one in a three-and-a-half-
month-old infant was recognized only after it had
led to death through uremia. The second patient, a
twenty-one-year-old man, had congenital prostatic ure-
thral valves which proved the basis of sixteen years of
bed-wetting. He also noticed increasing difficulty with
urination, small urinary stream, low backache, pain in the
right flank, and psychologic disturbances. He was
completely cured following transurethral resection of
the valves.
A brief review of the literature concerning the etiology,
classification, pathological anatomy, symptoms, diagnosis
and treatment are included.
References
1. Burnell, G. H.: Congenital valvular obstruction of posterior
urethra. Australian & New Zealand J. Surg., 4:322-326,
(Jan.) 1935.
2. Counseller, V. S., and Menville, J. G.: Congenital valves
of the posterior urethra. J. Urol., 34:268-277, (Sept.) 1935.
3. Davidsohn, I., and Newberger, C.: Congenital valves of the
posterior urethra in twins. Arch. Path.. 16:57-62, (July)
1933.
4. Day, R. V., and Vivian, C. S. : Congenital obstructions in
the posterior urethra. Transactions of Section on Urology
of A-M-A. 78th Annual Session. May 20. 1927.
5. Derow, H. A., and Brodny, M. L.: Congenital posterior
urethral valve causing renal rickets; report of case. New
England J. Med., 221:685-690, (Nov. 2) 1939.
6. Fagerstrom, D. P. : Congenital obstruction of lower urinary
tract in male with particular reference to valve formations.
T. Urol. 37:166-179. (Tan) 1937.
7. Fowler, M. F. : Diagnosis and management of congenital
valves at vesical neck; report of cases. J. Urol., 49:178-
183, (Jan.) 1943.
8. Kearns, W. M., and Jacobson, E. B. : Pediatric-urologic
problem; congenital valves, of posterior urethra with case
report. Wisconsin M. J., 39:603-606, (Aug;.) 1940.
9. Kretschmer, H. L., and Pierson, L. E.: Congenital valves
of posterior urethra. Am. J. Dis. Child., 38:804-817, (Oct.)
1929.
10. Landes, H. E., and Rail, R: Congenital valvular obstruc-
tion of posterior urethra. J. Urol., 34:254-267, (Sept.) 1935.
11. Nesbit, R. M. : Congenital valvular obstruction of prostatic
urethra; notes on surgical procedure. J. Urol., 51:167-169,
(Feb.) 1944.
12. Poole-Wilson, U. S-: Congenital valvular obstruction of
neck of bladder. Brit. J. Urol., 15:11-16, (Mar.) 1943.
13. Shih, H. E., and Char, G. Y. : Congenital urethral valves.
Chinese M. J., 52:19-32, (July) 1937.
14. Stevens, W. E. : Congenital obstructions of female urethra.
J.A.M.A., 106:89-92, (Jan. 11) 1936.
15. Thompson, G. J.: Urinary obstruction of vesical neck and
posterior urethra of congenital origin. J. Urol., 47:591-601,
(May) 1942. ■
16. Watson, E. M.: Structural basis for congenital valve for-
mation in the posterior urethra. J. Urol., 7:371, 1922.
17. Whipple, R. U. : Pediatric urological problem important to
general practitioner. Am. J. Surg., 68:297-302, (June) 1945.
18. Young, H. H., and McKay, R. W. : Congenital valvular
obstruction of prnstatic urethra. Surg.. Gynec. & Obst.,
48:509-535. (April) 1929.
3. Fabry, J.: tlber Behandlung von Rontgenulcera mit Thorium
X (Degea, frtiher Doramalsalbe) und Radium. II. Mit-
teilung. Med. Klin., 2:1891-1892, (Dec. 3) 1926.
4. Fricke, R. E. and Williams, M. M. D. : Radon ointment
treatment of irradiation ulcers. Radiology, 45:156-160,
(Aug.) 1945.
5. Low-Beer, B. V. A. and Stone, R. S. : The treatment of
late post-irradiation ulcers with radon ointment. Radiology,
46:149-158, (Feb.) 1946.
6. Uhlmann, Erich: The treatment if injuries produced by
roentgen rays and radioactive substances. Am. J. Roentgen-
ol., 41:80-90, (Jan.) 1939.
7. Uhlmann, Erich, and' Grossman, Abraham. The use of radon
ointment as a means of differentiation between radione-
crosis and recurrent carcinoma. Am. J. Roentgenol., 47 :
620-623, (Apr.) 1942.
Uses of Radon Ointment
(Continued from Page 53)
59
CASE REPORT
UNUSUALLY LARGE OVARIAN CYST IN AN ELDERLY WOMAN
LYMAN B. CLAY. M.D. and VERNE S. CABOT, M.D., F.A.C.S.
Minneapolis, Minnesota
THE unusual size of the tumor, age of the patient,
and the prolonged history are features which make
this case of interest to the surgeon.
The patient, a white woman, was first seen by us when
she was sixty-eight years of age. Her complaints were
'
Pig. 1. Abdominal distention with patient erect.
vertigo, fainting, and indefinite gastric distress. On
physical examination she was found to have a moderate
hypertention, and her abdomen was symmetrically dis-
tended and flat to percussion. The uterus was pushed
down deeply into the pelvis, and both vaginal vaults
were shortened and tense to palpation. A diagnosis was
made of a cystic tumor arising in the pelvis and extend-
ing as high as the xiphoid process. The patient gave a
history of having been examined fifteen years previously
and told that she had an ovarian cyst about the size of
a grapefruit. Since that time her abdomen had steadily
enlarged, although her extremities and face became pro-
gressively thinner. No treatment had been instituted.
We advised hospitalization but this was refused. She
was, therefore, treated symptomatically at home. During
the next three years the distention continued to increase
and her symptoms became more severe. She developed a
partial obstruction of the bowel, accompanied by pain,
and finally consented to be hospitalized.
Fig. 2. Abdominal distention with patient lying down.
After a few days of preparatory treatment, the ab-
domen was opened under local anesthesia supplemented
by nitrous oxide. A large cystic tumor was encountered
filling the entire abdominal cavity from the pelvis to the
diaphragm. The bowel was compr-essed and pushed into
the lateral gutters. The tumor was tense and thick
walled. A trochar was inserted and a large quantity of
clear straw-colored fluid evacuated. There were multiple
locules, many of wdiich had to be drained before delivery
of the cyst from the abdomen could be accomplished. A
large pedicle attached to the right broad ligament was
easily ligated and amputated. Immediately after closure
of the abdomen, a large turkish towel was folded and
strapped tightly over the dressing to compress the ab-
domen. The four extremities were wrapped with elastic
bandages. Although she vomited some bloody fluid the
first day, these measures proved successful in preventing
a marked fall in blood pressure and the patient’s con-
valescence was quite uneventful. She was discharged on
the twenty-third hospital day.
The cyst, when refilled with water, weighed 42 pounds
but due to the many small locules could not be distended
60
Minnesota Medicine
CASE REPORT
to its full capacity. The pathological report was, “a
multilocular cyst lined with a single layer of columnar
epithelium. There is no evidence of gross or microscopic
malignancy.”
After two and a half months of freedom from symp-
toms, the patient again became suddenly ill with fever
and vomiting. At this time she showed a weight gain
of thirty-five pounds since her discharge from the hos-
pital. Her symptoms subsided, but in a few days they
recurred, accompanied by rapid abdominal distention,
marked pyuria, and albuminuria. Gastrointestinal stud-
ies were negative except for a small herniation of the
stomach into the esophageal hiatus of the diaphragm. A
paracentesis was performed and nine liters of amber
fluid obtained. The centrifuged specimen showed meta-
static carcinoma cells.
One month later there was a return of the ascites, and
we elected to do an exploratory laparotomy. A large
amount of straw colored fluid was found, and the
omentum and abdominal organs were studded with meta-
static carcinomatous lesions.
Following operation, the patient failed rapidly and ex-
pired on the fourth postoperative day. The post-mortem
findings were :
1. Metastatic carcinoma involving the serous surfaces
of the abdominal organs and omentum.
2. Coronary sclerosis grade 4.
3. Pulmonary edema.
4. Thrombosis of the abdominal aorta and vena cava.
5. Fatty metamorphosis of the liver without carci-
nomatous involvement.
6. Cholelithiasis.
It was the pathologist’s opinion that the primary lesion
was probably small and passed unobserved in the original
cyst, as none could be found at post-mortem examination.
Observations on a Mild Form
of Epilepsy
( Continued from Page 51)
vulsive states of the military group were of a milder
character. Grand mal convulsions were induced
with the water-pitressin test in 23 per cent of
those with the final diagnosis of epilepsy. This is
less than one-half the percentage of positive tests
in a previous group which also suggests a less se-
vere grade of epilepsy in the present group.
References
1. Allen, F. M. : Spontaneous and induced epileptiform attacks
in dog9, in relation to fluid balance and kidney function.
Am. J. Psychiat., 102:67-73, (July) 1945.
2. Blyth, W. : Pitressir. diagnosis of idiopathic epilepsy. Brit.
M. T., 1:100-102, (Jan. 23) 1943.
3. Davidoff, E., Doolittle, G. M., and Bonafede, V. L. ; Psy-
chiatric aspects of epdepsy. J. Nerv. & Ment. Dis., 100:170-
184, (Aug.) 1944.
4. Finley, K. H., and Dynes, J. B.: Electroencephalographic
studies in epilepsy. Brain, 65:256-265, (Sept.) 1942.
5. Garland, H. G„ Dick, A. P., and Whitty, C. W. M. :
Water-pitressin test in diagnosis of epilepsy. Lancet, 2:566-
569, (Nov. 6) 1943.
January, 1947
6. Hilger, D. W., Mueller, A. R., and Freed, A. E. : The
pitressin hydration test in the diagnosis of idiopathic epi-
lepsy. Mil. Surgeon, 91:309-313, (Sept.) 1942.
7. McQuarrie, I. : Epilepsy in children. The relationship of
water balance to the occurrence of seizures. Am. J. Dis.
Child., 38:451-467, (Sept.) 1929. .
8. McQuarrie, I., and Peeler, D. B.: The effects of sustained
pituitary antidiuresis and forced water drinking in epileptic
children. A diagnostic and etiologic study. J. Clin. Inves-
tigation, 10:915-940, (Oct.) 1931. .
9. Yakovlev, P. I.: Neurological mechanism concerned in epi-
leptic seizures. Arch. Neurol. & Psychiat., 37:523-554,
(March) 1937.
Rectal Impalement
(Continued from Page 46)
Discussion
The wisdom of closing the rectal tear in the
primary operation might be questioned. This was
done, however, to prevent extrusion of a loop
of small gut; allowance was made for drainage
into the rectum from the contaminated area. That
this was adequate is evident from the prompt
formation of a rectovesical fistula without ap-
parent urinary diffusion into the perivesical tis-
sues.
The triple nature of this injury merits some
comment regarding anatomical variation of the
rectovesical pouch of Douglas. Obviously, only
a rather deep one would make it possible for the
impaling agent to penetrate in a straight line, the
rectum, peritoneal cavity and bladder, and such
was found to be the case at operation.
References
Bacon, H. E„ and Reuther, T. F.: Wounds of the anorectum
and their treatment. Surg. Clin. North America, 17:1809-
1821, (Dec.) 1937. .....
Ballon, H. C., and Goldbloom, Alton: Serious injury to the
rectum from improperly administered enemas. Canad. M.
A.J., 45:345-348, (Oct.) 1941. .
Behrend, Moses and Herrman, C. S. : Traumatic perfora-
tion of the sigmoid colon. J.A.M.A., 101 :1226-1227, (Oct.
14) 1933. . ,
Block F B., and Weissman, M. I.: Pneumatic rupture of
the sigmoid. J.A.M.A., 86:1597-1599, (May 22) 1926.
Brumbaugh, C. G. : Rupture of the rectum resulting from
instrumentation. Atlantic M. J., 27:651-652, (July) 1924.
Burt C A. V. : Pneumatic rupture of the intestinal canal.
Arch. Surg., 22:875, (June) 1931. , . ,
Crohn, B. B., and Rosenak, B. D.: Traumas resulting from
sigmoid manipulation. Am. J. Digest. Dis., 2:678-682, 1935-
Dodds, R. L. and Mayeur, M H.: Misguided efforts at
abortion. Brit. M. J., 1:921-922, (May) 1939.
Galbraith, W. W. : Severe rectal injuries caused by an
enema given through a rigid nozzle. Brit. M. J., 1:859-860,
(April) 24) 1937.
Goldman, C.: Rupture of the rectum during proctoscopic
examination. J.A.M.A., 93:31, (July 6) 1929.
Pearse, Herman E. : Instrumental perforation of the rec-
tosigmoid. Arch. Surg., 42:850, (May) 1941.
Peek, L. A. : Gunshot wounds of the rectum. J. Florida M.
A., 14:396, (Feb.) 1928. , . .,
Pinnock, D. D. : Dangerous rectal trauma due to a rigid
nozzle. Lancet, 1:205-206, (Jan. 23) 1937.
Powers, J. H., and O’Meara, E. S. : Perforated wound of
the rectum into the pouch of Pouglas. Ann. Surg., 109:
468-473, (March) 1939.
Sallick, M. A. : The conservative management of sigmoido-
scopic perforation. Surgery, 8:473-477, (Sept.) 1940.
Scott W. W. : Repair of the rectal tear and rectourethral
fistula. J. Urol., 33:643-656, (June) 1935.
Smiley, K. E. : Instrumental perforation of the rectum.
California & West. Med., 39:329, (Nov.) 1933.
Walkling, A. : Rupture of the sigmoid by hydrostatic pres-
sure. Ann. Surg., 102:471-472, (Sept.) 1935.
Wilhelm, S. F. : Treatment of recto-urethral and recto-
vesical fistula. J. Urol., 53:719-724, 1945.
61
HISTORY OF MEDICINE IN MINNESOTA
♦
♦
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester, Minnesota
(Continued from December is^ue)
Henry C. Grover, of Irish descent, was born to American parents on March
26, 1830, on a farm in Union County, Indiana. His father, Josiah Grover,
who successively was saddler, farmer and storekeeper, was a native of Ken-
tucky ; his mother was Sophia Everts Grover, daughter of Dr. Sylvanus
Everts, of Indiana, originally of Vermont. Sophia Everts, as has been told,
had six brothers, all of whom became physicians, so that it is not strange that
of her six sons one should enter the medical profession. Of her sons, S. E.
Grover and Daniel P. Grover made their homes in La Porte, Indiana; B. A.
Grover lived in Missouri and S. K. Grover in Capolis, Washington. Oscar
was killed in the Battle before Atlanta, Georgia, during the Civil War.
Henry Grover received his elementary education in the schools near his
father’s farm and he considered himself fortunate if he could attend classes
three months in the year. At the age of sixteen, he left the farm to become
the office boy of his grandfather, Dr. Sylvanus Everts; and predisposed as he
was to study medicine, the months spent in a medical atmosphere fixed his
determination to become a physician. In 1853 and 1854 he was a student at
the Medical School of the University of Michigan ; late in his course he trans-
ferred to the Medical School of the University of Keokuk (Iowa), of which
his uncle, Dr. Orpheus Everts, was a trustee, and there he received his de-
gree in medicine on February 22, 1855. In this same period a second uncle,
Thomas Haywood Everts, likewise a student of medicine at the University
of Michigan, also transferred to Keokuk, as has been told, and was graduated
in 1855.
Dr. Grover’s first period of medical practice, in Lake County, in northern
Indiana, was terminated by the Civil War. When hostilities were declared,
he enlisted as a private in the Twentieth Regiment of Indiana Volunteer
Infantry and was mustered in at Lafayette, Indiana, on July 22, 1861. Six
months later, on January 13, 1862, he was appointed assistant surgeon, and
for the next three years he met the fortunes of war with his regiment, which
not only helped to put down the Draft Riots of the week of July 13 to 16,
1863, in New York City, but was in twenty-two engagements, some of the
hardest fought of the campaigns, among them the battle of Chickahominy,
Hampden Roads, the Seven Days’ Battle before Richmond, Chancellors-
ville, Gettysburg, Spotsylvania Court House, Petersburg and Appomatox
Court House. Dr. Grover was continually at the front, ministering to the
sick and wounded, and alleviating suffering; the gratitude and blessings of
those whom he helped remained always one of his treasured memories. The
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HISTORY OF MEDICINE IN MINNESOTA
kit of surgical instruments which he used in his military service he long
afterward gave to Dr. R. V. Williams, of Rushford, and Dr. Williams in
turn, on September 16, 1941, when he was host to friends and colleagues m
the Olmsted-Houston-Fillmore-Dodge County Medical Society at a farewell
dinner on his retirement from practice, presented the kit to the Mayo Clinic ;
it has been preserved in the medical teaching museum of the Clinic and the
Mayo Foundation with other matters of interest pertaining to medical an
surgical practice.
In 1864, on the expiration of his army service, Dr. Grover re-entered the
Medical School of the University of Michigan for an additional year of study
before returning to medical practice in Lake County. Early m 1869 he left
Indiana for Minnesota, because of the excellent professional and nnancia
opportunity that the community of Rushford, Fillmore County, affor e , is
license to practice in the county was recorded on January 8 o t at year.
In Rushford he lived his long and useful life as a general practitioner, hig
in the esteem of his fellow citizens. For five years, from 1874 to 188U
he was in partnership with his uncle, Dr. Thomas H. Everts, who had settled
in Rushford in 1866, an association which was broken only when Dr. Everts
removed to Colorado to enter another profession.
Dr. Grover’s personal worth and ability were recognized in appointments
to various offices, civic and professional. He was mayor of Rushford an a
member of the village council, each for three years. As a councilman he was
instrumental in securing high license and in limiting the number of saloons
in the village. Twice he was sent as representative of his district to the
state legislature, between 1875 and 1877 and in 1879, and in his capacity
as legislator he was a faithful worker for measures that would advance t e
effectiveness of medical practice.
In his professional capacity he served as chairman of the local board of
health, as county physician, and as county coroner, first from January 8
1873, to January 8, 1880, and in a later term from 1891 to 1892. It happened
that during his first period of service as coroner, the discovery of the remains
of two human bodies in a box which was anchored in a branch of the Brook
Kedron in Sumner Township, caused horrified excitement, and Dr. Grover
of course was summoned. Fortunately, it proved that foul murder had not
been done; the cadavers had been placed in the brook by an enthusiastic
medical student to macerate that he might with a minimum of effort secure
the skeletons for study.
From the beginning an exponent of medical organization, Dr. Grover was
one of the early members of the Fillmore County Medical Society and he
was serving as its vice president in 1879 when the society suspended activity,
the officers to hold over to a more prosperous era. He was a member of the
Winona County Medical Society also and when, in 1904, the Houston-
Fillmore County Medical Society was formed, Dr. Grover, then seventy-
four years old, became an honorary member at the insistence of his younger
colleagues that his name appear on the roster. The proposal for member-
ship was presented by Dr. De Costa Rhines, to whom, as to many others of
his juniors in the profession, Dr. Grover was a kind and wise friend. A
devoted friendship held in common was that of Dr. Grover and his fellow
townsmen, Dr. J. W. Magelssen and Dr. H. W. Eldred, the well-known
surgeon-dentist ; these were a trio who by their loyalty to each other and
by their humor and spontaneous wit delighted their friends and acquaintances.
January, 1947
63
HISTORY OF MEDICINE IN MINNESOTA
In 1871 Dr. Grover became a member of the young Minnesota State Medi-
cal Society, and thereafter for many years he was active in its work. He
and Dr. Everts, among the few physicians in Fillmore County who responded
to requests from the organization, contributed valuable notes and reports for
its transactions and both men served on various of its committees. Dr.
Grover was at different times a member of the executive committee and of
the groups considering medical jurisprudence, obstetrics and necrology. On
November 14, 1883, under the law passed that year to regulate medical prac-
tice in the state, he received certificate No. 328 (R).
Dr. Grover did not use tobacco, was an enemy of alcoholic beverages.
Although he was stern and straightforward in dealing with serious problems,
he rarely expressed anger; he was kind and humorous, was fond of good
stories and a contributor of many. He was a Mason and a member and sup-
porter of the Unitarian Church. His absolute dependability and his zeal in
promoting any enterprise that was for the good of his fellow men come first
to the minds of those who knew him best.
Henry C. Grover was married to Sarah Jane Pratt, a school teacher who
was born at Jamestown, New York. Dr. and Mrs. Grover had two children,
Lucy, who died in childhood, and Fred H. Grover, a farmer, who by 1941
had retired and was living in Rushford. Dr. Grover, at the time of his death,
from carcinoma, on July 4, 1910, was making his home with his son.
Thomas Edmund Hall, the son of Mr. and Mrs. Thomas Hall, among the
earliest settlers of Fillmore County, was born at Preston in 1854 and spent
all of his life, with the exception of the vears when he was absent for study,
within a hundred miles of his birthplace. Immediately after his graduation
from Rush Medical College, in 1875, he began the practice of his profession
in the village of Lanesboro. Although he remained only a short time then,
he later spent many years there, and it is in that community that he has
been remembered most clearly, perhaps especially for his keen interest in
history and for his remarkable memory. One pioneer citizen of Lanesboro
has been quoted as saying that Dr. Hall knew more about the Civil War
than the men who fought in it; that he could read anything and recite it
word for word the next minute. Another person, a veteran of the Civil War
who had spent eighteen months in Libby Prison, was astonished to hear
Dr. Hall, who had never seen the place, describe the exact spot where the
veteran had been confined and the conditions that had existed in the prison.
Dr. Hall is said to have practiced medicine in several counties and many
different towns in southern Minnesota and, although the order and exact
time are not certain, trace has been discovered of various changes of resi-
dence. In 1875, in Fillmore County, he left Lanesboro for Preston and in the
same year went from Preston to Brownsdale and Austin, both in Mower
County. Shortly afterward he was for a time in Granada, Martin County,
and not long after that was in Lake City, Wabasha County, and in Frontenac,
Goodhue County. From 1878 into 1882 he was again in his native town of
Preston and was co-operating actively with the Minnesota State Medical
Society in obtaining data on the incidence and severity of diphtheria in Fill-
more County. From Preston he moved in the summer of 1882 to Dresbach,
Winona County. In the next period of three years, there were notes in the
Preston newspapers about his activities and his practice and about visits to
Preston by Dr. and Mrs. Hall and their little daughter. Then, in the sum-
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HISTORY OF MEDICINE IN MINNESOTA
mer of 1883 Mr. and Mrs. Thomas Hall, oldest citizens of Preston, moved per-
manently to Wilmington, Delaware. In this same period, under the act of
1883 to regulate medical practice. Dr. Hall received state certificate No. 781
(R).
Early in 1886 Dr. Hall settled once more in Lanesboro and through the
nineties and into the new century he was listed in medical directories as
practicing in that village. By 1909 he was in La Crescent, Houston County,
and in the following year he crossed the Mississippi River to practice medicine
and to make his home in La Crosse, Wisconsin. In La Crosse, on May 5,
1912, he died at the age of fifty-eight years. In 1941 his widow, Mrs. Rubie
T. Hall, continued to live in La Crosse.
Florence John Halloran, born on October 3, 1859, at Chatfield, Minnesota,
a village of both Lillmore and Olmsted Counties, was the son of 4 imothy
Halloran and Catherine McGuire Halloran.
Timothy Halloran was one of the notable pioneer settlers of the two
counties. He was the son of an Irish civil engineer, Florence Halloran, and
was born near Bandon, County Cork, Ireland, on December 5, 1832. When
he was twenty years old, he came to America, and after working for two
and a half years in Massachusetts and for some months in Wisconsin, -(
as he traveled west, he reached his goal of southern Minnesota in 1855 and
at once pre-empted some land in Pleasant Valley, Mower County. Very
soon, however, he transferred, these acres to his brother, who had accom-
panied him, and returned to Chatfield, through which he had passed en route
to Pleasant Valley. He lived in the village of Chatfield for five years and
spent the remainder of his life on farms which he owned in Elmira Town-
ship in Olmsted County. In 1858 he was married to Catherine McGuire,
of Chatfield, also a native of Ireland, who had come with her parents in the
early fifties to southern Minnesota. By unflagging hard work, the young
couple overcame the hardships and financial stress of pioneer life and won
through to comfortable prosperity. Their children, like themselves, were
good citizens : Michael D., a lawyer in Rochester, Minnesota, for many
years until his death ; Timothy, also deceased, of Duluth , Nora (Mrs. John
R. Manahan), of Chatfield, and Florence John, for forty-seven years a prac-
ticing physician. In 1897 I imothy Halloran, senior, wrote from memory his
History of Chatfield, often mentioned in these pages.
Florence John Halloran received his early education in the public schools
of Chatfield and his premedical training at the Campion Jesuit High School
at Prairie du Chien, Wisconsin. After his graduation from that school, in
1884, he taught school for a time before beginning his course at Rush Medi-
cal College; the Chatfield Democrat of October 3, 1885, stated that Florence
Halloran, “for the past two years a medical student under Dr. M. A. Trow,”
had left that week for “a course of lectures at Rush Medical.” On Feb-
ruary 21, 1888, he took his degree of doctor of medicine from Rush and
shortly afterward began his medical career in Forman, Sargent County,
Dakota Territory (North Dakota), where he practiced for about a year be-
fore settling in Chatfield. In the same year he was married to Nellie Tracy,
a school teacher, daughter of Mr. and Mrs. J. Tracy, highly respected
pioneer settlers of Laird, Eyota Township, Olmsted County. Dr. and Mrs.
Halloran had one son, Walter H. Llalloran, who became a physician.
From 1903 to 1912, Dr. Halloran practiced medicine in Saint Paul, devoting
January, 1947
65
HISTORY OF MEDICINE IN MINNESOTA
himself to the treatment of diseases of the heart and the stomach. During
this period, he became a member of the Ramsey County Medical Society and
was on the staffs of the Lutheran Hospital and the Bethesda Hospital.
With the exception of a short period in Winona in the autumn of 1894 and
the years in Dakota and Saint Paul, Dr. Halloran spent his entire profes-
sional life in Chatfield as a general practitioner. Tall and large, of fine
appearance, kind, genial and witty and, moreover, a competent physician
and skilled diagnostician, an omnivorous reader of the medical literature,
Dr. Halloran played an important part in the life of the village and the com-
munity. He had an extensive practice, served as local health officer, as medi-
cal examiner for the local draft board in World War I, and for many years
as mayor of Chatfield. He was enrolled in the local county medical society,
the Southern Minnesota Medical Association, the Minnesota State Medical
Association and the American Medical Association ; he was a member of the
Knights of Columbus and a faithful and active member of the Catholic
Church. In the years prior to 1900, his chief medical contemporaries in Chat-
field were John C. Dickson, Charles McH. Cooper, Aaron M. Stephens and
Milton A. Trow.
That Dr. Halloran was a strong and vivid personality is clear. Recollec-
tions of his kindly wit and especially of his generosity to the sick poor are
many. If fault or foible is mentioned, it is with affectionate tolerance.
In the last years of his life Dr. Halloran spent’ part of his time in Jackson,
Minnesota, with his son, Dr. Walter II. Halloran, who owns and operates
the Halloran Hospital, and after the death of Mrs. Halloran, on August 17,
1934, he moved permanently to Jackson. He died at the home of his son on
January 23, 1935.
In paying final tribute to Dr. Halloran, the editor of the Jackson County Pilot
wrote of him as one of the oldest and most prominent practicing physicians
in southern Minnesota, loved by all with whom he came in contact, both for
his skill and for the “pleasing geniality which always pervaded any company
that he entered.” And to this comment is added that of the son, who described
his father as “a general practitioner of the old school, who kept abreast of the
times and gave his services freely and willingly to his people, regardless of
personal agrandizement.”
“Dr. Hammer,” announced the Chatfield Democrat on November 3, 1883,
“will sell his stock and farming implements at public auction on November
15, at his old place near Pilot Mound.” This is the only mention of this
practitioner in Fillmore County that the writer has seen.
Possibly the same man, a Dr. Amos G. Hammer, graduate of the Physio-
Eclectic Medical College in 1867, was listed in the official state register of
physicians of 1883-1890 as a resident of Redwood Falls, Redwood County, and
the possessor of state certificate No. 297 (E) dated on November 10, 1883.
“Hammond, Thos.” was listed among the patrons of an illustrated historical
atlas of Minnesota of 1874 as a physician and surgeon of section 31, Elmira
Township, Olmsted County, post office Chatfield, a native of Adams County,
Pennsylvania, who came to Minnesota in 1864. There is reason to believe that
this was the Dr. FI. Thomas who lived in Chatfield for about fifteen years
and actively practiced medicine there into the eighties. A few notes on Dr.
Thomas follow in alphabetic place in the present series of sketches.
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HISTORY OF MEDICINE IN MINNESOTA
Henry Howard Haskin (a final “s” was added subsequently to the surname)
was born at Middlesex, Vermont, on September 10, 1844, and was one of
the five children of Samuel Haskin and Polly Almira Haskin. His brothers
and sisters were George, Dustin, Emmaline and Lois. Dustin died in in-
fancy. Of the others, in later years George lived in Cushing, Oklahoma;
Emmaline (Mrs. Blandin), in Minneapolis, Minnesota; and Lois (Mrs. Web-
ster Hills) in Downers Grove, Illinois. The father, Samuel Haskin, who
claimed direct descent from a passenger on the Mayflower, was a farmer
and miller.
When Henry was seven years old, his parents moved west with their family
to a homestead near Prairie du Sac, Columbia County, Wisconsin. There
the boy grew up, attending the rural school until at the beginning of the
Civil War he volunteered for service in the Union Army and was accepted.
For a short time he was a fifer, but when it was discovered that he wrote a
clear, legible hand he was chosen as clerk to the post adjutant at Benton
Barracks, St. Louis, Missouri, and in this office he remained until he re-
ceived his honorable discharge in 1865.
About three years later the Haskin family moved into southern Minnesota
and settled near Granger, in Bristol Township, Fillmore County, near the
Iowa line. In the winter of 1868 and 1869, Henry Haskin taught school in
the village of Harmony, in the bordering township of that name on the east,
and for the next three years he traveled for the Winneshiek Paper Mill Company.
On October 10, 1873, Henry Howard Haskin was married to Mary W.
Adams, a school teacher of English descent, who was a native of Brandon,
Vermont. To them were born two children, Leon Leroy and Ethel Leona.
At this period of his life Mr. Haskin was studying law in the office of an
attorney, a pursuit which he discontinued after a few months to undertake
the study of medicine at the Medical School of the University of Iowa,
from which he was graduated on March 7, 1877, as a doctor of medicine.
Dr. Haskin at once began to follow his profession at Kendalville, Iowa,
but soon moved to Elliota, Minnesota, which was three miles from the present
village, then nonexistent, of Canton. When Elliota became one of the disap-
pointed villages of the county by reason of being left to one side by the rail-
road, the commercial and professional interests were moved to Boomer,
which later received the name of Canton. It probably was early in his years
as a physician that Dr. Haskin added or, rather, accepted a final “s” on his
surname and became Dr. Haskins. As he said, everybody else put the “s”
on and therefore he did also.
In Canton from 1878 for the ensuing twenty-four years, Dr. Haskins was
a general practitioner of medicine and surgery and, on occasion, dentistry.
A trained pharmacist as well, he owned and operated one of the two drugstores
of the village; Dr. Robert A. Sturgeon, a pioneer physician in the county since
1865, who also had removed from Elliota to Canton, owned the second.
Dr. Haskins enlarged his interests by conducting with S. Manual, a general
store across the street from his drugstore. During these busy years Dr.
Haskins served his community well, kept abreast of advances in his profes-
sion, reading the literature, taking postgraduate work at Northwestern Uni-
versity and joining in the work of medical associations, among them the
local county medical society, the Southern Minnesota Medical Association
and the Minnesota Valley Society (the latter two groups merged in 1911,
taking the name “The Southern Minnesota Medical Association”), and the
January, 1947
67
HISTORY OF MEDICINE IN MINNESOTA
Minnesota State Medical Society. On October 11, 1883, under the new Medi-
cal Practice Act, Dr. Haskins received state certificate No. 50 (R). From
January 4, 1887, to January 6, 1889, he served as county coroner.
In the years from 1878 to 1887, Dr. James M. Wheat, of Lenora, in Canton
Township, one of the county’s earliest and most able pioneer physicians,
frequently called Dr. Haskins in consultation, and in a published report of
a “case of intrauterine fibroid tumor and operation” which he made to the
Committee on Gynecology of the State Medical Society credited Dr. Haskins
with assistance in carrying out the surgical procedure. Dr. Wheat moved to
California in 1887.
As a country physician with a heavy practice, Dr. Haskins had varied
experiences, some amusing, some touching or hazardous, all interesting. His
daughter, Ethel Haskins Gifford, has recalled the frequent sight, early in
the morning, of her father’s begrimed buggy, each spoke and hub laden with
mud, silent witness to the long tiresome trips in the rain and darkness. A
lantern on the dashboard was the only light ; side curtains and a rainproof lap
cover were the only protection against the weather. Sometimes the doctor
used his two-wheeled, spring-equipped cart and then was accompanied by
his shaggy little black and white dog Trax, who sat beside him, watching
the road eagerly. . . . One morning at three o’clock Dr. Haskins was called on
to perform an emergency operation, for strangulated hernia, on a citizen of
Canton ; the procedure was carried out successfully, the patient on the dining-
room table, in the light of an oil lamp which was held by his brother; the
patient made a good recovery and lived for forty years. Another time, Dr.
Haskins filled a tooth for the brother, melting a gold coin and pouring the
molten metal into the cavity. The patient withstood the operation without
benefit of anesthesia and carried the filling with him to his grave when he
died in his eighties. ... A favorite story was that of the little Norwegian boy
who walked in from the country to have his tonsils removed, replying to the
astonished physician’s question that he had come alone; and after the opera-
tion he walked home alone, “a true Nordic scout.”
Possessor of a brilliant mind and a keen wit, Dr. Haskins enjoyed lively
arguments, in which he was not always even-tempered. His pet diversions
were chess and checkers, and he took great satisfaction in having won high
score in the checkers club to which he belonged. The trophy, a belt which
the winner retained until defeated, was too tight for Dr. Haskins, who was
inclined to portliness, and he accordingly carried it in his pocket and proudly
displayed it on request. Persistency in any task he set himself was an out-
standing characteristic that is recalled by old friends; he taught himself
the Norwegian language and he learned to ride a bicycle, in spite of memor-
able mishaps.
Mrs. Haskins was an accomplished woman, intelligent and public-spirited.
She was active in organizing the Women’s Christian Temperance Union in
Canton and in securing free textbooks for the schools — bold undertakings,
unbecoming a woman it was thought by the scandalized older women of the
community, who nevertheless greatly admired Mrs. Plaskins. One woman,
who had heard Mrs. Potter Palmer speak as hostess at the Chicago World’s
Fair in 1893, said that she much preferred to hear Mary Haskins.
Although he was not a member, Dr. Haskins attended the Presbyterian
Church of Canton and sang in the choir. Later in his life he became much
interested in spiritualistic associations. He was a Mason, member of the
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HISTORY OF MEDICINE IN MINNESOTA
local Blue Lodge, of which he was several times Worshipful Master ; of
the Royal Arch Masons and the Order of the Eastern Star.
On Christmas night, 1899, Dr. Haskins’ drug store burned ; it was not re-
built and, in 1902, retiring from medical practice, the doctor left Canton for
Perth, North Dakota, where with his son he engaged in farming and in operat-
ing a general store. In 1919, having previously spent several winters in
Florida, he moved permanently to that state, to Southern Cassadaga Camp,
where he spent the remainder of his life. He died from influenza, compli-
cated by uremia, on May 9, 1922, survived by his wife, Mary W. Haskins ;
his son, Leon Leroy Haskins, of Warren, Minnesota; his daughter, Ethel
Haskins (Mrs. E. B.) Giflord, of De Land, Florida ; his sister, Lois Haskins
(Mrs. Webster) Hills, of Downers Grove, Illinois ;■ and his brother, George
Haskins, of Cushing, Oklahoma. Of this group, all were living in 1943
except Mrs. Haskins and George Haskins.
William Haslam was a homeopathic physician, apparently in good standing
among his colleagues in homeopathic associations, who settled in Chatfield in
1869. According to Haioran’s history of Chatfield, Dr. Haslam opened a
drug store in the village in partnership with W. R. Edward ; mention was
made of Mr. Edward selling the store to John S. Gove and Mr. Gove to J.
A. Ross, but further comment on Dr. Haslam was lacking. Only one other
note has appeared, and that in the Rochester Post of October 4, 1878: “Dr.
Haslam, an old philosopher well remembered in Chatfield, used to have one
weather sign that he regarded as never failing, to wit : That the direction
from which the wind blew when the sun was crossing the equator indicated
the direction from which it would prevail for the next six months. . . .”
(To be continued in February issue)
January, 1947
69
Louis A. Buie, M.D., President
Minnesota State Medical Association
70
Minnesota Medicine
Plesid ent s £.eite\
PHYSICIANS OF TODAY REJECT “PEACEFUL MEDIOCRITY" OF PAST
T N past years, an immense majority of physicians remained intellectually in a middle state.
They were not inefficient, but neither did they attempt to carry their activities beyond ac-
ceptable performance of their duties as practitioners of medicine. They were content to amble
on in peaceful mediocrity, adopting with little concern the current opinions of the day.
They merely maintained themselves on a level with their generation and conformed to the
standards of knowledge common to the age and the country in which they dwelt.
The physician of today is not like that. He knows that a passive attitude will not be
effective under present conditions. He knows that he must not limit his thought and activities
to purely professional duties. He knows that the welfare of the people, his patients, is menaced
by zealots who are so little conscious of their deficiencies that not only are they willing to
attempt impossible tasks, but they actually believe they are capable of accomplishing
those tasks. He realizes that these men, perched on their imaginary eminence, have become so
inflated by their fancied superiority that they attempt to teach and to manage that which they
themselves do not comprehend. He knows that those who are prey to such delusions, if
they also acquire the power to enforce them, will accomplish far more evil than good.
He is willing to tolerate temporary schemes which have been considered necessary in a
confused period of the world’s history. He has co-operated in the advancement of such
activities and is willing to continue to do so in spite of inconvenience and injustice to him.
He knows why these deficiencies exist. The hospital problem, the nursing problem, the office
and housing problem (probably he is a former medical officer returned to civil life), the
EMIC* problem and the bluebook, the prepayment insurance program, the service plan, the
indemnity plan, the situation regarding hospitals and certification, the specialty boards, the
Rich report and the reorganization of the American Medical Association, the meeting in
Two Harbors, Jim Murray, Bob Wagner, John Dingell, Claude Pepper — yes, all of these
obstructing problems, conditions and individuals, and more, are understood by him. And
he complains. That is a prerogative of the citizen in a free society. Had his forebears not
possessed this characteristic, probably the Declaration of Independence never would have
been written. Certainly he complains. He gets together with a group of general practitioners
and they speak their minds. He organizes the American College of Physicians and Surgeons
in an attempt to “do something about it.”
Despite unfavorable conditions that surround him, he performs his task sedulously. He
understands that for him to be possessed of knowledge concerning how to fulfill his duties
allows him to meet the intellectual obligations of his task and that if he is determined to do
these duties in spite of all inhibitors, he will meet the moral obligations of it. He under-
stands that these are the two most important items in his armamentarium and' that only if he
maintains them at peak efficiency and in harmonious relationship can he hope to contribute
to the objectives of his profession. He realizes that the success or failure of American medi-
cine rests squarely on his shoulders. He knows that the security and durability of the organi-
zation of which he is a part depend on him.
Consequently, as I assume my new duties, I feel neither uncertainty nor uneasiness. Mem-
bers of the Minnesota State Medical Association are well informed. The central office of
the Association is efficient. Together we can combat any man-made threats against the public
health.
President, Minnesota State Medical Association
*
Emergency Maternal and Infant Care.
January, 1947
71
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
MINNESOTA MEDICAL SERVICE
A DETAILED report of the meeting of the
House of Delegates of the Minnesota State
Medical Association, held in Saint Paul on De-
cember 22, 1946, to take action on the report of
its Committee on Minnesota Medical Service, ap-
pears in the section on Medical Economics in this
issue.
Although the last legislature passed an enabling
act authorizing the organized profession of the
state to establish a nonprofit medical service to
meet the need of insurance coverage for medical
fees, Minnesota Medical Service has not as yet
been incorporated. It is not surprising that in
such an involved project, progress has been slow.
The committee and its subcommittees have had
a multitude of meetings and have given much
thought to the subject. The findings were sub-
mitted to the House of Delegates at its December
22 meeting. The committee submitted two con-
tracts— one providing for surgical benefits alone
and the other for combined medical and surgical
benefits — and the rates which would be required.
Dr. Adson, chairman of the committee, then
brought out the fact that commercial insurance
companies now have available indemnity policies
providing benefits equal to and, in some instances,
greater than those proposed by Minnesota Medi-
cal Service, at considerably less cost. The es-
tablished insurance companies with 3,000 agencies
throughout the state are potential handlers of
these medical policies and can obviously under-
sell a small organization. Insurance of any kind
does not sell itself, and the cost of selling is a
large item in the insurance business.
It is not generally known that medical insurance
policies, providing benefits identical with those
proposed for Minnesota Medical .Service, are al-
ready being offered and sold by the commercial
insurance companies, for botli groups and in-
dividuals, at a very reasonable cost.
It was felt by the House of Delegates that phy-
sicians should do everything in their power to
promote the sale of these medical insurance poli-
cies offered by the commercial companies. The
House approved the appointment of a committee
of five physicians to publicize the availability of
such policies and to give the approval of the Min-
nesota State Medical Association to worthy
policies.
The House of Delegates, notwithstanding devel-
opments, decided to proceed with the incorpora-
tion of Minnesota Medical Service. Under its plan,
indemnity policies are sold to any wage earner
irrespective of his or her income. The policy-
holder pays the difference when the physician’s
fee is greater than that allowed by the policy. The
policy of the Minnesota Medical Service, how-
ever, will provide for fees applicable to indivi-
duals earning $1,200 or less a year and to mar-
ried persons earning $2,000 or less, and will
provide complete coverage of physicians’ fees for
this group, which today is a small one.
Insurance against hospital costs and physicians’
fees is the answer to the unequal cost of sick-
ness, and physicians can render their patients a
real service by urging them to take advantage of
these policies. A list of commercial policies ap-
proved by the Minnesota State Medical Asso-
ciation will doubtless be forthcoming in the near
future.
MORTALITY IN DIABETES
r"p HE incongruous fact that the mortality in
diabetes has been higher since insulin was
discovered has been generally known. The ex-
planation is made clear in a recent Bulletin of the
Metropolitan Life Insurance Company .f
There are today twice as many known diabetics
as there were twenty-five years ago when insulin
was discovered. This probably means an actual
increase in the disease itself, although the greatly
increased number of physical examinations that
include urinalyses undoubtedly accounts large-
ly for this fact. The rise in the percentage of
the population in the older age groups, a time
when diabetes is most likely to make its appar-
i A Quarter Century of Insulin. Bull. Metropolitan Life In-
surance Company, 27:8, (Oct.) 1946.
72
Minnesota Medicine
EDITORIAL
ance, also accounts for the increase in the dis-
ease.
Of course, it is well known that insulin has re-
sulted in a marked reduction in mortality among
diabetics, especially among those in the younger
age group. While it has resulted in a prolonga-
tion of life, diabetics can hardly live forever, and
the marked increase in deaths in diabetics over
the age of fifty-five is the reason for the rise in
the total mortality. As a matter of fact, the
death rate among diabetics, according to the
article mentioned, has heen markedly reduced in
each decade up to the age of fifty-five. An in-
crease is slightly apparent in men in the decade
from fifty-five to sixty-four, is more evident in
women in this age group, and then, in the decade
from sixty-five to seventy-four, the mortality be-
comes more than double that of the preceding
decade in both men and women.
The survey mentioned covers only the general
mortality among diabetics. What role the di-
abetes played as a cause of death doubtless can-
not be accurately determined — that is, how many
died with diabetes and how many died from the
disease. However, the analysis indicates, rather
than detracts from, the great value of insulin in
the treatment of diabetes.
HEART DISEASE
The Metropolitan Life Insurance Company, in co-
operation with the American Heart Society, is conduct-
ing an educational campaign on heart care. The pur-
pose of the campaign is to prevent heart disease and to
help people with heart disease to live longer and more
useful lives.
During the campaign, one and one-half million book-
lets entitled “Your Heart” will be distributed to the
laity, and a packet containing statistical information
will be sent to 43,000 physicians. Other means, such as
newspapers, radio, health departments and certain civic
groups, will also be utilized in disseminating information
about the heart and heart disease.
The campaign will coincide with the initial activity of
the Life Insurance Medical Research Fund recently es-
tablished by 148 life insurance companies in the United
States and Canada. This fund will make available over
$500,000 yearly for long-term research programs. Grants
are being made to medical schools and other research
institutions for heart studies.
The booklet, “Your Heart,” gives information about
the heart and heart disease suitable for an intelligent
layman. The statistics in the packet being sent to phy-
sicians are presented in the following excerpt from an
article entitled “Encouraging Trends in Heart Disease,”
which appeared in the Statistical Bulletin recently pub-
lished by the Metropolitan Life Insurance Company.
Encouraging Trends in Heart Disease
Measured in terms of sheer numbers of persons af-
fected, heart disease is our most important medical and
public health problem. There are today about four
million people in the United States who have some form
of heart disease, and the number of cases is steadily in-
creasing. Heart disease ranks first in the list of causes
of death. It is not surprising, therefore, that there is a
widespread impression that the situation with regard
to the disease is critical, that the outlook for the patient
with heart disease is poor, and that the conditions of
modern life are largely to blame. Actually, the situation
is much better than appears on the surface, and these
current gloomy beliefs about the disease are not war-
ranted by the facts. ■
It is true that the crude death rate from heart disease
has shown a steady increase over the years. The major
part of this increase, however, simply reflects the rap-
idly increasing proportion of older persons in our popu-
lation. In the past seventeen years, among the millions of
persons insured in the Metropolitan’s Industrial Depart-
ment, there has been an almost uninterrupted rise in the
crude death rate from the disease, reaching a maximum
in 1943, with a total increase of nearly 60 per cent since
1928. As against this large increase, the rate corrected
for changes in the age, sex, and color composition of the
insured shows a rise of only 12 per cent from 1928 to
the maximum in 1943, and the 1945 rate is only 4 per
cent above that for the year 1928.
Aside from the aging of the population, there are
other factors of importance that have brought about
an increase in the recorded death rate from heart dis-
ease. Unfortunately, it is not possible to “correct” the
rate to allow for their effect. Increasingly many deaths,
formerly reported as from nephritis or from cerebral
hemorrhage, have been more recently ascribed to heart
disease because of the changing medical concept regard-
ing the relationship of high blood pressure to these con-
ditions. For, the present concept is that the heart in most
such cases is the organ primarily affected by increased
blood pressure. Also, as a result of the more accurate
determination of the cause of edema (dropsy), a fre-
quent late complication in both heart and kidney disease,
many cases with dropsy are now recognized as due to
heart failure which formerly would have been ascribed
to renal disease.
* * *
Without any allowance for the factors indicated above,
there has been a definite reduction in heart disease mor-
tality up to age forty-five. At ages one to twenty-four
years, this death rate in recent years among the insured
white males has fallen about 60 per cent as compared
with 1911-1915. Among young white females the reduc-
tion is even larger. At ages twenty-five to forty-four
also their death rates have in recent years been lower
than at any time since 1911. Among white males twenty-
five to forty-four years old, the death rate has been
stable for ten years, but the recent level of the rate is
well below that for 1911-1915. These declines at ages
under forty-five are due chiefly to the decline in the
mortality from rheumatic heart disease.
As regards the diseases of the coronary arteries, which
account now for a large proportion of deaths ascribed
to heart disease, the rapid increase in the mortality from
these conditions represents almost entirely the changing
diagnostic concepts in heart disease that are reflected in
medical terminology. It is noteworthy that, as the mor-
tality from coronary thrombosis and occlusion has gone
up, the death rate from myocardial diseases has fallen.
The outlook in various types of heart disease has been
shown in recent studies by the Company and by a num-
ber of physicians to be much better than has previously
been realized. It is found, for example, that a consider-
able proportion of patients who have suffered an attack
of coronary occlusion are still living ten years after the
initial attack, and that many of these people are re-
(Continued on Page 102)
January, 1947
73
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
DUAL APPROACH SPEEDS PREPAYMENT
MEDICAL CARE PROGRAM
A dual approach, the result of months of care-
ful study by a committee appointed two years
ago by the House of Delegates, will provide a
comprehensive prepayment medical care program
for Minnesota within a short time.
This decision was made at a meeting of the
House of Delegates of the Minnesota State Medi-
cal Association held Sunday, December 22, in
Saint Paul. The delegates voted first to authorize
the establishment by the Minnesota State Medical
Association of a nonprofit corporation, to be
known as Minnesota Medical Service; and sec-
ond, to invite and encourage reliable insurance
companies to sell indemnity contracts which offer
health, sickness and accident policies that meet
definite minimum standards of services and bene-
fits set up by a newly appointed liaison com-
mittee of the state association.
It was felt that the undertaking was too large
for any one organization to handle if speedy
and broad health and sickness protection were to
be assured Minnesota citizens, and for that reason
the delegates voted to utilize not only the facili-
ties Blue Cross could offer, but also those of
established insurance companies whose enthusias-
tic co-operation is an established fact.
This decision on the part of the delegates might
well be spoken of as the “Minnesota Plan’’ for
while it will use different vehicles, there is but a
single over-all objective, and that is to offer to
the people of Minnesota as quickly as possible a
program for budgeted medical care with a broad
base and a comprehensive scope, to be sold in
packets that will fit the needs of the employe
and the employer, and at the same time be ac-
ceptable to Minnesota physicians.
Minnesota Medical Service to Begin Shortly
Minnesota Medical Service, a nonprofit cor-
poration created by the medical profession of
Minnesota, will come into being shortlv when
the Articles of Incorporation have been filed
with the Secretary of State. The House of Dele-
gates authorized the Council to appoint two
physicians from each councilor district, who, in
turn, will select three at large, for a total of
twenty-one physicians, to serve as incorporators
in accordance with the Enabling Act passed two
years ago. On this body will fall the responsibility
of selecting the first Board of Directors of the
new corporation from which its first officers will
be chosen. Of primary importance will be the
selection, as soon as possible, of an experienced
and capable director on whose council the in-
corporators and later, the Board of Directors, can
rely during the corporation’s early crucial period.
Subscriptions from Minnesota physicians to-
ward the corporate fund went over the $100,000
mark set by the House of Delegates in May.
However, it is not clear that all of the subscrip-
tions which were pledged at the time the Or-
ganization Committee was considering recom-
mending an indemnity contract for Minnesota
Medical Service, strongly favored by some of
the county medical societies, will be honored.
For that reason, a recommendation was voted by
the House of Delegates to empower the Council
to stipulate that the capital fund may be $50,000,
or a comparable amount, if that appears expedient,
instead of the $100,000 previously specified.
Organizing Committee Presents Final Report
Dr. B. J. Branton, who was chosen as general
chairman to head up the work of the Committee
on Organization for Minnesota Medical Service,
gave a complete report to the House of all the
work which his committee had done since its crea-
tion. Included in this report were preliminary
drafts of the Articles of Incorporation, the pro-
posed agreement with the Minnesota Hospital
Service Association which will handle sales pro-
motion, collection of premiums and certain book-
74
Minnesota Medicine
MEDICAL ECONOMICS
keeping' procedures, the two contracts proposed
and the schedule of benefits. It was the Commit-
tee’s recommendation that the final draft of the
agreement with Blue Cross as well as the con-
tracts proposed be left until such time as a
director had been selected.
The proposed Surgical Contract provides bene-
fits for surgical procedures up to $150 and in-
cludes maternity benefits after the contract has
been in force nine consecutive months. Service
in full to the extent of the benefits under the
contract is proposed for the single subscriber
whose net income is $1,200 a year or less; and
for the subscriber with one or more dependents
whose net income is $2,000 a year or less. For
subscribers whose income exceeds these amounts,
the benefits provided under the contract shall be
regarded as partial payments toward the physi-
cians’ fees. The monthly charge for a single
person has been set at $.85 ; for a subscriber and
one dependent, $1.60; and for a subscriber and
two or more dependents, $2.50.
The medical-surgical contract proposed is
identical to the surgical contract except that it
contains a section providing the following benefits
up to a total of $100 a year for the subscriber:
$2 per call, beginning with the first call, for medi-
cal care in the hospital; $3 per call, beginning
with the third call, for medical care in the home ;
and $2 per call, beginning with the third call, for
medical service in the office. Dependents of the
subscriber are allowed up to $60 a year at $2
a call, beginning with the third call, for medical
care rendered in a hospital. The monthly charge
in the case of the medical-surgical contract for the
single subscriber has been set at $1.45; for the
subscriber and one dependent, $2.60 ; and for the
subscriber and two or more dependents, $4.
To give a supplemental report of the Com-
mittee’s work, Dr. Branton asked that Dr. A. W.
Adson, chairman of a special committee appoint-
ed by the Council on December 1, be recognized.
He concluded his report by recommending that, in
view of the fact that the Committee on Organi-
zation had completed its work, it be dissolved.
Action was then taken by the House for setting
up by the Council of a board of twenty-one in-
corporators for Minnesota Medical Service.
Two Plans Proposed
Some of the members of the Organizing Com-
mittee, as their studies of various voluntary pre-
payment medical plans in the country have pro-
gressed, had come to the conclusion that Min-
nesota’s program would proceed at an accelerated
pace if not only the facilities which Blue Cross
was willing to offer, but also those of insurance
carriers, were utilized.
This was the gist of a report presented to the
delegates by Dr. A. W. Adson.
Furthermore, Dr. Adson stated, the Organizing
Committee was faced with two divergent view-
points, both in its own ranks and among the
profession at large. Several county medical so-
cieties had expressed the opinion in no uncertain
terms that an indemnity plan would be more ac-
ceptable in their communities as it would relieve
the physicians of the responsibility of determin-
ing the patient’s income level, which is particularly
difficult to establish among rural people. An-
other matter that had to be considered was that
no clear-cut legal opinion was forthcoming as to
whether Minnesota Medical Service could devel-
op an indemnity program and come under the
scope of the Enabling Act.
On the other hand, the committee recognized
that within the committee itself, as well as among
the profession, were staunch advocates for some
type of service plan that would provide com-
plete medical service to the extent of the benefits
under the contract to subscribers within a certain
income level.
It was to solve the problem of meeting both of
these viewpoints among the profession, Dr. Ad-
son said, that the Council at its meeting on De-
cember 1 appointed a special committee to ex-
plore the possibility of inviting reliable insurance
companies to participate in the Minnesota pro-
gram by writing indemnity contracts which would
meet certain minimum standards in services and
benefits.
Committee Seeks Insurance Company Proposals
Dr. Adson related what had transpired at the
meeting on December 5 when the committee ap-
pointed by the Council, all members of the Or-
ganizing Committee, had met with insurance com-
pany representatives. Several of these companies
he stated, are already working with state medical
associations. Among those present were repre-
sentatives from the Employers Mutual of Wau-
sau and the Hardware Mutual of Stevens Point,
writing a large number of health contracts in
co-operation with the State Medical Society of
Wisconsin. Another, the North American of Chi-
January, 1947
75
MEDICAL ECONOMICS
cago, has just announced a comprehensive sur-
gical and medical family contract developed in
co-operation with the Illinois State Medical So-
ciety.
The committee outlined the surgical and medical
benefits proposed by Minnesota Medical Service,
withholding information about the monthly
charges that were contemplated, and asked that
each insurance company submit proposals con-
sidering these as minimum standards for their
contracts. Dr. Adson then presented a chart out-
lining the proposals which had been submitted
following that meeting. Insurance companies not
only responded enthusiastically but indicated that
they were willing and able to match the benefits
proposed and, in many instances, to offer more
liberal coverage at lower rates.
On the national scene, he told the delegates, it
has become increasingly apparent during the last
year or two that large insurance companies have
been anxious to co-operate by writing low-cost
health, sickness and accident policies, with an
over-all coverage which was impossible for medi-
cal-profession-sponsored plans to match. It was
evident that their motives in evincing this co-
operation were not entirely unselfish, Dr. Adson
said, but rather it was a concerted attempt on
their part to stave off the movement in govern-
ment circles for compulsory health insurance.
Insurance men believe with the doctors that the
problem can best be solved by offering such in-
surance on a completely voluntary basis.
Insurance Men "In Dead Earnest"
That they are in dead earnest has been evi-
denced, said Dr. Adson, by the many conferences
they have had with the Council on Medical Serv-
ice of the American Medical Association, and
also by their co-operative attitude in various state
medical association programs.
Just to cite one instance of how successfully the
objectives can be attained, Dr. Adson pointed to
Wisconsin, which has demonstrated how a phy-
sician-sponsored-insurance-carrier program can
proceed to spread prepayment medical care to
the general public. While some 30,000 contracts
have been written under the so-called “Wisconsin
Plan” since it got under way in April or May of
last year, a great many more than that (probably
well over 150,000) have been written as in-
dividual contracts under the impetus furnished by
the Wisconsin Plan.
After studying all these facts, Dr. Adson said,
the committee had come to the unanimous con-
clusion that it would recommend that two plans
be proposed for Minnesota : first, that there be
organized immediately a nonprofit Medical Serv-
ice Corporation, in accordance with the Enabl-
ing Act which the medical profession had spon-
sored ; and second, that a broad indemnity in-
surance program be developed with insurance
companies working in close co-operation with a
liaison committee of the state association.
Council Takes Action to Spur Program
The committee’s recommendations were ap-
proved by the delegates and the appointment of
the liaison committee was left to the Council.
Immediately following adjournment of the House,
the Council met in special session and appointed
the following committee : Dr. A. W. Adson,
Rochester, chairman ; Drs. R. J. Rranton, Will-
mar ; R. W. Morse, Minneapolis ; V. P. Hauser,
Saint Paul, and B. J. Gallagher, Waseca.
The Council also asked that each councilor
contact and select two physicians from his dis-
trict, who favor the establishment of the non-
profit corporation, to serve as the incorporators of
Minnesota Medical Service. As this article goes
to press, these selections are being made, and an
important meeting of the incorporators has been
scheduled for January 4 in Saint Paul.
DELEGATES HEAR PLEA FOR ESTABLISH-
MENT OF PRACTICAL NURSE
TRAINING SCHOOLS
Following up action taken by the Northern
Minnesota and Southern Minnesota Medical As-
sociation last fall, Dr. R. F. Hedin, Red Wing,
urged the delegates to go on record approving the
establishment, as soon as the teaching personnel
can be secured and the courses can be set up, of
twenty one-year practical nurse training schools
to alleviate the critical shortage of nursing per-
sonnel in rural areas. The lack of nurses is one
of the crucial problems facing the medical profes-
sion today, Dr. Hedin said. A report was given
on discussions which had taken place by a special
committee, composed of representatives from the
medical, the hospital, and the nursing professions,
which has under consideration the drafting of a
bill for the licensure of the practical nurse. It has
yet to be determined who shall compose the
(Continued on Page 118)
76
Minnesota Medicine
MINNESOTA STATE BOARD OF MEDICAL EXAMINERS
230 Lowry Medical Arts Bldg., Saint Paul, Minnesota
Julian F. DuBois, M.D., Secretary
PHYSICIANS LICENSED FEBRUARY 8, 1946
January Examination
Name
ABRAHAMSON, Manford Nels
BLACKFORD, Ralph Ellis
BRAUDE, Abraham Isaac
CULMER, Charles Umess
DAHLIN, David Carl
ETTINGER, Jerome*
FAST, John G.
FISHER, Charles Edward
HALFERTY, Daniel Applegate
HALVORSON, Raymond Gaylord
McDONALD, William J.
McELIN, Thomas Welsh
MARIS, Robert West
MICHIENZI, Leonard Joseph
RALSTON, Donald Everett
SCHLEPER, Albin Tohn
SMYTH, John Joseph
STEIN, Burton R.
TARUN, Donald Walter
VASTINE, John .Robert
BRAASTAD, Frederick William
CLOSUIT, Frederick Charles
GRIFFIN, John Gordon
McDONNELL, James Layton
RYAN, Robert Emmett
FAWCETT, John Crozier
HAAS, William Reid
McMAHON, John Martin
MORGAN, John Lloyd
‘Revoked July 12, 1946.
ANDERSON, Ray Carl
ANDREASSEN, Rolf Lorntz
ANDREJEK, Arthur R.
BAKALINSKY, Max
BERG, Clinton Charles
BERGER, William J.
BERGLUND, Eldon Burdette
BISSINGER, Lester Leland
BONDURANT, James Earle
BRACKNEY, Edwin Leland
CLARK, Robert Strachan
COOPER, Robert Ray
COPE, Hershel Boyd
DAGGETT, Donald R.
DANIELS, Bernard Tetlow
DIESSNER, Grant Roy
EIDE, Odd Arvid
ENGSTROM, Denton Paul
January, 1947
School
Temple U.
Indiana U.
Rush Med. Col.
Northwestern U.
Rush Med. Col.
Northwestern U.
U. of Minn.
U. of Colo.
U. of Oregon
Marquette U.
Northwestern U.
Harvard U.
U. of Oregon
Marquette U.
Rush Med. Col.
Marquette U.
U. of Iowa
M.D. 1944
M.D. 1934
M.D. 1940
M.B. 1937
M.D. 1940
M.D. 1940
M.D.
M.B.
M.D.
M.D.
M.D.
M.D.
M.B.
M.D.
M.D.
M.D.
M.D.
M.D.
M.D.
1944
1941
1942
1943
1945
1945
1945
1944
1945
1945
1939
1945
1944
Address
1515 Charles Ave., St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
University Hospital, Minneapolis, Minn.
University Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
2024 Commonwealth, St. Paul, Minn.
4804 16th Ave. S., Minneapolis 7, Minn,
Mayo Clinic, Rochester, Minn.
St. Joseph’s Hospital, St. Paul, Minn.
1319 E. Third St., Duluth, Minn.
St. Joseph’s Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
General Hospital, Minneapolis, Minn.
14 Douglas St., St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
St. Mary’s Hospital, Duluth, Minn.
Nopeming Sanatorium, Nopeming, Minn.
u.
of
Buffalo
M.D.
1943
Mayo Clinic,
Rochester,
Minn.
u.
of
Illinois
M.B.
1943
Mayo Clinic,
Rochester,
Minn.
M.D.
1944
Jefferson Med.
M.D.
1932
Mayo Clinic,
Rochester,
Minn.
Reciprocity Candidates
U.
of
Mich.
M.D.
1940
Mayo Clinic,
Rochester,
Minn.
U.
of
Minn.
M.B.
1941
371 Wilson St., Winona,
Minn.
M.D.
1942
u.
of
Colo.
M.D.
1940
Mayo Clinic,
Rochester,
Minn.
St.
Louis U.
M.D.
1943
Montrose, S.
Dak.
Creighton U.
M.D.
1941
Mayo Clinic,
Rochester,
Minn.
National Board Candidates
Northwestern U. M.B. 1929
M.D. 1930
Duke Univ. M.D. 1938
Georgetown U. M.D. 1940
U. of Pa. M.D. 1940
Devils Lake, N. Dak.
1311 W. 24th St., Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
PHYSICIANS LICENSED MAY 3, 1946
March Examination
U.
of
Minn.
M.B.
1946
U.
of
Minn.
M.B.
1946
U.
of
Minn.
M.B.
1946
U.
of
Minn.
M.B.
1946
U.
of
Minn.
M.B.
1946
u.
of Minn.
M.B.
1943
M.D.
1943
u.
of Minn.
M.B.
1946
u.
of Minn.
M.B.
1946
u.
of Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of Chicago —
M.D.
1939
Rush
Med. Col.
u.
of Minn.
M.B.
1941
M.D.
1942
u.
of Minn.
M.B.
1946
u.
of Minn.
M.B.
1946
3912 W. 7th St., Duluth, Minn.
3829 19th Ave. S., Minneapolis, Minn.
Ivanhoe, Minn.
Ancker Hosp., St. Paul 1, Minn.
Ancker Hospital, St. Paul 1, Minn.
311 Broadway, W. Burlington, Iowa
Minneapolis Gen. Hosp., Minneapolis 15, Minn.
Ancker Hospital, St. Paul, Minn.
Hurley Hospital, Flint, Mich.
University of Chicago Clinics, Chicago, 111.
Ancker Hospital, St. Paul 1, Minn.
St. Mary’s Hospital, Detroit, Mich.
Bethesda Hospital, St. Paul 2, Minn.
Detroit Receiving Hospital, Detroit, Mich.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Fertile, Minn.
St. Barnabas Hospital, Minneapolis, Minn.
77
PHYSICIANS LICENSED
Name
ENGSTROM, Frederick W.
ERICKSON, Ethel Elma
ESENSTEN, Sidney
FRANZ, Willis Martin
FREY, Richard Joseph
FRIEND, Merril ' B.
FULLER, Benjamin Franklin, Jr.
GALLIGAN, John J.
GILBERTSON, David Grosser
GOLDISH, Robert Joseph
GORDON, Harold Norman
GORDON, Milton Earle
GREEN, Robert Alan
GUMPRECHT, Jane Doering
HADDY, Francis John
HANSON, Herbert Theodore
HAUSER, Donald Charles
HEILIG, William Richard
HUBLER, Willis Lester
1RMISCH, George William
JACOBSON, Lyle Frederick
IARVIS, Charles W.
JENSEN, Mary Tane
KARLEN, Markle
KAUFMAN, Jerome Edward
KIESLER, Frank, Jr.
KIRKPATRICK, Neal Richard
KNUTSON, Robert Charles
LIENKE, Roger I.
LINDBERG, Winston Rudolph
LINNER, Paul William
LOWREY, Jack Beltman
LUND, George Weldon
McCORMACK, Joseph George
MAHAFFY, John H.
MANDEL, Sheldon Lloyd
M ARTUR ANO, Frank Paul
MAYNE, John Gregory
MIDTHUNE, Atidreen Sylvain
MILLER. William Thomas
MISBACH, William Durward
MOORE, George Eugene
MUESING, William James
NOLLET, Donald Tames
NORBY, Richard Gerhard
OLSON, Detlof Maynard
OPSTAD, Earl Thomas
OURADA, Anthony L.
PERRY. Harold Otto
PETELER, Jennings, C. L.
PETERSON, Roy Lawrence
PHALEN, Joseph Stephen
POTTHOFF, Herbert Benjamin
REM OLE. William Dunn
ROCKNEM, Robert Eric
ROHOLT, Hartvig Benhail
ROSE. Ray Vincent
ST. CYR. Harry Merlin
SAKO, Yoshio
S( HTMNOSKI, Donald Ray
SCHULTZ, Alvin Leroy
SHRAGG. Robert Israel
SMITH, George Randall
SMITH, Ralph Eugene
SMITH. Richard Clinton
SOLVASON, Harold Magnus
SPERLING. Sydney Coleman
S I F.VENSON, Helen Peik
THOMAS. John Verran
ULSTROM, Robert Alger
von AMERONGEN, Werner Wm.
78
School
Address
u.
of
Alinn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Minn.
u.
of
Minn.
u.
of
A I inn.
u.
of
Minn.
u.
of
Alinn.
u.
of
Minn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
Temple Lb
U.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
Lb
of
Minn.
LJ.
of
Wis.
U.
of
Minn.
U.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
Lb
of
Minn.
U.
of
Alinn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
U.
of
Minn.
U.
of
Alinn.
u.
of
Minn.
u.
of
Minn.
u.
of
Alinn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Minn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Alinn.
u.
of
Minn.
u.
of
Minn.
u.
of
Alinn.
u.
of
Minn.
u.
of
Minn.
u.
of
Alinn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
u.
of
Minn.
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1945
M.D. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1941
M.D. 1942
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.D. 1940
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1941
M.D. 1942
M.D. 1943
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1940
M.D. 1941
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B, 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
MR. 1946
M.B. 1946
MR. 1945
M.D. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
M.B. 1946
Detroit Receiving Hospital, Detroit, Mich.
Lenox Hill Hospital, New York City
3416 Hennepin Ave., Minneapolis 8, Minn.
Miller Hospital, St. Paul, Minn.
Minneapolis Gen. Hosp., Minneapolis 15, Minn.
Beth Israel Hospital, Newark, N. J.
2187 Berkeley Ave., St. Paul 5, Minn.
Univ. of Minn. Hosp., Minneapolis 14, Minn.
John Sealy Hospital, Galveston, Texas
St. Luke’s Hospital, Duluth, Minn.
University of Chicago Clinics, Chicago, 111.
Fordham Hospital, Bronx, N. Y.
Univ. of Minn. Hosp., Minneapolis 14. Minn.
Minneapolis Gen. Hosp., Minneapolis 15, Minn.
Minneapolis Gen. Hosp., Minneapolis 15, Alinn.
Salt Lake Co. Gen. Hosp., Salt Lake City, Utah
Minneapolis Gen. Hosp., Alinneapolis 15, Alinn.
Northwestern Hospital, Alinneapolis 7, Alinn.
Alinneapolis Gen. Hosp., Alinneapolis 15, Minn.
Mayo Clinic, Rochester, Minn.
Detroit Receiving Hospital, Detroit, Mich.
Tacoma General Hospital, Tacoma, Wash.
Children’s Hospital, San Francisco, Calif.
Alercy Hospital, Chicago, 111.
1204 "Upton Ave. N., Alinneapolis 11, Minn.
Univ. of Minn. Hosp., Minneapolis 14, Minn.
Mayo Clinic, Rochester, Minn.
St. Louis City Hospital, St. Louis, Mo.
Univ. of Alinn. Hosp., Minneapolis 14, Minn.
Wesley Alemorial Hospital, Chicago, 111.
Denver General Hospital, Denver, Colo.
St. Joseph’s Hospital, St. Raul 2, Alinn.
Alinneapolis Gen. Hosp., Minneapolis 15, Minn.
3423 Harriet Ave. S., Alinneapolis 8, Minn.
Minneapolis Gen. Hosp., Minneapolis 15, Minn.
2921 18th Ave. N., Minneapolis, Minn.
Veterans Hospital, Alinneapolis 6, Minn.
3028 E. Superior St., Duluth 5, Minn.
829 8th St. S., Minneapolis 4, Minn.
Ancker Hospital, St. Paul 1, Minn.
Fairmont, Alinn.
4239 Crocker Ave., Alinneapolis 10, Alinn.
400 S. Washington St., New Ulm, Minn.
901 E. 5th St., St. Paul 6, Minn.
3056 N. Cramer St.. Milwaukee 11, Wis.
4249 Dupont Ave. N., Alinneapolis 12, Minn.
Glen Lake Sanitorium, Oak Terrace, Alinn.
Walnut Grove, Minnesota
20 10th St. N. E., Rochester, Alinn.
Receiving Hospital, Detroit, Mich.
U. S. Marine Hospital, Detroit 15, Alich.
Univ. Hosp., Univ. of Mich., Ann Arbor, Mich.
Colorado General Hospital, Denver, Colo.
Afilwaukee County Hospital, Milwaukee, Wis.
Minneapolis Gen. Hosp., Minnearolis 15, Minn.
Alilwaukee County Hospital, Milwaukee, Wis.
2292 Carter Ave., St. Paul 8, Minn.
St. Luke’s Hospital, Duluth, Alinn.
Univ. of Alinn. Hosp., Alinneapolis 14. Minn.
Fordham Hospital, New York, N. Y.
Ohio State University Hosp., Columhus, Ohio
1504 4th St. S. E., Alinneapolis 14, Alinn.
John Sealy Hosp.. U. of Texas, Galveston, Tex.
125 Oak Grove, Minneapolis, Alinn.
St. Joseph’s Hospital, St. Paul, Alinn.
4616 Wooddale Ave., Minneapolis. Minn.
Michael Rees Hospital, Chicago, 111.
Rochester General Hospital, Rochester, N. Y.
Albany Hospital, Albany. N. Y.
Strong Alemorial Hosnital. Rochester, N. Y.
485 Rice St., St. Paul 3, Minn.
AIinnesota Medicine
PHYSICIANS LICENSED
Name
WENTE, Harold Alois
WESTMAN, Charles Will
WIERZBINSKI, Francis Albert
WOLFF, John Maney
WOLTER, Frederick Henry
ZELLER, Nicholas Henry
BLAIR, James Berl
BROWN, Hugh Sharp
GLENN, William Vincent
IVINS, John Cyrus
ANDERSON, Donald Carl
BURLEIGH, John Sullivan
CALIN, Stanford Hartley
COLLETT, Robert Waterman
EBERLEY, Tobe Sommers
FAULCONER, Albert, Jr.
FREEMAN, Donald Wilmer
FRIESEN, Stanley Richard
FRETHEM, Ardelles Allen
GIBSON, Dunbar Porter
HAYES, Elmer Russell
HEALY, Joseph Patrick
HEWITT', Charles Christian
JOHNS, Sylvia Maury
KEATING, John Urich
KINPORTS' Edward Backus
KOLLER, Robert Louis
KULLAND, Roy Emmanuel
LaFOND, Edward Marcus
LAMPERT, Elmer Graham
LAW, Stanley Guy
LOYD, Earl Lavon
LUNDELL, Carl Lamberg
McCOOL, Robert Francis
MOVIUS, Andrew M.
MUNDAHL, Harold Russell
O’BRIEN, Raymond Wilson
PELTZER, Wesley Eugene
SCHROEDER, Mellgren Cuyler
SLAUGHTER, Owen Leroy
STENERODDEN, Sidney Cbnton
STENNES, John Lowell
TOWNE, Russel Edward
WALSH, Alvin Cyril
WARKENTIN, John
WILLIAMS, Russell Ross, Jr.
WOOLNER, Lewis Benjamin
CAIN, James Henry
CORBIN, Kendall Brooks
DORNBERGER, George Raymond
FISHER, Dan William
HANSEN, Theodore Marcus
HILDEBRAND Carl Herbert, Tr.
KUMPURIS, Frank Gus.
PARKE, Fred Ford
School
Address
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
u.
of
Minn.
M.B.
1946
St. Joseph’s Hospital, Milwaukee, Wis.
Emanuel Hospital, Portland, Ore.
C. T. Miller Hospital, St. Paul 2, Minn.
St. Mary’s Hospital, Duluth, Minn.
Ancker Hospital, St. Paul 1, Minn.
St. Mary’s Hospital, Duluth S, Minn.
Reciprocity Candidates
U. of Neb.
Med. Col. Va.
U. of Neb.
U. of Neb.
M.D. 1939
M.D. 1943
M.D. 1940
M.D. 1939
Clarkson Memorial Hospital, Omaha, Neb.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
PHYSICIANS LICENSED MAY 3, 1946
April Examination
U.
of .
Minn.
M.B.
1944
M.D.
1945
U.
of
S. Calif.
M.D.
1941
u.
of
Minn.
M.B.
1946
u.
of Kans.
M.D.
1944
u.
of
Minn.
M.B.
1941
M.D.
1942
u.
of Kans.
M.D.
1936
u.
of
Minn.
M.B.
1941
M.D.
1942
u.
of
Kans.
M.D.
1943
u.
of
Minn.
M.B.
1946
Howard Univ.
M.D.
1940
Baylor Univ. M.D. 1938
Creighton U. M.D. 1945
U. of Minn. M.B. 1946
U. of Texas M.D. 1944
Cornell U. M.D. 1944
U. of Chicago M.D. 1942
U. of Minn. M.B. 1946
Baylor U. M.D. 1945
U. of Minn. M.B. 1944
M.D. 1945
Loyola U. M.D. 1940
U. of Chicago M.D. 1930
Rush. Med. Col.
U. of Kans.
U. of Minn.
St. Louis U.
U. of Minn.
Marquette U.
U. of Kansas
M.D. 1941
M.B. 1942
M.D. 1943
M.D. 1946
M.B. 1945
M.D. 1945
M.D. 1943
M.D. 1939
M.D. 1937
M.D. 1943
M.D. 1941
M.D. 1941
M.D. 1945
M.D. 1939
U. M.B. 1942
M.D. 1943
M.D. 1943
M.D. 1942
U. of 111.
Northwestern U.
U. of Neb.
Rush Med. Col.
Wash. U., Mo.
St. Louis U.
U. of Manitoba
Northwestern
Ohio State U.
Dalhousie U.
Lamberton, Minn.
Luverne, Minn.
Denver General Hospital, Denver, Colo.
Mayo Clinic, Rochester, Minn.
Perham, Minn.
Mayo Clinic, Rochester, Minn.
1527 E. River Terrace, Minneapolis 14, Minn.
Univ. of Minn. Hosp., Minneapolis 14, Minn.
Minneapolis Gen. Hosp., Minneapolis 15, Minn.
424 Metropolitan Bank Bldg., St. Paul 1, Minn.
Univ. of Minn. Hosp., Minneapolis 14. Minn.
3328 N. 44th Ave., Omaha, Neb.
Christmas Lake, Excelsior, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
439 Third St., International Falls, Minn.
St. Joseph’s Hospital, St. Paul, Minn.
701 Summit Ave., St. Paul 5, Minn.
Fairview Hospital, Minneapolis 6, Minn.
Mayo Clinic, Rochester, Minn.
1409 Willow St., Minneapolis 4, Minn.
Mayo Clinic, Rochester, Minn.
Granite Falls Clinic, Granite Falls, Minn.
Miller Hospital, St. Paul 2, Minn.
Virginia Lane, Billings, Mont.
1600 Ashland Ave., St. Paul 5, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
728 22nd St., San Francisco 7, Calif.
Mayo Clinic, Rochester, Minn.
St. Cloud Clinic, St. Cloud, Minn.
816 LaSalle Bldg., Minneapolis 2, Minn.
328 E. Henn., Rm. 205, Minneapolis 14, Minn.
Mayo Clinic, Rochester, Minn.
228 E. Huron St., Chicago 11, 111.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Reciprocity Candidates
U. of Okla.
M.D.
1942
Hoffman, Minn.
Stanford U.
M.D.
1935
Mayo Clinic, Rochester,
Minn.
U. of Neb.
M.D.
1938
Mayo Clinic, Rochester,
Minn.
U. of Mich.
M.D.
1929
Emerson Clinic, E. 7th
& Mounds
Paul, Minn.
U. of Neb.
M.D.
1942
Box 389, Alden, Minn.
U. of Neb.
M.D.
1942
101 7th Ave. S., St. Cloud, Minn.
Tulane U.
M.D.
1943
Mayo Clinic, Rochester,
Minn.
Northwestern
U. m.b.
1941
Mayo Clinic, Rochester,
Minn.
M.D.
1942
January, 1947
79
Name
TEICH, Kenneth William
WEISBERG, Raphael Joseph
WRIGHT, Robert Raymond
BUSSE, Edwin Arthur
DOUGLAS, John Munroe
GROSKLOSS, Howard Hoffman
McCONAHEY, Wm. McConnell, Jr.
MOERSCH, Robert Urban
SEKHON, Mohan Singh
SHELLITO, John Gardiner
ANDERSON, James John
ANDERSON, Margaret Connor
ANDERSON, Russell Edward
ARHELGER, Stuart Waldo
BARGER, James Daniel
BARONOFSKY, Ivan Donald
BEAHRS, Oliver Howard
BREITENBUCHER, Robt. Bertram
BROKER, Henry Michael
CROSS, Frederick Samuel
DeWEERD, James Henry
DODDS, William Clark
ELLISON, Ellis
FINK, James Russell
FORD, John Laurence
FORSGREN, Arthur Lawrence
FRIEDMAN, Jack
GARSKE, George Leo
GROOM, Dale
HANSEN, Robert Edward
HENEGAR, George
HILKER, Marcus Dudley
HOON, James Richard
HUNT, Van William
JOHNSON, Benjamin Hardy, Jr.
JOHNSON, Merton Ardell
KAELSEN, Robert August
KEVERN, Jay Leland
KRAWCZYK, Henry Joseph
KRUCHEK, Thomas Francis
LALLY, James J.
LEE, Jack Bennett
LEWIS, Charles William
LISTER, Kenneth Evan
MACH, Ralph Franklin
MAERTZ, Richard William
MASLER, Sherman
McBEAN, James Blish
McGRAW, Tohn Phillip
MEDLIN, Charles Fred
PHYSICIANS LICENSED
School
Address
U. of Neb. M.D. 1943
U. of Minn. M.B. 1940
M.D. 1941
Northwestern U. M.B. 1940
M.D. 1941
Duluth Clinic, 205 W. 2nd St., Duluth 2, Minn.
Univ. of Minn. Hosp., Minneapolis 14, Minn.
Austin Clinic, 209 W. Mill St., Austin, Minn.
National Board Candidates
Boston U.
Duke Univ.
Yale U.
Harvard U.
U. of Pa.
U. of Minn.
M.D. 1942
M.D. 1939
M.D. 1935
M.D. 1942
M.D. 1944
M.B. 1940
M.D. 1941
M.B. 1942
M.D. 1943
Northwestern U.
4400 W. 44th St., Minneapolis 10, Minn.
Mayo Clinic, Rochester, Minn.
735 Med. Arts Building, Minneapolis 2, Minn.
Mayo Clinic, Rochester, Minn.
710 9th Ave. S. W., Rochester, Minn.
1533 Como Ave., St. Paul 4, Minn.
Mayo Clinic, Rochester, Minn.
PHYSICIANS LICENSED JULY 12, 1946
June Examination
u.
of Alberta
M.D.
1941
u.
of Manitoba
M.D.
1938
Syracuse U.
M.D.
1939
U.
of Wis.
M.D.
1945
U.
of Pa.
M.D.
1941
Marquette U.
M.D.
1943
Northwestern U.
M.B.
1941
M.D.
1942
U.
of Minn.
M.B.
1946
Marquette U.
M.D.
1945
Western Reserve
M.D.
1945
U.
of Mich.
M.D.
1940
U.
of Minn.
M.B.
1943
M.D.
1944
u.
of Minn.
M.B.
1946
Loyola U.
M.D.
1938
Marquette U.
M.D.
1945
U.
of Minn.
M.B.
1944
M.D.
1945
U.
of 111.
M.D.
1939
U.
of Minn.
M.B.
1944
M.D.
1945
Med. Col. of Va.
M.D.
1943
U.
of Minn.
M.B.
1943
M.D.
1943
U.
of 111.
M.D.
1942
U.
of Minn.
M.B.
1941
M.D.
1942
U.
of Pittsburgh
M.D.
1940
U.
of Chicago
M.D.
1944
Northwestern U.
M.B.
1940
M.D.
1941
Loyola U.
M.D.
1943
U.
of Minn.
M.B.
1944
M.D.
1945
U.
of Minn.
M.B.
1944
M.D.
1945
U.
of Minn.
M.B.
1945
M.D.
1946
Creighton U.
M.D.
1946
Northwestern U.
M.B.
1943
M.D.
1944
U.
of Texas
M.D.
1938
u.
of Minn.
M.B.
1944
M.D.
1945
u.
of Iowa
M.D.
1938
u.
of Minn.
M.B.
1945
M.D.
1946
Creighton U.
M.D.
1946
U.
of Minn.
M.B.
1939
M.D.
1940
Chicago U.
M.D.
1935
U.
of Colo.
M.D.
1939
U.
of Minn.
M.B.
1942
M.D.
1943
Miller Hospital, St. Paul 2, Minn.
Fairview Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
916 Medical Arts Building, Duluth, Minn.
Mayo Clinic, Rochester, Minn.
Univ. of Minn. Hosp., Minneapolis 14, Minn.
Mayo Clinic, Rochester, Minn.
Univ. of Minn. Hosp., Minneapolis 14, Minn.
208 8th St. So., St. Cloud, Minn.
2284 W. Lk. of Isles Blvd., Mpls. 5, Minn.
Mayo Clinic, Rochester, Minn.
St. Luke’s Hospital, Thief River Falls, Minn.
Minneapolis Gen. Hosp., Minneapolis 15, Minn.
2501 W. Deyon Ave., Chicago, 111.
600 W. Redwood St., Marshall, Minn.
1299 Seminary, St. Paul, Minn.
Ancker Hospital, St. Paul, Minn.
4949 Colfax Ave. So., Minneapolis 9, Minn.
Mayo Clinic, Rochester, Minn.
St. Mary’s Hospital, Duluth, Minn.
Mayo Clinic, Rochester, Minn.
634 Hamm Building, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Route No. 1, Maple Plain, Minn.
Pipestone, Minn.
10830 So. Pacific Hwy., Seattle 88, Wash.
1217 5th St. N. E., Minneapolis, Minn.
St. Mary’s Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic. Rochester, Minn.
Henning, Minn.
5043 41st Ave. So., Minneapolis 6, Minn.
New Prague, Minn.
658 Grand Ave., St. Paul, Minn.
Veterans Hospital, Minneapolis 6, Minn.
Mayo Clinic, Rochester, Minn.
6020 4th Ave. So., Minneapolis, Minn.
Truman, Minn.
80
Minnesota Medicine
PHYSICIANS LICENSED
Name
School
Address
MORRIS, Donald Shonk
NERENBERG, Samuel Theodore
NIGRO, Joseph Albert
NIXON, James Barron
PARKIN, Thomas William
PFUETZE, Max Ensign
RANG, Robert Halter
REMSBERG, Robert Raymond
RYDLAND, Arne Daniel
RYNDA, Edwin Roger
SALASSA, Robert Maurice
SCHMID, John Frederic
SHARICK, Paul Robert
SMITH, Franklin Robert
STAM, John
STEVENS, John Edgar, Jr.
STIMAC, Emil Michael
STONE, Norman Francis
STRAND, Sherman O’Neil
STUERMER, Harry Walter
THORSEN, David Stuart
WINCHESTER, Wm. Wellington
BIGLER, Earl Edward
BLOEMENDAAL, Edwin John
Gerald
CLARK Ivan Thomas
COLBERT, Lawrence Desmond
HAMMER, Raymond W.
HASTINGS, Donald Wilson
JACOBSON, Ferdinand Carl
KOSZALKA, Michael Francis
MAREK, Frank Henry
NELSON, Glenn Edward
NICKERSON, John Roger
O’NEAL, Ruth
PERRY, Edward Louis
PETERSON, John Robert
PIERCE, Paul Preston
SMITH, Oscar Orton, Jr.
SMITH, Theodore Sprague
SUMMERS, Joseph Stewart, Jr.
VAUGHAN, Luther Matthews
WEST, Harriet Katherine
WITTROCK, Louis Henry
Med. Col. of Va. M.D. 1941
U. of Minn. M.B. 1945
M.D .1946
St. Louis U. M.D. 1942
U. of Minn. M.B. 1944
M.D. 1945
Northwestern U. M.B. 1945
M.D. 1945
U. of Kans. M.D. 1940
Indiana U. M.D. 1940
U. of Kans. M.D. 1942
Marquette U. M.D. 1944
Loyola Univ. M.D. 1945
Indiana Univ. M.D. 1939
U. of Minn. M.B. 1941
M.D. 1942
U. of Minn. M.B. 1945
M.D. 1946
Marquette U. M.D. 1942
U. of 111. M.D. 1943
Med. Col. of Va. M.D. 1941
U. of Minn. M.B. 1945
M.D. 1946
U. of Minn. M.B. 1944
U. of Minn. M.B. 1945
M.D. 1946
U. of 111. M.D. 1944
U. of Minn. M.B. 1943
M.D. 1943
U. of Chicago M.D. 1942
Rush Med. Col.
Mayo Clinic, Rochester, Minn.
Veterans Hospital, Knoxville, Iowa
Mayo Clinic, Rochester, Minn.
519 1st St. S. W., Crosby, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Valentine Clinic, Tracy, Minn.
Crookston, Minn.
U. S. Vet. Adm., Fac., St. Cloud, Minn.
Mayo Clinic, Rochester, Minn.
Veterans Hospital, Minneapolis, Minn.
2328 4th Ave. W., Hibbing, Minn.
Mayo Clinic, Rochester, Minn.
953 Medical Arts Bldg., Minneapolis 2, Minn.
Mayo Clinic, Rochester, Minn.
1512 10th St. So., Virginia, Minn.
91 N. 16th St., Minneapolis 3, Minn.
538 Snelling Ave. No., St. Paul 4, Minn.
4808 Nicollet Ave., Minneapolis 9, Minn.
3536 Edmund Blvd., Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Reciprocity Candidates
Northwestern U.
M.B.
1934
M.D.
1936
U. of Iowa
M.D.
1936
Ohio U.
M.D.
1941
Creighton U.
M.D.
1942
Wayne U.
M.B.
1940
M.D.
1941
U. of Wis.
M.D.
1934
U. of Chicago
M.D.
1936
Rush Med. Col.
Georgetown
M.D.
1938
Tulane U.
M.D.
1940
Marquette U.
M.D.
1943
Western Res.
M.D.
1940
Med. Col. of Va.
M.D.
1943
U. of Wis.
M.D.
1941
Marquette U.
M.D.
1940
Harvard U.
M.D.
1939
Med. Col. of Va.
M.D.
1944
U. of Oregon
M.D.
1943
Washington U.
M.D.
1940
Tulane U.
M.D.
1936
U. of Okla.
M.D.
1942
Marquette U.
M.D.
1943
221 E. 4th St., Claremont, Okla.
Lake Park, Minn.
824 Medical Arts Building, Duluth, Minn.
Royal, Iowa
Mayo Clinic, Rochester, Minn.
126 Millard Hall Univ. of Minn., Mpls., Minn.
St. Luke’s Hospital, Duluth 5, Minn.
2301 Arthur St. N. E., Minneapolis 13, Minn.
Mayo Clinic, Rochester, Minn.
Box 55, Fairfax, Minn.
Heron Lake, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
3749 17th Ave. So., Minneapolis 7, Minn.
Dept, of Radiology, Univ. Hosp., Mpls., Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Watkins, Minn.
BAILEY, Joseph Augustine
DU SHANE, James William
EDWARDS, Jesse Efrem
FLEESON, William
FRIEFELD, Saul
GRULEE, Clifford Grosselle
HATCHER, Albert Crow
McAFEE, George Deshon
MYHRE, James Gifford
January, 1947
National Board Candidates
Georgetown U. M.D. 1944
Yale U. M.D. 1937
Tufts M.D. 1935
Yale U. M.D. 1942
McGill U. M.D. 1940
Northwestern U. M.D. 1938
Northwestern U. M.B. 1942
M.D. 1943
Geo. Wash. U„ M.D. 1941
D. C.
Temple U. M.D. 1942
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Loring Medical Bldg., 1409 Willow St., Minne-
apolis 4, Minn.
Wadena, Minn.
Dept, of Ped., U. Hosp., Minneapolis 14, Minn.
Mayo Clinic, Rochester, Minn.
NPBA Hosp., 1515 Charles, St. Paul, Minn.
3053 Jersey Ave., Minneapolis 16, Minn.
81
PHYSICIANS LICENSED
Name
School
Address
5621 41st Ave. So., Minneapolis 6, Minn
5621 41st Ave. So., Minneapolis 6, Minn
R.R. No. 3, Wayzata, Minn.
SMITH, Carol Kander
SMITH, Marcus Joel
SORENSEN, Roy Warren
WHITE, Neil Kenneth
New York U. M.D. 1942
Long Island Col. M.D. 1942
Col. Med. M.D. 1944
Evangelists
U. of Minn. M.B. 1940
M.D. 1941
Mayo Clinic, Rochester, Minn.
PHYSICIANS LICENSED NOVEMBER 8, 1946
October Examination
ALCORN, William John
U.
of
Minn.
M.B.
M.D.
ASHE, William McLellen
u.
of
Rochester
M.D.
BARBER, Tracy Ezra, Jr.
Temp!
le U.
M.D.
BERRIS, Barnet
U.
of
Toronto
M.D.
BROOKER, Warren lay
u.
of
Iowa
M.D.
BROOKS, Lowell M.
u.
of
Louisville
M.D.
CARDY, lames de Vic
u.
of
Alberta
M.D.
CARTER, James Wm„ Jr.
u.
of
Texas
M.D.
CHISHOLM, Tague Clement
Harvard U.
M.D.
CONNERY, David Bradford
U.
of
Pa.
M.D.
CUNNINGHAM, Ernest Samuel, Jr.
U.
of
Texas
M.D.
ECKLES, Nylene Elvira
U.
of
Minn.
M.B.
M.D.
EKSTRAND, Leroy Alagnus
U.
of
111.
M.D.
FOSTER, Orley Walter
U.
of
Minn.
M.B.
M.D.
FRIDEN, Frank Joseph
u.
of
Minn.
M.B.
M.D.
GAY, James Rowland
lohns
Hopkins
M.D.
GENTLING, Allen Archibald
Louisiana U.
M.D.
HALL I DAY, Phillip Vernon
U.
of
Minn.
M.B.
M.D.
HASSKARL. Walter Frederick, Jr.
U.
of
Texas
M.D.
HEADLEY, Nathan Edwin
Ohio
U.
Al.D.
HIGHTOWER, Nicholas Carr, Jr.
U.
of
Texas
M.D.
HOSKINS, lames Howard
u.
of
111. .
M.D.
KOFF, Sheldon
u.
of
Minn.
M.B.
M.D.
KORUAI, Lyle W.
u.
of
Minn.
M.B.
M.D.
KUIPER. Klaire Van Zanten
Rush
Med. Col.
Al.D.
LANDRY, Rudolph Alatas
Tulane U.
Al.D.
LERNER, Abraham Ross
U.
of
Manitoba
M.D.
LUELLEN, Thomas Joseph
u.
of
Kans.
M.D.
McLAUGHLIN, Blaine Edmund
u.
of
Syracuse
M.D.
MUNSON, Martin Sigfred
u.
of
Minn.
AI.B.
PRATT. William Coleman
Wi
ash.
U.
Al.D.
RAAISEAr, William Horn II
Temple U.
M.D.
RUFF, Curtis Cleaver
U.
of
Pa.
Al.D.
SEILER. Hawley Howard
Med.
Col. of Va.
M.D.
STEDENBURG, Richard Henry
St.
Louis U.
M.D.
SIEGEL, Sheldon Colman
U.
of
Minn.
M.B.
SKOOG-SAIITH, Anton William
U.
ofMinn.
M.B.
M.D.
SMITH, Marie Anne
U.
of
III.
Al.D.
STARK. David Berkeley
U.
of
Toronto
Al.D.
STAUFFER. Afaurice Havelvn
U.
of
Kans.
Al.D.
VAN PATTER, Ward
U.
of
West. Ont.
M.D.
WARREN, WARD B
Indiana U.
Al.D.
WENZEL, Ralph Erhart
Northwestern U.
M.B.
M.D.
WHITESELL, Frank Bean, Ir.
Georgetown U.
M.D.
ZIEVE, Leslie
U.
of
Minn.
M.B.
M.D.
1943 5829 Pleasant Ave., Minneapolis, Minn.
1943
1943 Mayo Clinic, Rochester, Minn.
1943 802 Park Ave., Austin, Minn.
1944 Box 45, Univ. Hosp., Minneapolis, Minn.
1945 St. Luke’s Hospital, Duluth, Minn.
1943 Mayo Clinic, Rochester, Minn.
1940 Dept, of Path., Univ. of Minn., Mpls., Minn.
1940 Mayo Clinic, Rochester. Minn.
1940 308 Phys. & Surg. Bldg., Minneapolis, Minn
1932 Mayo Clinic, Rochester, Minn.
1941 Mayo Clinic, Rochester, Minn.
1945 318 Harvard S. E., Minneapolis, Minn.
1946
1943 108 E. 2nd St., Wabasha, Minn.
1943 1149 Medical Arts Bldg., Minneapolis 2, Minn
1943
1943 1705 St. Clair Ave., St. Paul 5, Minn.
1943
1939 Mayo Clinic, Rochester, Minn.
1942 Mayo Clinic, Rochester, Minn.
1945 518 No. 12th St., Virginia, Minn.
1946
1942 Mayo Clinic, Rochester, Minn.
1941 Mayo Clinic, Rochester, Minn.
1944 Mayo Clinic, Rochester, Minn.
1924 5408 Elliott Ave. So., Minneapolis, Minn.
1937 2214 4th Ave. No., Minneapolis 5, Minn.
1938
1943 5432 Bryant Ave. So., Minneapolis, Minn.
1944
1942 Vet. Adm. Hosp. N.P. Staff, Mpls. 6, Minn.
1942 Mavo Clinic, Rochester, Minn.
1932 3755 Joppa Ave., St. Louis Park, Mpls., Minn.
1941 Mayo Clinic, Rochester, Minn.
1942 453 Winona St., Winona, Minn.
1946 St. Luke’s Hospital, Duluth, Minn.
1938 Mayo Clinic, Rochester, Minn.
1941 Mayo Clinic, Rochester, Minn.
1941 Mayo Clinic, Rochester, Minn.
1937 Mayo Clinic, Rochester, Minn.
1943 Mayo Clinic, Rochester, Minn.
1945 2154 Randolph, St. Paul, Minn.
1943 3518 Nicollet Ave., Minneapolis 8, Minn.
1943
1943 Glenwood Hospital, Minneapolis, Minn.
1943 Mayo Clinic, Rochester, Minn.
1941 Mayo Clinic, Rochester, Minn.
1944 Alayo Clinic, Rochester, Minn.
1939 Alayo Clinic, Rochester, Minn.
1937 Albert Lea, Alinnesota
1938
1941 Alayo Clinic, Rochester, Minn.
1943 317 S. E. 4th St., Minneapolis, Minn.
1943
ADLER, Benard Charles
ANGLAND, Thomas Anthony
ANTHONY. Russell Albert
BOYLAN, Richard Nelson
CULLEN, Richard Corbin
DETIEN. Edward Donald
DFAVF.ESE, Wilford Joel
ECKSTAM, Eugene Emanuel
Reciprocity Candidates
Wash. U„ Mo. M.D. 1937
U. of Minn. M.B. 1932
M.D. 1933
U. of Texas Al.D. 1938
Northwestern U. M.D. 1940
U. of Neb. M.D. 1940
U. of Wis. ALD. 1943
U. of Neb. M.D. 1940
U. of Wis. M.D. 1943
1118 Lowry Med. Arts Bldg., St. Paul, Minn.
805 W. Yakima Ave., Yakima, Wash.
U. of AHnn. Med. School. Alinneapolis, Minn.
Alayo Clinic, Rochester, Minn.
2101 29th Ave. S., Alinneapolis 6, Minn.
Veterans Hosp., Bldg. 3. Alinneapolis, Minn.
Kings Co. Hospital, Brooklyn, N. Y.
Alayo Clinic, Rochester, Minn.
82
AIinnesota AIedicine
PHYSICIANS LICENSED
Name School
FORSYTHE, Robert Wallace
Tulane U.
M.D.
GATES, Edward Martin
U.
of
Mich.
M.D.
GRAMSE, Arthur Edward
U.
of
Md.
M.D.
GROSS, John Burgess
Western Reserve
M.D.
HAMILTON, C. Ferrill
St.
Louis U.
M.D.
HEISE, Philip von Rohr
U.
of
Ark.
M.D.
JOHNSON, Marcellus A. Ill
u.
of
Va.
M.D.
TOHNSON, Richard Moltzen
u.
of
Neb.
M.D.
JONDAHL. Willis Holder
Tulane U.
M.D.
fCIEFER, Edward Jern
Marquette U.
M.D.
LOUGH, Roger Robert
Syracuse U.
M.D.
MABON, Robert Ford
Harvard U.
M.D.
McCREIGHT, William George
U.
of
Okla.
M.D.
McGAVIC, John Samuel
U.
of
Iowa
M.D.
OLCOTT, Eugene Diebold
u.
of
Louisville
M.D.
OLSON, Oscar Charles
u.
of
Wis.
M.D.
OWEN, Charles Archibald, Jr.
u.
of
Iowa
M.D.
POSEY, Ernest Leonard, lr.
Tulane U.
M.D.
RATKE, Henry Victor
Tefferson
M.D.
Med.
Col.
RESCH, Toseph Anthony
U.
of
Wis.
M.D.
RUDOLPH, Frank Alvin
u.
of
Vermont
M.D.
SEXTON, Thomas Scott
u.
of
Maryland
M.D.
SHORT, Charles Augustus, Jr.
Northwestern U.
M.B.
M.D.
SKOUGE, Oren Tenner
U.
of
Iowa
M.D.
VAN HERIK, Martin
U.
of
111.
M.D.
VOLLMER, Frederick John
Rush
Med. Col.
M.D.
WASHKO, Peter John "
U.
of
Pa.
M.D.
WENDLAND, John Prentice
U.
of
Neb.
M.D.
Address
1941 Mayo Clinic, Rochester, Minn.
1942 Mayo Clinic, Rochester, Minn.
1942 Mayo Clinic, Rochester, Minn.
1945 Mayo Clinic, Rochester, Minn.
1940 Mayo Clinic, Rochester, Minn.
1942 259 E. Broadway, Winona, Minn.
1941 Mayo Clinic, Rochester, Minn.
1942 Slayton, Minn.
1941 Mayo Clinic, Rochester, Minn.
1941 Mayo Clinic, Rochester, Minn.
1920 Winona, Minn.
1938 Mayo Clinic, Rochester, Minn.
1940 Mayo Clinic, Rochester, Minn.
1934 c/o Mr. John D. M. Hamilton, Union League,
Philadelphia, Pa.
1943 Mayo Clinic, Rochester, Minn.
1936 1305 12th Ave. N. E., Rochester, Minn.
1941 Mayo Clinic, Rochester, Minn.
1944 Mayo Clinic, Rochester, Minn.
1941 Mayo Clinic, Rochester, Minn.
1938 5248 46th Ave. S., Minneapolis, Minn.
1943 805 W. 3rd St., Red Wing, Minn.
1939 Mayo Clinic, Rochester, Minn.
1944 Mayo Clinic, Rochester, Minn.
1945
1941 4416 Zenith Ave. No., Robbinsdale 12, Minn.
1942 Mayo Clinic, Rochester, Minn.
1933 172 Main St., Winona, Minn.
1939 Mayo Clinic, Rochester, Minn.
1941 215 Walnut St. S. E., Minneapolis, Minn.
National Board Candidates
BAGGENSTOSS. Osmond Jacob Rush Med. Col. M.D. 1941
BLACKBURN, Charles Marvin Duke U. M.D. 1944
EGER, Alban U. of Buffalo M.D. 1942
FELDER, Davitt Alexander Yale U. M.D. 1942
GOLDSMITH, los. Washington, Jr. Long Island Col. M.D. 1938
JENSEN, Edwin I.
LINNER, John Henry
MANKEY, James Charles
MASCHMEYER, Joseph Everett
McCREADY, Frederick Joseph
McDOWELL, Richard E.
MORGAN, Edward Henry
NIX, James Thomas, Ir.
PASCHALL, Jack, Jr!
PLASS, Herbert Fitz Randolph
ROBINSON, Cortland Otis
SCANLAN, Robert Lawrence
SMITH, Robert Shaw
TAYLOR, Edmund Rhett
M ILDER, Thomas Carroll
Syi
racuse U.
M.D.
1943
U.
of
Minn.
M.B.
1943
M.D.
1943
u.
of
Minn.
M.B.
1943
M.D.
1943
Col
1. Med. Evang.
M.D.
1942
Tufts
U.
M.D.
1943
U.
of
Buffalo
M.D.
1943
Northwestern U.
M.B.
1942
M.D.
1943
La.
State. U.
M.D.
1940
U.
of
S. Calif.
M.D.
1943
Harvard U.
M.D.
1939
U.
of
Minn.
M.B.
1939
M.D.
1940
Columbia U.
M.D.
1942
Geo. Wash. U.
M.D.
194)
Johns
Hopkins
M.D.
1941
U.
of
Md.
M.D.
1941
1404 27th Ave. N. E., Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
502 4th Ave. S. W., Rochester, Minn.
Univ. of Minn. Hosp., Minneapolis 14, Minn.
Emerson Clinic, E. 7th & Mounds Blvd., St.
Paul 6, Minn.
Mavo Clinic, Rochester, Minn.
4959 Colfax Ave. So., Minneapolis, Minn.
530 So. Fairview, St. Paul, Minn.
526 16th Ave. S. E., Minneapolis 14, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
629 Med. Arts Bldg., Minneapolis, Minn.
156 E. 52nd St., New York 22, N. Y.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester. Minn.
Internal Derangement of the Knee
(Continued from Page 44)
that a stiff knee will not result from the operation.
Naturally some immediate postoperative stiffen-
ing due to pain and lack of use will occur but,
barring ankylosis of the knee which results from
severe postoperative infection, stiffness of the
knee does not occur after operation. It is our
duty as physicians to dispel the still prevalent
opinion among both laymen and physicians that
letting the synovial fluid off the knee will cause
stiffness.
References
1. Badgley, C. E. : Internal derangement of joints. In Ghorm-
ley, R. K. : Orthopedic Surgery. Pgs. 328-341. New York:
Thomas Nelson & Sons, 1938.
2. Camp, J. D., and Coventry, M. B. : The use of special
views in roentgenography of the knee joint. U. S. Nav. M.
Bull., 42:56-58, (Jan) 1944.
3. Henderson, M. S., and Lipscomb, P. R. : Personal com-
munication to the author.
January, 1947
83
Minneapolis Surgical Society
STATED MEETING HELD OCTOBER 3, 1946
The President, Robert F. McGandy, M.D., in the Chair
THE SURGICAL APPROACH TO RENAL AND
OTHER RETROPERITONEAL TUMORS
THEODORE H. SWEETSER, M.D.
Minneapolis, Minnesota
Abstract
Three factors are especially important in the surgical
approach to any malignant tumor. First it must allow
exposure and division of the veins and lymphatics be-
fore any tumor cells can be squeezed into them by oper-
ative manipulation. Secondly the approach must give
the best possible exposure of the tumor and ifs sur-
roundings in order to allow better hemostasis and more
accurate dissection. Thirdly and less important, over-
lying tissues and neighboring organs should be dam-
aged as little as possible. Damage to nerve trunks is
most serious because of the consequent muscle paralysis.
Damage to the neighboring intraperitoneal organs and
to the patient’s general functions is also serious and
may be caused by prolonged exposure and by the ma-
nipulation of packs and retractors.
Operation for any mass in the kidney or retroperi-
toneal tissues should be undertaken with recognition of
the possibility of malignancy and with adequate prepara-
tion and draping of the field. Malignancy being often
in question, exploration is begun through an oblique
incision in the flank, and only when malignancy is dem-
onstrated is the incision extended as described.
In cases of malignancy (on the right side, for ex-
ample) the oblique incision is extended parallel to and
between the eleventh and twelfth dorsal nerve trunks
across the right rectus muscle about halfway between
the navel and the symphysis pubis and extended thence
upward close to the median line to the xyphoid. The
large triangular flap is lifted laterally and upward over
the retracted right rib margin. With sufficiently ex-
tensive skin preparation beforehand, the entire inci-
sion is made easily while the operator remains in the
usual position behind the patient. Using the extra-
peritoneal layer of fat as a line of cleavage, the peri-
toneum is pushed aside unopened. The left abdominal
wall and abdominal contents enclosed in peritoneum fall
away by gravity toward the patient’s left, exposing the
right renal vessels with very little retraction. We have
been astounded at the good exposure and ease of ap-
proach to the renal vessels without manipulation of the
kidney. We also have been pleased by the prompt, strong
healing of the wound.
The incision described above preserves the nerve sup-
Abstract of paper to he published in Tonrnal of Urology.
ply of all the abdominal muscles. The unopened peri-
toneum helps in control and retraction of the intraperi-
toneal organs and protects them from infection and
damage by evaporation and by trauma of packs and re-
tractors. The lateral posture of the patient and shape
of the flap result in better exposure than any other
approach because the abdominal contents drop away
toward the opposite side with little or no need for re-
tractors, and the area of the renal vascular pedicle
comes well up into the wound for accurate and adequate
primary treatment.
In cases of papillary carcinoma of the renal pelvis
or ureter, one should deal with the lower end of the
ureter and ureteral orifice even before dealing with the
renal vascular pedicle. That can be done easily with
the approach described by extending the midline part
of the incision downward to the symphysis as well as
upward. That allows one to reach the lower ureter at
least as easily as by the midline suprapubic incision
of Monsarrat. As suggested by Hugh Cabot in his paper
in 1925, there are other conditions in which the advan-
tages of unusually good operative exposure will recom-
mend this approach. I would recommend it particu-
larly for certain cases of tuberculosis and calculous
pyonephrosis wherein extensive inflammatory reaction
and fibrosis make protection of neighboring organs par-
ticularly difficult. ,
Discussion
Dr. Stanley R. Maxeiner : I talked to Doctor
Sweetser about this incision, anticipating its use in a
case of hypernephroma. Subsequently I used it with
great satisfaction. I could only suggest that the lower
end of the incision be curved instead of a sharp angle
as the curved flap will undoubtedly heal better than
will a sharp-angle flap. Those who observed the use
of the incision stated that it was nearer an autopsy ex-
posure than anything they had ever seen. I have sub-
sequently examined the patient and he had primary
healing with a completely competent scar.
TRANSTHORACIC GASTRECTOMY
Case Report
STANLEY R. MAXEINER, M.D., F.A.C.S.
Minneapolis, Minnesota
Carcinoma of the cardiac portion of the stomach has
until recently been extremely resistant to surgical at-
tack. The abdominal approach has been very difficult
and too often productive of poor end results. Only in
recent years has it been attacked transthoracically and
transdiaphragmatically. This approach has been made
84
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
safer by the use of endotrachial anesthesia which per-
mits compression or expansion of the lung at will.
OhsawaB, about 1933, performed three transthoracic
gastrectomies but none survived. It was not until 1938
that Adams and Phemister1 reported the first successful
transthoracic resection of the distal end of the esophagus
and cardiac portion of the stomach with esophagogas-
trostomy. This patient was reported well without recur-
rence three years and four months later. Ochsner and
DeBakey5 performed the first similar operation for car-
cinoma of the stomach.
This operation has now been popularized by Phem-
ister, Garlock, Ochsner and DeBakey, Sweet, Clagett
and others. The early mortality was very high but with
increasing experience and greater advancements in tech-
nique, it has been reduced so that it now compares
favorably with similar surgery via the abdominal route.
Bradshaw and O’Neill2 report a mortality rate of
46.6 per cent in approximately fifty-six patients so
treated. Garlock4 in four years explored twenty-five
patients with adenocarcinoma of the pars cardia. Nine
were found operable, that is, 36 per cent. There was no
mortality in the inoperable group and the nine operable
patients received radical surgery with four deaths, that
iSj 44.4 per cent mortality. Garlock states that from
their experience and that of others, a patient with a
resectable carcinoma of the pars cardia has a 60 per
cent chance of surviving the operation and then an 80
per cent chance of living two years or more. Clagett3
reports fifty-seven transthoracic operations on the cardia
and lower esophagus, of which twenty-four were found
to be inoperable and thirty-three underwent resection.
There were no deaths among the explored cases; and
of the thirty-three who underwent radical resection, five
died, a mortality of about 15 per cent. Thus, the mor-
tality of transthoracic gastric operations in his hands
does not carry a much greater mortality than carcino-
mata of the stomach approached via the abdominal route.
He states that carcinoma of the cardia occurs in about
10 per cent of all carcinomata of the stomach and that
33 to 60 per cent of carcinomata of the esophagus
occur in its lower third.
Because of the fact that carcinoma of the cardia
spreads upward toward and into the esophagus and that
the reverse is true of carcinoma of the esophagus, both
lesions are usually discussed together. There is no
block which limits the spread of the disease as occurs
at the pylorus. Lesions in this area may require resec-
tion of both the stomach and the esophagus, which re-
quirement demands that they be approached transtho-
racically
The diagnosis of carcinoma is usually made by x-ray
examinations. Clinical signs and symptoms may not even
suggest the presence of a gastric lesion, but dysphagia
suggests a lesion in the esophagus or one in the cardia
extending into the esophagus. The gastroscope is prob-
ably least valuable in lesions of the cardia, but in the
esophagus it may determine the exact area of involve-
ment and, through biopsy, the character of the growth.
Lahey has for years advised exploration of gastric le-
sions of doubtful character. Bradshaw and O’Neill2
strongly endorse the recommendation of Ochsner and
January, 1947
DeBakey that exploration of this obscure area of the
stomach is even more imperative. Several writers on this
subject recommend preliminary exploration through an
abdominal incision but Clagett3 states that extension of
carcinoma of the cardia above the diaphragm can be
determined and surgically removed only through a
transthoracic incision. On the other hand, the extent
of the involvement of the liver and regional glands and
the degree of fixation which determine the operability
of a carcinoma are just as easily detected through an
incision in the diaphragm, with no greater hazard. A
preliminary abdominal exploration in the presence of a
resectable lesion means two operations or two incisions
at one operation and constitutes an unnecessary added
load on a patient who is already a substandard risk.
Preliminary preparation of the patient implies a com-
plete evaluation of his examination reports which might
contraindicate surgery. Transfusions, high protein diet,
vitamins, intravenous fluids, et cetera, should be used
to counteract the effect of weight loss, dehydration,
debility and anemia. Sulfa drugs and penicillin are
favored preoperatively by some. This preparation and
careful study demands adequate preoperative hospitaliza-
tion.
The subject of anesthesia for thoracic surgery will
be left for the discussion of our specialist in that field,
Dr. Ralph Knight.
The technique of transthoracic resection of the cardia
and lower end of the esophagus is not yet standardized,
but certain fundamental principles are universal.
After the induction of anesthesia and the introduction
of the endotrachial tube the patient is placed on his
right side and his position well secured by pillows,
sand bags and straps or wide adhesive tape. The left
arm should be anchored to a frame at the head of the
table. Intravenous needles of competent size should be
introduced and the solution kept dripping so that fluid
and blood may be given as indicated throughout the
entire operation. A catheter with suction is retained
in the esophagus to prevent gastric content from enter-
ing the pharynx and lungs. The chest area should be
prepared widely and draped.
A long incision is made over the ninth rib which is
removed subperiosteally from the cartilage anteriorly
well back to the spine. The pleura is opened an,d the ribs
widely spread apart and, if necessary, the seventh and
eighth ribs may be divided posteriorly to increase the
exposure. The lung is permitted to collapse partially
and is retracted into the upper chest. The diaphragm
may be paralyzed temporarily by injection of the left
phrenic nerve as it traverses the lateral wall of the
pericardium. Involvement of the esophagus, mediastinal
regional glands or pleura can be determined by palpa-
tion and vision. The diaphragm is next incised radially
in its dome to permit abdominal exploration. Vision of
adjacent stomach and peritoneum is now possible and the
examining hand may be passed through the rent in the
diaphragm and the stomach, liver, regional glands,
omentum, et cetera, palpated or visualized. Exploration
should determine the operability of the carcinoma and
if the lesion is inoperable the diaphragm is sutured
and the chest closed. If the lesion is found to be re-
85
MINNEAPOLIS SURGICAL SOCIETY
sectable, the rent in the diaphragm is enlarged so as to
join the esophageal hiatus. The esophagus is freed
and the upper involved area of the stomach and regional
glands are liberated. As in any other gastric resection
such cases Sweet7 has advised ligation and division of
the central vessels of the jejunal loop, with reliance on
the marginal vessels for circulation. By this expedient
a loop which could be brought through the transverse
Fi£. 1. X-ray shows an extensive carcinoma, Fig. 2. X-ray shows the slightly dilated
causing a large filling defect in the pars cardia esophagus, the anastomosis to the anterior wall
of the stomach. of the intrathoracic stomach and the narrowed,
tubulated stomach which remains below the dia-
phragm.
it may be advantageous to include the spleen, omentum
and part of the tail of the pancreas in the mass re-
moval. The stomach is clamped below the growth and
closed completely. Although the stomach has unusual
vascularity, one must be alert not to devascularize it
entirely. The right gastroepiploic surely and the right
gastric artery if possible should be preserved. The
esophagus is divided above the upper limits of the
lesion. Light compression about the esophagus above
the lesion during liberation of the stomach will prevent
expression of gastric content into the pharynx. The
cut-off end of the esophagus is now anastomosed with
nonabsorbable sutures to the anterior wall of the re-
maining part of the stomach. Free stomach is brought
into the chest to prevent any pull on the line of suture
and the diaphragm is closed about the stomach, to
which it then is anchored. The tube in the esophagus
is now' passed into the stomach for the purpose of
suction or early feeding. Two rubber tubes are intro-
duced through stab wounds into dependent sites in the
pleural cavity. Continual suction for a few days re-
moves pleural fluid and induces expansion of the lung.
Bronchoscopic aspiration at the close of the operation
may be advisable to remove gastric content from the
bronchi.
Total gastrectomy, where indicated, has been per-
formed but with almost prohibitive mortality because
the first or second loop of jejunum often cotdd not be
brought up to the cutoff end of the esophagus without
tension and subsequent leak at the line of suture. In
mesocolon to a point only 1 or 2 centimeters above the
diaphragm may now he brought to a level of 3 inches
into the chest.
Postoperative care is very important and every effort
is exerted to conserve the patient’s resources. Admin-
istration of oxygen, blood transfusions, parenteral
fluids, amino acids and vitamins are even more important
now than preoperatively. Suction on the nasal tube and
that on the thoracic drains is maintained. In view of the
fact that nearly all these operations are done without
clamps, there is some soiling ; but infection is well
borne by the pleural cavity. The liberal use of penicillin
has greatly reduced the mortality from infection. Oral
fluids and food are given when safety permits.
Report oi Case
Mr. A. B., aged sixty, married and a cabinet maker
by occupation, was a patient of Dr. Douglas Head and
under his observation for several years.
Family and past history is negative except that in
January 1946, the patient fell and cracked some ribs.
In March 1946, the patient was examined by Dr.
Head at which time he complained of cramps in the
legs, numbness in the arms and loss of pep. A vague
feeling of distress in the left upper quadrant became
worse on lying down. Appetite was good. There was
no weight loss nor change in bowel habit. The genito-
urinary system was normal.
Hemoglobin was 65 per cent. Gastric expression
showed no free hydrochloric acid. Total hydrochloric
acid was 25. Blood and pus were present.
Roentgenograms of the gastrointestinal tract in May
1946, showed a large mass involving the cardia of
86
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
stomach producing displacement of the esophagus and
a probable very extensive carcinoma of the cardia in-
volving the lesser curvature. ...
The patient entered Asbury hospital Tune 4, 1940,
where the hemoglobin was found to be 56 per cent;
plasma proteins, 5.8 and an electrocardiogram showed
left axis deviation. He was placed on a high protein,
high caloric diet. Vitamins and blood transfusions were
given.
On Tune 8, 1946, a transthoracic subtotal gastrectomy
was performed under endotrachial anesthesia given by
Dr. Joseph Baird. The cut-off end of the esophagus was
anastomosed with silk to the anterior wall of the stomach
and the suction tube passed through into the stomach.
Two rubber tubes for suction drained the pleural cavity.
The operation time was almost six hours and he was
oiven 2000 cubic centimeters of whole blood during
the operation. The blood pressure was 142/75 on en-
trance to the hospital, 150/80 at the start and 120/60
at the end of the operation. The pulse- remained under
90 throughout the whole procedure. Nasal suction was
removed in six days and he took food well.
The specimen included 3 inches of esophagus, all of
the lesser curvature and most of the rest of the stomach,
well distal to the carcinoma, the spleen and a large
piece of omentum.
The sloughing and infected neoplasm resulted in
increased contamination. The chest suction tubes never
drained well and be developed a wound infection and
later an empyema. Penicillin and sulfa were gi\en
freely throughout most of his convalescence. The chest
was repeatedly aspirated and only bloody fluid obtained.
On the twenty-fourth day the real abscess cavity was
encountered and bloody purulent exudate yielded Gram-
positive cocci in clusters and chains. A catheter was
introduced through a trochar into the abscess and the
cavity irrigated with penicillin. Thereafter recovery was
prompt and the patient is well and working every day.
He eats well and is gaining weight slowly.
Note.— The patient was shown personally before the
Society, together with x-rays before and after his opera-
tion and numerous slides photographed from published
articles demonstrating different methods of technique.
References
1 Adams W. E., and' Phemister, D. B. : Carcinoma of the
lower end of the esophagus. Report of a successful resec-
tion and esophagogastrostomy. J. lhoracic burg., 7:621,
2. Bradshaw, H. H.. and O’Neill, J. F. : Surgical treatment
of some lesions of lower esophagus and upper stomach. J.
Thoracic Surg., 14:187, 1945. ,.
3. Clagett, O. Theron: Transthoracic resection of the cardia
and esophagus. Texas State J. Med., 42:7-11, May, 1946.
4. Garlock, John H. : Radical surgical treatment for car-
cinoma of cardiac end of stomach. burg., Oynec. o;
Obst., 74.555, 1942. , c . .
5. Ochsner, Alton and DeBakey, Michael: Surgical aspects
of carcinoma of the esophagus. J. Thoracic Suig., 10. ,
1 040.41
6. Ohsawa, T. : Arch. f. Japanische Chir., 10:605, 1933.
7. Sweet, Richard H.: Total gastrectomy by the transthoi-
acic approach. Report of several cases. Ann. burg., 116.-
816, (Nov.) 1943.
Discussion
Dr. John R. Paine: One point in the technique which
Doctor Maxeiner did not stress and which has been a
great help to me is not to transect the esophagus until
the two posterior rows of sutures in the anastomosis
have been placed. If the esophagus is not tiansected,
it can be pulled upon and released in large measure in
tension at the line of anastomosis at the time the anas-
tomosis is being made. It is the policy of all who try
to do these operations at the University Hospitals to
place two posterior rows of sutures before opening the
lumen of the esophagus. The esophagus is then tran-
sected in stages as the inner layers of the anterior suture
January, 1947
lines are placed. Tension at the line of anastomosis
can be relieved by anchoring the posterior wall of the
stomach to the parietal pleura of the posterior wall of
the chest.
The patient who Doctor Maxeiner mentioned had a
carcinoma of the lower middle third of the esophagus.
This man died approximately ten days after operation.
When he got up out of bed, he collapsed at once. At
necropsy, it was found he had a pulmonary embolism.
The result of transthoracic resection of the cardia of
the stomach and esophagus at the University Hospitals
is not as good as any of the series of cases which Doc-
tor Maxeiner mentioned.
As I remember, practically no operations of this
type were done at the University Hospitals prior to
1941. Since that time, I cannot give you the exact
figures, but it is my impression that between twenty-five
and thirty such operations have been performed. The
mortality has been between 20 and 25 per cent. T. he
chief cause of death has been separation of anastomotic
suture lines. Empyema has been not an infrequent com-
plication.
Dr. Thomas J. Kinsella : One is somewhat surprised
at times at the amount of exposure which can be ob-
tained through a trans-thoracic, trans-diaphragmatic ap-
proach to the stomach and esophagus. 1 he stomach may
be mobilized almost to the pylorus and brought up into
the chest to the apex of the pleura. I now have a pa-
tient at St. Mary's Hospital, ten days postoperative, in
whom I resected a carcinoma of the mid-esophagus,
bringing the stomach into the chest so the anastomosis
was made above the arch of the aorta. Because of the
position of the tumor only a small amount of the cardia
and lesser curvature were sacrificed. The stomach
survives such mobilization and elevation better than the
jejunum if care is exercised to protect the right gastric
and right gastroepiploic vessels which must furnish
its sole blood supply. It must also be fixed well up in
the chest and to the diaphragm to avoid tension on the
anastomosis.
The point which Dr. Paine brought up of using the
lower esophagus as a retractor until the first layer of
posterior sutures is placed is important. The esophagus
is somewhat like a rubber band and snaps back when
released unless fixed in some way. Mattress sutures
should be used as simple sutures pull out readily.
All patients subjected to thoracotomy form fluid in
the' pleural cavity postoperatively. If this fluid is con-
tinually removed the pleura will fuse and obliterate the
space 'in a few hours. In all such resections. there is
some contamination of the pleura and mediastinum foi
the anastomosis is done by an open method because the
blood supply of the esophagus is poor and will not
tolerate clamps. Two or three catheters placed in stra-
tegic locations will with constant suction keep the fluid
out of the chest and permit obliteration of the pleura
and walling off of any infection. Both the pleura and
mediastinum tolerate contamination well under such con-
ditions.
Postoperatively these patients have some difficulty,
dyspnea and so forth, when the stomach becomes dis-
tended, but this is a minor matter. Some have tem-
porary difficulty with pylorospasm as the result of \agus
section incident to the resection.
This approach has widened our surgical attack on
carcinoma of the stomach and opened a new field in
treatment of carcinoma of the esophagus in the lower
and middle third, esophageal strictures and perfora-
tions previously untouched.
Another incision has been used by Sampson and others
in the handling of thoraco-abdominal wounds during the
recent war. It involves resection of the ninth rib with
the patient in the lateral position and extension of the
incision forward to the mid-line if necessary. Wide ex-
posure is obtained with better access to the abdominal
contents than with resection of the eighth rib.
87
MINNEAPOLIS SURGICAL SOCIETY
These procedures are long drawn out affairs but sur-
prisingly well tolerated considering their magnitude.
Some patients may be saved in this way who cannot be
handled in any other manner. Its wider use is to be
encouraged, but abdominal surgeons who plan to employ
this approach should give some thought to the physiol-
ogy of the chest for it differs somewhat from that of
the abdomen. Some of the postoperative problems and
complications can be avoided by forethought and a little
planning.
ANESTHESIA FOR TRANSTHORACIC
GASTRECTOMY
RALPH T. KNIGHT, M.D.
Minneapolis, Minnesota
In providing anesthesia for transthoracic gastroecto-
my, certain requirements must be met. These require-
ments are quite similar to those for most transthoracic
operations, but there are some differences. For most
transthoracic operations, especially those involving the
lungs, the lung must be collapsed for the convenience of
the surgeon for a considerable part of the time. That
is not so necessary for the transthoracic approach to the
stomach. The lung must be collapsed, but it need be
only partially collapsed. It may be packed back out of the
way of the surgeon, depending upon how high he needs
to work upon the esophagus and that makes little dif-
ference in the care rendered the patient by the anesthetist.
T he requirements are that the physiology of the pa-
tient be kept up, that he have an adequate exchange of
gases, presentation of oxygen and removal of carbon
dioxide ; but there must be quietness of breathing so
that the structures may be handled under a minimum
of motion. The special requirement in case of work
upon the stomach through the thoracic cage is that
while, at first thought, relaxation of the abdominal
muscle is not of so much importance, in practice, and upon
second thought, it becomes of rather major importance.
Tension of the abdominal muscles, possibly in the effort
of breathing with no aid from the diaphragm, may
make a considerable amount of motion and may tend
to force abdominal contents up into the thorax to the
inconvenience of the surgeon. It, therefore, is even more
important in this type of operation on upper abdominal
organs through the thorax that the anesthetist carry
on respiration for the patient with very little active
motion on the patient’s part, and that the abdominal
muscles be relaxed ; in other words, that respiration
must be carried on, but general anesthesia must be deep
enough so that the abdominal muscles will be relaxed.
Especially during the closure of the diaphragm, this
relaxation must be provided. It seems in watching the
surgeon work that it is just as much of a problem in
closing the diaphragm as closing the abdominal wall after
an abdominal incision. That involves also the relaxation
of the intercostal muscles and quietness of the thoracic
wall. While carrying on this controlled respiration, of
course, the lung in the open side of the chest is ex-
panded to a certain degree with each artificial inspira-
tion. It does not fully expand even when an amount of
pressure with each filling is carried up to 10 to 12
millimeters of mercury. It expands from one-half to
two-thirds of its expanded size and may be controlled
very easily by a small amount of packing and use of
retractors.
There is one difficulty that is sometimes encountered
and that is that if there is considerable involvement by
inflammation about the esophagus, while this is being
freed up, it sometimes happens that the pleura of the
opposite side is opened. Both lungs collapse. The
patient is then, of course, unable to breath for himself
at all and all of his breathing must be accomplished by
the anesthetist.
One more difference between operations on the abdom-
inal organs through the thorax and those upon the
thoracic organs is that most surgeons like to use a
cautery in severing the stomach, either an actual cautery
or a diathermy or something of that sort. That cannot
be allowed if we are using an inflammable anesthetic
because some small leaks from the lungs may be
present and if any of this gas should leak out from the
lung into the thoracic cavity, it is very apt to catch
fire and explode. This problem must be met in one
of two ways. Either the surgeon must relinquish his
desire to use a cautery and rely on a knife and an
antiseptic or an entirely noninflammable anesthetic must
be employed.
We like in transthoracic surgery to use cyclopropane.
Some anesthetists and surgeons use an ether vapor.
The patient’s general welfare is not held at quite such
a high level if ether is used. Either one is just as explo-
sive. There is no difference. Recently we have been
using sodium pentothal, curare, and nitrous oxide, using
either a mixture of pentothal and curare in the same
syringe which Doctor Baird has developed or using
them separately in different syringes. We use nitrous
oxide with high enough oxygen so that the welfare of
the patient is increased over the usual nitrous oxide
anesthesia and still provide enough analgesia so that
the amount required of pentothal and curare is definitely
reduced. By using this combination we manage to finish
a long surgical procedure with an amazingly small
amount of sodium pentothal and the patient is ready to
wake up at the end.
The anesthetist must be right in on the operation. He
must watch the operation as closely as any interested
bystander must watch (even if not as carefully as the
surgeon), because anesthesia and management of the
physiology of the patient must be his concern. His
hope is to finish with as light an anesthetic as possible
at the end of the operation and allow the patient to
wake up quickly so that breathing will be well carried
on. The patient’s lungs must be filled with helium or
nitrogen and adequate oxygen and kept expanded dur-
ing closure of the chest, except that it must not
be fully expanded while the stitches are put into the
pleura. As Doctor Maxeiner mentioned, this final lung
expansion is very important as one of the means of
avoiding atelectasis, which is an especially disagreeable
complication following this type of surgery.
88
Minnesota Medicine
Minnesota Academy of Medicine
Meeting of October 9, 1946
The regular monthly meeting of the Minnesota Acad-
emy of Medicine was held at the Town and Country
Club on Wednesday evening, October 9, 1946. Dinner
was served at 7 o’clock and the meeting was called to
order at 8:15 by the President, Dr. S. E. Sweitzer.
There were fifty-five members present.
Minutes of the May meeting were read and approved.
The President announced the election of new mem-
bers at the November meeting.
The scientific program followed.
ECTOPIC KIDNEY WITH HYDRONEPHROSIS
C. D. CREEVY. M.D.
Minneapolis, Minnesota
This report is prompted by the satisfactory result,
after fifteen months, of a Y plasty in a young man
who had been told by a medical consultant that he had
polycystic kidneys and had better sell his farm so that
he could lead a less active life. The unusual combina-
tion of an ectopic, incompletely rotated kidney with a
stricture at the ureteropelvic juncture is also worthy
of comment.
Case Report
E. M., a farmer, aged thirty-four, in the period be-
tween November 1944 and March 1945 had three
attacks of severe pain in the right upper quadrant of the
abdomen. Each lasted about two hours until relieved by
morphine. He had lost fifteen pounds in weight.
Development and nutrition were excellent. The blood
pressure was 140/80. There was an ill-defined, rounded,
rather tender mass in the right middle quadrant of the
abdomen. Routine studies of the blood and urine gave
normal results. The Wassermann was negative, and the
urea nitrogen was 19 mgm. per cent.
A plain x-ray of the urinary tract showed the right
renal shadow to be somewhat enlarged and low in posi-
tion. Cystoscopy disclosed a normal lower urinary tract.
Clear urine was collected from each kidney. The right
renal pelvis was low in position, dilated grade three,
and its calices were clubbed and directed medially (Fig.
1). There was a half-inch long constriction of the first
portion of the ureter, which had a high origin and
followed a course like that seen in horseshoe kidney.
The left renal pelvis was normal in size and position,
but its calices were directed medially and its ureter,
which was intrinsically normal, followed a course simi-
lar to that of the right.
It was obvious that there was a noncalculous obstruc-
tion at the right ureteropelvic junction, probably due to
a congenital stricture. Since the kidneys were so far
apart, it seemed likely that the patient had an ectopic,
incompletely rotated right, and a normally placed but
incompletely rotated left kidney. A plastic operation
upon the right ureteropelvic junction was advised.
He returned on June 26, 1945, because of recurrent
attacks, the end of the spring planting season, and
the advice of his physician.
From the Urological Division of the Dept, of Surgery in
the Medical School' of the University of Minnesota.
The right kidney was explored at St. Barnabas Hos-
pital on June 28, 1945, under spinal anesthesia through a
low lumbar extraperitoneal approach. There was a low
lumbar ectopy with failure of rotation, a sizable an-
teriorly placed extrarenal hydronephrosis, and a stric-
ture at the ureteropelvic junction which lay upon the
anterior aspect of the lower pole of the misshapen kidney.
After a typical Schwyzer-Foley Y plasty and nephros-
tomy, the kidney was rotated so that the pelvis lay
medially, and was sutured in this position. The low
origin and shortness of the renal vessels prevented
moving the kidney to a higher location. Recovery was
retarded by a wound infection, but he was discharged
on July 25, in good condition.
He returned on August 9, 1945, because of persistent
drainage of pus from the wound. Pale, unhealthy gran-
ulations protruded above the surface about the site pre-
viously occupied by a penrose drain. These were excised
with scissors and moist heat was applied. An excretory
urogram showed striking improvement jn the hydro-
nephrosis (Fig. 2). Indigo carmine given intravenously
did not appear in the wound.
Microscopic examination of the removed tissue showed
chronic inflammation; culture yielded aerobacter aero-
genes. He was dicharged on August 16 with the wound
healing rapidly.
On November 16 the wound was healed, the urine
was clear, and he had no complaints. He returned for
checkup again on August 29, 1946, without complaints.
The urine was microscopically normal, and the urogram
showed diminution of the hydronephrosis, return of the
calices toward normal, and a funnel-shaped ureteropelvic
junction.
Discussion. — The kidneys develop low in the sacral
region, in which position the pelves lie anterior to the
renal substance. Early in fetal life ascent begins and
is accompanied by rotation ; both processes end nor-
mally with the kidney beneath the diaphragm and the
pelvis lying medial to the renal substance. Arrest either
of ascent or of rotation, or of both, may occur at any
point between the fetal and definitive adult positions.
Contact between the two kidneys during ascent results
in some form of fusion (horseshoe, L-shaped, sigmoid
unilateral fused kidney).
In 37,500 autopsies Bell found ectopic kidneys once in
750 cases. The two sexes were affected about equally ;
the right side was involved a little more often than the
left. Six per cent were bilateral. Crossed ectopy, with or
without fusion, is very rare.
The ectopic kidney, despite statements to the contrary,
is not per se more subject to disease than the normally
placed organ, although its vascular supply is often ab-
normal, a fact which may lead to hydronephrosis from
compression of the ureteropelvic junction by anomalous
blood vessels. A pelvic kidney may interfere with labor.
According to Bell, hydronephrosis is the commonest
renal disorder found at autopsy (3.8 per cent of 32,360
cases excluding those due to stone). Of. all the hydro-
nephroses in the series 2.1 per cent were due to non-
calculous obstruction at the ureteropelvic juncture; 69
per cent of these resulted from strictures at the uretero-
January, 1947
89
MINNESOTA ACADEMY OF MEDICINE
pelvic juncture. Other causes of obstruction at this level
include accessory blood vessels, distortion of the juncture
by sheets of peripelvic fascia, ptosis, inflammatory muco-
sal polyps, neuromuscular dysfunction, and various com-
binations of these factors.
ureteropelvic juncture. What is of even greater interest
is the fact that he succeeded in doing a plastic opera-
tion at the ureteropelvic juncture and that a year later
he discovered the kidney to have normal function.
It has been my experience that ectopic kidney quite
frequently is accompanied by pathologic lesions. In fact,
Fig. 1.
Thus we have in the patient under discussion a com-
bination of unusual anomalies : lumbar ectopy, malrota-
tion, and a stricture at the ureteropelvic junction. The
striking degree of hydronephrosis with a palpable, ten-
der mass in the right renal area obviated the not un-
common mistake of assuming that a kidney which is
normal except for position is causing pain.
Treatment involved two problems: relief of the ob-
struction and placement of the kidney in as normal a
position as the length of its blood vessels would permit.
The Schwyzer-Foley Y plasty was chosen because it
does not interrupt the continuity of the pelvis and
ureter (thus permitting the normal downward progress
of peristalsis after operation) ; because it restores more
or less normal relationships between pelves, ureter, and
kidney; and because good results have followed its use
in a high proportion of my personal series of fifty-eight
cases.
Placing the kidney in a normal position is desirable
but not essential to a satisfactory result. It is, of course,
too soon to classify this patient as permanently cured,
but the fact that he has remained free of symptoms
for more than a year, coupled with the spontaneous
clearing of the postoperative pyuria, and the diminu-
tion of the hydronephrosis are all favorable signs.
The superiority of preservation of a kidney with almost
normal function over nephrectomy in a young man
needs no emphasis.
Discussion
Dr. W. F. Braasch, Rochester : Dr. Creevy has re-
ported an interesting type of renal anomaly, namely, an
ectopic kidney with malrotation and obstruction at the
Fig. 2.
in the majority of cases the urographic evidence may
show either malrotation, pyelocaliectasis, pyelonephritis
or atrophy. In many cases the renal function is reduced
to such an extent that urographic visualization is either
absent or very dim and the condition may be easily over-
looked in the excretory urogram. When there is ob-
struction at the ureteropelvic juncture, with intrapelvic
retention of urine, the resulting pain may be easily con-
fused with that caused by a diseased appendix. In sev-
eral cases observed at the clinic the appendix had been
previously removed. Dr. Creevy deserves credit be-
cause of the excellent results obtained in this case, since
the concomitant malrotation, chronic infection and re-
duction in function often will not permit such excellent
results.
I would like to show a series of urograms illustrating
the various complications in anomalies of this type, which
include the following lesions : pyelectasis, incomplete
rotation, bilateral ectopy and stone in ectopic kidney.
The kidney may be described as ectopic in case of
crossed renal ectopia.
Dr. T. H. Sweetser, Minneapolis: I enjoyed Dr.
Creevy’s excellent presentation and especially the result
of his conservative treatment. I think that is what we
should try to accomplish — relief by some conservative
measures.
The case I wish to call to your attention was a
psychoneurotic patient with pains referred to different
systems and treated by various doctors. We were called
in consultation at Minneapolis General Hospital in April
1941 because of the presence of pain in the right lower
abdomen. Her pain was reproduced at cystoscopy by
filling the right renal pelvis for pyelography. Pyelo-
grams showed hydronephrosis of the right ectopic kid-
ney located at the brim of the bony pelvis with short
ureter. On exploration, the vessels supplying the kidney
came from the iliac artery as well as the aorta. Nephrec-
tomy had to be performed. She is free of pain and of
urinary symptoms but has been treated for neurasthenia.
90
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
Dr. P. F. Donohue, Saint Paul : Dr. Creevy’s pres-
entation of this case was most interesting. Relief of
obstruction at the ureteropelvic junction by a type of
pyeloureteroplasty which preserved the continuity of the
ureter provided an excellent result. Preservation of the
continuity of the ureter is certainly desirable but may
not always be feasible. In occasional cases, it may be
necessary to sever the ureter from the renal pelvis as in
the case of obstruction due to stricture when the tissues
are extremely thin. It may be required when it is
desirable to move the ureteropelvic junction away from
the compression effects of renal blood vessels which
supply large areas of the kidney and, therefore, must be
preserved. Anastomosis of the cut end of the ureter to
the pelvis is then performed in a manner to provide
a widely opened junction. In a recent case of stricture
this method led to a good result and can be recom-
mended in properly selected cases.
REMARKS ON POLIOMYELITIS
MAURICE B. VISSCHER. M.D.
Minneapolis, Minnesota
An epidemic of infantile paralysis is more than a
medical emergency in Minnesota. It is a social and polit-
ical problem as well. There are man}? reasons for its
social implications. The recorded case incidence is more
than one per thousand of population and the mortality
rate has been 6 per cent of recorded cases. In any
case an epidemic of this magnitude of a serious disease
would cause great alarm. In the case of infantile paral-
ysis the public reaction has been heightened because of
the great publicity which has centered around the dis-
ease for a number of years.
A past mayor of Minneapolis hitched his political
wagon to the rising star of an Australian physiotherapy
nurse who came to the city offering to handle the in-
fantile paralysis problem. It is a misfortune that a few
years after she came here the city and state suf-
fered its worst epidemic of all time and a large number
of victims have died. Ex-mayor Marvin Kline is now
an officeholder in the Sister Elizabeth Kenny Institute.
The present mayor, Hubert H. Humphrey, was un-
willing to be stampeded into an unscientific approach to
the poliomyelitis problem and recognized that preven-
tion rather than palliative treatment was the ultimate
pressing need. He saw that in a disease with a death
rate of 6 per cent the first problem was not physio-
therapy, great as its value may be at the present time.
He therefore established the Minnesota Poliomyelitis
Research Commission, with active students of preventive
medicine, immunology, pharmacology, neuropathology,
physiology, pediatrics and internal medicine undertaking
a comprehensive study of the 1946 Minnesota epidemic
and of every possible means to prevent its recurrence.
This Commission is now hard at work analyzing the
1946 cases and pressing for solutions to the major un-
solved problems. The problems of greatest importance
seem to me to be: (1) determining the mode of spread
of the disease; (2) determining the portal of entry;
(3) ascertaining the factors that determine suscepti-
bility; (4) finding useful chemical agents influencing the
susceptibility to, and the course of, the disease; (5)
January, 1947
elucidating the mechanism of death and finding better
methods for its prevention; and (6) improving methods
of treatment and rehabilitation. The treatment of the
acute phases of poliomyelitis has been very largely
neglected by most workers, yet it is of the highest
importance, as is evident when one looks at the death
rate and when one sees the emotional problems of par-
ents and relatives, and the clinical problems of the pa-
tients themselves in an epidemic.
Poliomyelitis is a medical problem of front rank im-
portance only in epidemic situations. Then, however, it
is a crucial emergency. The time to work at its solu-
tion is not so much during epidemics, although it is
essential that many epidemics be studied to learn about
the epidemiology, pathogenesis and clinical history of
the disease. But the great body of experimental work
must be done as a long-time, carefully planned and ex-
ecuted program. This is the objective of the Minne-
sota Poliomyelitis Research Commission.
Dr. Edwin F. Robb, Minneapolis, then presented his
Inaugural Thesis.
ENURESIS
EDWIN F. ROBB, M.D.
Minneapolis, Minnesota
Early medical literature is filled with voluminous re-
ports concerning enuresis, its causes and its cures. Many
and varied were the etiological suggestions, the chief
of which seem to have been weak kidneys, irritable
bladder, too much sleep, not enough sleep, bad behavior,
phimosis, and pinworms. The remedies suggested ranged
from a wide variety of drugs and elaborate electrical
equipment to bribery, ridicule, punishment, and hypno-
tism.
Most of our advances in pediatric urology have been
made during the past twenty years. Helmholz has con-
tributed greatly to our knowledge and conception of
infections of the urinary tract. Campbell, White, and
many others have been able through the use of improved
miniature cystoscopes to add invaluable information con-
cerning pathology of the urinary tract. The roentgenol-
ogist, too, has contributed his share with the introduc-
tion of excretory or intravenous pyelography and im-
proved roentgenological technique.
With this tremendous increase in information it is
only natural that enuresis is viewed in an entirely dif-
ferent light than it was a few years ago. It is no longer
considered merely a passing phase of childhood and one
that will surely take care of itself as maturation occurs;
it is now viewed as a distinct entity, or, at least, as a
symptom of an underlying condition that must not be
ignored, one that, if allowed to continue, is not only un-
pleasant, inconvenient, and embarrassing, but may lead
to serious psychological, social, and even physical dam-
age to the individual.
That enuresis is not just a disease of childhood is
amply proven by Shilonsky et ah, 5 Thorne,8 and others
in reporting on the large amount of enuresis in the
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MINNESOTA ACADEMY OF MEDICINE
recent armed forces. Thorne8 found that of 1000
consecutive inductees examined 161 had wet the bed
until five years of age or over, and that twenty-five
or 2.5 per cent of the 1000 men were still enuretics, and
unfit for military service. Most of these were in the
eighteen- to nineteen-year-old group, but the oldest was
thirty-three years of age. Shilonsky,5 in reporting on
100 cases of enuresis in the Army, found that most of
the men had had inadequate care when younger. Most
of them had come from rural districts, and had been
compelled, as children, to use out-door toilets. Many of
them came from large families of limited means, and
there was frequently a history of brothers and sisters
that also were bed wetters. Furthermore, practically
all of them had long since discontinued seeking medical
advice because they had received no help. Since adults
would naturally be reticent about discussing this situa-
tion with their physicians, his conclusion that enuresis
is much more common in the adult population than is
commonly supposed, seems entirely logical.
The act of urination in an infant is purely a reflex,
but in time sufficient maturation occurs for the infant
to develop sensations and conditioned reflexes for urinary
control. The time that this occurs is influenced by many
factors, but in the average child seems to occur at
about two and a half years of age for day and three
years for complete night control. European observers
place these ages at a somewhat lower level. Certainly,
if complete control has not occurred by tbe end of the
third year, a diagnosis of enuresis should be made, and
a sincere effort be made to correct the situation.
Since it is well agreed that 90 per cent of enuresis
may be classified as functional and 10 per cent as due
to organic lesions, most of which are of the urinary
tract, it is only natural that attention should be directed
to tbe larger group first.
Possibly the first consideration should be an investiga-
tion of the child’s intelligence. There is much evidence
to show that as intelligence goes down, the percentage
of enuresis rises. However, there is also ample data to
prove that bright and alert children are too frequently
afflicted. Despert3 in a well-controlled study on sixty
children in the Payne Whitney Nursery School (all with
above-average intelligence) showed an enuretic incidence
of 23 per cent. Stockwell and Smith7 in a study of 100
enuretics with an average age of nine years found 70
per cent to be of average intelligence, with 15 per cent
above average and 15 per cent below. Enuresis is usually
thought to be more common in the high-strung, nervous
type of child, yet Despert3 found that infants that were
alert and reacted most to wet diapers, et cetera, usually
had early psychomotor development and early bladder
training while those with relatively late psychomotor
development had late bladder training. This latter group
all ate well, gained well, slept quietly, and were con-
firmed thumb suckers. It would seem that the lowered
intelligence factor has been overemphasized. There is
usually little difficulty in housebreaking domestic ani-
mals, so with patience and some effort, children of
lowered intelligence should be easily taught bladder
control.
We have ample proof that an untold number of
psychological and psychogenic factors are to be found
with a group of enuretics, and that the aid of a psychia-
trist is invaluable. Fifty-two per cent of Stockwell and
Smith’s7 100 cases were found to be of a psychogenic
nature, and were treated by a psychiatrist. Of these,
forty-six were improved or cured. If all the lesser
emotional and behavior problems are included in this
group, the percentage would undoubtedly be much high-
er than 52 per cent; yet one wonders if many of the
emotional and behavior problems in the mother as
well as in the child might not result from the bickering,
scolding, and ridicule that so often accompanies enuresis.
In studying the histories of several hundred cases of
enuresis, one fact stands out more clearly than all oth-
ers. In fact it seems to be present in some form in all
cases. Namely, some mistake or neglect in the original
bladder training program of the infant. This may be in
the choice of time to initiate the program, the method
or consistency of carrying it out, the handling of emo-
tional problems that arise, et cetera. Perhaps in our
search for the etiology of enuresis, we have been un-
able to see the forest for the trees. It seems quite
possible or probable that the greatest single contributing
cause of enuresis is nothing more that the lack of a
definite and intelligent training program for the infant.
If true, the fault lies squarely on the doorstep of the
pediatrician and the family physician. Rarely does he
take the time to outline a good training regime, and
emphasize the importance of carrying it out completely
and consistently. This is usually left for mothers to
learn from various magazines and from relatives and
friends. The author readily admits his negligence in this
matter, and finds upon discussion of the subject with
several other pediatricians that they, too, are equally
guilty.
While there are many instances of infants being
trained, and with no relapses, in the very early months,
it seems reasonable to assume that training should not
be attempted until there is sufficient maturation of struc-
tures involved to insure a reasonable prospect of success.
Statistical data seem to dictate that this time should be
not earlier than the eighth month of life nor later than
the twelfth month. Best results will be obtained if the
training is done by the one person that elicits the most
favorable reactions generally in the infant. This is, of
course, in most cases the mother. A chair close to the
floor where the infant feels secure, in a bright cheerful
spot, with a smiling and encouraging mother in at-
tendance is of the utmost importance. Little can be gained
if the child is resisting and unhappy. Many methods
have been used for training, but the one most likely to
succeed is for the mother to put the child on his chair
at regular intervals during the day, gradually lengthen-
ing the intervals as the child learns control. Accidents
are bound to occur, and should be passed over lightly
while much praise should accompany successful per-
formance. Diapers should be discarded at this time,
and the fact must be recognized that the training of
boys requires more patience than does the training of
girls. This is due to the fact that boys require two
92
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MINNESOTA ACADEMY OF MEDICINE
training periods, first in the sitting position and again
in the erect position. This may in part account for the
supposedly higher incidence of enuresis in boys than
in girls.
Night training should not be attempted until day-
time control has been attained. When this daytime
conditioned reflex is completely established it will tend
to carry over into the subconscious mind of the child
asleep. Dryness at night can be encouraged by giving
milk to the child after his afternoon nap, and by giving
a supper relatively low in liquids. If the child is con-
sistently wet at night he should be taken up before
the expected time for urinating, but he should be
awakened completely, not placed on his chair in a semi-
conscious condition. To do this is but to train him to
urinate in his sleep. Here again the interval of time
should be lengthened as rapidly as possible until it is no
longer necessary to awaken him. Our goal, we must re-
member, is to go through the night without urinating,
not merely to have a dry bed.
This may sound elementary to us, but it is of the
utmost importance to check every detail with the
mother, for this procedure requires a mother or a nurse
that is completely convinced of its necessity and one
who is patient and willing to follow through with the
program. It is sometimes helpful to use an alarm clock
to awaken the child at night. The ringing of the clock,
or rather the realization by the child that the alarm
will awaken him, may speed the development of
subconscious inhibitory control. If, however, with in-
telligent and conscientious effort on the part of the
mother or nurse, the physician, and, if need be, the
psychiatrist, full continence is not attained by the time
a child is four years of age (five years at the latest)
one must consider the very likely possibility that an
organic lesion is responsible, and enlist the aid of the
urologist and roentgenologist.
While it is true that only 5- 10 per cent of enuresis is
due to organic pathology, it is with this group that
we should be most concerned. Even minor organic
lesions may eventually lead to serious renal changes and
chronic disturbances of micturation in the adult.
Since Campbell’s report2 in 1937 there have been
many excellent contributions to this subject by urolo-
gists both here and abroad. There is no longer any
doubt that a wifle variety of organic lesions of the
urinary tract are to be found in children, and have, in
many cases, proven to be the underlying cause of
enuresis. For the most part these lesions are either
infections or obstructions or both. In many cases with
infections the urine is not only negative microscopically,
but will be culture negative as well. Complete and care-
ful urological examination becomes essential as the only
means of a definite diagnosis. White9 emphasizes the im-
portance of looking for minor lesions, especially in the
urethra, and feels that failure to find them may account
for the majority of so-called failures in treatment. This
seems reasonable since we know that psychic influences
such as the sound of running water, or the proximity
of a toilet has a very much greater effect on the patient
with a, cystitis or urethritis than on one with a normal
urinary tract.
Campbell2 in 1937 reported a series of 700 children
suffering from persistent enuresis. Cystoscopic and
urethroscopic examination revealed an amazing amount
and degree of pathology. He concluded, “that com-
plete urological examination should be performed if
enuresis persists after three to four months of good medi-
cal and psychiatric care ; that all urological procedure can
be carried out in children, and that in many ways they
are tolerated better than in the adult.” He points out,
however, that excretory urographic study should be
done first even though in his experience diagnostic help
was obtained in only 50 per cent. Spence and. Moore6
in 1939 reported a series of fifty female children from
three to fourteen years of age, either with acute pyuria
or a history of previous pyuria, 20 per cent of whom
were enuretics, 76 per cent showed a chronic urethritis,
and in many there was a diminution in the size of the
urethra and a loss of its elasticity.
White10 in 1941 reported a study of 310 cases of
enuresis in children at the Princess Elizabeth of York
Hospital in London. He emphasized the importance of
infection as an etiological factor in enuresis, although
only 15 per cent of his cases showed any evidence of
infection in the urine. Sixty per cent of his cases were
female and 16 per cent definitely followed infectious
diseases such as measles, scarlet fever, et cetera. Twenty-
seven per cent of the boys in this series showed inflam-
mation and constricture of the external urinary meatus.
In girls the external urinary meatus was seldom con-
stricted, but adjacent local inflammation was usually
present. Of 220 cases with cystoscopic and posterior
urethroscopic examination, 70 per cent showed evidence
of inflammation on the front of the trigone and at the
internal urinary meatus. Of 150 cases with intravenous
urograms, 60 per cent showed variations from the nor-
mal in the upper urinary tract, all of which were minor
but important as indicating early changes due to inflam-
matory processes below. White treated this series by
dilatation of the urethra, and reported benefit in some
degree for 97 per cent. Eighty per cent benefited by
one treatment only, 55 per cent ceased to have enuresis
for from three months to two years, and 42 per cent
continued to have enuresis, but were much improved.
Meatotomy was necessary in 70 per cent of the cases
in order to pass a sufficiently large sound.
Higgins,4 too, emphasized the importance of a care-
ful examination of the vulva and urethra in girls, and
the external urinary meatus and urethra in boys for
signs of inflammation or obstruction, both of which he
felt to be a common cause of enuresis.
Brodny and Robins1 in an excellent article in the
Journal of the A.M.A. in 1944 recognized the value of
early and complete urological study of enuresis. They
emphasized the value and advantage of cystography and
urethrography over other methods of urological exami-
nations. They believe that it is not only much easier
and safer, but in many ways more valuable, since it can
be done on younger children and repeated if necessary
to watch the progress of a lesion. They also emphasize
the necessity of teamwork between the pediatrician or
family physician, the psychiatrist, the roentgenologist,
and the urologist if the best results are to be obtained
January, 1947
93
MINNESOTA ACADEMY OF MEDICINE
in the diagnosis and treatment of enuresis due to organic
lesions of the urinary tract.
During the past few years I have sought urological
help on a small number of cases of persistent enuresis.
They were referred to the late Dr. Ernest Meland,
who was very much interested in this subject. Un-
fortunately there is no record of those patients who
failed to show pathology of the urinary tract, but my
impression is that the number was small, since most
of the group consisted of older children that had resisted
all medical and psychiatric treatment.
I should like to present briefly nine cases in which
definite disease was found, and to thank Drs. Creevy,
Webb, and Smith for making these records available
to me. Two of this group of patients have moved from
the city, and the end results of the treatment are un-
known.
Case 1. — S. S., female, aged twelve, had a history of
diurnal frequency and nocturnal enuresis. Cystoscopic
examination revealed a granular urethritis, grade 2.
Internal sphincter, bladder, and ureteral orifices all ap-
peared normal. Both ureters were catheterized, and
specimens collected. Cultures from the kidneys and
bladder were negative. Kidneys, ureter and bladder were
normal.
Diagnosis : Granular urethritis.
Note : this patient moved out of town in a few
weeks, and has not been followed.
Case 2. — C. P., male, aged twelve, had severe eczema
as a baby and frequent colds with spasmodic bronchitis.
Severe pertussis at seven years, after which he developed
severe attacks of asthma and persistent and severe
enuresis. Dr. Meland dilated this boy’s urethra, and
instilled 1 per cent silver nitrate. There was no im-
provement and two months later he was readmitted for
urological study. Cystoscopic examination revealed a
normal urethra, but there was hypertrophy of the veru,
grade 2, and a marked redundancy of the mucosa at
the vesical neck producing an obstruction. Ureteral
orifices were normal. The verumontanum was ful-
gurated down smooth, and the mucosa at the vesical
neck was fulgurated by means of strip cautery. A No. 12
catheter was left in the bladder for two days.
Note: For three to four months this patient wet his
bed occasionally, but for the past three years he has
had no enuresis.
Case 3. — F. B., male, aged ten, had had persistent
enuresis since infancy with microscopic hematuria at
times. Cystoscopic examination revealed a flap in the
urethra attached to the distal portion of the verumon-
tanum, and acting as a valve. K.U.B. and all other
findings were normal. The flap was destroyed by fi-
guration. Diagnosis : Posterior urethral valve.
Note : There was no apparent improvement in the
enuresis for one year, at which time it ceased and the
patient has had no trouble for two years.
Case 4.— S. H., male, aged seven, had had persistent
enuresis since infancy. Cystoscopic examination revealed
a normal anterior urethra. In the prostatic urethra there
was some lateral lobe intraurethral fullness at the vesical
orifice with four slight longitudinal bands radiating
from the apex of the verumontanum to the vesical neck
producing some constriction at the neck. Around the
posterior half of the urethra just below the verumon-
tanum was a shaggy inflammatory collar. The bands
in the posterior urethra were fulgurated, strip figura-
tion was applied to the lateral lobes at the vesical neck,
light figuration of the veru, and the inflammatory collar
94
described was destroyed. Kidney ureter and bladder
examinations gave negative findings. A No. 12 catheter
was left in for twenty-four hours.
Diagnosis: Posterior urethral valve and hypertrophy
of the verumontanum.
Note : This boy was much improved, but was still
wetting his bed occasionally when he moved from the
city six months later.
Case 5. — L. T., female, aged five, had had enuresis
since infancy with diurnal frequency the past two years.
Cystoscopy revealed polypoid granulations in the region
of the internal sphincter. The bladder was normal. Kid-
ney, ureter, bladder examinations and intravenous uro-
gram showed a normal condition. The urine was micro-
scopically negative, but colon bacilli were found on
culture.
Diagnosis: Urethritis and Bacilluria.
Note: This patient has not been seen since hospitaliza-
tion four years ago. It is therefore assumed that treat-
ment was unsatisfactory. The patient was an only child
and the mother was extremely neurotic. She was a
greater problem than the child.
Case 6. — M. B., female, aged three, had had enuresis
and some diurnal incontinence. There was no history of
urinary infection. Cystoscopy was normal except for
some inflammatory tags and redundancy of the mucosa
in the proximal urethra. A K.U.B. was normal. The
urine was normal on culture. The tags and mucosa
were fulgurated. This patient was readmitted to the
hospital two months later. Dr. Meland’s note at this
time was as follows : “There was marked improvement
for a time, but there has been some recurrence of her
symptoms.” Cystoscopy again revealed a redundancy of
the mucosa with tags in the distal urethra. These tags
were fulgurated. ,
Note: The patient again showed improvement for, a
time, but now, two years later, has occasional diurnal
incontinence and nocturnal incontinence two to three
times a week.
Case 7. — K. S., male, aged ten, had had persistent
enuresis since infancy. Cystoscopy revealed a hyper-
trophy of the verumontanum which practically filled the
posterior urethra, and there was a moderate redundancy
of the vesical neck; otherwise it was normal. K.U.B.j
et cetera, were negative. The veru was fulgurated,
there was a strip cautery of the mucosa at the vesical
neck in four quadrants.
Note : The mother states that there was no improve-
ment in this boy’s condition for one year. During the
next two years there was gradual improvement. For
the past two years he has had no trouble.
Case 8. — V. T., female, aged six and one half, had suf-
fered from recurring urinary tract infections and per-
sistent enuresis. The infections responded nicely to
chemotherapy, but would recur. K.U.B. was negative,
and intravenous pyelogram was normal. Cystoscopic
examination was negative except for a urethritis, grade
2. The urethra was dilated to No. 18 French sound and
1 per cent silver nitrate applied to the urethra.
Note : There was no improvement in symptoms, and
she has for the past three years been under the care
of another physician. The mother reports that there
is still no improvement in the enuresis.
Case 9. — S. S., Jr., male, aged nine, had had enuresis
and diurnal frequency since infancy. He was the older
of two children, and came from a fine, intelligent family.
He had become such a behavior problem that he failed
constantly in school, had no friends in the neighborhood,
and was simply impossible in every way. He had good
psychiatric help, and was placed in a new school with-
out benefit. Cystoscopy was negative except for an hyper-
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
trophy of the verumontanum that practically filled the
posterior urethra and a redundancy of mucosa at the
vesical neck. The veru was fulgurated down smooth,
and strip cautery carried out in four quadrants in the
vesical neck. A No. 12 catheter was left in for twenty-
four hours.
Note : This boy showed immediate improvement. He’
wet his bed occasionally for one month, but has had no
enuresis for the past five years. His entire personality
has likewise changed. When enuresis ceased, the be-
havior problem disappeared. His school work has been
good, and he can be considered a normal boy in every
way.
Comment
Obviously no conclusions can be drawn from such a
small series of cases, their chief function being merely
to stimulate one’s further interest in the subject. It
might be noted, however, that there were four girls in
this group and five boys. The girls all showed evidence
of inflammatory changes in the urethra, and culture of
the urine was positive in two of them. Fulguration of
granulations and redundant mucous membrane was done
in two girls. Results in all four of the girls treated were
unsatisfactory. Perhaps better results would be ob-
tained in treating enuresis in girls if we treated them
in much the same manner as one would treat a persistent
pyuria.
In the boys, urine culture was negative in all. Four
showed hypertrophy of the verumontanum, four showed
redundancy of the mucous membrane in the posterior
urethra, and two showed definite posturethral valves.
Fulguration of the obstructive lesions was done in all
five with apparent improvement in all. One was com-
pletely cured, and three were either much improved or
completely cured after periods of from three months
to one year. Since all other treatment had failed in these
boys for many years, it seems reasonable to assume that
removal of the obstructive lesions had a part in their
eventual cure.
It has been impossible, in the time allotted me, to go
into many phases of the diagnosis and treatment of
enuresis. Simple urological procedure such as determina-
tion of residual urine, bladder capacity, et cetera, may
give invaluable information. Likewise many drugs have
therapeutic value. Of these ephedrine and atropine prob-
ably take first rank, but even these can be used more
intelligently and effectively following a complete urolog-
ical examination.
Summary
In summarizing we seem justified in the following
conclusions :
1. Enuresis is a serious medical problem, and de-
serves careful study.
2. It is not only a pediatric problem, but may be
one for the internist, psychiatrist, roentgenologist and
urologist as well.
3. The best cure for enuresis usually lies in its pro-
phylaxis. More attention to bladder-training programs
for infants is definitely necessary.
4. Organic lesions of the urinary tract must always
be suspected, and urological investigation instituted in
those cases refractory to good medical and psychiatric
care.
References
1. Brodney, M. L., and Robins, Sam A.: Enuresis: Use
of cystourethrography in diagnosis. T.A.M.A., 126: 1000-
1006, (Dec.) 1944.
2. Campbell, M. : Tirol. & Cut. Rev., 41:542-545, (Aug.)
1937.
3. Despert, J. L. : Urinary control and enuresis. Psycho-
som. Med., 6:294-307, (Oct.) 1944.
4. Higgins, T. T. : Discussion on Enuresis. Royal Soc.
Med., 37:344-346, (May) 1944.
“5. Shilonsky et al. : Functional enuresis in the Army. Clin-
ical study of 100 cases. War Med, 7: (May) 1945.
6. Spence and Moore: Texas State J. Med., 35:234-238,
1939.
7. Stockwell, L., and Smith, C. K. : Enuresis. Am. J. Dis.
Child., 59:1013-1033, (Jan.-June) 1940.
8. Thorne, F. C. : Incidence of nocturnal enuresis after
five years of age. Am. J. Psychiat., 100:686-689, (Mar.)
1944.
9. White, H. P. Winsbury: Brit. J. Urol., 6:81-93, (Sept.)
1944.
10. White, H. P. Winsbury: Brit. J. Urol., 13:149-161, 1941.
Discussion
Dr. C. D. Creevy, Minneapolis: I believe that all of
these patients whom Dr. Robb has discussed were seen
by Dr. Meland. I have enjoyed Dr. Robb’s paper very
much. It seems to me that the pediatrist must cure
most of the cases of enuresis because I see very few.
The problem is simpler in the male than in the female.
From the urologic point of view one can divide enuresis
into two main types : The functional, and the organic.
The functional type can be divided into two subgroups :
the sound sleepers, and the malingerers or psychiatric
problems.
Most of those whom I see appear to be sound sleep-
ers. The children have trouble only at night. The urine
is normal and the urological investigation shows nothing
abnormal. One can relieve most of these patients with
the Cunningham clamp or the Foley artificial sphincter.
If the child and parents are co-operative, the device
needs to be used only for a comparatively short time
after which a habit seems to be established, and the
difficulty straightens around.
The malingerers are those patients who can be rec-
ognized readily by an interview. Characteristically, the
child or the mother, or both, are resistant to and rather
resentful of, all suggestions and betray this fact by their
attitude. These people, of course, belong in the hands
of the psychiatrist.
Patients in the organic group are troubled day and
night. Dr. Robb has covered this group pretty thorough-
ly. It includes patients with lesion of the nervous system,
such as spina bifida, spina bifida occulta, and various
other congenital disorders ; those with local irritative
lesions in the urethra ; and an occasional patient with
an ectopic ureteral orifice. This last group consists en-
tirely of girls.
One. serious problem from the point of view of the
urologist is the difficulty of examining the prostatic
urethra satisfactorily in an infant or young boy. The
cystoscopes are so small that the objective of the tele-
scope, and the light, necessarily come too close to the
mucous membrane of the prostatic urethra, which then
tends to shut off the light by the objective so that vision
is relatively poor.
Dr. W. F. Braasch, Rochester : I appreciate the op-
portunity of hearing, not alone the thorough review of
the subject of enuresis by Dr. Robb, but also the ex-
cellent discussion by Dr. Creevy. I can add very little
to Dr. Creevy’s remarks. I might say, however, that
the urologist has for a long time recognized the exist-
ence of etiologic factors of enuresis such as Dr. Robb
has cited, but apparently the pediatrician has not. In
fact, Dr. Robb is the only pediatrician to my knowledge
who recognizes the frequent existence of urologic lesions
to account for enuresis and who has written a paper
describing them. I trust that he will read this paper
before pediatric societies so that his colleagues may be
influenced to look for the lesions in the urinary tract
which he has described.
January, 1947
95
WOMAN’S AUXILIARY
Although many cases of enuresis undoubtedly are of
a functional nature, the possibility of an organic lesion
must be considered, particularly if the symptoms persist
beyond the age of puberty. There is one lesion which
I would like to mention particularly, namely, dysfunc-
tion of the muscles at the neck of the bladder. This
lesion is characterized by relaxation of the muscles in
this area extending into the adjacent urethra, and it
usually can be recognized on cystoscopic examination:
Another lesion which always should be excluded is a
pin-point meatus at the external urethra. It is not an
infrequent cause of enuresis.
The treatment of functional enuresis mentioned by
Dr. Creevy is an excellent one, namely, the penile clamp.
This has been applied in several cases to my knowledge,
with excellent results.
Dr. T. H. Sweetser, Minneapolis : I was glad that Dr.
Robb mentioned the training of the parents. In the
cases I have seen, the training of the parents and im-
provement of the environment at home have been im-
portant aids in the care of the patients. Hospitalization
as a means of changing environment has sometimes
helped. Dr. Creevy and Dr. Robb have covered the
subject well, but there is just one point I want to
emphasize.
Dr. Robb mentioned the importance of urinary infec-
tion. After removing any obstructions, local treatment
of the posterior urethra and chemical treatment of the
infection will clear up the difficulty. But many urinary
infections are treated only until symptoms are relieved
and urine has become clear ; the trouble then recurs with
the first intercurrent infection or lowering of the pa-
tient’s resistance. The infection should be treated until
the urine is sterile by culture to give the best chance of
permanent cure.
Dr. Alexander .Stewart, Saint Paul : I think a good
deal as Dr. Robb does about the importance of the
functional side. I had a boy in the office this after-
noon who has just recovered from polio; while he was
in bed for three weeks with polio he never wet the
bed, but as soon as he was released from quarantine
he started again having enuresis the same as before his
illness.
I wish to congratulate Dr. Robb on his fine thesis
and I believe that from now on I will refer more of
my patients who do not respond to general and psy-
chiatric treatment to the urologist for investigation.
Dr. Robb, closing : I wish to thank my discussants for
their generous words. Undoubtedly, most cases of en-
uresis are functional in origin, but I wish to emphasize
again the importance of searching for organic causes.
We have, I think, been very negligent in our institu-
tion of bladder-training programs. Obviously, we do
not want to create a behavior problem as well, hut it is
amazing how easily many children are trained when
this program is started when the infant is only ten or
twelve months of age.
The meeting adjourned.
A. E. Cardi.e, M.D., Secretary
Because of peculiarities in its pathology and epidemi-
ology, tuberculosis, especially the pulmonary form, has
attained world-wide prevalence. The mode of transmis-
sion is simple, and while there are great variations in
susceptibility, no class or subdivision of mankind is
immune. These peculiarities make it reasonably certain
that no nation could eradicate the disease and by arti-
ficial barriers prevent its introduction from without.
Even if such procedures were theoretically possible, the
limitations which they would place upon travel and com-
merce would make them impracticable.— James A.
Doull, M.D., NTA Transactions, 1946.
96
WOMAN'S AUXILIARY
Blue Earth County
The Blue Earth County Medical Auxiliary enter-
tained the Redwood-Brown and Nicollet-LeSueur auxili-
aries on December 7.
After a joint dinner with their husbands at the Saul-
paugh Hotel, the fifty wives were guests at the home of
Mrs. Roger Hassett.
Mrs. Roger Engel spoke on Germany, and Mrs. Walter
Kaufman reported on the State Board Meeting held in
Saint Paul, December 6. Mrs. Kaufman was appointed
chairman of the Blue Earth County Cancer Society.
Business meetings of the three county organizations
were held after the program. Mrs. George Penn pre-
sided in the absence of Mrs. Troost, the president.
Hennepin County
The Hennepin County Medical Auxiliary held its an-
nual Christmas party in the Medical Arts Lounge, De-
cember 6.
Mrs. Jessie D. Hamer, Phoenix, Arizona, president of
the Women’s Auxiliary to the American Medical As-
sociation, and Mrs. Melvin S. Henderson, Rochester,
Minnesota, state president, were guests of honor.
Reading of the play, “The First Christmas Tree,”
was given by Mrs. Leonard Arling, followed by a pro-
gram of Christmas music.
Mrs. Elmer O. Dahl and Mrs. Arthur A. Wohlrabe
were tea chairmen for the day.
Olmsted-Houston-Fillmore-Dodge Counties
The Olmsted-Houston-Fillmore-Dodge County Auxil-
iary again sponsored the Christmas Seal essay contest
in the Junior and Senior High School in Rochester,
awarding a $5.00 prize for the best original essay in each
age group. The Auxiliary also aided in the sale of
Christmas seals by staffing booths in the downtown hotels.
Mrs. B. M. Black is directing the collection of medical
and surgical instruments and medical supplies to be sent
overseas to the needy.
Dr. A. W. Adson addressed the auxiliary on the
“Minnesota Plan for Pre-payment Medicine,” at the
fall meeting. A tea and social hour followed.
Wright County
The Wright County Medical Auxiliary held its fall
meeting October 14 at the home of Mrs. W. P. Ander-
son, Buffalo.
Bandages were made for the Cancer Society, and the
auxiliary subscribed to The Bulletin.
A turkey dinner was served to the members and their
husbands by Mrs. John J. Catlin of Buffalo.
The health of all peoples is fundamental to the attain-
ment of peace and security and is dependent upon the
fullest co-operation of individuals and states. — Constitu-
tion of the World Health Organization, U.N.
Minnesota Medicine
SEARLE
RESEARCH
when
results from
overstimulation
“Smoothage” — the term coined to describe the
action of Searle Metamucil — seeks to avoid further
irritation, to soothe and to protect the
overstimulated intestinal mucosa, and to reestablish the
normal reflexes of elimination.
Metamucil softens the fecal residue, affords bland bulk
and exerts a gentle, stimulating, physiologic peristalsis.
METAMUCIL
is the highly refined mucilloid of Plantago ovata (50%),
a seed of the psyllium group, combined
with dextrose (50%), as a dispersing agent.
Metamucil is the registered trademark of
G. D. Searle & Co., Chicago 80, Illinois.
IN THE SERVICE OF MEDICINE
January, 1947
97
Reports and Announcements
*
MEDICAL BROADCAST FOR JANUARY
The following radio schedule of talks on medical
and dental subjects by William O’Brien, M.D., Di-
rector of Postgraduate Medical Education, University
of Minnesota, is sponsored by the Minnesota State
Medical Association, the Minnesota State Dental Asso-
ciation, the Minnesota Hospital Service Association in
co-operation with the Minnesota Hospital Association
and the Minnesota Nurses Association, and the Uni-
versity of Minnesota School of the Air.
2 — 4:45 P.M. WCCO Cause and Spread of Infantile
Paralysis
4—11:30 A.M. KUOM KROC- Medicine in the News
K FA M
7 — - 4:45 P.M. WCCO Diagnostic Hospital Equipment
8 — 11:00 A.M. KUOM Foods Undergo Many Changes
in the Body
9 — - 4:45 P.M. WCCO Treatment of Infantile Paralysis
11 — 11:30 A.M. KUOM-KROC-Medicine in the News
KFAM
14 — 4:45 P.M. WCCO The Nurse and Public Health
15 — 11:00 A.M. KUOM The Blood Travels in a Continu-
ous Stream
16 — 4:45 P.M. WCCO Results of Infantile Paralysis
18 — 11:30 A.M. KUOM-KROC-Medicine in the News
KFAM
21 — 4:45 P.M. WCCO Treatment Hospital Equipment
22 — 11:00 A.M. KUOM Waste Materials Are Removed
from the Body
23 — 4:45 P.M. WCCO The Common Cold
25 — 11:30 A.M. KUOM-KROC-Medicine in the News
KFAM
28 — 4:45 P.M. WCCO Visiting Nurse
29 — 11:00 A.M. KUOM Sunlight and Fresh Air Are
Health Essentials
30 — 4:45 P.M. WCCO Mouth Problems of Advancing
Years
AMERICAN ACADEMY OF ARTS AND SCIENCES
OFFERS FRANCIS AMORY PRIZE
In compliance with the terms of a gift under the will
of the late Francis Amory of Beverly, Massachusetts,
the American Academy of Arts and Sciences offers a
substantial prize for outstanding work addressed to the
alleviation or cure of diseases affecting human reproduc-
tive organs. The gift provides a fund, the income of
which may be awarded at seven-year intervals “as a
prize and gold medal, or other token of honor or
merit,” to any individual or individuals for work of
“extraordinary or exceptional merit” in this field. In
case there has appeared work of a quality to warrant it,
the next award will be made in 1947. Awards will be
made for what in the judgment of the Committee on
the Amory Fund appears to be the most outstanding con-
tribution or contributions in the field as outlined and
as based on published work and recognized accomplish-
ment for the current seven-year period.
No formal applications and no essays or treatises from
individuals are solicited, but suggestions will be welcome
from any appropriate source that will be of aid to the
Committee in making a wise selection.
Recommendations may be addressed to Secretary,
Amory Fund Committee, American Academy of Arts
and Sciences, 28 Newbury Street, Boston, Massachusetts.
NATIONAL CONFERENCE ON
MEDICAL SERVICE
The twentieth annual meeting of the National Confer-
ence on Medical Service will be held at the Palmer
House, Chicago, on February 9. Registration will com-
mence at 9 a.m., and the program will include discussions
in the fields of national affairs, economics and medical
education. All physicians are invited to attend ; there is
no registration fee. Dr. 'Cleon A. Nafe, Indianapolis, is
president of the Conference and Creighton Barker,
New Haven, is secretary.
CHICAGO MEDICAL SOCIETY
The third annual clinical conference of the Chicago
Medical Society will be held at the Palmer House, Chi-
cago, March 4-7, 1947. The previous two conferfences
have warranted the continuance of the meeting, the
program of which is selected particularly for the general
practitioner. Scientific exhibits from Chicago and ad-
joining medical centers and commercial exhibits will be
included in the program. All physicians are invited to
attend. Further information may be obtained from the
Society Office, 30 No. Michigan Avenue, Chicago 2,
Illinois.
PHILADELPHIA SEMINAR IN RADIOLOGY
The second annual Philadelphia postgraduate seminar
in radiology will be held March 30 to April 4, 1947.
The course is sponsored by the American College of
Radiology and the Philadelphia Roentgen Ray Society.
Registrants will be limited to one hundred, and pref-
erence wall be given to members of the American Col-
lege of Radiology wffio served in World War II. The
tuition fee will be $50.00.
Interested radiologists should contact the office of the
American College of Radiology, 20 No. Wacker Drive,
Chicago 6, Illinois.
MINNESOTA MEDICAL SERVICE
At a meeting held in Saint Paul on January 4, 1947,
the articles of incorporation for a non-profit organiza-
tion to be known as Minnesota Medical Service, Inc.
were signed by twenty-one incorporators, and a board
of eleven directors was elected.
Dr. Olaf I. Sohlberg, Saint Paul, was named presi-
dent of the board ; Dr. R. R. Cranmer, Minneapolis, vice
president; Dr. C. A. McKinley, Minneapolis, secretary;
Dr. W. A. Coventry, Duluth, treasurer. Other board
members are: Dr. E. C. Bayley, Lake City; Philip G. E.
Hoeper, Mankato; Dr. J. F. Norman, Crookston; Dr.
E. M. Hammes, Saint Paul ; Dr. E. J. Simons, Swan-
ville ; Dr. L. L. Sogge, Windom, and Dr. W. W. Yeager,
Marshall.
ANNUAL COUNTY OFFICERS MEETING
Officers of all component medical societies of the Min-
nesota State Medical Association are reminded to keep
open Saturday, March 1, 1947, which is the date selected
by the Council for the Annual County Officers Meeting.
County officers will convene this year at Hotel Lowry,
(Continued on Page 100)
98
Minnesota Medicine
s
For the Treatment
of NON-SURGICAL
and NON-INFECTIOUS
DISEASES
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Only ten minutes from the Minneapolis loop, the
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is emphasized at each of seven separate stations.
Every facility for comfort and care is assured the
patient. Available to all reputable members of the
medical profession.
Operated in connection with HOMEWOOD HOSPITAL
ScAool PtofcAiaPUc 'TtunAutg,
A course in nursing
offers training in a
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Students work with
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A one year course in our school of psychiatric nurs-
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the subject are skillfully presented by a capable and
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Classroom and laboratory studies are combined, with
an interesting program of actual work on the wards.
Here's an opportunity to obtain a useful higher edu-
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pin, a diploma and cape are awarded on completion
of the course.
Classes begin in January, June and September.
June class now being organized.
Write for particulars. Director, School of Nursing
Glenwood Hills Hospitals, 3501 Golden Valley Road, Route Seven, Minneapolis, Minnesota
January, 1947
99
REPORTS AND ANNOUNCEMENTS
caught in the
storm center of the meno-
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When you base your
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given your patient the best assistance possible
through medication.
Physicians using Solution of Estrogenic Sub-
stances, Dorsey, may rest upon that certainty. . .for
this product is manufactured under rigidly regu-
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A reliable product . . . judiciously ad-
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100
ANNUAL COUNTY OFFICERS MEETING
(Continued from Page 98)
Saint Paul. The program begins at 2 p.m. and will end
with a banquet at which an outstanding speaker will be
selected to address the delegates.
MINNESOTA PATHOLOGICAL SOCIETY
The regular meeting of the Minnesota Pathological
Society of the University of Minnesota Medical School,
was held on Tuesday evening, December 17, in the
Medical Science Amphitheater. The speaker was Dr.
Edith L. Potter, of the University of Chicago. Dr.
Potter’s subject was “The Pathologist’s Contribution
to the Clinical Diagnosis of Disorders of the Newborn.”
GOODHUE COUNTY SOCIETY
Dr. Grant F. Hartnagel was elected president of the
Goodhue County Medical Society at the annual meeting
held at the St. James Hotel on December 6. Other
officers are Dr. Martin G. Flom, vice president; Dr.
James Iw Brusegard, secretary-treasurer; Dr. Raymond
F. Hedlin, delegate to the State Medical Association,
and Dr. McGuigan, alternate delegate.
Dr. Woodward L. Colby, of Saint Paul, discussed a
pediatric survey which will be conducted by pediatricians
of the state.
INTERURBAN ACADEMY OF MEDICINE
The annual election of officers of the Interurban
Academy of Medicine was held at the Hotel Spalding
in Duluth on November 20. The new president is Dr.
Philip F. Eckman, Duluth, who succeeds Dr. H. A. Sin-
cock, of Superior. Dr. Conrad Giesen, of Superior, was
elected vice president, and Dr. Henry E. Bakkila, of
Duluth, was made secretary-treasurer, replacing Dr.
Herbert P. Christianson, of Superior. Dr. Richard Bar-
don, of Duluth, was elected to the board of censors
for a three-year term.
Speakers at the meeting were Dr. Giesen and Dr.
Frank J. Hirschboeck of Duluth.
RAMSEY COUNTY SOCIETY
The Ramsey County Medical Society at its meeting
in Saint Paul named Dr. Clayton K. Williams, Saint
Paul, as president-elect to take office in 1948. The
president for the ensuing year is Dr. John M. Culligan.
Other officers who assumed their duties on January 1
are Dr. Lyman R. Critchfield, vice president, and Dr.
Laurence D. Hilger, secretary-treasurer.
A feature of the meeting was a symposium of the
recent polio epidemic. Discussion leaders included Dr.
Robert B. J. Schoch, Saint Paul city health physician,
Dr. Wallace Cole, Dr. P. K. Artz and Dr. Frank
Hedenstrom. About 149 members of the society at-
tended.
REDWOOD-RENVILLE COUNTY SOCIETY
Dr. Ralph E. Erickson, of Hector, was elected presi-
dent of the Redwood-Renville County Medical Society
( Continued on Page 102)
Minnesota Medicine
The newly diagnosed
diabetic and
Globln Insulin
noon meal, and 2/5 at the evening meal. Any
tendency toward midafternoon hypoglycemia
may usually be offset by giving 10 to 20 grams
of carbohydrate between 3 and 4 p.m.
WHEN DIETARY MEASURES ALONE Cannot Control
a recently established case of diabetes and insu-
lin must be resorted to, one daily injection of
intermediate-acting ‘Wellcome’ Globin Insulin
with Zinc will often prove both adequate and
beneficial. This simplified regimen can be ini-
tiated in the following manner:
ESTIMATING THE DOSAGE: The simplest method
is to start with 15 units of Globin Insulin and in-
crease the dosage every few days, as required.
A closer estimation is obtained by quantitative
sugar determination of a 24-hour urine speci-
men. For the initial dosage, % of a unit of
Globin Insulin is given for every gram of sugar
spilled in 24 hours.
This starting diet may subsequently be adjusted
as required to suit the needs of the patient. Final
adjustment of carbohydrate distribution may be
based on fractional urinalyses.
ADJUSTING TO 24-HOUR CONTROL: Simulta-
neously adjust the Globin Insulin dosage to
provide 24-hour control as evidenced by a fast-
ing blood sugar level of less than 150 mgm., or
sugar-free urine in the fasting sample.
‘Wellcome’ Globin Insulin with Zinc is a clear solu-
tion, comparable to regular insulin in its freedom
from allergenic properties. Available in 40 and 80
units per cc., vials of 10 cc. Accepted by the Council
on Pharmacy and Chemistry, American Medical
Association. Developed in The Wellcome Research
Laboratories, Tuckahoe, New York. U. S. Patent
No. 2,161,198. LITERATURE ON REQUEST.
'Wellcome' Trademark Registered
Both diet and dosage must subsequently be
adjusted to meet the needs of each individual
patient.
ADJUSTING THE DIET: In general it has been
found that a good carbohydrate distribution for
the patient on Globin Insulin consists of 1/5 of
the total carbohydrate at breakfast, 2/5 at the
BURROUGHS WELLCOME & CO. (U.S.A.) INC., 9 & II EAST 4IST STREET, NEW YORK 17, N.Y
January, 1947
101
REPORTS AND ANNOUNCEMENTS
URINE-SUGAR TESTING
made
SIMPLE • SPEEDY • CONVENIENT
with
CLI N ITEST
The Tablet, No Heating Method
Simply drop one Clinitest Tablet into test tube con-
taining proper amount of diluted urine. Allow time for
reaction — compare with color scale.
NOTE — NEW ATTACHMENT
FOR ADDED CONVENIENCE
The test tube clip now supplied with each pocket-size
case enables the test tube to be hooked on to the out-
side of case, as shown in illustration.
This simple device provides an added convenience lor
the user — tube is maintained in an upright position,
tube is held motionless during reaction.
FOR OFFICE USE:
Clinitest Laboratory Outfit (No. 2108)
FOR PATIENT USE:
Clinitest Plastic Pocket-Size Set (No. 2106)
Complete information upon request.
AMES COMPANY, Inc.
ELKHART, INDIANA
REDWOOD-RENVILLE SOCIETY
(Continued from Page 100)
at the annual business meeting held in the community
hall at Morgan. Dr. Ralph E. Billings, of Franklin,
was elected secretary.
Following the dinner and meeting, the twenty-two
members who attended were entertained at a social
gathering at the home of Dr. and Mrs. William E.
Johnson in Morgan.
ST. LOUIS COUNTY SOCIETY
Results of the annual election of officers of the St.
Louis County Medical Society, which was conducted by
mail balloting were announced at the annual banquet
held at the Northland Country Club at Duluth on De-
cember 12. The president-elect is Dr. Peter S. Rudi,
of Duluth. Dr. Elizabeth C. Bagley, Duluth, was re-
elected secretary-treasurer, and Dr. Reginald A. Salter,
Virginia, vice president. Dr. Daniel W. Wheeler, Du-
luth, is the 1947 president, succeeding Dr. Paul G.
Boman, Duluth.
Dr. Gerhard von Glahn, professor of political science
and economics at the Duluth State Teachers College,
spoke on “The European Scene Today.”
WASHINGTON COUNTY SOCIETY
At the annual meeting of the Washington County
Medical Society, the following officers were elected for
1947: President — Francis M. McCarten ; first vice
president — Russell E. Carlson; second vice president —
Emmett R. Samson; secretary-treasurer — E. Sydney
Boleyn ; delegate — E. Sydney Boleyn ; alternate delegate
— Wade R. Humphrey; censor for 1947, 1948, 1949 — R.
J. Josewski, all of Stillwater.
Heart Disease
(Continued from Page 73)
stored to full or partial working capacity. Similarly,
studies of children attacked by rheumatic fever show that
more than 90 per cent of those who escape serious heart
damage lived ten years or longer, and even among those
with heart damage a great majority are living ten years
after onset. Those without serious heart involvement
can usually lead normal lives, with little restricton.
This applies also, in considerable measure, to those with
damaged hearts, although they must avoid certain types
of occupations.
Altogether, then, there is little cause for alarm over
the situation in heart disease today. The great bulk
of the deaths from this cause occur in older people.
It is necessary, of course, to see that elderly heart disease
patients are properly cared for. Relatively few of them,
however, require or can afford expensive hospital or in-
stitutional care. Many cardiacs in the older age groups
can live happy useful lives in their own households.
Their social, economic, and cultural problems are often
more important than their medical problems. The spe-
cial types of facilities required to cater to these people
are in many instances a responsibility of the community.
102
Minnesota Medicine
to combat
depression associated with
persistent pain.
Many patients suffering from persistent pain
are subject to attacks of depression characterized
by deep apathy and emotional exhaustion.
Thus, pre-existing neurotic tendencies
may be exaggerated and the pain threshold
progressively lowered.
By restoring morale and optimism, benzedrine sulfate
Benzedrine Sulfate will often effectively
combat the depression which may complicate
the management of painful conditions. Needless to
say, Benzedrine Sulfate is not indicated in the
casual case of low spirits, as distinguished
from true mental depression.
( racemic amphetamine sulfate, S.K.F.) Tablets and Elixir
Smith, Kline & French Laboratories, Philadelphia Pa.
\nuary, 1947
103
Vlie Stethetron
'{(airo
REMARKABLE development which
assures accuracy in auscultatory diagnosis.
An electronic stethoscope which ampli-
fies the faint heart and chest sounds you
wish to hear while subduing the other
sounds to con ven ient levels for com-
parison.
Easily detects faint murmurs and dis-
ease sounds which cannot be heard
through the old-fashioned acoustic stetho-
scope.
A demonstration will convince you.
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TT°mewood HOSPITAL is one of the
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treatment of Nervous Disorders — equipped
with all the essentials for rendering high-grade
service to patient and physician.
Operated in Connection with
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HOMEWOOD HOSPITAL
Corner Penn and Plymouth Avenues North
Minneapolis Minnesota
THE MARY E. POGUE SCHOOL
For Retarded and Epileptic Children
Children are grouped according to type and have their own separate departments. Separate
buildings for girls and boys.
Large beautiful grounds. Five school rooms. Teachers are all college trained and have
Teachers’ Certificates.
Occupational Therapy. Speech Corrective Work.
The School is only 26 miles west of Chicago. All west highways out of Chicago pass
through or near Wheaton.
Referring physicians may continue to supervise care and treatment of children placed in the
School. You are invited to visit the School or send for catalogue.
26 Geneva Road Wheaton, 111. Phone: Wheaton 319
104
Minnesota Medicine
(Above) Fitting practice session at recent CAMP Instructional Course
YOUR PATIENTS ARE PROPERLY FITTED
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CAMP fitters are conscientiously trained to work on the physician’s
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January, 1947
105
Of General Interest
Dr. Henry P. Linner, Minneapolis, has been elected
surgeon for the Hamilton Fish Camp No. 7, U. S.
Spanish War Veterans.
* * *
The regular quarterly chest clinic conducted by the
Rochester Department of Health, was held at the city
hall on December 3. Dr. Carl Pfeutze, superintendent
of the Mineral Springs Sanatorium, was in charge.
* * *
Dr. Alfred W. Adson, Rochester, was guest speaker
at the meeting of the Four County Medical Auxiliary
held in Mayo Foundation House on November 29.
Dr. Adson discussed prepayment medical care.
^
Dr. Clyde E. Wilson has closed his hospital at Blue
Earth after more than thirty years of operation. The
termination of his hospital activities will not affect
his private practice, which will be continued.
* * *
Dr. Ernest F. Cowern, village doctor at North Saint
Paul for the past forty-three years, was guest of honor
at a dinner sponsored by fellow lodge members on
December 13.
* * Jjf
Dr. Orville J. Swenson, of Waseca, recently under-
went surgery at Rochester for the correction of two
slipped discs in the upper part of his spine. Dr. Swenr
son expects to be out of practice for about two months.
* * *
Dr. William H. Hengstler, specialist in nervous and
mental diseases, discussed the “Emotional Effects of
Children’s Experiences” at the December meeting of
Section 1 of the Child Psychology Study Circle of
Saint Paul.
* * *
Dr. M. M. D. Williams, of the Mayo Clinic, has re-
turned from Chicago, where he assisted with the exami-
nations for the American Board of Radiology. Dr.
Williams also attended the meeting of the Radiological
Society of North America.
* * ~ *
Organization of a Minnesota Chapter of the Ameri-
can College of Physicians and Surgeons has been com-
pleted. Dr. Fred Benn, of Minneapolis, was elected
president and Dr. Albert E. Ritt, of Saint Paul, secre-
tary-treasurer.
* * *
A tuberculin test was conducted recently by Dr.
Kathleen Jordan, of the Minnesota Public Health As-
sociation, at the public schools at Willmar. About
660 pupils in the first, sixth, ninth and twelfth grades
were tested.
* * *
Dr. Louis R. Buie, of the Mayo Clinic, has been in
Chicago for the meetings of the Judicial Council, the
Committee on the Revision of the Constitution and
By-laws, and the House of Delegates of the American
Medical Association.
* * *
Dr. Harry B. Zimmerman, Saint Paul, was re-elected
recorder of the Western Surgical Association at the
annual meeting held in Memphis, Tennessee, during
the first week of December. Dr. Frank C. Mann, of
Rochester, was elected first vice president.
* * *
Under the will of the late Dr. Julius A. Hielscher,
Mankato, two hospitals are included as beneficiaries. One-
half of Dr. Hielscher’s estate, which is in excess of
$60,000, goes to St. Joseph’s Hospital and one-fourth
to Immanuel Hospital, both in Mankato.
* * *
Announcement has been made of the appointment
of Dr. Charles W. Mayo, of Rochester, as chairman
of a nineteen-member advisory committee on medical
care for veterans by the Veterans Administration in
Washington, D. C.
:jc Jjc
While Dr. H. Cope has been interning at Bethesda
Hospital in Saint Paul, Mrs. Cope, who is a pianist,
has been completing her musical studies at the Mc-
Phail School of Music in Minneapolis. On November
14, Mrs. Cope played her graduation recital.
Dr. Andrew Gullixson, who has been in medical prac-
tice in Albert Lea for the past forty years, is assembling
a history of the early doctors of Freeborn County which
will be included in the History of Medicine in Minne-
sota.
* * *
. Correction — Due to a printer’s error, the amount of
the Van Meter Prize Award for 1947 was incorrectly
listed in the announcement which appeared in the No-
vember number of Minnesota Medicine. The amount
of the Award is $300.00.
* * *
While on a brief visit at the Mayo Clinic, Dr. V. G.
Vaishampayn, chief medical officer of the N. W. Wadia
Charitable Hospital at Shaolpaur, Bombay Presidency,
India, completed the arrangements for some of the
fifty-four doctors whom the India government is send-
ing to America on fellowships to study at the Clinic.
* * *
Dr. John Collin Hays, formerly of Saint Paul, who
is a ward officer at Mason General Hospital, Brentwood,
New York, has been promoted to the rank of captain.
Dr. Hays took his B.A., M.B., and M.D. degrees at the
University of Minnesota and served both his internship
and residency at the Minneapolis General Hospital.
(Continued on Page 108)
106
Minnesota Medicine
Qet 9t Moua-
Equipment In Stock Available for Immediate Delivery
Heidbrink Oxygen Tents
McKesson and Emerson Resusci-
tators
Colson and Myrick Inhalators
Waste Receptacles and Waste
Baskets
Vollrath Polio-Pak Heaters
C.S.E. Paraffin Embedding Ovens
Electric Heating Pads and Blan-
kets
Leitz Photo Electric Colorimeters
Castle and American U. V. Germ-
icidal Lights
Castle Portable and Ceiling Model
Operating Lights
Improved Davis-Bovie Electro
Surgical Units
Stainless Steel, Wearever Alum-
inum and White Enamel Utensils
Castle "Monarch" Hopper Type,
Urinal and Bedpan Washer
Sterilizer, Flush Valve for Cold
Water, Separate Valve for
Steam, Wall Piping
Simmon's Hospital Beds, Inner-
spring Mattresses, Dressers, Ov-
erbed Tables, Bedside Cabinets,
Chairs, Cribs, Bassinettes, Etc.
McKesson Water Type Metabolor
Despatch Hot Air Sterilizer
Pelton, Castle and Burton Spotlites
Ultra-Violet and Infra Red Lights
Cincinnati Obstetrical Tables
Mont Reid Operating Tables
Wocher Explosion-Proof Operating
Tables
All Kinds of Gomco Suction Pumps
Castle, Pelton and American In-
strument Sterilizers
Ritter Ear, Nose and Throat Units,
Cuspidors and Stools
Improved Bellevue Hospital Model
Suction Pumps
Wheel Stretchers, Invalid Walkers
and All Kinds of Wheelchairs
Hamilton Examination Tables,
Treatment Cabinets, Instrument
Cabinets, Waste Receptacles
and Stools— white with Black
Trim
American 10-Gallon Water Steril-
izers, 220 Volt A.C., 6,000 watt,
type A heater on each tank, low
water cutout, pressure control,
standard plated finish, 101 white
stand
All Items Are Subject to Prior Sale
PHYSICIANS AND HOSPITALS SUPPLY C0.# Inc.
MINNEAPOLIS MINNESOTA
January, 1947
107
OF GENERAL INTEREST
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"ERcKhroME
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^•fcisiCOTT & oww|*fi **
».TiMomu •"*
HERCUROCHROME
(H. W. & D. brand of merbromin,
dibromoxymercuri fluorescein-sodium)
Extensive use of the Surgical
Solution of Mercurochrome
has demonstrated its value in
preoperative skin disinfec-
tion. Among the many advan-
tages of this solution are:
Solvents which permit the
antiseptic to reach bacteria
protected by fatty secretions
or epithelial debris.
Clear definition of treated
areas. Rapid drying.
Ease and economy of pre-
paring stock solutions.
Solutions keep indefinitely.
The Surgical Solution may
be prepared in the hospital or
purchased ready to use.
Mercurochrome is also sup-
plied in Aqueous Solution,
Powder and Tablets.
HYNSON, WESTCOTT
& DUNNING, INC.
Baltimore 1, Maryland
(Continued from Page 106)
Announcement has been made of the appointment
of Dr. Joseph C. Klein, of Shakopee, as department
surgeon of the Veterans of Foreign Wars of Minne-
sota, by the State Council of Administration of the
VFW. During the war Dr. Klein was a member of the
Naval Corps.
* * *
Dr. John Eiler, of Park Rapids, has been joined in a
partnership by Robert G. Tinkham, formerly of Minne-
apolis. Since his discharge from the Army last Feb-
ruary. Dr. Tinkham has been associated with the
Duluth Clinic. He was in service for two and a half
years.
* * *
The American Pharmaceutical Manufacturers As-
sociation Award of Distinction was presented to the
Mayo Foundation for Medical Education at the mid-
year meeting of the manufacturers in New York City
on December 9. Dr. Donald C. Balfour accepted the
award for the Foundation.
* * *■
Dr. Russell Frost, assistant chief of the tuberculosis
section, Veterans Administration, Fort Snelling, was
guest speaker at the anunual Public Health Dinner,
sponsored by the Kiwanis Club at Willmar on Novem-
ber 12. His subject was “The Tuberculosis Program
of the Veterans Administration.” Dr. Frost is a former
Willmar resident.
* * *
Drs. Frances M. McCarten and Russell Carlson, of
Stillwater, whose offices were burned out in
the recent fire which destroyed the drug store building
in which they were located, have established temporary
offices with Dr. James H. Haines in the Holcombe
Block. Both doctors lost much valuable equipment
but were able to save their records and books.
* * *
Dr. Earl Crow, assistant superintendent of the State
Sanatorium at Walker, has been appointed superintend-
ent of the institution, succeeding Dr. Francis F. Calla-
han, who has resigned to enter private practice in Saint
Paul.
Dr. Crow is a native of Walker and a graduate of the
University of Minnesota Medical School.
* * *
Dr. James C. Crabtree, of Princeton, has been filling
a vacancy temporarily at the Northern Pacific Hospital
in Saint Paul, caused by the resignation of Dr. Louis
Rosenbladt who has gone to Tacoma, Washington. Dr.
Crabtree expected to return to Princeton as soon as the
Community Hospital opens, which should be short-
ly after the first of the year.
* * *
Announcement has been made of the marriage of
Miss Mary Lou Helmerson of Minneapolis, to Dr.
James C. Breneman at Zion Lutheran Church, Fort
Custer, Michigan.
Dr. Breneman, whose home was in Martin County,
is a graduate of Gustavus Adolphus College, St. Peter,
(Continued on Page 110)
108
Minnesota Medicine
OAILY DOSAGE:
Each GRAM
VITAMIN A a,
62.500 U.S.P. UNITS
1,000 U.S.P. UNITS
■ 30 drops i
Dropper furnished delivers ;
Each drop contains not less tl
and 333 U S P
A Ester concentrate with activated
Riboflov
DROPS MAY BE ADDED TO MIUC, FRUIT
JUICES OR FOOD
DROPPER SUPPLIED DELIVERS APPROX.
15 DROPS PER CC.
H99HI warn
ASCORBIC
ACID
lOO MG
WALKER’S
ose: 1 daily or
s prescribed
3y physician.
HEXAVITAMIN
(U.S.P.)
/ITAMIN PRODUCTS. INC
i phyiician in.
need* of rhj
““-rrsr.^
TOO TABLETS
k
WA
VITAMIN P
Mount Verr
ASCORBIC
ACID
(VITAMIN C)
50 MG.
CONFIDENCE
The hallmark of Walker manu-
facture is its uncompromising
emphasis on quality. Rigid con-
trols at every stage of produc-
tion, from raw materials to the
finished products, insure their
dependability. Physicians know
that Walker vitamin products can
be prescribed with confidence.
WALKER
50 MG
RIBOFLAVI
THIAMINE
HYDROCHLORIDE
WALKER VITAMIN PRODUCTS, INC.
SOLUTION
THIAMINE
HYDROCHLORIDE
lOO MG.
To be used only
by. or on prescrip-
tion of physician.
Dose: 1 daily or
as prescribed
by physician.
To be. used only
by, or on prescrip-
tion of physician.
STABILIZED AQUEOUS SOLUTION
Per CC.
THIAMINE HYDROCHLORIDE IB,) 5 Mg
DOSAGE. XM.B.R.
INFANT 3 Drop* 400%
CHILD 1-6 Yr*. -6 Drop* 400%
CHILD 6-12 Yr*.- 9 Drop* 400%
ADULT 12 Drop* 400%
MOIE AS OUECTEO BY PHYSICIAN
Dose. 1 daily or
as prescribed
by physician.
lO MG.
Caution :
for therapeutic use
only. To be used only
by or on prescription
of a physician.
To be used only
by, or on prescrip-
tion of physician.
50 MG.
WALKER’S
WALKER
VITAMIN PRODUCTS, INC.
MOUNT VERNON, NEW YORK
[ANUARY, 1947
109
OF GENERAL INTEREST
(Continued from Page 108)
and the University of Minnesota Medical School. He
is now associated with the Veterans Hospital at Fort
Custer and makes his home at Battle Creek.
* * *
The Minnesota State Medical Association and the
State Society for the Prevention of Blindness have
appointed a four-man committee to arrange facilities
for obtaining human eyes for the blind.
The members of this committee, who will serve as
contact for persons wishing to donate eyes to blind
persons, are Dr. Frank Burch, Saint Paul, chairman;
Dr. Frank Knapp, Duluth ; Dr. Erling Hansen, Minne-
apolis, and Dr. William Benedict, of Rochester.
* * *
Dr. James W. Reid has opened offices for the prac-
tice of medicine and surgery in the West Twins Build-
ing in West Saint Paul, Dr. Reid is a 1942 graduate
of the University of Minnesota Medical School. He
entered military service the same year, and with the
rank of captain was assigned to the European Theater
for over two years. Dr. Reid made his home in South
Saint Paul for twenty-five years and he is a nephew
of Andrew Reid, postmaster at South Saint Paul.
* * *
Dr. Winchell McK. Craig, Mayo Clinic, has been in
Washington, D. C., where he attended a conference of
the Naval Reserve Policy Board called by Secretary of
the Navy James Forrestal.
Members of the board, which serves as an advisory
unit to the Secretary of the Navy, were put on active
duty for the duration of the conference. Dr. Craig
attended in his capacity as. rear admiral.
* * *
The Minnesota State Medical Association has signed
a contract with the Veterans Administration under
which veterans suffering from a service-connected dis-
ability or illness may be treated by their local phy-
sicians. Under the plan, in which 2600 doctors will
participate, statement for services will be rendered to
the State Medical Association and it, in turn, will col-
lect from the VA.
* * *
In addition to his private practice, during which he
has delivered 1,360 babies, Dr. Cowern has also been
staff physician at St. John’s Hospital, and has served
as deputy coroner. A graduate of Dartmouth Medical
College, Dr. Cowern spent a brief period of practice
in Massachusetts and New Hampshire before locating
in Saint Paul. During World War I he was medical
instructor in the medical corps at Fort Oglethorpe,
Georgia.
* * *
Dr. Kenneth W. Covey, of Mahnomen, has an-
nounced his association with Dr. A. W. Skoog-Smith, of
Minneapolis, as of December 2.
Dr. Skoog-Smith took his premedical work at the
University of Ohio and he graduated from the Univer-
(Continucd on Page 112)
The Birches Sanitarium, Inc.
2391 Woodland Avenue
Duluth 3, Minnesota
A hospital for the care and treatment of
Nervous and Mental disorders. Quiet, cheer-
ful environment. Specially trained personnel.
Recreational and occupational therapy.
Psychiatrists in Charge
L. R. Gowan, M.D. L. E. Schneider, M.D.
FREE SAMPLE
I
Address |
City .
State ,
WITH ADDED POTASSIUM CARBONATE 1.1%
FOR CONSTIPATED BABIES
Borcherdt Malt Soup Extract is a
laxative modifier of milk. One or
two teaspoonfuls dissolved in a
single feeding produce a marked
change in the stool. A Council
Accepted product. Send for free
sample.
BORCHERDT MALT EXTRACT CO., 217 N. Wolcott Ave., Chicago, III.
110
Minnesota Medicine
Chicago Medical Society
Third Annual Clinical Conference
A Four -Day Intensive Post-Graduate Course
The Program again presented by outstanding
medical authorities will please all physicians,
and particularly the General Practitioner.
Technical and Scientific Exhibits
March 4, 5, 6 and 7, 1947 Palmer House, Chicago
Make your Hotel Reservations , NOW, to avoid disappointment
AFTER HOURS A laugh for the Doctor
" JACK . . . WRENCH . . . SPARE."
Over two thousand grocers in the Northwest carry
HOME BRAND STRAINED BABY FOODS.
HOME BRAND ON THE LABEL MEANS GOOD FOOD ON BABY’S TABLE
Home Biand •
8TRAINED
FOODS J
STRAINED
baby foods
January, 1947
GRIGGS, COOPER & CO. • TWIN CITIES, TWIN PORTS, FARGO
111
OF GENERAL INTEREST
(Continued from Page 110)
sity School of Medicine in 1943. He interned at Gen-
eral Hospital in Minneapolis. Following the comple-
tion of his internship he entered the Army, where he
served for twenty-two months in Holland and Germany.
* * *
The Hennepin County Medical Society was addressed
by Dr. Nils Westermark, x-ray chief at the University
of Stockholm, at their meeting on December 9 in the
Medical Arts Building.
Dr. Westermark, who discussed bronchial cancer, is
visiting American medical schools and has lectured at
the University of Minnesota, the Mayo Clinic in
Rochester and at the meeting of the Radiological So-
ciety held in Chicago recently.
* * *
Educational talks on cancer will be given by Duluth
members of the St. Louis County Medical Society on
request at various clubs and fraternal meetings through-
out the city. The Duluth Chapter, Minnesota Cancer
Society, is sponsoring these talks. Among the doctors
already having given their services for this purpose are
Dr. Charles Bagley, Dr. Duncan V. Luth, Dr. Karl
Johnson, Dr. Clarence H. Christensen, Dr. John D.
Barker and Dr. Henry G. Geronimus.
* * *
Support of legislation giving counties or groups of
counties the authority to establish local health depart-
ments, which is to be presented at this session of the
legislature, is urged by Dr. Donald A. Dukelow, head
of the health and medical care division, Minneapolis
Council of Social Agencies, and vice president of the
Minnesota committee on local services.
According to Dr. Dukelow, a survey made in 1942
revealed that only 34 per cent of Minnesota’s popula-
tion was served by local full-time health officers.
* * *
Drs. John J. Bittner and George Crane Christian, can-
cer research specialists at the University of Minnesota,
and Dr. Robert A. Huseby, fellow of the International
Cancer Research Foundation, at the University, at-
tended the conference on Nutrition in Relation to Can-
cer which was held in New York City on December
6 and 7.
The conference was sponsored jointly by the New
York Academy of Sciences and the Panel on Nutrition,
Committee of Growth, National Research Council.
* ^ *
Specially prepared films are being produced by the
McGraw-Hill Book Company for supplementing the
use of a Textbook of Healthful Living, by Dr. Harold
S. Diehl, dean of medical sciences at the University of
Minnesota Medical School. The 16 mm. sound-motion
pictures, illustrating such subjects as Body Care and
Grooming, Personal Health, Sex Education, Mental
Hygiene, et cetera, present this information in an en-
tirely factual manner, and the innovation is said to
be of value in explaining the more difficult text matter.
(Continued on Page 114)
^•IlieilllllllllllllllllllMlllllltlllllllllllllllllllllllllllllllllllllllllMMIIIIIIMIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllltlllllllllllllllllllllllllllllllliiiiiiniu
THE VOCATIONAL HOSPITAL
TRAINS PRACTICAL NURSES
Nine months Residence course, Registered Nurses and
Dietitian as Teachers and Supervisors. Certificate from
Miller Vocational High School. VOCATIONAL NURSES
always in demand.
EXCELLENT CARE TO CONVALESCENT AND
CHRONIC PATIENTS
Rates Reasonable. Patients under the care of their own physicians,
who direct the treatment.
5511 Lyndale Ave, So. LO. 0773 Minneapolis, Minn.
REST HOSPITAL
A quiet, ethical hospital with therapeutic facilities
for the diagnosis, care and treatment of Nervous
and Medical cases. Invites cooperation of all
reputable physicians who may supervise the treat-
ment of their patients.
PSYCHIATRISTS IN CHARGE
Dr. Hewitt B. Hannah
Dr. Joel C. Hultkrans
2527 2nd Ave. S., Minneapolis, Pbone At. 7369
112
Minnesota Medicine
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
DOBBS TRUSSES
Designed for
COMFORT and SECURITY
• No Bulbs
• No Belts
• No Straps
Eliminates
Chafing — Binding — Rubbing
and All Constricting Pressure
Touches body in two places only — the
soft front and back pads. Soft rubber
CONCAVE PAD fits the curvature of the
body and pubic bone — securely holds the
rupture with a firm but gentle pressure.
Fitted by carefully trained technicians.
DOBBS TRUSS SALES CO.
608 Nicollet Ave. Main 0729
Minneapolis 2. Minn.
Complete Optical
Service
Lens Grinding
Dispensing
Contact Lenses
Eye Photography
N. P. BENSON OPTICAL
COMPANY
Established 1913
Main Office and Laboratory
450 Medical Arts Building. Minneapolis 2. Minn.
Lake Street Office — 1611 A West Lake Street
— BRANCH LABORATORIES —
Aberdeen - Duluth • Eau Claire - Winona
Bismarck - La Crosse - Wausau - Stevens Point
Albert Lea - Rapid City - Huron - Beloit - Brainerd
Rochester
January, 1947
113
OF GENERAL INTEREST
Kalman & Company, Inc.
Investment Securities
Members:
Chicago Stock Exchange
Minneapolis-St. Paul Stock Exchange
ST. PAUL MINNEAPOLIS
PALM ORTHOPEDIC
APPLIANCE CO.
Braces for the Handicapped
Abdominal and Arch Supports
Elastic Stockings
Sacro Iliac Belts
Expert Truss Fitters
Crutches and Canes
54 W. 4tli St. - GArfield 8947
ST. PAUL 2, MINN.
Practical Nursing Course
Nine months' course open to high school
graduates or women with equivalent
education.
For further information
write
Mrs. Lydia Zielke. Supt. of Nurses
FRANKLIN HOSPITAL
501 Franklin Avenue Minneapolis 5, Minnesota
(Continued from Page 112)
Dr. Manfred W. Comfort, of the Mayo Clinic, pre-
sented a paper on “Gastric Acidity Before and After
Development of Gastric Carcinoma” at the recent con-
ference on gastric cancer held at the Billings Hospital,
Chicago University. The paper was co-authored by
Drs. Mavis P. Kelsey and Joseph Berkson, both of the
Clinic.
The conference was attended by about 125 physicians,
research workers and representatives of cancer research
foundations. Among them were Drs. Berkson, Frank
C. Mann, George M. Higgins, John R. McDonald,
Harold L. Mason and Hugh R. Butt, all of Rochester.
* 5{f *
The first dinner meeting of the general medical fac-
ulty o'f the University of Minnesota since the end of
the war was held in Coffman Memorial Union on
Monday evening, December 9.
Major school developments during the past year were
outlined by Dr. Harold S. Diehl, dean of medical
sciences, who also announced future plans.
A report of the status of fund drives for the proposed
Mayo Memorial Building to be constructed on the uni-
versity campus was made by Dr. Donald Cowling of
Saint Paul, who is chairman of the Memorial Commit-
tee.
* * *
At the annual meeting of the American Public Health
Association in Cleveland in November, five members
of the staff of the University of Minnesota Medical
School were elected to office in the organization. Dr.
Harold S. Diehl, dean of medical sciences, Dr. Gaylord
Anderson, head of the School of Public Health, and Dr.
Albert J. Chesley, clinical professor emeritus of public
health and secretary of the Minnesota State Board of
Health, were elected to the governing council of the
organization for three-year terms.
Harold A. Whittaker, professor of public health
engineering, was made vice president, and George 0.
Pierce, associate professor of public health engineering,
was elected secretary of the association.
* * *
Veteran members of the medical profession in the
neighborhood of Slayton joined recently with the local
Civic and Commerce Association in sponsoring a dinner
in honor of Dr. Leon A. Williams, of Slayton, who
recently retired after a half century in medical prac-
tice in Murray County. Dinner was served in Wesley
Hall and a program of interesting addresses and music
by a male quartet was presented. Visiting doctors
who paid tribute to Dr. Williams were Dr. Ludwig
L. Sogge, of Windom, Dr. Herminus De Boer, of
Edgerton, Dr. Byron O. Mork, of Worthington, Dr.
Walter H. Valentine, of Tracy, and Dr. Sidney A.
Slater, of Southwestern Sanatorium, at Worthington.
* * *
Dr. Ralph E. Wenzel has entered practice at Albert
Lea with offices in the Albert Lea Medical and Surgical
Center.
Dr. Wenzel, who is a 1938 graduate of Northwestern
University Medical School, was in the U. S. Public
114
Minnesota Medicine
OF GENERAL INTEREST
Health Service prior to entering military service. A
member of the Coast Guard, he served as chief medi-
cal officer, captain of the Port of Los Angeles, and as
assistant district medical officer in Honolulu. Later he
was assigned to the Marine Hospital in Chicago. Since
his separation from service he has been engaged in
special study in obstetrics at the University of Iowa
Medical School.
* * *
Headquarters, Fifth Army, has announced the pro-
motion of Maxwell M. Barr, 1035 N. Washburn, Min-
neapolis, to the rank of captain, on December 19. Cap-
tain Barr was one of four medical officers who were
promoted here.
Captain Barr received his medical degree at the
University of Minnesota and was employed at the
Mayo Clinic as an obstetrician prior to his entry into
the armed services. He was commissioned in July,
1945, and attended an Army Specialized Training Pro-
gram school before coming to the station hospital at
Camp McCoy. His present duties are those of Receiving
and Disposition Officer at the McCoy hospital.
* * *
The following Minnesota surgeons were received into
fellowship in the American College of Surgeons on De-
cember 20, 1946, during the Clinical Congress held in
Cleveland: David P. Anderson, Jr., Austin; William
H. Bickel, Rochester ; Everett B. Coulter, Minneapolis ;
Earl H. Dunlap, Minneapolis; Reinhold M. Ericson,
Minneapolis; George T. R. Fahlund, Rochester; Fred
Z. Havens, Rochester ; Eugene M. Kasper, Saint Paul ;
Rochfort W. Kearney, Mankato ; Paul C. Kiernan,
Rochester; Howard H. Lander, Rochester; Paul N.
Larson, Minneapolis ; Donovan L. McCain, Saint Paul ;
John R. Paine, Minneapolis ; Wesley G. Schaefer, Min-
neapolis ; Anthony J. Spang, Duluth.
* * *
Dr. Kenneth A. Peterson has opened offices for the
practice of medicine and surgery at Marshall in as-
sociation with Dr. Frank D. Gray.
Dr. Peterson, who is the son of Dr. Roy A. Peterson,
of Vesta, graduated from the University of Minnesota
Medical School. He interned at the Minneapolis Gen-
eral Hospital and was resident physician at the Midway
Hospital for two years prior to entering military service.
His army assignments included Northington General
Hospital in Tuscalusa, Alabama, where he was engaged
in neurosurgical, orthopedic and plastic surgery. Just
prior to his separation from service he was at the
Regional Hospital at Ft. McClellan, Alabama, where
he was chief of the outpatient department.
* * *
Dr. Lawrence M. Randall was elected president of the
staff of the Mayo Clinic at the annual staff dinner
and meeting held at the Rochester Golf and Country
Club, on November 18.
Dr. Edward N. Cook is the new secretary, Dr. John
D. Camp was made first counselor and Dr. Monte C.
Piper, second counselor.
Eleven physicians who have attained the rating of
emeritus staff members at the Clinic were honored with
testimonial booklets and gifts from the staff. Some of
INGLEWOOD
NATURAL* OR DISTILLED
SPRING WATER
^osi Ita+m and o^ice
\
NatuAalh}. Mitte/uilifyexi, Natusuillif tJleGdtUjjul
^jdor
professional Supplies
and
s.
service
BROWN & DAY, INC
St. Paul 1. Minnesota
January, 1947
115
OF GENERAL INTEREST
l
Cook County
Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY — Two-week intensive course in Surgical
Technique starting January 20, February 17, March
17.
Four-week course in General Surgery starting Feb-
ruary 3 and March 3.
Two-week Surgical Anatomy ft Clinical Surgery start-
ing February 17 and March 17.
One week Surgery of Colon & Rectum starting March
10 and April 7.
Two weeks Surgical Pathology every two weeks.
GYNECOLOGY — Two-week intensive course starting
March 17. and April 14.
One-week course in Vaginal Approach to Pelvic Sur-
gery starting March 10 and April 7.
OBSTETRICS — Two-week intensive course starting
March 3 and April 28.
MEDICINE — Two-week intensive course starting April
7 and June 2.
One month course Electrocardiography & Heart Dis-
ease starting February IS and June 16.
General, Intensive and Special Courses in all
Branches of Medicine, Surgery and the Specialties
TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar. 427 S. Honore St., Chicago 12, III.
TAILORS TO MEN
SINCE 1886
The finest imported and
domestic woolens such as
SCHUSLER'S have in stock
are not too fine to match
the hand tailoring we al-
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them had been retired within recent months. These
physicians were Dr. Samuel Amberg, Dr. William F.
Braasch, Dr. H. Milton Conner, Dr. John L. Cren-
shaw, Dr. Herbert Z. Giffin, Dr. John H. Rosenow,
Dr. Christopher Graham, Dr. Willis S. Lemon, Dr.
Archibald H. Logan, Dr. Albert Miller and Dr. Charles
G. Sutherland.
3|c JK
Six states were represented at the North Central
Medical Conference held in Saint Paul in November.
An address on rural medical care was given by Dr.
L. W. Larson, of Bismarck, who is secretary of the
North Dakota Medical Association. Pointing out that
the two major phases of rural medical care are availabil-
ity and cost, Dr. Larson stated that young physicians
are being encouraged to locate in rural areas where
the need is greatest, but added that farm people “must
be able to offer a doctor a decent living wage, oppor-
tunity for advancement, facilities with which he can
practice modern medicine and a desirable town in which
to live.’’
* Jfc :jc
HOSPITAL NEWS
Alvin Langehaug has been appointed superintendent
of Fairview Hospital in Minneapolis, effective January
1. Mr. Langehaug comes from Chicago where he has
been superintendent of a 180-bed Norwegian-American
Hospital. He is a graduate of St. Olaf College and
was a school superintendent in Minnesota from 1926
to 1937. He entered military service in 1943 and was
discharged in 1945, as captain in the Army Medical
Administrative Corps.
At one time Mr. Langehaug was superintendent of
the Lutheran Hospital at Fort Dodge, Iowa, for six
years. He is a past president of the Iowa Hospital
Association, a • member of the American Hospital As-
sociation and of the American College of Hospital
Administrators.
* * *
Announcement has been made by the Board of Direc-
tors of Asbury Hospital, Minneapolis, of the election
of Dr. Henry E. Hoffert as president of the staff.
Other officers selected at the same time were Dr. Alfred
N. Bessesen, vice president ; Dr. Paul J. Preston, secre-
tary and treasurer ; and Dr. R. R. Cranmer, member of
the advisory board. Holdover members of the board
are Dr. Ernest R. Anderson, Dr. Thomas A. Peppard,
and Dr. Leonard K. Buzzelle.
DANIELSON MEDICAL ARTS PHARMACY, INC.
10-14 Arcade, Medical Arts Building „n„B.
PHONES: HOURS:
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116 Minnesota Medicine
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
THE CHEST — A Handbook of Roentgen Diagnosis. Leo G.
Rigler, M.D., Professor and Chief, Department of Radiology,
University of Minnesota. 352 pages. 338 illus. Price $6.50.
Chicago: Year Book Publishers, Inc., 1946.
As might be expected by those who are familiar with
Dr. Leo Rigler’s teachings and previous writings, his
new book on “The Chest” is a particularly outstanding
work. The book is one of a series of handbooks of
Roentgen Diagnoses published by the Year Book Pub-
lishers, Inc., of Chicago. Probably its greatest virtue is
the number and brilliance of the reproductions and the
exacting clarity and ease of correlation of the accom-
panying descriptions. The normal and normal variations,
as well as the pathological, are adequately presented — a
feature of real value to the student and occasional ra-
diographer.
The entire field of abnormal chest roentgenology is
remarkably well presented in the section on pathologic
conditions. The amount of factual information presented,
together with the wide variety of subjects covered, is,
for a book of this size, most unusual. Most certainly the
general coverage is such that it well provides “a founda-
tion of knowledge and a guide for the analysis of any
roentgenograms of the chest.” This book will find wide
usage as a constant reference for radiologists and as a
source of fundamental information for students and
practitioners. It far outdistances anything yet published
in the field of chest roentgenology. It is a good reflection
of a dynamic and brilliant teacher of Radiology — Leo
Rigler !
C. N. Borman, M.D.
NATIONAL FORMULARY VIII. 888 pages. Price, $7.50.
Eastin, Pa. ; Mack Publishing Co., 1946.
The eighth edition of this standard work is now avail-
able. Published by the American Pharmaceutical As-
sociation, it provides official specifications for many
widely used drugs not included in the U. S. , Pharma-
copoeia. Some 188 new admissions appear in the new
issue. As new standards and formulas are devised, they
will be made known through interim revisions or supple-
ments. The new N. F. VIII becomes official April 1,
1947.
ACCIDENT • HOSPITAL • SICKNESS
INSURANCE
FOR PHYSICIANS, SURGEONS, DENTISTS EXCLUSIVELY
f PHYSICIANS\
SURGEONS
V DENTISTS J
PREMIUMS
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$5,000.00 accidental death $8.00
$25.00 weekly indemnity, accident Quarterly
and sickness
$10,000.00 accidental death $16.00
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and sickness
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$75.00 weekly indemnity, accident Quarterly
and sickness
$20,000.00 accidental death $32.00
$100.00 weekly indemnityt accident Quarterly
and sickness
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WIVES AND CHILDREN
86c out of each $1.00 gross income used for
members’ benefits
$3,000,000.00
INVESTED ASSETS
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PAID FOR CLAIMS
$200,000.00 deposited with State of Nebraska for protection of our members.
Disability need not be incurred in line of duty — benefits from
the beginning day of disability
PHYSICIANS CASUALTY ASSOCIATION
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January, 1947
117
MISCELLANEOUS
Delegates Hear Pleas
(Continued from Page 76)
licensure board, it was reported. The delegates
approved Dr. Hedin’s motion that two members
of the present board of nurse examiners, one rural
hospital administrator and one representative
each from the medical profession and the prac-
tical nurses group should compose this board to
have jurisdiction over all matters pertaining to
the practical nurse.
In addition to approving the establishment of
twenty one-year practical nurse training schools,
the delegates also voted their approval of in-
creasing the present three-year nurse training
schools by ten.
Cognizance is being taken of this plea from the
medical profession for remedial measures in the
nursing field. Just recently the Board of Regents
approved the establishment of a one-year course
for practical nurses in connection with the School
of Nursing at the University of Minnesota.
Doubtless many hospitals throughout the state
will take similar action as soon as the courses
can be established.
Treatment of Hyperthyroidism
( Continued from Page 41)
ing has been discovered to equal the results of
thyroidectomy successfully performed.
References
1. Astwood, E. B.: Treatment of hyperthyroidism with thiourea
and thiouracil. J.A.M.A., 122:78-81, (May 8) 1943.
2. Jackson, A. S.: Discussion of the meeting of the American
Association for the Study of Goiter. Jackson Clinic Bull.
(Editor’s Comments), 8:147-152, (Sept.) 1946.
3. Jackson, A. S.: Thiouracil. Wisconsin M. J., 45:677-679,
(July) 1946.
4. Jackson, A. S.: Thiouracil in the treatment of hyperthy-
roidism. Jackson Clinic Bull., 6:146-154, (Sept.) 1944.
5. Jackson, A. S.: Thiouracil will not replace thyroidectomy.
Surg., Gynec. & Obst., 83:249-252, (Aug.) 1946.
6. Jackson, A. S. : The use of thiouracil in hyperthyroidism;
ten illustrative cases. Am. T. Surg., 67:467-478, (March)
1945.
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POSITION WANTED — Young M.D., Class A gradu-
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Minnesota Medicine.
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Ground floor, new building, with druggist and den-
tist. Telephone Deephaven 715.
FOR SALE — Practice and office equipment in Har-
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prosperous farming community in southern part of
state. No physician there at present. Price, $2,000.
Address Alfred H. Wolf, M.D., 1417 West Lake
Street, Minneapolis 8, Minnesota.
WANTED — Doctor for general work in long-estab-
lished Minnesota clinic. Address E-2, care Minnesota
Medicine.
FOR RENT — Newly finished ground floor offices. Four
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Robert, St. Paul 7, Minnesota.
OPPORTUNITY FOR GENERAL PRACTICE in
thriving community. Modern office, fireproof build-
ing, with or without equipment. Present physician
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WANTED — Physician trained in eye, ear, nose and
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permanently. Ideal office suite located in Lowry Medi-
cal Arts Building, Saint Paul, Minnesota. Address
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POSITION WANTED — Experienced office nurse
desires position in Southern Minnesota. Best of ref-
erences. Address E-3, care Minnesota Medicine.
FOR SALE — Lot suitable for Medical Clinic. Address
Bernard E. Ericsson, Moorland Park Agency, 424
New York Life Bldg., Minneapolis 2, Minnesota.
FOR RENT — Physician’s office, corner of Thomas and
Hamline, Saint Paul. Inquire at dentist’s office or
at corner drug store.
nedtwtudL (plaatmsnL SsdwIcsl . . . fok hosp,tals - CLINSVEHNUTNoSFncEs
PART TIME— TEMPORARY— PERMANENT
When in need of a PHYSICIAN, DENTIST, OFFICE NURSE, TECHNICIAN, MEDICAL SECRETARY, or
OTHER PERSONNEL for medical and dental offices, clinics, and hospitals contact —
Minneapolis, Minn. — GE. 7839 The Medical Placement Registry St. 5Paul, 3Minn.— GAln|718
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118
Minnesota Medicine
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
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Holidays, 9 a.m. to 6 p.m.
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ATlantic 5445 82 So. 9th St., Mpls.
Orthopedic Braces and
Appliances
Physicians' specifications
followed precisely.
Scientific manufacture
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AUGUST F. KROLL
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SAFEGUARD YOUR
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A safe deposit box assures
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to your needs.
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MURPHY LABORATORIES
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PRESCRIPTION PHARMACY
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SAINT PAUL
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January, 1947
119
Old Way...
CURING RICKETS in the
CLEFT of an ASH TREE
T70R many centuries, — and apparently down
to the present time, even in this country —
ricketic children have been passed through a
cleft ash tree to cure them of their rickets, and
thenceforth a sympathetic relationship was
supposed to exist between them and the tree.
Frazer* states that the ordinary mode of effec-
ting the cure is to split a young ash sapling
longitudinally for a few feet and pass the child,
naked, either three times or three times three
through the fissure at sunrise. In the West of
England, it is said the passage must be "against
the sun.” As soon as the ceremony is performed,
the tree is bound tightly up and the fissure
plastered over with mud or clay. The belief is
that just as the cleft in the tree will be healed, so
the child’s body will be healed, but that if the
rift in the tree remains open, the deformity in
the child will remain, too, and if the tree were to
die, the death of the child would surely follow.
•Frazer, J. G.: The GoldeD Bough, vol. 1, New York, Macmillan & Go., 1928
New Way . . .
It is ironical that the practice of attempting to
cure rickets by holding the child in the cleft of
an ash tree was associated with the rising of the
sun, the light of which we now know is in itself
one of Nature’s specifics.
Preventing and Curing Rickets with
OLEUM PERCOMORPHUM
NOWADAYS, the physician has at his
command. Mead’s Oleum Percomor-
phum, a Council-Accepted vitamin D product
which actually prevents and cures rickets, when
given in proper dosage.
Like other specifics for other diseases, larger
dosage may be required for extreme cases. It is
safe to say that when used in the indicated dos-
age, Mead’s Oleum Percomorphum is a specific
in almost all cases of rickets, regardless of
degree and duration. Mead’s Oleum Percomor-
phum because of its high vitamins A and D
content is also useful in deficiency conditions
such as tetany, osteomalacia and xerophthalmia.
* * *
COUNCIL-ACCEPTED
Oleum Percomorphum With Other Fish-Liver Oils and Viosterol.
Contains 60,000 vitamin A units and 8,500 vitamin D units per
gram and is supplied in 10 c.c. and 50 c.c. bottles; and in bottles
containing 50 and 2 50 capsules.
MEAD JOHNSON & COMPANY, Evansville, Indiana, U. S. A
Please enclose professional card when requesting samples of Mead Johnson products to co-operate in preventing their reaching unauthorized person*
120 Minnesota Medicine
implies exposure, infection and a therapeutic need.
MAPHARSEN* has filled the requirement for a relatively safe,
antiluetic agent of unquestioned and proved efficacy in case
after case, in country after country, in civilian life and for the
military services, year in and year out— building an unmatched
record of therapeutic performance.
MAPHARSEN is one of a long line of Parke-Davis
preparations whose service to the profession created a dependable
symbol of significance in medical therapeutics— medicamenta vera.
MAPHARSEN ( 3-amino-4-hydroxy-phenvl-arsineoxide
hydrochloride) in single dose ampoules of 0.04 Gm. and
0.06 Gm.; boxes of 10 ampoules. Multiple dose,
hospital size ampoule of 0.6 Gm.
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MASSACHUSETTS INDEMNITY INSURANCE COMPANY
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MINNEAPOLIS 2, MINNESOTA
122
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 February. 1947 No. 2
Contents
The Use of Insulin Mixtures.
Randall G. Sprague, M.D., and Laurentius 0.
Underdahl, M.D., Rochester, Minnesota 153
The Present Southern Minnesota Medical
Association.
Carle B. McKaig, M.D., Pine Island, Minnesota. . . 157
Glomus Tumors.
Henry W. Meyerding , M.D., and James H. Var-
ney, M.D., Rochester, Minnesota 159
Chronic Mastoiditis with Cholesteatoma and
Stenosis of the External Auditory Meatus.
H. I. Lillie, M.D., and James B. McBean, M.D.,
Rochester, Minnesota 161
Further Observations on the Prognosis in An-
gina Pectoris Due to Coronary Sclerosis.
George E. Montgomery, Jr., M.D., Thomas J. Dry,
M.B., and Robert P. Gage, M.S., Rochester,
Minnesota 162
Polyneuritis.
Major Charles L. Yeager, Medical Corps, AUS,
Waco, Texas 166
Industrial -Integration.
Albert E. Ritt, M.D., Saint Paul, Minnesota .... 174
Clinical-Pathological Conference :
Epithelial Neoplasms of the Appendix.
Arthur H. Wells, M.D., and Harold LI. Joffe,
M.D., Duluth, Minnesota 176
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. (Continued from Jan-
uary issue.)
Nora IT. Guthrey, Rochester, Minnesota 179
President’s Letter :
Physicians Obligated to Remedy Conditions in
State Institutions 185
Editorial :
Streptomycin 187
Fluids in Heart Disease 187
More Nurses Needed 188
Consumers Co-operative Medical Care 188
Mobile Speech Clinic Undertakes Survey 189
Medical Economics :
AMA House of Delegates Agenda Indicate Asso-
ciation’s Growth 190
/
Minnesota State Board of Medical Examiners . . 194
Minneapolis Surgical Society :
Meeting of November 7, 1946 195
Postoperative Anuria.
L. A. S teller, M.D., Minneapolis, Minnesota . . 195
The Use of Chemical Agents in the Treatment of
Hyperthyroidism.
Edmund B. Flink, M.D., Minneapolis, Minnesota 198
Exteriorization Procedures for Colon Injuries.
U. Schuyler Anderson, M.D., Minneapolis,
Minnesota 200
Reports and Announcements 204
Woman’s Auxiliary 206
In Memoriam 207
Communication 210
Of General Interest 212
Book Review's 219
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918.
February, 1947
123
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
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Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
C. L. Oppegaard, Crookston
EDITORIAL STAFF
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George Earl, Saint Paul, Associate Editor
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BUSINESS MANAGER
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The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
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ST. CROIXD ALE ON LAKE ST. CROIX
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therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
CONSULTING NEUROPSYCHIATRISTS
RESIDENT PHYSICIAN Hewitt B. Hannah, M.D. SUPERINTENDENT
Howard J. Laney, M.D. Joel C. Hultkrans, M.D. Ella M. Mackie
Prescott, Wisconsin 511 Medical Arts Building Prescott, Wisconsin
Tel. 39 Minneapolis, Minnesota Tel. 69
Tel. MAin 4672
124
Minnesota Medicine
THIS INFORMATIVE COMPENDIUM
ON A TIMELY SUBJECT
TJHYSICIANS are invited to use the ap-
pended coupon to request a compli-
mentary copy of the new brochure
"Nutrition As A Therapeutic Factor.”
In a terse, straightforward manner, this
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Gentlemen: You may send me a complimentary copy of "Nutrition As A Therapeutic Factor."
M.D.
Address
City and State
February, 1947
125
► The Cute Little Baby he helped deliver back in 1925 is now suing him
for $5,000 because of an instrument scar.
► His state’s 2-year statute of limitations is no help, for the 2 years didn’t
start ’til the "baby” was 21.
► Yet this doctor would lose neither time, money, sleep nor reputation if
protected by our policy and service (as are thousands of other doctors, for
about the cost of a good pair of shoes).
► For the world’s largest legal staff of malpractice experts already would be
cutting through mountains of conflicting court decisions and anticipating
schemes that might otherwise "prove” his guilt.
► All cost of defense against disgruntled patients, even through the court of
last appeal (including fee of attorney whom you help choose), is paid by us.
If not acquitted, we also pay the judgment, as provided in our policy.
Professional Protection exclusively. . . since 1899
MINNEAPOLIS Office: Robert L. McFerran, Manager, 816 Medical Arts Building, Telephone Atlantic 5724
126
Minnesota Medicine
When life is measured in days
Not years, nor months, but days measure the life of a new-born infant.
And during the first 30 days when infant mortality is at its highest,
every effort must be made to minimize the hazards to life. At this crit-
ical time, the right start on the right feeding can be of vital importance.
'Dexin' has proved an excellent "first carbohydrate." Because of its high
dextrin content, it (1) resists fermentation by the usual intestinal or-
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Readily prepared in hot or cold milk, 'Dexin' brand High Dextrin Carbo-
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, EXEEE/E//CE /<5 77/E BEST TE4C//EB/
visnttMr
rtteAo^«8P'
Counters \***°
ons „ different
„ brand tto «
According to a recent
Nationwide survey-.
More Doctors
smoke Camels
than any other cigarette
Doctors too smoke
for pleasure. Their
taste recognizes and
appreciates full, rich
flavor and cool mild-
ness just as yours
does. And when
three independent
research organiza-
tions asked 113,597 doctors — What cig-
arette do you smoke, Doctor? — the brand
named most was Camel!
128
Minnesota Medicine
EXPERIENCE
TAUGHT MILLIONS
the Differences in Cigarette Quality
... and now the demand for Camels —
always great — is greater than ever in history.
r Your'T-ZONE' U
will fell you...
> T FOR. TASTE...
T FOR. THROAT...
That's your proving ground
■for any cigarette. See
if Camels dont ^
y Suit your'T-ZONE'
cigarette agrees with me”. . . or . . .“That one
doesn’t.”
That’s when millions of people found that
their “T-Zone” gave a happy okay to the
rich, full flavor and the cool mildness of
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And today more people are asking for
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We do not tamper with Camel quality. We use
only choice tobaccos, properly aged, and
blended in the time-honored Camel way!
R. J. Reynolds Tobacco Company
Winston-Salem, North Carolina
DURING the war shortage of cigarettes
...that’s when your “T-Zone” was
really working overtime.
That’s when your Taste said, “I like this
brand”. .. or .. .“That brand doesn’t suit
me.” That’s when your Throat said, “This
February, 1947
129
EASE AND ECONOMY OF USE
Specification of CARTOSE* as the
mixed carbohydrate for infant feed-
ing formulas provides ease and econ-
omy of use. The liquid form of this
milk modifier permits rapid, accurate
measurement, thereby avoiding
waste.
Double protection against con-
tamination is afforded by: (1) the
narrow neck of the bottle, preventing
spoon insertion, and (2) the press-on
cap, assuring effective resealing.
CARTOSE supplies nonferment-
able dextrins in association with mal-
tose and dextrose ... a combination
providing spaced absorption that
minimizes gastrointestinal distress
due to fermentation.
Available in clear glass bottles
containing 1 pt. • Two tablespoonfuls
(Iff. oz.) provide 120 calories.
CARTOSE
• fC U. S. Off.
Mixed Carbohydrates
*The word CARTOSE is a registered trademark of H. W.
Kinney & Sons, Inc.
H. W. KINNEY & SONS, INC.
COLUMBUS, INDIANA
130
Minnesota Medicine
Write for
detailed literature
Demeroi, the potent, synthetic analgesic, spasmolytic
and sedative, relieves labor pains promptly and effectively
without danger to mother and child. There is no weakening
of uterine contractions, lengthening of labor, or postpartum
complication due to the drug. Bad effects on the newborn are
practically nil: no respiratory depression or asphyxia from too much
analgesia of the mother. Simplicity of administration is another commend-
able feature. Warning: May be habit forming.
Ampuls (2 cc., 100 mg.); vials (30 cc., 50 mg./cc.). Narcotic blank required.
HYDROCHLORIDE
Brand of meperidine hydrochloride (isonipecaine)
COMPANY,
INC.
DEMEROL, trademark Reg. U. S. Pat. Off. & Canada
February, 1947
New York 13, N. Y. * Windsor, Ont.
131
•ramp Anatomical Supports have
met the exacting test of the pro-
fession for four decades. Pre-
scribed and recommended in many
types for prenatal , postnatal , post-
operative!, pendulous abdomen ,
visceroptosis , nephroptosis , /ier-
nia, orthopedic and other condi-
tions. u you do not hai'e a copy
of the Camp ** Beference Book
for Physicians and Surgeons,** it
will be sent upon request.
HALLMARK AND PRICE TAG:
Economic conditions have shown
many swings during the four dec-
ades of CAMP history. But in the
rhythm and flow of changing con-
ditions, CAMP price tags always
have been and always will be con-
scientiously based on intrinsic value,
just as the credo and pledge of the
CAMP hallmark always have been
and always will be expressed in the
superb quality and functional effi-
ciency of CAMP products. All are
the measure of true economy to the
patient.
ANATOMICAL SUPPORTS
S. H. CAMP & COMPANY • Jackson, Mich. • World's Largest Manufacturers of Scientific Supports
Offices in CHICAGO • NEW YORK • WINDSOR, ONTARIO • LONDON, ENGLAND
132
Minnesota Medicine
(brand of iodoalphionic acid)
a photogenic
contrast medium
PRIODAX, a superior contrast medi-
um for oral cholecystography, is
photogenic — taking a “good picture”
consistently. Because it is rarely lost by
vomiting or diarrhea from the gastro-
intestinal tract, a maximum is concen-
trated in the gallbladder to produce a
clear, sharp shadow. “Retakes” are
therefore reduced to a minimum,
while little or no residual contrast sub-
stance appears in the colon to
obscure accurate diagnosis.
PRIODAX, beta-(4-hydroxy-3, 5-diiodophenyl) -
alpba-phenyl-propionic acid, is available in 0.5 Gm.
tablets in economy boxes of 100 envelopes and in boxes of 1, 5
and 25 envelopes. Each envelope contains 6 easily swallowed tablets
constituting the usual dose. Directions for the patient are enclosed
with each package.
Trade-Mark PRIODAX-Reg. U. S. Pat. Off.
&
CORPORATION
* BLOOMFIELD, N. J.
N CANADA, SCH BRING CORPORATION LI MITED, MONTREAL
IT IS
GOOD PRACTICE
. . . in judging the irritant properties of cigarette
smoke ... to base your evaluation on scientific research.
In judging research, you must consider its source *.
Philip Morris claims of superiority are based not
on anonymous studies, but on research conducted only
by competent and reliable authorities, research re-
ported in leading journals in the medical field.
Clinical as well as laboratory tests have shown
Philip Morris to be definitely and measurably less
irritating to the sensitive tissues of the nose and throat.
May we send you reprints of the studies?
Philip Morris
Philip Morris & Co., Ltd., Inc.,
119 Fifth Avenue, N. Y.
'Laryngoscope. Feb. 1935. Vol. XLV. No. 2. 149154 Proc. Soc. Exp. Biol, and Med.. 1934. 12, 241
Laryngoscope, Jan. 1937, Vol. XLVII, No. 1, 58-60 N. Y. State Journ. Med., Vol. 35, 6-1-3 5, No. II, 590-fW.
TO THE PHYSICIAN WHO SMOKES A PIPE: We suggest an unusually fine new blend-CoUNTRY
Doctor Pipe Mixture. Made by the same process as used in the manufacture of Philip Morris Cigarettes.
134
Minnesota Medicine
Educating the public to “see your doctor” <
This is No. 201 in the Parke-Davis series of messages
published in the interest of the medical profession. Appear-
ing in color in LIFE and other leading magazines, it will reach
an audience of over 23 million people.
. have a sore ihroat.
' Pr05t V , ho* a bad sore ,'“°al "
end may «" >°" „ffet you son* s
sulfa tabled a may
ii-y them* .
U be exuomely on"'5'-
l‘o do so wou d a type °f ’n^eC
Foryou,fneodm.,^;^.vc r^s°r
hind on wh'ch sulfa h ,t
any eve, ««*»* ”
cj a phys’can »
most people reah:e- ^
H you tab' sulfa ‘".’JX.S »««■ ^
becoT5:^»"-’°“tdoc'orrai
Seau,,—
you dose youtsc f'% atld od.ee
uisiance, you
if you should
d il unwise u
d»spense<
oUr doctor is /
"Ueryovr a^en ««
nent^^’ aKl lhe
Wr'°“
pae, wM
E YOUR doctor- W
lh,„lf,.. «*** “»
friend’s sugges''°n'
« firs, sign of illness
^on qualified » £
.vhich concern you
physicians
February, 1947
FOR THE FAILING MYOCARDIUM...
and in a Matter of Hours
How Supplied
Digitaline Nativelle is available
through all pharmacies in 0.1
mg. tablets (pink) and 0.2 mg.
tablets (white) in bottles of 40
and 250, and in ampules of 0.2
mg. ( 1 cc.) and 0.4 mg. (2 cc.)
in packages o f 6 ampules and 50
ampules. Oral and intravenous
dosage identical.
Six tablets of Digitaline Nativelle (0.2 mg. each)
usually enable the heart in the throes of decom-
pensation to cope again with the circulatory
demands. This total oral digitalizing dose,
taken at one time, effects complete digitaliza-
tion in 6 to 8 hours.
The action of Digitaline Nativelle, the orig-
inal digitoxin, is virtually free from locally
induced nausea and vomiting, yet produces all
the desirable cardiotonic influence of whole
leaf digitalis from which it is extracted. Initial
maintenance dose, 0.1 mg. daily; in some pa-
tients 0.05 mg. suffices, in others, 0.2 mg. daily
may be required.
Physicians are requested to send for a complimentary copy of
the brochure "Management of the Failing Heart ” and a
clinical sample of Digitaline Nativelle sufficient to digitalize
one patient.
VARICK PHARMACAL COMPANY, INC.
A Division of E. Fougera & Co., Inc.
75 Varick Street, New York 13, N. Y.
DIGITALINE NATIVELLE
REG. U.S. PAT. OFF.
THE ORIGINAL DIGITOXIN
136
Minnesota Medicini
u
enuuDOd
s os
]i a s
NEW AND MODERN HOSPITALS
beautifully located amid the rolling hills of Golden Valley.
Only 10 minutes from the Minneapolis loop, the hospitals have
all the advantages of the rural setting. The spacious and con-
venient arrangement of physical plant makes the proper classi-
fication of patients possible. The latest in specialized and
scientific treatment is emphasized at each of seven separate
stations. Every facility for comfort and care is insured the patient.
Available to all reputable members of the medical profession.
SCHOOL OF PSYCHIATRIC NURSING
A CAREER IN NURSING OFFERS:
• Training in a highly paid profession
• A secure position unaffected by economic depression
• Work with skilled professional men and women
• The best preparation for marriage
A one-year course in our School of Psychiatric Nursing is available to
eligible applicants. All phases of the subject are skillfully presented by a
capable and experienced faculty. Classroom and laboratory study is
combined with an interesting program of actual work on the ward. . . .
Here is an opportunity to attain a useful higher education — and at the
same time prepare for a highly paid, interesting and respected career.
Tuition free. Class pin and diploma awarded on completion of course.
Write for particulars.
DIRECTOR, SCHOOL OF NURSING, GLENWOOD HILLS HOSPITALS
Classes begin January, June, September. JUNE CLASS NOW BEING ORGANIZED
GLENWOOD HILLS
HOSPITALS
3501 Golden Valley Road
Route Seven, Minneapolis, Minn.
February, 1947
137
PYORTANIN SURGICAL GUT
Plain and Jematijed
Manufactured Since 1899 by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia
• • •
Price i.Ut
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE G NONBOILABLE
Sizes 000 — 00 — 0—1—2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
« • I
I
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FDR SALE BY SURGICAL DEALERS AND DRUGGISTS
138
Minnesota Medicine
Formulac Infant Food provides a balanced and flexible formula
basis for general infant feeding — both in normal and difficult
diet cases.
Developed by E. V. McCollum, Formulac is a concentrated
milk in liquid form, fortified with all vitamins known to be
necessary for proper infant nutrition. No supplementary vitamin
administration is necessary with Formulac. The Vitamin C
content is stabilized, assuring greater safety.
The only carbohydrate in Formulac is the natural lactose
found in cow’s milk— no other carbohydrate lias been added. This
permits you to prescribe both the amount arid the type of carbo-
hydrate supplementation required.
Formulac is promoted ethically, to the medical profes-
sion only. Clinical testing has proved it satisfactory in promoting
normal infant growth and development. On sale in grocery and
drug stores throughout the country, Formulac is priced within
range of even modest incomes.
Distributed by KRAFT FOODS COMPANY
NATIONAL DAIRY PRODUCTS COMPANY, INC.
NEW YORK, N. Y.
• For further information about
FORMULAC, and for professional
samples, mail a card to National
Dairy Products Company, Inc., 230
Park Avenue, New York 17, N. Y.
February, 1947
139
SPEED
WITH ACCURACY
These units meet the
most rigorous demands
and have proved out-
standing in transure-
thral prostatic resection.
BIRTCHER
ELECTROSURGICAL
UNITS
are precision- built for
flawless service:
■fa Cutting speed to satisfy the most
critical requirements whether dry
field or under water.
■fa Control is easy and perfect, in
cutting and hemostasis, sepa-
rately or blended together.
^ Performance is unfailingly exact.
Accurate calibration of control
dials insures precise repetition of
proved technics.
Dependability is assured.
AMERICAN MEDICAL ASSOCIATION ACCEPTED
C. F. ANDERSON CO., INC.
Surgical and Hospital Equipment
901 Marquette Minneapolis 2, Minn.
140
Minnesota Medicine
Furunculosis ... . second in the series; "FACIAL EXPRESSIONS OF SICKNESS'
From a practical standpoint, the use of penicillin orally should be limited to the infections in which low doses of
parenteral penicillin have proved adequate; to prophylaxis; and to the convalescent stages of such acute infections as
furunculosis. Here, when the crisis is past and the fever receded, the use of two tablets (100,000 units) every
hour or six tablets (500,000 units) at three hour intervals, day and night, for 48 hours is a tested safeguard
against relapse. For such prophylaxis, tablets of calcium penicillin, 50,000 units each, are available in bottles of 12.
P E IV I C I L L I IV TABLETS ORAL by
February, 1947
141
You can write it
with certainty . . .
Chances are most physicians have never
visited the pharmaceutical laboratories
where the medications they use routinely
are manufactured. You yourself, perhaps
could not name the scientific staff or de-
scribe the methods followed in your favorite
drug house.
One factor you depend upon — "THE
NAME OF THE MANUFACTURER." All
other factors — laboratory facilities, per-
sonnel, procedure — are wrapped up in
THE NAME.
Physicians have relied on the name DORSEY
(until recently Smith-Dorsey ) for over 38
years because the factors behind the name
are right. Dorsey laboratories are fully
equipped, capably staffed, follow rigidly
standardized testing procedures throughout.
When you write the name, do it with cer-
tainty . . . "Dorsey."
THE SMITH-DORSEY COMPANY
Lincoln, Nebraska • Dallas • Los Angeles
MANUFACTURERS OF FINE PHARMACEUTICALS SINCE 1908
MANUFACTURERS OF
PURIFIED SOLUTION OF LIVER-DORSEY
SOLUTION OF ESTROGENIC SUBSTANC
ACCIDENT * HOSPITAL " SICKNESS
INSURANCE
FOR PHYSICIANS, SURGEONS, DENTISTS EXCLUSIVELY
$5,000.00 accidental death $8.00
$25.00 weekly indemnity, accident Quarterly
and sickness
$10,000.00 accidental death $16.00
$50.00 weekly indemnity, accident Quarterly
and sickness
$15,000.00 accidental death $24.00
$75.00 weekly indemnity, accident Quarterly
and sickness
$20,000.00 accidental death $32.00
$100.00 weekly indemnityt accident Quarterly
and sickness
ALSO HOSPITAL EXPENSE FOR MEMBERS
WIVES AND CHILDREN
86c out of each $1.00 gross income used for
members’ benefits
$3,000,000.00
INVESTED ASSETS
$14,000,000.00
PAID FOR CLAIMS
$200,000.00 deposited with State of Nebraska for protection of our members.
Disability need not be incurred in line of duty — benefits from
the beginning day of disability
PHYSICIANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION
45 years under the the same management
400 FIRST NATIONAL BANK BUILDING • OMAHA 2, NEBRASKA
Complete Optical
Service
Lens Grinding
Dispensing
Contact Lenses
Eye Photography
N. P. BENSON OPTICAL
COMPANY
Established 1913
Main Office and Laboratory
450 Medical Arts Building, Minneapolis 2, Minn.
Lake Street Office — 1611 A West Lake Street
— BRANCH LABORATORIES —
Aberdeen - Duluth - Eau Claire - Winona
Bismarck - La Crosse - Wausau - Stevens Point
Albert Lea - Rapid Citv - Huron - Beloit - Brainerd
Rochester
142
Minnesota Medicine
Diabetes , diet and
Globin insulin ♦ ♦♦
The advantages of one -injection control of
diabetes can, through adjustment of diet and
dosage, be made available to the majority of
patients requiring insulin. In view of the con-
venience and freedom afforded by the unique
intermediate action of ‘Wellcome’ Globin Insulin
with Zinc, the necessary adjustment is well
worth while. Though not a complicated pro-
cedure, the regulation of carbohydrate balance
warrants reiteration because of its importance:
SOME FACTS ABOUT DIETARY ADJUSTMENT: The
distribution of carbohydrate in the meals must
be adjusted in accord with the type of action ex-
hibited by Globin Insulin, which is intermediate
between regular and protamine zinc insulin.
Proper carbohydrate distribution with proper
insulin timing is essential; lack of balance may
lead to poor control or to an erroneous impres-
sion of the characteristics of Globin Insulin.
A good carbohydrate distribution for the patient
on Globin Insulin is to divide the total carbo-
hydrate per day into 1/5 at breakfast, 2/5 at
lunch and 2/5 at suppertime. This initial diet
may be adjusted in accord with the indications
of blood sugar levels and urinalyses. (For ex-
ample, a low blood sugar before supper indicates
too little carbohydrate for lunch or vice versa.)
Globin Insulin is ordinarily given before break-
fast. Onset of action is usually sufficiently rapid
to eliminate the need for a supplementary injec-
tion of regular insulin. However, the amount of
breakfast carbohydrate should not be too large.
The right amount, as well as the optimal time
interval between the injection and breakfast,
must of course be determined for each patient.
Since the maximum action of Globin Insulin
usually occurs in the afternoon or early evening,
hypoglycemia is sometimes noted at this time.
As a guard against it, the carbohydrate content
of the noon meal may be increased, or a midafter-
noon lunch provided. Thus the original distribu-
tion of 1/5, 2/5 and 2/5 might, for example,
require adjustment to 2/10, 5/10 and 3/10 or
to 2/10, 4/10, 1/10 and 3/10. Once the balance
of carbohydrate intake and insulin timing has
been established, the patient must be impressed
with the importance of adhering to the regimen.
‘Wellcome’ Globin Insulin with Zinc is a clear solu-
tion, comparable to regular insulin in its freedom
from allergenic properties. Available in 40 and 80
units per cc., vials of 10 cc. Accepted by the Council
on Pharmacy and Chemistry, American Medical
Association. Developed in The Wellcome Research
Laboratories, Tuckahoe, New York. U.S. Patent
No. 2,161,198. LITERATURE ON REQUEST.
'Wellcome' Trademark Registered
NC., 9 & II EAST 4 1ST STREET, NEW YORK 17, N.Y.
February, 1947
143
\/ he combined use of an occlusive diaphragm and vaginal
jelly remains, in the published opinions of competent clini-
cians, the most dependable method of conception control.
Dickinson1 has long held that the use of jellies alone cannot be
relied upon for complete protection. It is noteworthy that in
the series of patients studied by Eastman and Scott-, an occlu-
sive diaphragm was employed in conjunction with a spermi-
cidal jelly for effective results. Warner3, in a carefully con-
trolled study of 500 patients, emphasized the value of a
diaphragm.
In view of the preponderant clinical evidence in its favor, we
suggest that physicians will afford their patients a high degree
of protection by prescribing the diaphragm and jelly tech-
nique.
You assure quality when you specify a product bearing the
’'RAMSES”* trademark.
1. Dickinson, R. L.: Techniques of Conception Control. Baltimore, Williams and
Wilkins Co., 1942.
2. Eastman, N. J., and Scott, A. B.: Human Fertility 9:33 (June) 1944.
3. Warner, M. P.: J. A. M. A. 115:279 (July 27) 1940.
gynecological division
JULIUS SCHMID, INC.
Quality First Since 1883
423 West 55 Street New York 19, N. Y.
•The word "RAMSES'' is a registered trademark of Julius Schmid, Inc.
144
Minnesota Medicine
To restore nasal patency
in colds and sinusitis .
Neo-Synephrine decongests promptly . . . clears the nasal airways
for greater breathing comfort ... promotes sinus drainage. Relief
lasts for several hours. Virtual freedom from compensatory
vasodilatation precludes development of dependency symptoms.
rfiebhrine
X K A M D O/ f PHCHYL CP HRINg
r D R O C H LORI D E
For Nasal Decongestion
THERAPEUTIC APPRAISAL: Prompt,
prolonged nasal decongestion without
appreciable compensatory recongestion;
virtual freedom from local and systemic
side effects; sustained effectiveness on re-
peated use.
INDICATED for symptomatic relief of
the nasal congestion of common colds,
sinusitis and allergic rhinitis.
; KO.SYMPHHNI Hi
I HYDTOCHLORIDI
p solution %%
fjf
ADMINISTRATION may be by drop-
per, spray or tampon, using the 14% in
most cases, the 1 % when a stronger so-
lution is indicated.
SUPPLIED as 14% and 1% in isotonic
saline and 14% in Ringer’s with aro-
matics, bottles of 1 fl. oz.; 1/2 % jelly in
convenient applicator tubes, y8 oz.
/O
7am
(7
DETROIT 31, MICHIGAN
NEW YORK KANSAS CITY SAN FRANCISCO WINDSOR, ONTARIO SYDNEY, AUSTRALIA AUCKLAND. NEW ZEALAND
Trade*Mark Neo-Synephrine Reg. U. S. Pat. Off.
February, 1947
145
COUNCIL ACCEPTED
Brand of theobromine-calcium salicylate.
Trade Mark reg. U. S. Pat. 0*f.
the patient comfortable. Theocalcin strengthens heart
action, diminishes dyspnea and reduces edema.
Bilhuber-Knoll Corp. Orange, N. J.
146
Minnesota Medicine
Top-rank chemist
His work is performed with infinite care . . . But
he chooses his meals on whim. He eats only the
foods he likes — a choice of notably limited range.
The inevitable result is a further increase in the
ranks of the self-made victims of borderline vita-
min deficiency. You know many of them: the
ignorant and indifferent, patients "too busy” to
eat properly, those on self-imposed and badly
balanced reducing diets, excessive smokers, alco-
holics, and food faddists, to name but a few.
First thought in such cases is dietary reform, of
course. But this is often more easily advised than
accomplished. Because of this, an ever-growing
number of physicians prescribe a vitamin supple-
ment in every case of deficiency. If you’re one of
these physicians — or if you prescribe vitamins
only rarely — consider the advantages of specify-
ing an Abbott vitamin product: Quality — Certain-
ty of potency — A line which includes a product
for almost every vitamin need — And easy avail-
ability through good pharmacies everywhere.
Abbott Laboratories, North Chicago, Illinois.
specify-. Abbott Vitamin Products
February, 1947
147
oke Stethetron
•%
./iiaico
A REMARKABLE d evelopment which
assures accuracy in auscultatory diagnosis.
An electronic stethoscope which ampli-
fies the faint heart and chest sounds you
wish to hear while subduing the other
sounds to convenient levels for com-
parison.
Easily detects faint murmurs and dis-
ease sounds which cannot be heard
through the old-fashioned acoustic stetho-
scope.
A demonstration will convince you.
MAICO of Minneapolis, 74 So. 9th Street
Adams Bros. Distributors Tel. Atlantic 4329
MAICO of St. Paul, 1108 Commerce Bldg.
Louis J. Kelly, Mgr. Tel. Garfield 6144
Homewood hospital is one of the
Northwest's outstanding hospitals for the
treatment of Nervous Disorders — equipped
with all the essentials for rendering high-grade
service to patient and physician.
Operated in Connection with
Glenwood Hills Hospitals
HOMEWOOD HOSPITAL
Corner Penn and Plymouth Avenues North
Minneapolis Minnesota
r
Dr. ...
Address
City
State
WITH ADDED POTASSIUM CARBONATE 1.1%
BORCHERDT MALT EXTRACT CO., 217 N. Wolcott Ave., Chicago,
FREE SAMPLE
FOR CONSTIPATED BABIES
Borcherdt Malt Soup Extract is a
laxative modifier of milk. One or
two teaspoonfuls dissolved in a
single feeding produce a marked
change in the stool. A Council
Accepted product. Send for free
sample.
148
Minnesota Medicine
February, 1947
149
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
If you care for samples, have your office phone
or write us.
HOME BRAND ON THE LABEL MEANS GOOD FOOD ON BABY’S TABLE
GRIGGS, COOPER & CO • TWIN CITIES, TWIN PORTS, FARGO
'
STRAINED
FOODS
STRAINED
baby foods
150
Minnesota Medicine
0
Why r S/'/'///S//Y// "
in Menopausal Therapy?
Because it is Orally Effective.
Rarely elicits Toxic Reactions.
Produces rapid
Symptomatic Relief...
3%
//
S/Y//////Y//
is a naturally
occurring conjugated estrogen which is therapeutically effective when administered
by mouth. It usually produces prompt remission of distressing symptoms, and provides,
an emotional uplift and feeling of well-being which is gratifying to the patient.
Toxic effects or even minor unpleasant side reactions are relatively rare.
Available as:
Tablets of 1.25 mg.— bottles of 20, 100 and 1000.
Tablets of 0.625 mg.— bottles of 100 and 1000.
MEDICAL |
8 ASSN. II
A palatable liquid— containing 0.625 mg. in each teaspoonful (4 cc.), in 4-ounce bottles.
Conjugated estrogens (equine)
0 Ayerst, McKenna & Harrison Ltd.
on C ACT ilATu CTftrrr kin.t is ..
22 EAST 40TH STREET. NEW YORK 16, N. Y.
February, 1947
151
fw\
'T/C tttc ^
^ifirvo Ac^&AUhjV f^t&tc/
sie^f, ~4^>ecLa4(y a*
<Y * co-A/jCv&tc, /Ac
/a Ac fAoA<r*.^e<£ .
Cawthorne, T.: The Treatment of the Common Cold, Clin. Sup. to King's College Hosp. Gaz. I8:iil.
Rapid, prolonged relief
Between office
treatments, Benzedrine Inhaler, N.N.R., affords quick and effective
symptomatic relief to those patients whose chief complaint is
nasal congestion and discomfort. The Inhaler produces a shrinkage
equal to, or greater than, that produced by ephedrine— and
approximately 17% more lasting.
Each Benzedrine Inhaler is packed with racemic amphetamine, S.K.F., 250 mg.; menthol, 12.5 mg.; and aromatics.
152
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30
February, 1947
No. 2
THE USE OF INSULIN MIXTURES
RANDALL G. SPRAGUE, M.D., and LAURENTIUS O. UNDERDAHL, M.D.
Rochester, Minnesota
DURING the first fifteen years following the
discovery of insulin in 1921, there was a
growing appreciation by physicians interested in
the treatment of diabetes of the shortcomings of
soluble insulin. The principal of these shortcom-
ings are related to its brief, intense action. The
results of this inefficient type of action are the
necessity for multiple injections each day in the
treatment of severe diabetes, the danger of insulin
reactions due to precipitous falls of the blood sug-
ar level, and the lapses of control of severe dia-
betes in the interval between the waning of action
of one dose and the injection of the next.
With the introduction of protamine insulin m
1936, and of protamine zinc insulin shortly after-
ward, the possibility of modifying insulin in the
direction of a more prolonged action of lesser in-
tensity was realized. At that time it was hoped
that in many of the cases in which multiple injec-
tions daily of soluble insulin had been lequired,
the diabetes would remain under satisfactory con-
trol with a single injection daily of protamine zinc
insulin. Unfortunately, in many cases this hope
has not been realized, for reasons which now seem
obvious. Protamine zinc insulin does not have
sufficient intensity of action to prevent excessive
glycosuria following the ingestion of food in cases
of severe diabetes, while its continuing action dur
ing the fasting hours of the night may result in
hypoglycemic reactions while the patient is asleep.
Among all the cases in which diabetes is severe
enough to require insulin, only the relatively mild
From the Division of Medicine, Mayo Clinic, Rochester, Minne-
sota.
Read at the meeting of the Northern Minnesota Medical
Assocaition, Crookston, Minnesota, August 24, 1946.
ones (usually those requiring 20 units or less
daily) are satisfactorily regulated with a single
dose of protamine zinc insulin alone with assur-
ance that nocturnal reactions will be avoided.
Thus, it soon became apparent that some com-
promise between the short, intense action of sol-
uble insulin and the prolonged, weak action of
protamine zinc insulin would have greater thera-
peutic usefulness than either of these two insulins
alone. Treatment with both types of insulin in-
jected separately has been widely employed as a
means of achieving this compromise, but this
[method is objectionable because multiple injec-
tions are required. Lawrence3 of London was the
first to. suggest treating diabetes with a single
daily injection of soluble and protamine zinc in-
sulin mixed in one syringe. Following his sug-
gestion, the Section on Metabolism Therapy of
the Mayo Clinic has been using such mixtures
since 1938 in the treatment of many diabetic pa-
tients. Day-by-day clinical observation and con-
trolled clinical investigation by ourselves and oth-
ers have taught us much about the mode of action
and the clinical applicability of such mixtures.
The most important single lesson that has been
learned from observation of patients is that mix-
tures containing two or three times as much sol-
uble insulin as protamine zinc insulin are the most
suitable for the treatment of diabetes which is se-
vere enough to require the use of mixtures. This
observation is corroborated by several experimen-
tal studies, notably those of Colwell and his col-
leagues.2 The latter investigators showed that
definite intermediate effects, in terms of prompt-
ness, intensity and duration, are not obtained un-
February, 1947
153
INSULIN MIXTURES— SPRAGUE AND UNDERDAHL
til the mixture contains at least as much soluble
insulin as protamine zinc insulin. By increasing
the proportion of soluble insulin further, any de-
sired effect intermediate between those of the two
kinds of insulin alone can be obtained.
Colwell1 showed further that when excess solu-
ble insulin is added to protamine zinc insulin in
ratios as high as 4:1, virtually no soluble insulin
remains in the supernatant, and the mixture has
a monophasic action on injection. In simple
terms, this means that protamine has a tremen-
dous capacity to combine with insulin, with the
result that the insulin in the commonly employed
mixtures is in a single complex rather than two
(rapid-acting and slow-acting) compounds. Thus,
it is not technically correct to speak of the quick
action of the regular insulin and the slow action
of the protamine zinc insulin in a mixture. The
mixture is in reality a single compound which is
different from either of the component types of
insulin in that the protamine is more saturated
with’ insulin than it is in commercial protamine
zinc insuln. The result of such saturaton of pro-
tamine is that insulin is released at a more rapid
rate than from standard protamine zinc insulin.
Aims of Treatment
Let us digress for a moment to consider the
aims of treatment of diabetes with particular ref-
erence to the physiologic problem involved in the
use of insulin in the treatment of diabetes. The
aim of treatment can be simply stated as being
the maintenance of health and vigor for a normal
span of life. This implies avoidance of acute
■complications, such as insulin reactions and keto-
sis, as well as the chronic degenerative complica-
tions of the disease, such as retinopathy, neurop-
athy and intercapillary glomerulosclerosis. At the
present time it seems that the treatment which is
most likely to achieve the desired end is that
which maintains optimal nutrition and reduces the
excretion of glucose in the urine to the lowest
possible level consistent with a livable program
and the avoidance of insulin reactions. Precise
control of the level of the blood sugar, which in
some cases can be achieved only by frequent in-
jections of insulin and bizarre adjustments of the
diet, and in other cases cannot be achieved at all,
probably offers no additional advantage. Evi-
dence is accumulating that even the most precise
control of diabetes will not always prevent the de-
velopment of degenerative complications.
I he theoretical aim in administering insulin to
the patient who has diabetes is to supplement his
own endogenous production of insulin in such a
way as to imitate as closely as possible the secre-
tion of insulin by the normal pancreas. While
there is much that is not understood about the
regulation of insulin secretion, a reasonable phys-
iologic hypothesis provides useful guidance in the
administration of insulin to patients. Indirect evi-
dence suggests that there are two types of secre-
tion: (1) a continuous slow secretion during
fasting, which serves to prevent excessive catabo-
lism of body protein and fat and to maintain the
blood sugar at a normal level against the various
factors which tend to elevate it, and (2) an aug-
mented secretion following the ingestion of food,
which in most persons prevents the excretion of
more than small amounts of glucose in the urine.
An exact imitation of these mechanisms is im-
possible to attain, but by skillful employment of
quick and slow acting insulins the physician is
usually able to achieve a reasonably satisfactory
approximation of the normal processes. Obvious-
ly, in the treatment of severe diabetes in which
most, if not all, of the body’s requirement for
insulin must be injected, the normal mechanisms
of insulin secretion will be better imitated by a
type of insulin which provides both rapid and
slow actions than they would be by an insulin
which provides only one of these.
The principal indication, then, for the use of
mixtures of protamine zinc insulin and regular
insulin is diabetes of such severity that glycosuria
is not adequately controlled and insulin reactions
are not avoided by the use of a single morning
dose of protamine zinc insulin of moderate size.
It would be extravagant to claim that such mix-
tures solve all the therapeutic problems of severe
diabetes, for there still remains a small group of
cases in which insulin reactions and poor control
of glycosuria continue to be major problems.
Clinical Use of Mixtures
The use of extemporaneous rather than fixed
mixtures of the two types of insulin provides nec-
essary flexibility of quick and slow action.* The
*The use of extemporaneous mixtures of protamine zinc insulin
and soluble insulin in one syringe calls for precautions to prevent
the introduction of one kind of insulin into the other bottle. An
appropriate volume of air is first injected into the bottle of prota-
mine zinc insulin and the needle is withdrawn without permitting
any insulin to enter the syringe. Then the desired dose of
soluble insulin is drawn into the syringe in the usual manner.
After this the needle is again inserted into the bottle of protamine
zinc insulin and the desired dose is allowed to flow into the
syringe, overlying the soluble insulin which is already there. The
two kinds of insulin are mixed by drawing a small bubble of air
into the syringe, inverting the syringe several times and then
expelling the bubble.
154
Minnesota Medicine
INSULIN MIXTURES— SPRAGUE AND UNDERDAHL
combined dose is administered in one syringe in
the morning before breakfast. As previously stat-
ed, mixtures containing two to three times as
much soluble insulin as protamine zinc insulin
have proved to be the most effective in the treat-
ment of severe diabetes. Of 100 patients who
were recently treated with mixtures, the ratio of
soluble to protamine zinc insulin was from 2:1
to 3:1, inclusive, in eighty-seven (Table I). The
more severe the diabetes, or the higher the carbo-
hydrate content of the diet, the more likely is the
ratio to be in the neighborhood of 3 :1 rather than
2:1. The strong effects of the mixture prevent ex-
cessive glycosuria during the day when food is be-
ing ingested, and the prolonged slow effects pre-
vent escape from control overnight.
TABLE I. MIXTURES OF SOLUBLE AND PROTAMINE
ZINC INSULIN IN 100 CASES OF
DIABETES MELLITUS
Ratio of soluble to protamine
zinc insulin
Cases
1:1 to 1.5:1
5
1 .5 + : 1 to 2-:l
5
2:1 to 2.5:1
62
2.5 +:1 to 3:1
25
3 +:1 to 3.5:1
2
3.5 + :1 to 4:1
1
As pointed out by Colwell,1 problems of insulin
therapy would be simplified by the marketing of
a modified insulin having an action like that of a
2:1 mixture of soluble and protamine zinc insulin,
in place of the commercial protamine zinc insulin
which is now available. Such an insulin would
obviate the need for extemporaneous modifica-
tion in many cases, as it would fill the needs of
all the patients who are now successfully treated
with protamine zinc insulin alone, as well as of
the majority of the patients who are now treated
with mixtures. In the few cases in which higher
ratios of soluble to protamine zinc insulin are re-
quired, supplementation with additional soluble
insulin could be readily accomplished in accord-
ance with the needs of the individual patient.
Patients whose diabetes is eventually found to
be controllable with mixtures in which the ratio
of soluble to protamine zinc insulin is 1:1 or less,
usually have relatively mild diabetes, which fares
equally well with a single small morning dose of
protamine zinc insulin. The use of various kinds
of insulin in diabetes of different degrees of se-
verity has been discussed by Wilder5 and by
Sprague.4
Adjustment of the Dose
The size of the initial mixed dose in new cases
depends on clinical judgment and an estimate of
the fundamental severity of the diabetes. For ex-
ample, if the patient is an adult whose diabetes
is anticipated to be basically mild, even though the
patient may present himself with fairly intense
glycosuria, the starting dose may be of the order
of 6 units of protamine zinc insulin and 12 units
of soluble insulin. If the diabetes is of greater
severity, as is the rule among children, adolescents
and young adults, the dose may be of the order of
12 units of protamine zinc insulin and 24 units or
more of soluble insulin. Rarely need the total
initial dose exceed 60 units. Small children can be
expected to respond to smaller doses than young
adults. In the absence of ketonuria, caution
should be exercised in increasing the dose during
the first few days of treatment, for the full ef-
fects of the starting dose may not be apparent for
several days.
Whatever the initial dose of insulin, subsequent
adjustments are made on the basis of frequent
tests of the urine for sugar. Until a satisfactory
balance is established, the urine is tested four
times daily. Once reasonable control has been
achieved, further adjustment of the doses of the
two kinds of insulin can be made on the basis
of two daily tests: (1) The test of a fresh speci-
menf voided in the morning before breakfast is
a satisfactory criterion of the adequacy of the
dose of protamine zinc insulin. The dose is ad-
justed so that there will be no nocturnal insulin
reactions and no more than traces of sugar in the
morning specimen. (2) The test of a fresh spec-
imen voided late in the afternoon before supper
serves as an index of the adequacy of the dose of
soluble insulin. The aim is to adjust this dose so
that there will be few or no insulin reactions dur-
ing the day and no more than traces of sugar in
this specimen.
When it is necessary to increase or decrease the
dose of insulin, the magnitude of the change
should depend on several factors. As a rule, the
larger the dose, the larger the change should be.
Since most mixed doses will contain approximate-
ly twice as much soluble insulin as protamine zinc
insulin, the magnitude of change of the two kinds
of insulin is kept in about the same proportion
tOnly if the urine has been recently secreted by the kidneys
will the urine tests provide accurate information about the state
of the diabetes at the time when the test is made. To this end,
the patient is instructed to empty the bladder about thirty
minutes before collecting the specimen for testing-.
February, 1947
155
INSULIN MIXTURES— SPRAGUE AND UNDERDAHL
For example, the soluble insulin may be changed
4 units at a time, and the protamine zinc insulin 2
units at a time. Very large doses of soluble in-
sulin may be raised or lowered 6 or 8 or more
units at a time. Some small children, and a few
adults, are so sensitive to small changes that al-
terations in steps of more than 2 units may be
inadvisable.
Any rules for adjustment of doses must be
modified to suit the vagaries of the individual
case. In some cases of severe diabetes, for exam-
ple, once preliminary regulation has been com-
pleted and tolerance has become stabilized, it may
be wise not to alter the doses of the two kinds of
insulin in spite of occasional intense glycosuria or
mild insulin reactions, since such transient fluc-
tuations may be due to factors other than insulin.
Among these factors are emotional disturbances,
irregularities of rate of absorption of insulin from
different sites of injection, and variations of food
intake and physical activity. A sound principle
in such cases is to find a dose of insulin which
provides adequate control on most days and ad-
here to it until there is good reason to make a
change.
Most physicians have had experience with
cases of severe diabetes in which glycosuria is
not satisfactorily controlled and insulin reactions
are not avoided throughout the twenty-four hours
by the use of a single mixed dose of protamine
zinc insulin and soluble insulin. Control in such
cases is sometimes improved by the addition of a
small dose of soluble insulin before supper.
Usually this dose need not exceed 10 or 12 units.
Adjustments of dose are then made chiefly in the
soluble insulin taken in the morning and evening,
for the dose of protamine zinc insulin can usually
be kept small and requires little or no alteration.
The afternoon test of the urine, and insulin re-
actions occurring during the day, are the guides
for adjustment of the morning dose of soluble in-
sulin. The evening dose of soluble insulin is ad-
justed on the basis of the morning test of the
urine and nocturnal reactions.
Summary
Mixtures of protamine zinc insulin and soluble
insulin in proper proportions provide both quick,
intense action and slow, prolonged action. They
are more effective than either of the two compo-
nent insulins alone in most cases of moderately
severe to severe diabetes. A proper proportion in
most instances is between 2 and 3, units of soluble
insulin to 1 unit of protamine zinc insulin.
Such mixtures attain their greatest effectiveness
in those cases of moderately severe diabetes
which have long been recognized as being reason-
ably easy to treat by a variety of therapeutic pro-
grams involving multiple doses of soluble insulin.
They do not solve all the problems of insulin ther-
apy in patients who have severe, “brittle” diabetes
of the type which has always been difficult to
control with any program of treatment.
Extemporaneous mixtures have the advantage
of flexibility, which makes them adaptable to a
variety of cases. Such flexibility is desirable as
it has not been possible thus far to produce any
single modification of insulin which will fill the
needs of all cases of diabetes. However, a modi-
fied insulin having an action like that of a 2:1
mixture of soluble and protamine zinc insulin
could be used without modification in many more
cases than the standard protamine zinc insulin
which is now available. It could be further modi-
fied by the extemporaneous addition of more sol-
uble insulin when necessary.
References
1. Colwell, A. R.: Nature and time action of modifications of
protamine zinc insulin. Arch, Int. Med., 74:331-345, (Nov.)
1944.
2. Colwell, A. R.; Izzo, J. L, and Stryker, W. A.: Interme-
diate action of mixtures of soluble insulin and protamine zinc
insulin. Arch. Int. Med., 69:931-951, (June) 1942.
3. Lawrence, R. D.: Treatment of insulin cases by one daily
injection. Acta med. Scandinav. _ (Suppl.), 90:32-53, 1938.
4. Sprague, R. G. : The use of various kinds of insulin. M.
Clin. North America, 30:933-944, (July) 1946.
5. Wilder. R. M.: Clinical Diabetes Mellitus and Hyperinsulin-
ism. Philadelphia: W. R. Saunders Company, 1940.
ATOMIC ENERGY— ITS MEDICAL APPLICATION
A problem of extraordinary importance is before the
Council on Physical Medicine and the Council on In-
dustrial Health of the American Medical Association,
namely, atomic energy and its medical applications.
At a joint meeting of the two Councils, specialists
on roentgen rays, radium and atomic energy discussed
a long-range program for considering the products, the
problems and the means of disseminating information.
The Council on Industrial Health decided to sponsor
articles on the dangers associated with the manufac-
ture of radioactive material. The Council on Physical
Medicine voted to prepare articles for publication in
The Journal of the American Medical Association on the
therapeutic and diagnostic uses of radioactive isotopes.
156
Minnesota Medicine
THE PRESENT SOUTHERN MINNESOTA MEDICAL ASSOCIATION
Its Antecedents, Purposes and Character
CARLE B. McKAIG, M.D.
Pine Island, Minnesota
I'T is said that excessive preoccupation with the
past is an indication of senility and, no doubt,
this is true. Age dreams of the past while youth
anticipates the future with eagerness. However,
I believe that a reasonable pride in our history
and tradition is commendable, and our organi-
zation has a history of which we may well be
proud.
The older members of the association are fa-
miliar with its history. There are, however, those
who have become members since the history was
last reviewed. This was in 1935, when Dr. M. C.
Piper presented an excellent historical sketch.
It is for the newer members particularly that I
present this review.
The present Southern Minnesota Medical As-
sociation was formed August 3, 1911, at Roches-
ter. It was brought into being by merger of the
Minnesota Valley Medical Association and the
old Southern Minnesota Medical Association.
The organization thus formed was given the
name of the latter component association.
The Minnesota Valley Medical Association
The Minnesota Valley Medical Association,
the older of the two components, was organized
December 1, 1880', at Le Sueur Center. A pre-
liminary meeting had been held the previous Oc-
tober in Le Sueur Center.
It is said that the plan for the organization
originated with the physicians of Mankato. How-
ever, Dr. Otis Ayer, of Le Sueur Center, took
the initiative to the extent of writing to a number
of physicians, requesting their presence at the
organizational meeting. The original plan speci-
fied that there were to be two meetings a year,
one of which always was to be held in Mankato.
This organizational meeting was held sixty-six
years ago. To correlate it with national events,
let me point out that this was only fifteen years
after the close of the Civil War. President Gar-
field was in office. The great Indian War of the
Northwest was just over, and the country was still
mourning those who had died at the Battle of the
Presidential Address, Southern Minnesota Medical Association,
delivered at Faribault, Minnesota, September 9, 1946.
February, 1947
Little Big Horn, in 1876, just four years before.
To correlate the organizational meeting with con-
temporary medical history, 1880 was the year in
which Lord Lister introduced the use of catgut
in surgery of the vascular system. Only thir-
teen years had passed since he had published his
revolutionary paper, “On the Antiseptic Principle
in the Practice of Surgery,” which marked the
beginning of modern surgery.
Medical education in the United States was in
a chaotic state and momentous changes were tak-
ing place in medical knowledge and practice. The
earnest men who formed the Minnesota Valley
Medical Association truly appreciated the vital
need for an organization which would further
medical knowledge.
Transportation was an important factor and
was necessarily by railroad. Hence, it was plan-
ned that the membership of the Minnesota Val-
ley Medical Association be drawn, in a general
way, from those communities which lay along
the “Omaha Road,” as one portion of the Chicago
and Northwestern Railroad was called in those
days. There were thirteen charter members but,
by 1883, the members numbered forty-five. Dr.
Otis Ayer was elected the first president. He had
been surgeon to the Second Minnesota Regiment
of Volunteers and he became president of the
Minnesota State Medical Association in 1877.
He died in 1889.
Dr. C. F. Merritt, of St. Peter, was first treas-
urer and continued to hold this office through
the entire existence of the association, and also
after its merger with the Southern Minnesota
Medical Association, until his death in 1921.
At the time of the merger, in 1911, Dr. E. J.
Davis, of Minnehaha, presented a brief historical
sketch of the Minnesota Valley Medical Associa-
tion. He recalled that the original programs had
consisted entirely of reports of cases. Each mem-
ber in turn described cases he had encountered in
his practice since the last meeting and the entire
membership then discussed each case. Later,
the meetings came to assume a more formal char-
acter, with prepared papers and open discussion
following.
157
PRESENT SOUTHERN MINNESOTA MEDICAL ASSOCIATION
In the same sketch, Dr. Davis also pointed out
that inasmuch as money was very scarce and hard
to obtain in those days, no avoidable expense was
incurred by the association. In this matter, the
interests of the young physician were being con-
sidered particularly, as it was thought that he
needed the association most and he had the least
money to pay for its maintenance. It was thought
that everything should be done to encourage his
attendance. There were no banquets for this
reason. The annual dues were 50 cents, with an
extra assessment of 50 cents whenever the treas-
ury was empty.
In 1880, wheat sold for 87 cents per bushel,
but beef brought $3.66 per hundred weight, and
pork $5.10 per hundred weight. This was the
economic background against which the Minne-
sota Valley Medical Association was founded.
Members of the association were all pioneers ;
many were former army surgeons, and some had
been Indian fighters. Their origins were largely
in the East. Some were Europeans. They were
truly representative of the original stock of the
State of Minnesota. The association was the
first district medical organization in the state.
The Old Southern Minnesota Medical
Association
The second of the two original component so-
cieties, the Southern Minnesota Medical Asso-
ciation, was formed in Winona on July 26, 1892.
Agitation for formation of this organization ap-
parently had existed for a long time. For in-
stance, Mrs. N. H. Guthrie, of the Mayo Clinic,
while engaged in research on the history of medi-
cine in Minnesota, discovered an item in the
Rochester City Post for January 16, 1869. There-
in it was reported that a communication had been
received by the Olmsted County Medical Society,
from Dr. Youmans, of Winona, advocating that
the Olmsted County Medical Society, which had
been formed only the previous year, be enlarged
to include all Southern Minnesota.
At the first meeting of this old Southern Min-
nesota Medical Association, a program of five
papers was presented. It was as follows :
Cerebrospinal meningitis — Dr. McGaughey, Winona
Less common forms of surgical tuberculosis — Dr. W. J.
Mayo, Rochester
Endometritis — Dr. W. T. Adams, Elgin
158
Hypertrophic rhinitis — Dr. H. H. Witherstine, Roches-
ter
Consideration of the knee jerk symptoms — Dr. R. M.
Phelps, Rochester
The meetings rotated among Winona, Rochester
and Owatonna, and were held annually.
One of the duties of the secretary was to can-
vass the members for papers to be presented at the
annual meeting. Apparently the response was
good because the papers presented were, for the
most part, by the members themselves. I think
our present membership might take a lesson from
this and give a better response to the request of
the program committee for papers. It is becom-
ing increasingly difficult for the committee to ob-
tain papers from the members. During the entire
eighteen years of the existence of the old Southern
Minnesota Medical Association, there were only
two secretaries : Dr. Adams, of Elgin, and Dr.
Witherstine, of Rochester.
The New Southern Minnesota Medical
Association
The Minnesota Valley Medical Association and
the old Southern Minnesota Medical Association
existed side by side for eighteen years. There
was considerable duplication of function and over-
lapping of territory. Many physicians were mem-
bers of both. A merger of the two associations
obviously was indicated and was effected, as has
been said, on August 3, 1911, thirty-five years ago,
at a meeting in Rochester. An entirely new so-
ciety was formed but the name, Southern Min-
nesota Medical Association, was retained, as has
been pointed out. This name was considered
appropriate because the object of the organiza-
tion was to serve the needs of members of the
medical profession in the southern part of the
state.
Dr. L. A. Fritche of New Ulm was the first
president of the new society. Following the
merger, the society grew rapidly. Programs be-
came elaborate and meetings extremely well at-
tended. Many national figures appeared on the
programs. For instance, in 1914, the guest speak-
ers included Dr. Bertram W. Sippy, Dr. Dean
Lewis, Dr. Allen B. Kanavel, Dr. Oliver S. Orms-
by, Dr. H. M. McClanahan, Dr. James S. Goetz,
and Dr. Arthur D. Dunn.
In 1919 it was apparent to many members that
the association had become too large and its pro-
(Continued on Page 173)
Minnesota Medicine
GLOMUS TUMORS
Report of Two Cases
HENRY W. MEYERDING, M.D. and JAMES H. VARNEY, M.D.
Rochester, Minnesota
LOMUS tumors may cause excruciating pain.
Because of their rarity they may remain un-
recognized for years. Recently we have operated
on two patients who had glomus tumors of nine
and sixteen years’ duration, respectively. In each
case there was complete relief of symptoms. Early
diagnosis and eradication are dependent on the
recognition of the lesion by the general practition-
er when he is consulted.
Glomus enlargements, or arteriovenous shunts,
occur normally in skin and subcutaneous tissue.
They occur most frequently in the finger tips,
where they regulate temperature when the hands
are exposed to cold. With increased growth of
these tumors, they become excruciatingly painful.
They are usually located under the nail in the vis-
ible part, or as far back as the root of the nail
under the skin, where they may be more ob-
scure. The most common source of histologic
material for the study of the glomus has been
the foot of the goose, where the glomus attains
a large size normally and maintains the tempera-
ture of the foot. These shunts never have been
found in cold blooded animals such as the rep-
tiles.
Mason and WeiF have written the most com-
prehensive report on glomus tumors. They
stressed the wide distribution of the tumors aside
from the usual subungual location. They found
the tumors located over the acromion, on the pal-
mar surface of a finger, in the forearm, in the
arm at the insertion of the deltoid, in the thigh, in
the leg, in the knee joint, under the toenails and
in the sole of the foot. The essential finding which
should lead one to suspect a glomus tumor is any
very painful, discreet region of trigger-like pain,
where a small grayish blue or reddish purple
nodule can be palpated or seen. In the differen-
tial diagnosis, subungual hematoma, fibroma, epi-
thelioma, angioma, neuroma and melanoma have
been mentioned, but in none of these is there the
typical paroxysm of pain.
Treatment of the lesion consists in simple exci-
sion. The tumors are well encapsulated and easily
shelled out. Occasionally the tumor may be very
Dr. Meyerding is in the Section on Orthopedic Surgery, Mayo
Clinic, and Dr. Varney is a Fellow in Orthopedic Surgery,
Mayo Foundation, Rochester, Minnesota.
tiny and found with difficulty. In these cases
Love2"4 uses the “pin test,” consisting of locating
the tumor by means of a sharp pin ; after it is
found, the pin is left in place while nerve block
Glomuts
tumor
Fig. 1. Position and small size of glomangioma, also incision
for removal. The majority of these tumors are subungual.
is performed with procaine at the base of the
finger. In this manner, the lesion can be complete-
ly removed, as its exact location is known.
The tumors are essentially neuromyo-arterial
nodules in the subcutaneous tissue as described by
Dockerty.1 The arteriovenous short circuits con-
sist essentially of (1) an afferent arteriole, (2) an
efferent venule, (3) various small connecting
loops lined by endothelium, the canals described
by Sucquet-Hoyer. These canals can be opened or
closed quickly as a result of local nerve reflexes.
The nodules are usually very small bluish ones
that are exquisitely tender. Microscopically, there
are anastomosing vascular spaces, some with thick
walls, others with thin walls. Around these ves-
sels there are numerous small cells, which resem-
ble nevus cells (small with oval nuclei, small nu-
cleoli and speckled chromatin). Some patholo-
gists consider these cells to be endothelial in ori-
February, 1947
159
GLOMUS TUMORS— MEYERD1NG AND VARNEY
gin ; others consider them to be epithelioid cells or
even myoblasts. Smooth muscle and nerve fibrils
may be seen intermingled with the other elements.
The presence of oval, dark-staining cells in a
Fig. 2. (above) Encapsulated glomangioma showing the general
architecture with small nests of nevus-like cells in a myxoma-
tous stroma. Several dilated vascular canals are visible at the
top of the photograph (X 35).
Fig. 3. (below) High power detail of the endothelial, nevus-
like cells comprising the bulk of the tumor (X 1,300).
vascular network with occasional nerve fibers and
end organs should determine the diagnosis.
Report of Cases
Case 1. — A housewife, forty years of age, reported
at the Mayo Clinic with a history of an excruciatingly
painful region of the right fifth finger, which was located
under the base of the nail bed and had been present for
nine years. The pain occurred with any pressure on
this region and even the weight of the bedclothes would
awaken her at night. The pain was trigger-like, sharp
and shooting and extended up the finger as far as the
proximal phalangeal joint. She had noticed that the tu-
mor turned reddish purple and enlarged during the
painful spasm. With time, it had shown a slow increase
in size and had become more painful. If she struck
the finger the pain was so intense that she would turn
pale and become faint. It was necessary to immerse
the hand in as hot water as she could stand in order
to obtain relief from her pain. The pain was more
readily precipitated during cold weather than at other
times. She had consulted a number of physicians dur-
ing the nine years prior to admission and a diagnosis of
arthritis of the terminal joint of the fifth finger had
been made. She avoided shaking hands and was in con-
stant fear of the recurrent paroxysms of pain. Physical
examination revealed a small dusky red tumor under
the right fifth subungual region. Almost all of it was
lying under the cover of the skin at the base of the nail
(Fig. 1).
The tumor was removed while the patient was under
regional procaine block and tourniquet. A curved inci-
sion was used, incising part of the nail and extending up
into the skin. Immediately beneath the upper part of
the matrix could be seen a firm, grayish, rounded tumor,
5 mm. in diameter, which was dissected free and re- I
moved in toto. The grayish color of this tumor re-
sulted from pressure under the nail and the tourniquet.
The pathologist reported this tissue as an encapsulated
subungual glomangioma (Figs. 2 and 3). The incision
healed by primary intention and the patient experienced
complete relief of symptoms.
Case 2. — A housewife, forty-two years of age, com-
plained of a painful tumor located on the mesial aspect
of the distal phalanx of the left index finger, which
had been present for more than sixteen years and had
interfered with her work. It had been operated on
twice, the last time being about fourteen years prior to
her admission at the Mayo Clinic. However, the tumor
had not been located and the patient had not obtained
relief of symptoms. Examination revealed a mass of
scarlike tissue, which was tender on palpation. The
roentgenograms showed this mass to be confined to the
soft tissues. The roentgenograms of the lungs were neg-
ative. The blood count, urinalysis and flocculation test
gave negative results. Excision of the tumor was per-
formed while the patient was under regional procaine
block and tourniquet. A small nerve and a blood vessel
were seen entering the scarlike mass proximally. These
were cut and tied. The surgeon suspected that the le-
sion was a neurofibroma but when the pathologist ex-
amined the tissue, he found that it was a glomus tumor.
The tumor itself was very small, 1 mm., and was sur-
rounded by fibrous tissue from previous operations. A
number of sections had to be cut to find the heman-
giomatous tissue with the typical oval, dark-staining cells
of a glomus tumor. The incision healed by primary in-
tention and the patient obtained relief from her
symptoms.
(References on Page 194)
Minnesot\ Medici xf.
160
CHRONIC MASTOIDITIS WITH CHOLESTEATOMA AND STENOSIS
OF THE EXTERNAL AUDITORY MEATUS
Report of Two Cases
H. I. LILLIE, M.D., and TAMES B. McBEAN, M.D.
Rochester, Minnesota
IT TS well known that stenosis of the external
auditor}* canals presents a diagnostic problem
in cases in which pain or discharge is present.
The following cases are presented with two pur-
poses in mind : first, to call attention to this
difficult diagnostic problem, and second, to em-
phasize the importance of adequate drainage in
cases of chronic otitis media.
Stenosis of the external auditory canal may
be congenital, in which case the patient has no
symptoms referable to the ear and it is usually
possible to insert a small ear speculum and obtain
a reasonably satisfactory view of a normal tym-
panic membrane. Acute otitis externa frequently
produces such swelling in the auditory canal that
inspection of the tympanic membrane is impos-
sible. In these cases the disease is of short dura-
tion, the pain is localized in the ear itself and
there is pain on moving the auricle or pressing
on the tragus. If a small speculum can be in-
serted and the discharge cleaned out, the hearing
is found to be normal.
When stenosis is produced by chronic otitis
media, there will be a long history of discharge
from the ear. The pain is more deep-seated, the
patient usually complains of deep headache in the
temporal and mastoid region, and the hearing is
usually much diminished. There is no pain on
movement of the auricle but there may be a deep
mastoid tenderness.
Report of Cases
Cme 1. — A white man, aged twenty-two years, reg-
istered at the Mayo Clinic on April 16, 1946. He com-
plained of discharge from the left ear since the age
of six years. At that time he had a head injury, was
not unconscious but was “dazed” for a day or two.
He did not remember whether there was bleeding from
the ear at that time. There had been a constant dull
ache in the ear for a long time with occasional exacer-
bation of more severe pain. At the time of examina-
tion he was having severe steady pain in the ear and
left side of the head.
Examination revealed almost complete stenosis of
the left external auditory canal with purulent, foul
smelling discharge present. There was profound con-
From the Section on Otolaryngology and Rhinology, Mayo
Clinic. Rochester. Minnesota.
February, 1947
duction type deafness on the left. General physical
examination gave negative results. On roentgenographic
examination, sclerosis of the left mastoid was observed.
On April 18, 1946, the left mastoid was explored through
a postauricular incision. Hypertrophic osteitis had
caused considerable sclerosis but there were still a
large number of cells present, all of which contained
pus under pressure. These cells were uncovered in the
mastoid tip, behind and above the knee of the sigmoid
sinus. In the region of the mastoid antrum a large
abscess had uncovered the dura of the middle fossa.
A tract of infected cells was explored inferior to the
labyrinth leading toward the petrous apex. In the mid-
dle ear, medial to the stenosis of the external canal,
was a large cholesteatoma. This was removed. The
cholesteatoma had caused a large cavitation in the mid-
dle ear and adjacent tissues. Radical mastoidectomy was
completed by removing the posterior bony wall of the
external canal, making one cavity of the external canal,
middle ear and mastoid cavity. A plastic skin flap
was cut in the membranous canal and turned back into
the cavity, which was lightly packed with vaselin gauze.
The wound was tightly closed.
The patient’s postoperative course was smooth and
uneventful. Penicillin, 160,000 units daily, was admin-
istered. He was dismissed from the hospital on the
eighth postoperative day and observed in the clinic for
three weeks. All discomfort and pain had disappeared.
He was seen again two months later, at which time
he felt well and made no complaints. The cavity had-
become almost completely epithelized.
Case 2. — A white, married woman, aged thirty-nine,
registered at the Mayo Clinic on April IS, 1946. She
gave a history of purulent discharge from the right ear
since an attack of measles when she was eight years
old. In the past five years she had had four exacerba-
tions with severe pain, lasting about three weeks and
relieved when the ear discharged profusely. During
these episodes the pain was worse at night than during
the day.
Examination revealed severe stenosis of the right
external auditory canal with purulent discharge present.
The stenosis prevented examination of the tympanic
membrane. There was a moderately severe conduction
type deafness on the right. General physical examina-
tion revealed mild asthmatic bronchitis and rheumatic
mitral endocarditis. On roentgenographic examination
partial sclerosis of the right mastoid was observed.
Exploration of the right mastoid process was done on
April 20, 1946. There was extensive cellular develop-
ment and the intercellular septa were sclerosed. The
cells contained greenish brown fluid and thickened mu-
cous membrane. Cells were removed in the tip, around
(Continued an Page 165)
161
FURTHER OBSERVATIONS ON THE PROGNOSIS IN ANGINA PECTORIS ‘
DUE TO CORONARY SCLEROSIS
A Study of 405 Patients Who Survived Ten or More Years
GEORGE E. MONTGOMERY. JR.. M.D., THOMAS J. DRY, M.B., and ROBERT P. GAGE. M.S.
Rochester, Minnesota
T N MAY, 1946, Parker, Dry, Willius and Gage1
reported on the survival rate of 3,440 pa-
tients who had angina pectoris due to coronary
sclerosis.
The conclusions of this study, in effect, were :
(1) the highest mortality rate occurs in the first
years after the onset of the disease; (2) the
survival rate was definitely lower when the dis-
ease manifested itself before patients were forty
years old than when they were older; (3) the
survival rate of females was greater than that of
males; (4) when sclerosis of the choroidal ar-
teries was associated, the five-year survival rate
was much lower than it was when this condition
was absent, and (5) associated cardiac hypertro-
phy, hypertension (especially hypertension of
groups 3 and 4 of the Keith and Wagener2 classi-
fication), previous myocardial infarction, conges-
tive heart failure and significant electrocardio-
graphic abnormalities (particularly conduction
defects and disturbances of rhythm) all influence
prognostic trends adversely. Attention was drawn
to the curious observation that the inverted T1i2
pattern seems to be associated with a less favorable
prognosis than all other types of inverted T wave
patterns.
I Among this group of 3,440 patients were 405
/ who had survived ten years or longer after the
diagnosis of angina pectoris was made at the
Mayo Clinic. The following report is based on a
more detailed analysis of this group. A study
of data about patients who have survived for a
long time has the advaptage of providing a view-
point in retrospect which serves to reflect prognos-
tic trends.
When information concerning these 405 pa-
tients was last received, 281 (69.4 per cent) of
the group were still living; fifty-four (13.3 per
cent) were known to have died of cardiac dis-
ease; eighteen (4.4 per cent) had died of other
Dr. George E. Montgomery, Jr., is a Fellow in Medicine, Mayo
Foundation, Rochester, Minnesota; Thomas J. Dry is a mem-
ber of the Division of Medicine. Mayo Clinic, and Robert P.
Gage is wi»h the Division of Biometry and Medical Statis-
tics, Mayo Clinic, Rochester, Minnesota.
TABLE I. AGE OF PATIENTS AT TIME OF DIAGNOSIS
OF ANGINA PECTORIS AT THE CLINIC.
Age of patients, years
Cases
Per cent
20-29
2
0.5
30-39
11
2.7
40-49
96
23.7
50-59
177
43.8
60-69
109
26.9
70-79
9
2.2
80-89
i
0.2
Total
405
100
Mean age
55.1 years
disease, and fifty-two (12.8 per cent) had died
of unknown causes.
In general, the age distribution at the time of
diagnosis at the clinic of this long-surviving group
(Table I) was similar to that noted by Parker
and his co-workers1 for the entire group, the av-
erage age being four years younger. However,
the sex ratio shows an interesting change, for,
whereas it was reported as 4.3 males to 1 female
for the whole group, we found that, of the 405
patients who survived ten years, 292 were men
and 113 were women, a ratio of 2.6 to 1. This
change in the sex ratio reflects emphatically the
well-known fact that females who have the dis-
ease survive much longer than males who have
the disease.
As in the original study, we found that those
patients who had cardiac enlargement, congestive
heart failure and the more severe type of hyper-
tension, and those who had choroidal sclerosis,
did not fare well. They were poorly represented
among these long survivors. Thus, only sixty-
eight (16.8 per cent) of the 405 patients were
found to have had cardiac enlargement ; only ten
patients (2.5 per cent) gave a history indica-
tive of an episode of congestive failure ; only
seventy-nine patients (19.5 per cent) had hyper-
tension, and none of these had hypertension
group 3 or 4. In only fifteen of 237 cases in
which a record of funduscopic examinations was
found, was sclerosis of the choroidal arteries
present at the time of the original diagnosis of
angina pectoris at the clinic.
162
Minnesota Medicine
ANGINA PECTORIS— MONTGOMERY ET AL
Influence of Acute Myocardial Infarction
At the time of the original diagnosis of angina
pectoris at the clinic, seventy-one patients (17.5
per cent) had had previous coronary occlusion.
Only 3.7 per cent of the patients in the group are
known to have had coronary occlusion subsequent-
ly. While others may have had unrecognized
or unreported episodes of myocardial infarction,
the number is impressively small among’ those who
survived for ten years or longer after the diag-
nosis was made at the clinic. Isolated instances j
of multiple infarction, among the long survivor^/
provide the exception that proves the rule.
Electrocardiographic Findings
A detailed study of the electrocardiagrams was
made in these 405 cases in an effort to determine
what, if any, are the significant changes that may
occur which would aid the physician in giving a
correct prognosis to the patient suffering from
angina pectoris.
In 236 cases (58.3 per cent) in this group, the
initial electrocardiagram was considered to be
normal. The electrocardiographic abnormalities
among the remainder consisted mainly of (1)
inversions of the T wave, which can be consider-
ed to be either relics of acute myocardial infarc-
tion or the result of hypertension; (2) auriculo-
ventricular and intraventricular conduction dis-
turbances of various types, and (3) disturbances
of rhythm (Table II). The relative infrequency
with which the initial electrocardiogram revealed
conduction disturbances, and the infrequency with
which it revealed ectopic rhythm in this long-sur-
viving group, reflect a significant prognostic trend
and need no further comment. As far as ab-
normalities of the T wave are concerned, the point
worthy of re-emphasis is the infrequency (seven
cases) with which the inverted T1i2 pattern occurs
in this group in comparison with all other ab-
normalities of the T wave. There were thirty
cases in which the electrocardiographic findings
became normal after having been found to be ab-
normal initially. In only one was the original ab-
normality an inversion of the Tli2 waves. The
remainder of the abnormalities were divided about
equally among Tx inversion, T2>3 inversion and
Ti,2,3 inversion. What makes this fundamental
prognostic difference between this T1>2 pattern on
the one hand and the Tx pattern (and for that
matter other combinations of inversions of the
T waves) on the other, is difficult to explain.
February, 1947
TABLE II. ELECTROCARDIOGRAPHIC FINDINGS AT
TIME OF DIAGNOSIS IN PATIENTS SURVIVING
, TEN YEARS OR MORE WITH
ANGINA PECTORIS.
Electrocardiograpliic findings
Cases*
Per Cent
Normal
236
58.3
Inverted T1
44
10.9
Inverted T1-2
7
1.7
Inverted T2.3
43
10.6
Inverted T1*2-8
14
3.4
Left bundle-branch block (concordant)
9
2.2
Left bundle-branch block (discordant)
1
0.2
Right bundle-branch block
0
—
Wide S wave
2
0.5
Complete heart block
0
—
Delayed auriculoventricular conduction
3
0.7
Auricular fibrillation
3
0.7
*No totals are given because several of the noncontributory electro-
cardiographic classifications are omitted.
In 154 cases; subsequent electrocardiograms
were available for further study and for com-
parison with those obtained at the clinic at the
time of the diagnosis of angina pectoris.
It is noteworthy that in sixty-seven cases in
which the original electrocardiogram was normal,
no significant changes occurred in the subsequent
electrocardiograms. These sixty-seven cases com-
prised 70 per cent of those in the group of 154
cases in which the original electrocardiogram
was normal. Moreover, in half of the cases'
in which the electrocardiographic findings were
originally abnormal, they were found to have
returned to normal at a subsequent examination.
This illustrates the tendency for the electrocar-
diographic findings to remain normal or to re-
turn to normal among the long-surviving subjects
with angina pectoris due to coronary sclerosis.
The prognostic trend in so far as the electro-
cardiographic criteria are concerned is reflected
further by comparing the five-year survival rate
of all patients who had angina pectoris due to
coronary sclerosis with the survival rate among
our group who lived ten years or longer (Table
III).
Comment
The normal heart possesses collateral channels
which may, for the most part, remain function-
less until occlusive changes in the main arteries
or their branches stimulate them to supplement
163.
ANGINA PECTORIS— MONTGOMERY ET AL
TABLE III. FIVE-YEAR AND TEN-YEAR SURVIVAL RATES OF PATIENTS HAVING
ANGINA PECTORIS ACCORDING TO ELECTROCARDIOGRAPHIC
CLASSIFICATION.
Results of Electrocardiogram
Traced
Patients*!
Lived Five 0
Following
Ch
r More Years
diagnosis at
nic
Traced
Patients*!
Lived Ten or More Years
Following Diagnosis at
Clini c
Number!
Per Cent
Number!
Per Cent
Normal
1,112
772
69.4
571
236
4L3
Inverted Ti
445
190
42.7
214
44
20.6
Inverted Ti, 2
228
51
22.4
130
7
5.4
Inverted T2, s
363
174
47.9
181
43
23.8
Inverted Ti, 5, s
140
54
38.6
61
14
23.0
Left bundle-branch block (concordant )
126
39
31.0
65
9
13.8
Left bundle-branch block (discordant )
102
33
32.4
19
1
5.3
Right bundle-branch block
5
2
40.0
1
0
Wide S wave
25
14
56.0
8
2
25.0
Complete heart block
4
1
25.0
2
0
—
ui ,j miuary i, me nve-year group mciuaes only tnose cases in which the rlimrnnsiQ nf „n,rin„ • i a
years prior to the time of inquiry, that is, 1936 or earlier; the ten-year group includes only those cases diagnosed
fNo totals are given because several of the noncontributory electrocardiographic classifications are omitted -or earlier.
made five or more
the arterial supply to the myocardium. Herein
might lie congenital or hereditary factors which
decide the fate of the individual patient who
has coronary arteriosclerosis and its complica-
tions. Because coronary sclerosis is inevitable
with aging and at times is accelerated by coexist-
ent disease, such as hypertension, diabetes,
obesity or myxedema, the future course can well
be pictured to depend on which process — the
occlusive or the supplemental — exhibits the great-
er potentiality toward progression.
Given an instance in which the arteriosclerotic
process in itself is diffuse and rapidly progres-
sive or in which the anatomic arrangement of the
main coronary arteries is such that the left
ventricle receives its blood supply almost entirely
from one or the other of the coronary arteries
(thus vitiating the establishment of adequate sup-
plemental circulation should this important chan-
nel become sclerotic) or in which the clinical
course is punctuated by repeated episodes of myo-
cardial infarction, the outlook must of necessity
be unfavorable. However, given an instance in
which the occlusive process is slow or limits itself
to a minor branch of a coronary artery, in which
the groundwork for collateral circulation is un-
usually adequate because of a fortuitously favor-
able anatomic arrangement of the coronary ves-
sels or in which factors capable of aggravating
arteriosclerosis are absent, the outlook is more
favorable and acute myocardial infarction con-
titutes a much less hazardous event. It is pos-
164
sible that a minor occlusive episode in certain
instances such as these, may even stimulate the
establishment of collateral circulation. Therefore,
the fact that the mortality rate is high in the
earlier years after the inception of this disease
is understood readily. In those cases in which
the coronary circulation is prepared against the
effects of both gradual and sudden interference
with arterial supply the patients can be expected
to survive this stormy period.
Finally, we can speculate, with some reser-
vations, on the degree to which treatment in-
fluences prognosis. Given a large number of
patients suffering from the same disease who
can be assumed to receive essentially the same
treatment what, other than natural endowments
inherent in coronary circulation, could account
for the wide variation in the subsequent course?
One answer might well be the difference in
ability of patients to make the necessary physical
and psychologic adjustments which the disease
imposes. The limiting effect of anginal pain
ordinarily precludes overindulgence in physical
activity. Unfortunately, this is not always true of
overindulgence at the table. Still less can we ex-
pect successful psychologic adjustments inpatients
already in middle age or older, whose habits have
become fixed, who often have reached the most
responsible part of their life and who inherently
fear the possibility of a cardiac disorder. Fear,
as a potent vasoconstrictor, can only influence
the successful establishment of collateral circula-
Minnesota Medicine
ANGINA PECTORIS— MONTGOMERY ET AT
tion adversely and perhaps to an extent more
lastingly than some other environmental influ-
ences, not excluding excesses in some habits.
Summary and Conclusions
In this report, data concerning 405 cases in
which the patients survived ten years or longer
after the diagnosis of coronary sclerosis and an-
gina pectoris were analyzed.
The ratio of men to women in this group was
2.6 to 1.
This study further revealed that cardiac en-
largement, coronary occlusion and congestive
heart failure, when associated with angina pec-
toris, definitely increase the mortality rate. _ The
infrequent occurrence of choroidal sclerosis in
this group indicates that it is an unfavorable prog-
nostic finding.
Not a single patient with hypertension, group
3 or 4, was represented in this long-surviving
group.
The number of cases in which electrocardio-
graphic findings were normal in this group was
high. In addition, when initial and subsequent
electrocardiograms were compared a tendency of
the electrocardiographic findings to revert toward
normal was noted in cases in which they were
initially abnormal. The negative T1>2 pattern
apparently indicates unusually severe damage to
the heart, because for patients who had this
abnormality in their initial electrocardiogram,
the mortality rate was extremely high as com-
pared to other patterns which are considered to
be relics of previous myocardial infarction.
In the final analysis, the most potent factor
in determining prognostic trends probably centers
around the success or failure of establishment of
adequate intercoronary anastomoses.
References
1. Parker. R. L. ; Ory. T. T.; Willuis. F A., and Gage R. P :
Life expectancy in angina pectoris. J.A.M.A., 131 .ys-iuu,
(May 11) 1946.
2. Wagener, H. P-. and Keith, N. M.: Oiffuse arteriolar^ dis-
ease with hypertension and the associated retinal lesions.
Medicine, 1 R :317-430', (Sent.) 1039.
CHRONIC MASTOIDITIS
(Continued from Page 161)
and posterior to the sigmoid sinus, and in the root of
the zygoma. The dura of the middle fossa had been
exposed by the disease process in two places. The
middle ear and external canal medial to the stenosis
were packed with cholesteatoma, which was removed.
Radical mastoidectomy was done and a plastic flap was
turned back from the external membranous canal. The
cavity was lightly packed and the incision was closed.
The postoperative course was uneventful and the patient
was given penicillin, 160,000 units daily, for four days.
She had no further pain. She returned for observation
two months later, at which time she felt well. The
ear canal was open and the mastoid cavity was almost
dry.
Comment
The first patient had been recently discharged
from the army. While overseas, he had had a
flare-up in his ear and had been treated for otitis
externa. The character of his pain and the his-
tory of discharge for many years should have
enabled the attending physician to make the diag-
nosis. In both cases, the severe stenosis of the
canals had prevented adequate drainage from
what otherwise might have been benign otitis
media. In both cases the infection had spread
throughout extensively pneumatized mastoid proc-
esses and had uncovered the dura, forming an epi-
dural abscess in one case. Irritation of the ex-
posed dura is the cause of the deep-seated pain.
In both cases cholesteatoma had formed medial
to the stenosis of the ear canal. This is due to
the piling up of desquamated epithelium.
Summary
Two cases of extensive chronic mastoiditis with
stenosis of the external auditory canal are pre-
sented in which the extensive disease process and
cholesteatoma are aggravated by lack of adequate
drainage. In order to prevent extension to intra-
cranial structures or to the sigmoid sinus, sur-
gical intervention is urgent in cases of chronic
otitis media when there is obstruction of drainage
due to stenosis of the external auditory canal. No
other type of treatment is adequate.
February, 1947
165
POLYNEURITIS
Differentiation of Infectious Polyneuritis (Guillain-Barre Syndrome)
and the Neuritis of Porphyria
MAJOR CHARLES L. YEAGER, Medical Corps, AUS
Waco, Texas
TN the study of multiple neuritis, two syndromes
merit careful clinical differentiation: the so-
called infectious polyneuritis or Guillain-Barre
syndrome, and the polyneuritis of acute porphy-
ria. Each has been presented at length in the lit-
erature, but a close diagnostic differentiation has
not been made between them. During an acute
episode of porphyria, the neuritis may not differ
from polyneuritis of any cause; but similarities
are even more striking between the so-called
acute infectious polyneuritis and porphyria be-
cause of the obscurity of etiology in both cases,
the traceable toxic factors in many cases of por-
phyria, the equally rapid onset of symptoms in
both cases, and the similarity in length and course
of the two diseases. However, the difference in
prognosis is so striking that the two conditions
should be differentiated early. In infectious poly-
neuritis, one may feel reasonably assured of re-
covery, whereas, in porphyria, an ultimate fatal
outcome is anticipated.
Several splendid reviews of the literature have
been written describing infectious polyneuri-
tis5,6’16’18 and porphyria,8-12 to which the reader
may refer for more complete discussion.
Infectious Polyneuritis (Guillain-Barre
Syndrome)
In 1892, Osier15 described a form of acute fe-
brile polyneuritis with Landry’s ascending type of
paralysis. In 1916, Guillain-Barre and Strohl7
likewise demonstrated cases of supposed infec-
tious polyneuritis in which the spinal fluid con-
tained high quantities of protein and low cellular
content, known as albuminocytologic dissociation,
which in combination with multiple neuritis has
come to be known as the Guillain-Barre syn-
drome. Other terms describing the condition are
encountered with confusing frequency.16
The cause of infectious polyneuritis has not
been adequately demonstrated. Both Osier15 and
Guillain6 believed that the condition had an infec-
tious etiology, but Gilpin and his associates3 were
of the opinion that a virus is the causative agent.
The disease is no respector of persons, and both
sexes are affected equally. Although no age is
exempt, the majority of cases occur in individuals
between the ages of twenty and forty. There is
no apparent diathesis for the disease, and the
strong and otherwise healthy person may be
struck down. Cases occur both epidemically and
sporadically, but there is some seasonal variation,
the greater incidence paralleling upper respiratory
infections in changeable fall and spring weather,
bamilial and hereditary tendencies are not demon-
strable. As a rule, psychogenic symptoms and
personality disturbances are not elicited.
The Guillain-Barre syndrome is a multiple neu-
ritis, involving in various degrees the peripheral
spinal nerves and nerve roots, as well as the cra-
nial nerves. Of the cranial nerves, the seventh
nerves are the most commonly affected, resulting
in unilateral or bilateral facial palsy. The motor
nerves are more severely involved than the sen-
sory.
Frequently, at the outset, the otherwise healthy
individual is stricken with an acute upper re-
spiratory infection which is accompanied by mild
to moderate fever, malaise and gastrointestinal
disturbances. The acute episode subsides and
complete recovery is apparent.
Within a few days to a few weeks, the first
signs of neuritis become apparent. Although ul-
timately impairment of motor nerve function is
more severe than impairment of sensory function,
sensory symptoms may appear long before weak-
ness is noted. At the outset, there are paresthesias
of the hands and feet, deep aching and tenderness
of the large muscle groups of the extremities and
body, and scattered areas of dyseshesia and pares-
thesia over the body and face. In some cases,
there is no demonstrable objective sensory deficit
throughout the course of the disease; in others,
glove and stocking type of sensory loss develops
in all modialities.
Days or weeks after the appearance of sensorv
changes, progressive flaccid paralysis sets in, be-
ginning in the distal portion of the lower extrem-
ities or of the lower and upper extremities si-
multaneously, and spreading proximally in the
166
Minnesota Medtcine
POLYNEURITIS— YEAGER
pattern of Landry’s paralysis. Weakness is usual-
ly uniformly bilateral, but impairment may show
unilateral predominance. While the onset of
weakness is in the fine distal muscles, the large
proximal muscles of the shoulder and pelvic gir-
dles, arms and thighs, are most severely affected.
When the paralysis reaches its maximum, any
remaining movement is confined to the small
muscles of the hands and feet. As paralysis as-
cends, the large muscles of the trunk fail, and res-
piration is embarrassed by paralysis of the inter-
costal nerves so that the burden of respiration is
placed upon the diaphragm. If the diaphragm
fails, death may ensue. It has been noted that if
paralysis is sufficiently complete to warrant the
use of a respirator, death is imminent.
Development of the disease is dramatic and
very incapacitating, yet the prognosis is exceed-
ingly favorable. The mortality rate varies from
16 to 25 per cent, but good nursing care through
the critical period in which the patient is help-
less frequently averts death. A good prognostic
maxim is that if one is able, by any means, to
keep the patient alive during the critical period of
maximum paralysis, complete recovery is reason-
ably assured.
All the cranial nerves may be involved. The
seventh is the most susceptible, resulting in bilat-
eral peripheral palsy with facial diplegia.1 The
extrinsic muscles of the eye may become notice-
ably affected, resulting in partial or complete fix-
ation of the eyeball. Paralysis of the intrinsic
muscles of the eye, as well, has been observed.
Sensation of the face may be changed, both sub-
jectively and objectively. Hearing is seldom af-
fected. Involvement of the ninth, tenth, eleventh
and twelfth nerves present numerous and various
patterns of disturbance, resulting in deglutition,
taste loss, taste distortion, increased salivary se-
cretion and disarticulate speech.
All deep reflexes are lost, but the superficial
reflexes are usually preserved.- Signs of pyram-
idal tract involvement are lacking, muscles are
flabby, and tone is destroyed. The picture is that
of a lower motor neuron paralysis.
Accurate co-ordination studies are seldom ob-
tained because of the marked motor disability.
Response to galvanic and foradic stimulation is
reduced or lost.
Although albuminocytologic disassociation in
the cerebrospinal fluid is a common finding, the
phenomenon is by no means constant. The fluid
may be under increased pressure. Some of the
cases described by Gilpin et al3 showed choking of
the optic disc, indicating significant increase in
intracranial pressure. Systematically, there may
be evidence of liver and heart damage.
Pathologic changes are not specific. The periph-
eral nervous system is primarily involved, re-
sulting in demyelinization and Wallerian degen-
eration. Severe neuron changes in the central
nervous system have been demonstrated. There
may be edema of the brain and spinal cord with
scattered petechial hemorrhages.
Treatment is supportative, and success hinges
on skilled nursing care. Although the adminis-
tration of vitamins is routine, little can actually
be said in its behalf. Recovery follows with or
without vitamin intake. The administration of
beer and salt, although strictly empirical, seems
to be a pleasant source of vitamins and minerals.
Physiotherapy helps to maintain muscle tone and
prepares the individual for more rapid recovery
when nerve regeneration develops.
Polyneuritis with Porphyria
Porphyria is a heredofamilial constitutional
disorder of pigment metabolism with protean
manifestations, resulting in excretion of large
quantities of uroporphyrin and coproporphyrin
in the urine.
A red complex pigment termed hematoporphy-
rin was originally synthetized by the action of
strong sulphuric acid on hemoglobin.8’10’12’13,21 It
has been demonstrated that hematoporphyrin oc-
curs normally in small amounts in the urine.8’11,14
In 1911, Gunther8 described a condition in which
pigments were excreted in the urine in such large
quantities that the urine became a dark bur-
gundy wine color. He attributed the condition
to an anomaly of pigment metabolism and called
the disease hematoporphyria. In 1924, Fischer2
demonstrated that individuals with hematopor-
phyria excreted gross quantities of uroporphyrin
and coproporphyrin in the urine but not hema-
toporphyrin, which apparently does not appear in
nature but is only a laboratory product. There-
fore, porphyria is considered the correct termi-
nology for the disease in question.
The porphyrias are classified into chronic por-
phyria, congenital porphyria and acute porphyria.
Acute porphyria takes on two forms with identi-
cal clinical manifestations, but presumably the
acute toxic form is distinguished from the idio-
February, 1947
167
POLYNEURITIS— YEAGER
pathic form only by evidence of some toxic sub-
stance acting as the precipitating agent. 11,13,20
Chronic porphyria is a neuropathic disease
which is manifested by signs of chronic nervous
system irritation. There are recurrent episodes of
irritability, restlessness, insomnia and multiple
vague gastro-intestinal complaints. Porphyrins
may or may not be excreted in the urine. The
condition is referred to as “porphyrismis.” Con-
siderable doubt exists as to whether there is such
a disease entity.
Congenital and acute porphyria differ not only
symptomatically but also, according to the beliefs
of Gunther,9’19 in their basic constitutional dia-
theses. The underlying abnormal basis of the
congenital form was referred to as “porphyrosis”
and that of the acute form as “porphyrism.”
Even though, in porphyrosis, manifestations are
systemic, there is a definite but hidden neuropathic
constitutional factor. In porphyrism, on the other
hand, the nervous system is directly involved,
giving rise to general nervousness, anxiety reac-
tion, insomnia, irritability, depression and organic
psychotic reactions (delirium).
Congenital porphyria, a Mendelian recessive
disease, dominant in males, is characterized by its
development in early infancy, the appearance of
large quantities of porphyrins and other pigments
in the urine, and photosensitive skin with pur-
plish brown pigmentation of the skin and teeth.
The pigmentation is the result of deposits of uro-
porphyrin I in the sublayers of the skin and teeth.
Uroporphyrin I is excreted in large quantities in
the urine. The predominant skin lesions are the
disfiguring hydro-aestivale or vacciniforme.
Photosensitivity, in the presence of exposure to
intense or prolonged light, leads to restlessness,
generalized pruritis, accelerated pulse and respira-
tion, weakness, coma and possibly death. Skin
necrosis may develop secondary to vascular con-
striction. Recurrent episodes lead to chronic
hardening of the skin, resembling scleraderma.
Acute porphyria is inherited as a Mendelian
dominant, appears later in life, usually during the
third or fourth decade, is more frequent in fe-
males than in males in a ratio of 3:1. Photosen-
sitivity and discoloration of the teeth are rare ;
largely, uroporphyrin III is excreted in the urine.
Acute porphyria has been subclassified as acute
idiopathic porphyria and acute toxic porphyria.
The diseases are indistinguishable. The latter
differs etiologically in that there is an apparent
idiosyncrasy to certain toxic agents, among which
are acetanilid, nitrobenzol, barbiturates and sul-
fonamides. Latent forms13, 17,20,21 of porphyria have
been described in which abnormal quantities of
porphyrins are excreted in the urine in the ab-
sence of of clinical symptoms. Conversely,17’21
characteristic symptoms may appear in the ab-
sence of excretion of porphyrins. The porphyrin
pigments may appear only during the peak of an
attack, disappearing from the urine as symptoms
subside, or the urine may remain free of porphy-
rins even during the height of an attack, but the
symptoms and signs warrant the diagnosis. The
condition in which porphyrins are not present was
referred to by Waldenstrom21 as “porphyria with-
out porphyrins.”
Acute porphyria is really a chronic familial dis-
ease characterized by exacerbations and remis-
sions. Family and early personal history indicate
numerous ill-defined nervous manifestations which
may be considered in the category of psychoneu-
rosis.
The disease is manifested clinically by recur-
rent colic-like abdominal pain, involving the low-
er quadrants and centering about the umbilicus
with radiation to. the flanks, thighs or chest. An
acute episode may be preceded for months by un-
explained weakness, nervousness, sleeplessness,
and vague flitting pains in the abdomen and ex-
tremities.
The protracted mild illness is followed by sud-
den onset of severe abdominal cramps, nausea,
vomiting, severe constipation, accompanied by
fever and leukosytosis. The abdomen is soft, but
excruciatingly tender. X-ray of the abdomen re-
veals dilatation of the duodenum, ileum or large
bowel. There may be signs of paralytic ileus.
The general physical examination is usually nor-
mal. During the attack, the urine is the color of
burgundy wine and contains porphyrins. Watson
and Schwartz22 devised a simple test for porpho-
bilinogen, a colorless chromogen substance, which
when found in the urine is pathognomonic of acute
porphyria. Approximately 80 per cent of indi-
viduals with porphyria, in contrast to the 20 per
cent with the Guillain-Barre form of polyneuritis,
ultimately terminate fatally.
Common among the neurologic signs is paresis
and paralysis. Both efferent somatic and effer-
ent sympathetic motor nervous systems are af-
fected by the disease. Among the more frequent
forms of paralysis is Landry’s ascending type,
168
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POLYNEURITIS— YEAGER
which may result in death if the respiratory mus-
cles are paralyzed. Waldenstrom21 and Roth17
have pointed out that irregular forms of paralysis
involving scattered groups of muscles are equally
common. Although subjective sensory symptoms
in the form of paresthesias occur, in consideration
of the severity of motor involvement the absence
of sensory defect is notable. Paralysis is of the
flaccid type, involving all of the extremities, and
may involve all cranial nerves, leading to signs of
acute bulbar palsy with dysphagia, dysphonia and
asphyxia. All deep reflexes become obliterated,
but the superficial abdominal and cremasteric re-
flexes may be preserved. In a number of cases
described by Gunther,8-10 anesthesia was wide-
spread.
Involvement of the sympathetic nervous system
as a result of changes in the abdominal autonomic
ganglia is held responsible for the signs of con-
stipation, colic and paralytic ileus.
One of the properties of porphyrins is the abil-
ity to produce spasm of smooth muscle,14 result-
ing in hypertension, oliguria, neuritis (secondary
to spasm of the nutrient vessels of nerves) and
amaurosis (secondary to retinal angiospasm).
Psychiatric manifestations in porphyria vary
widely in type and degree and may lead to admis-
sion to a psychiatric hospital. The organic reac-
tion type is secondary either to organic cerebral
damage, as a result of degeneration of the paren-
chyma, or perhaps to metabolic disturbances.
Gross evidence of organic damage to the brain
may be lacking, and in such cases, the condition
may be confused with the minor psychogenic re-
actions such as anxiety and hysteria, the impres-
sion being based on the vague abdominal cramps,
bizarre patterns of motor weakness and transient
attacks of amaurosis. These, in addition to a long
history of functional nervous manifestations in
the patient and members of his family, and the
paucity of organic signs by exclusion lead to such
misinterpretations.
Pathologic studies in acute porphyria show
scattered pigment (both iron-free and iron-con-
taining) throughout various organs. Large quan-
tities of pigment are deposited in the liver. Vas-
cular thromboses leading to impairment of func-
tion of various organs of the body have been
known to occur. The preponderance of patho-
logic changes found at autopsy, however, are in
the nervous system. There are parenchymatous
degenerative changes in the mixed peripheral
nerves, with involvement primarily of motor fi-
bers, scattered demyelinization, and degenerative
changes in the cells of the sympathetic ganglia,
horn cells of the spinal cord, and Purkinje cells
of the cerebellum. Although the peripheral ner-
vous system and lower segments of the cord are
involved more completely than the higher seg-
ments of the cord, bulbar signs, from time to time,
are predominant.
In the congenital forms, pigment is deposited
throughout the body, and pathologic changes with-
in the nervous system are minimal.
Case Reports \
Ca'se 1. An enlisted WAC, aged twenty-five, was ad-
mitted to Lawson General Hospital, June 11, 1944.
Several days following a cold, the patient noted weak-
ness and pain in the legs and numbness of the hands and
feet on May 25, 1944. At that time, examination in the
infirmary was not remarkable except for a slight drag-
ging of both feet in walking. Because of increased dis-
ability in walking, it was felt advisable on May 27 to
have her admitted to the station hospital. By May 30,
walking was impossible, but paralysis continued to in-
crease so that by June 11 it was complete in both lower
extremities and trunk. Slight movement, however, per-
sisted in the upper extremities. She could roll her head
from side to side, but could not raise it. The muscles
of her face and extrinsic muscles of her eyes were but
slightly affected. All deep reflexes were absent. Flexion
of the knee, hip and back was painful. Paresthesias of
the extremities persisted. Fever and other physical signs
of acute infection were absent.
Admission blood count, as well as subsequent blood
counts, was within normal limits. Urinalysis was re-
peatedly normal. Examination of the spinal fluid on
June 11 showed a very slight xanthochromic fluid which
contained a 169 RBC and an occasional white cell. Smear
and culture were normal. Sugar was 83 mg. per cent.
X-ray of the chest on June 21 showed slight atelectasis
in the anterior-posterior view, but this could not be dem-
onstrated in the lateral view. Porphyrins were not found
in the urine.
A diagnosis of Guillain-Barre syndrome was made.
The patient remained afebrile. She was treated sympto-
matically with foot board to the extremities, frequent
changes of position and high vitamin diet. On two oc-
casions, she developed dyspnea which was considered due
to atelectasis, and which disappeared with frequent
changes in position. By June 25, a month after onset
of the disease, improvement in strength was noted.
Physiotherapy, which was begun shortly after admission,
was continued and by the first of August the patient was
able to mobilize enough strength to move about the bed
without aid, but not until September was she able to
walk without assistance. Improvement in strength con-
tinued until October 4, at which time a thirty-day fur-
lough for continued convalescence was granted. She
returned from the furlough in good condition Novem-
February, 1947
169
POLYNEURITIS— YEAGER
her 3, and after a further brief period of convalescence,
she was pronounced fit for full duty and was discharged
from the hospital.
Case 2. A lieutenant colonel of the Air Corps, aged
twenty-nine, a white, married man, who had ten and one
half years of continuous service, was admitted to Law-
son General Hospital on November 29, 1945.
The chief complaint on admission was generalized mus-
cular weakness, numbness of the extremities, face and
ears, disturbances of taste, and double vision.
History revealed no evidence of familial or hereditary
diseases, and his personal history was entirely negative
with respect to his present illness. He had no unusual
childhood diseases referable to the nervous system. He
was a well-educated man who has apparently been ad-
justed physically emotionally and socially.
Military service records revealed that he was in the
tropics in Africa and the China-Burma-India Theater
from August, 1942, to February, 1944.
The onset of the present illness is dated to October
1, 1945, when the patient was admitted to a station hos-
pital in Illinois because of chills and fever. On admis-
sion, he was found to have a temperature of 103.8°.
No cause for the fever was demonstrated, and evidence
of malaria was lacking. The episode was considered
an innocuous upper respiratory infection and on October
7, 1945, he was pronounced cured and returned to duty.
Upon leaving the hospital he drove to Atlanta, Georgia,
and remained well until October 14, at which time he
took a fishing trip with his wife and brother. They
all drank white mountain corn liquor. The others noted
no ill effects but on the night of October 14, the pa-
tient after going to bed feeling well, was awakened dur-
ing the night with intense nausea which soon gave way
to protracted vomiting, retching and hiccups. After
about three hours he was admitted to a station hospital
near Atlanta, Georgia, and was found to be in partial
shock. Intravenous fluids were administered with result-
ing improvement. At that time, he complained of diffi-
culty in swallowing, but no positive neurologic signs were
noted. The patient remained in the hospital for four
days and because of improvement, he was discharged
to his quarters.
On October 19, he was cognizant of all food tasting
like chocolate. During the latter part of the day he was
overcome by a second attack of nausea, vomiting and hic-
cups. He felt tingling sensation on the medial aspect of
the left arm. On October 22, he experienced difficulty
in focusing his eyes and became aware of double vision
on looking to the right and left. By then, the pares-
thesias had spread to involve all extremities and his gait
was staggering in character. By October 26 weakness and
ataxia had progressed to an alarming degree and it was
felt advisable to return him to the hospital. Upon ad-
mission, the strength of the large muscles of all four
extremities was found to be noticeably reduced, and the
extrinsic muscles of the eyes did not function co-ordi-
nately, although, as yet no objective sensory deficit was
demonstrable. There was a profound tenderness to deep
pressure anywhere on the body. All deep reflexes were
reduced but the superficial reflexes remained active.
A positive Lasegue sign was found bilaterally.
Laboratory studies on readmission were essentially
normal. Glucose tolerance varied from 108 to 133 milli-
grams per cent, sugar being found in the urine. On
October 29, a spinal fluid examination showed a clear
fluid with 3 lymphocytes, negative globulin, negative
Wassermann, a gold curve of 0011000000, and a total pro-
tein of 60 mg. per cent.
Because of rapidly developing paralysis, the patient
was transferred to Lawson General Hospital on October
29, 1945. Upon admission, examination revealed severe
impairment of the cranial nerves, loss of taste, paralysis
of the extrinsic muscles of the eyes with immobilization
of the eyeballs, complete bilateral ptosis, and nearly com-
plete paralysis of the facial muscles. Generalized weak-
ness w'as also progressing. He described paresthesis
from the toes to the face. Deep muscle tenderness and
pain upon movement were increasing. The deep and
superficial reflexes by then were absent. Complete glove
and stocking anesthesia extending to the mid-thigh and
mid-arm regions had appeared. Within twenty-four
hours, the condition had progressed to such extent that
only the toes of the right foot and the fingers of the right
hand could be wiggled slightly. Trouble in swallowing
W'as encountered and respiration was difficult. Because
of the graveness of the patient’s condition all precau-
tions were taken. He remained in this condition until
the last week in December, at which time some improve-
ment in strength was noted. From that point on, im-
provement was progressive and in four months, 80 per
cent of the lost strength was recoverd, and the only sen-
sory disturbance was a mild hyperesthesia of the soles
of the feet. This was considered a Guillain-Barre syn-
drome, and laboratory studies supported the diagnosis.
Urine porphyrins were negative. Throat cultures were
negative. The spinal fluid on October 29 revealed a
total protein of 60 mg. per cent, and on November 6 the
total protein was 256 mg. per cent. On February 7,
1946, the total blood protein was 5.3; serum albumin, 3.7 ;
serum globulin, 1.6; nonprotein nitrogen, 34; and urea
nitrogen, 17. Cerebral spinal fluid examination on Feb-
ruary 22, 1946, showed 160 mg. of total protein and a
zone curve of 2211000000.
Case 3. A twenty-seven-year-old white WAC private
of English descent, was admitted to Lawson General
Hospital on April 5, 1945, complaining of paralysis of
all four extremities and weakness of phonation and deg-
lutition. At the age of five she had a tonsillectomy; at
seventeen, an appendectomy ; at twenty-five, because of
irregular menses, a dilation and curretage was done, fol-
lowing which the menstrual cycle was normal. Her
mother died at twenty-eight years of age of paralysis,
the exact nature of which is unknown. The patient was
ten years old at the time. She had a sister one year
younger who had been observed in state institutions on
a number of occasions because of emotional instability.
There were two younger brothers, apparently healthy.
The patient occasionally had tantrums which were de-
scribed by her father as reminiscent of similar attacks
evidenced by her mother before her death. The patient
170
Minnesota Medicine
POLYNEURITIS— YEAGER
completed grammar school but interrupted high school
to obtain employment as a drill press operator. After
working a while with a good record, she quit to enter
the army.
She enlisted in August, 1944. On January 15, 1945,
she developed recurrent cramping abdominal pain asso-
ciated with the passage of about five loose normal-colored
stools a day. She continued to perform her clerical du-
ties and on February 6 went home on furlough. The
abdominal colic continued and at times was severe
enough to cause her to double up. She vomited occa-
sionally but sought no medical aid until her return to
the army air base to which she was assigned. On Feb-
ruary 24, 1945, she reported to the dispensary and was
immediately hospitalized. Physical examination, includ-
ing rectal, pelvic and neurological studies were normal,
except for generalized abdominal tenderness, most pro-
nounced in both lower quadrants. She appeared anxious
and emotionally unstable. She vomited ocasionally but
had no diarrhea nor fever.
Laboratory studies were normal except for the urine
which appeared smoky, was positive for acetone, but
otherwise was negative. X-rays of the chest and gastro-
intestinal tract were normal, except for some pyloro-
spasm, which was not present on subsequent examinations.
She was given intravenous fluids, barbiturates and
antispasmodic drugs, in order to relieve symptoms which
were at first thought to be psychiatric in origin.
On March 10, the fourteenth hospital day, she stated
that she was unable to control her arms and legs, which
had become weak. Movement was choreiform in na-
ture, and the extremities trembled when motion was
attempted. The loss of strength was of a bizarre nature
in that she could not rise from a chair, but if assisted
to a standing position, she could walk the length of the
ward. The diagnosis of hysteria was seriously enter-
tained. On March 14, she developed bilateral flank pain,
blood pressure of 160/120, and the urine revealed 2
plus albuminuria, 3 to 4 white blood cells per high-pow-
ered field, and a specific gravity of 1.023. Repeated
tests resulted in similar findings. The blood nonprotein
nitrogen and urea were normal. A spinal puncture was
performed on March 29 with normal findings through-
out. During the next few days her symptoms improved.
She vomited less and complained of less abdominal
pain. The blood pressure fell to 132/100, but there were
no changes in the urine findings. Neurological exami-
nation showed loss of all deep reflexes except the knee
jerks which could be elicited if re-enforced. Her tem-
perature occasionally rose to 100° F. in the afternoon.
Considerable wasting of the extremities and apparent
weight loss were noted, although the weight was not
recorded.
On April 4, she was seen to pass dark colored urine
which contained neither blood nor bile. Ehrlich’s test
for porphorobilinogen was positive. The diagnosis of
acute porphyria was made, and the patient was transfer-
red to Lawson General Hospital.
Previous clinical and laboratory findings were con-
firmed. The systolic blood pressure remained at 130 to
140 mm. and diastolic at 108 to 110. She lost the abil-
ity to phonate and could not talk above a whisper.
Neurological examination revealed widespread flaccid
paralysis of the lower motor neuron type. The muscles
of the palate moved normally. The vocal cords were
completely paralyzed. An electrocardiogram was normal.
Examination of the urine was positive for porphoro-
bilinogen. Coproporphyrin was observed spectroscopi-
cally in the urine on mutiple occasions. Uroporphyrin
was not found. The color of the urine varied from
normal to dark wine color. Total plasma protein, albu-
min-globulin ratio, and the blood count were normal.
She had recurrent bouts of bilateral flank pain, ano-
rexia, and abdominal cramps, which were usually ac-
companied by the excretion of dark urine. Her cough
was weak. She suffered several disturbing episodes of
cough and dyspnea, associated with the aspiration of
mucus, which were relieved only by a motor-driven suc-
tion apparatus. She required constant vigil by special
nurses because she could not call out, nor could she
control her arms enough to ring a bedside bell. During
the early part of her hospitalization she took food and
fluid poorly because of dysphagia. Her diet was aug-
mented by intravenos fluids and parenteral vitamin con-
centrates. She was fitted with braces for the extremi-
ties and a special wheel chair was devised. Amenorrhea
has been present since January. During June and July,
muscle strength gradually, although incompletely, re-
turned. The muscles of the trunk, shoulders, and pelvic
girdle became stronger, but there was little improvement
in the small muscles of the hands. The voice returned
to a hoarse whisper ; appetite, vigor, and spirits became
much better. The patient was transferred to a veterans’
facility near her home.
A diagnosis of acute porphyria was made and sub-
stantiated.
Case 4. A private in the Army Air Forces ground
crew, aged eighteen, white, with three months of serv-
ice, was admitted to Lawson General Hospital, December
19, 1945. His chief complaints were “spells,” weakness,
and “passing out.” The patient’s history revealed that
he had had pain in his back and flanks since early child-
hood. A doctor had stated that he had “kidney trouble”
of some type. He suffered pneumonia at the age of elev-
en years and had had enuresis since early childhood.
The patient, however, stated that he never recalled pass-
ing any dark colored urine. However, he was not a
good witness and his statements were vague. From the
age of twelve, he suffered recurrent abdominal cramps
of sufficient intensity to immobilize him in a flexed posi-
tion. At the age of fifteen, he began to have vague
fainting spells beginning with hot and cold sensations
followed by dizziness and unconsciousness. They had
not been accompanied by convulsions, biting of the ton-
gue, nor loss of control of the bladder. These attacks
had occurred from two or three times weekly to every
three or four months. The patient quit school in the
ninth grade to work as a constructor and mechanic. He
did this to help support his family, but he also stated
that school was difficult for him and he did not enjoy it.
For many years he had been shaky, shy and introverted.
He did not enjoy mixing with people and was afraid
of the opposite sex. The patient stated that throughout
February, 1947
171
POLYNEURITIS— YEAGER
his life he had had peculiar experiences, had thought he
heard footsteps behind him but, upon looking around,
no one was there. Also, on occasions he had heard his
name called when no one was near. The family his-
tory was contributory, in that the father had suffered
from stomach trouble for many years, had been wounded
in the last war and had been hospitalized frequently.
The mother suffered from asthma and had had numerous
“nervous breakdowns.” But as far as could be deter-
mined, there was no family history of epilepsy or mental
disease. Two brothers and one sister were in good health.
The military history was short. He stated that he
came into the army in September, 1945, but he did not
recall the date. He began basic training but said he
“couldn’t take it” because of headaches and swollen
throat. He had always had physical complaint, but the
strenuous activity of basic training accentuated his symp-
toms. Before and after coming into the army, he suf-
fered from episodes of crying, and since being in the
army he had had three occasions when he would break
down crying, which led to a fainting spell.
The present illness began while en route from Camp
Chaffee, Arkansas, to Keesler Field, Mississippi, when
he developed headache, malaise, chills, fever and sore
throat. He was admitted to the station hospital, where
he was treated for severe pharngitis with sulfa drugs
and penicillin. Improvement was rapid and he was dis-
charged in several days from the hospital. Repeated
throat cultures were negative. He was readmitted on
November 18, 1945, because of persistence of the same
symptoms and an additional complaint of unsteadiness
on his feet. On this admission, he was found to be
ataxic and to walk with a wide gait. There was mod-
erate in-co-ordination of the upper extremities. Further
neurologic examination revealed Rhombergism, astereog-
nosis, and abscence of the deep reflexes. The patient
complained of a burning sensation in the feet which
made walking uncomfortable. Deep sensibility, especial-
ly vibration, was impaired but superficial sensation was
spared. All findings were more pronounced on the left.
There was hesitation and blocking of speech.
The general physical examination was normal. An
electrocardiogram showed evidence of left axis deviation.
Laboratory studies at Keesler Field revealed normal
blood and urine, and the spinal fluid pressure was normal.
Globulin was negative and total protein was 59 mg. per
cent. Only two white blood cells, lymphocytes, were
found.
The patient was then transferred to Lawson General
Hospital on December 19, 1945. Upon admission, he
continued to show ataxia and in-co-ordination, progres-
sive weakness of the legs, and complete loss of deep sen-
sibility. On January 14, the spinal fluid showed 128
mg. per cent total protein, with a gold curve of 3322-
100000; globulin was negative and there were 3 lympho-
cytes. All other laboratory studies were within normal
limits.
As the case progressed, further studies were obtained,
and an alert ward man stated that he was afraid that the
soldier was suffering from a kidney disease because his
urine was very dark red. This led to further investi-
gation, and the urine was found to be positive for hema-
toporphyrins. Llroporphyrin and coproporphyrin were
negative. Gastrointestinal examination was negative.
Throat and stool culture were negative.
Upon admission to the hospital, the patient was men-
tally somewhat confused. He complained of hearing
voices. He showed tremor of the face and hands, had
feelings of insecurity, and manifested evidence of fear.
Because of some of his reactions, it was thought that he
might be suffering from an acute schizophrenic reac-
tion, and confinement on a closed ward was felt to be
advisable. After about a week, the period of confusion
and incoherence gradually subsided, and he was released
to the open ward. His mental reaction was apparently
acute, and presented a crescendo and diminuendo pat-
tern. The dark urine was discovered at the height of
the psychotic episode and at no other time. Porphyrins
in the urine have subsequently remained negative.
Comment
Two cases of infectious polyneuritis and two
cases of neuritis secondary to porphyria have been
presented. With respect to the neuritis, the two
forms are essentially identical, but there are other-
wise certain fundamental and distinct differences
Infectious polyneuritis, on the one hand, prob-
ably results from a virus infection. It follows,
after some delay, acute upper respiratory infec-
tion. It occurs in an otherwise healthy individual
and may be sporadic or epidemic. The neuro-
logic signs are referable to both the sensory and
motor peripheral nervous systems. There are few
general systemic manifestations. Hereditary and
familial factors are absent. The disease is self-
limiting and prognosis is good. Complete recov-
ery may be expected in 75 or 80 per cent of cases.
Albuminocytologic disassociation in the spinal
fluid is common but is not always present and por-
phyrins in the urine are invariably absent.
Porphyria, on the other hand, is a familial
hereditary disease, resulting in the production
and secretion of abnormal porphyrins. There is
a long-standing family and personal history re-
ferable to the gastrointestinal and nervous sys-
tems. There are ill-defined and unexplained epi-
sodes of nervousness, irritability, insomnia, trans-
itory blindness, abdominal cramps, and constipa-
tion. The neurologic signs are referable almost
exclusively to the peripheral motor nervous sys-
tem ; however, some cases may show sensory
deficits. Mental symptoms, such as organic de-
lirium, depressions, disturbances of mental con-
tent, may be prominent during an acute episode.
In the spinal fluid, the albuminocytologic disas-
sociation is seldom noted, but occasionally does
172
Minnesota Medicine
POLYNEURITIS— YEAGER
appear. Prognosis is grave, and 80 per cent of
those affected are expected to terminate fatally.
Other conditions to be differentiated from both
diseases are hysteria, poliomyelitis, multiple scle-
rosis, progressive atrophy, periodic family paraly-
sis, diphtheritic polyneuritis, tic paralysis, serum
paralysis and parotitic paralysis.
In discussing the four cases which have been
presented, we have the first two which showed
fairly clearly the Guillain-Barre syndrome with
the classical albuminocytologic disassociation. The
third case was unequivocally an acute porphyria
with positive clinical and laboratory proof.
In the fourth case, the diagnosis of porphyria
was made for the following reasons : The family
and previous personal histories were filled with
psychogenic manifestations of the type described
by Roth.14 From the history of recurrent colic,
the sudden onset of unexplained neuritis and
psychosis, and the fact that at the height- of
symptoms the urine was wine-colored and con-
tained abnormal quantities of hematoporphyrins,
it is felt that a diagnosis of porphyria, though
not absolutely proved, was undoubtedly justified
because of strong presumptive evidence.
Summary
In conjunction with a brief review of the litera-
ture, two cases of infectious polyneuritis and two
cases of porphyria were presented. They have
been differentiated clinically. A diagnosis was
made in the fourth case on the basis of clinical
manifestations, in spite of the fact that absolute
laboratory evidence was lacking.
It is felt that in instances of multiple neuritis,
porphyria should be kept in mind and carefully
differentiated from other forms of neuritis, espe-
cially the Guillain-Barre type, because of the ul-
timate serious prognosis in porphyria. A diag-
nosis of porphyria in the abscence of excreted
porphyrins may be made with reasonable accu-
racy from clinical signs and symptoms.
Bibliography
1. Briskier, A. A.: Unusual rapid evolution in Guillain-Barre
syndrome with bulbar palsy. J. Nerv. & Ment. Dis., 100:
462-465, 1944.
2. Fischer, H., and Zerweck, W. : Zur Kenntnis der Naturlichen
Porphyrine: V. Weber Koproporphyrin iur Horn & Lerum
unter normalen und pathologischer Bedingungen. Ztschr. f.
physical, chem., 142:12-33, 1924.
3. Fitgerald, P. J., and Wood, H.: Acute ascending paralysis
(Guillain-Barre syndrome). U. S. N. Med. Bull., 43:4-12,
1944.
4. Gilpin, S. T. : Moersch, F. P., and Kernohan, J. W. :
Polyneuritis ; clinical and pathological study of special
group of cases frequently referred to as instances of neuron-
itis. Arch. Neurol. & Psychiat., 35:937-963, 1936.
5. Idem.
6. Guillain, G. : Radiculoneuritis with acellular hyperalbumi-
nosis of the cerebrospinal fluid. Arch. Neurol. & Psychiat.,
36:975-990, 1936.
7. Guillain, G. ; Barre, J. A., and Strohl, A.: Sur un syn-
drome de radiculonevrite avec hyperalbuminose du liquide
cephalo-rachidien sans reaction cellulaire. Remarque sur les
caracteres et graphiques des reflexes tendineux. Bull, et
mem. Soc. med. d’hop. de Paris. 40:1462, 1916.
8. Gunther, H. : Die Hamatapaporphyrie. Deutsches Arch. f.
klin, Med., 105:89, 1912.
9. Gunther, H.: Die Bedeutung der Hamatoporphyrine in
Physiologie und Pathologie. Ergebn. de. Allg. Path. u. path.
Anat., 20:608, 1922.
10. Gunther, H.: Porphyrie (Haematoporphyrie). Neue
Deutsche Klinik, 14:256, 1936.
11. Mason, V. R. ; Courville, C., and Ziskind, E. : The por-
phyrins in human disease. Medicine, 12:355-439, 1933.
12. Mason, V. R, and Farnham, R. M. : Acute hematoporphyria.
Report of two cases. Arch. Int. Med., 47:467, 1931.
13. Nesbitt, S., and Watkins, C. H.: Acute porphyria. Am. J.
Med. Sci., 203:74-83, 1942.
14. Nesbitt, S. : Acute porphyria. J.A.M.A., 124:286-294, 1944.
15. Osier, W. : The Principles and Practice of Medicine. New
York: D. Appleton and Co., 1892.
16. Roseman, E., and Aring, C. D.: Infectious polyneuritis;
infectious neuronitis, acute polyneuritis with facial diplegia,
Guillain-Barre syndrome, Landry’s paralysis, et cetera. Med-
icine, 20:463-494, 1941.
17. Roth, N. : The neurophychiatric aspects of porphyria. Psy-
chosomatic Med., 7:291-321, 1945.
18. Stearns, A. W., and Harris, H 1.: Infectious polyneuritis,
a report of four cases. U.S.N. Med. Bull., 43:13-16, 1944.
19. Turner, W. J., and Obermayer, M. E: Studies of porphy-
ria: II. A case of porphyria accompanied with epidermolysis
bullosa, hypertrichosis and melanosis. Arch. Dermat. &
Syph., 37:549-572, 1938.
20. Turner, W. J.: Studies in porphyria: III. Acute idio-
pathic porphyria. Arch. Int. Med., 61:762, 1938.
21. Waldenstrom, J: Neurological symptoms caused by so-
called acute porphyria. Acta psychiat., et neurol., 14:375,
1939.
22. Watson, C. J., and Schwarts, S.: The excretion of zinc uro-
porphyrin in idiopathic porphyria. J. Clin. Investigation,
20:440-441, 1941.
THE PRESENT SOUTHERN MINNESOTA MEDICAL ASSOCIATION
(Continued from Page 158)
grams too elaborate to serve the purpose for which
the organization had been formed. It was also
apparent that, to some extent, it was duplicating
the functions of other organizations, such as the
state medical association and the tri-state asso-
ciation. The trend of thought among the mem-
bers was in favor of smaller and more simple
meetings, such as those of more recent years,
since such meetings permit closer association of
the members and more individual participation in
discussion.
The primary object of the organization has been
improvement of the practice of medicine through
dissemination of medical knowledge. In this, it
has been eminently successful. Of equal im-
portance, although perhaps intangible, has been
the inspiration members have derived from ac-
quaintance with others whose problems and as-
pirations are identical with their own. I think
that all old members will agree that the, associa-
tion has been invaluable in furthering this ac-
quaintance and fellowship.
February, 1947
173
INDUSTRIAL INTEGRATION
ALBERT E. RITT, M.D.
Saint Paul, Minnesota
HP HOSE of us engaged in a part-time or full-
time industrial program, during the war, and
because of it, were placed in unusual and strained
positions. As a result we were forced to “stream-
line” many of our routine industrial procedures.
It was expedient and extremely workable to
place much of the preplacement physical examina-
tion in the: hands of a competent nursing staff.
This, when properly supervised, resulted in a
program that was satisfactory, particularly in
view of the demands made by industry for an
ever-increasing rate of employment. Inasmuch
as the rate of “hired-to-terminated” is still high,
our “streamlined” program is still much in
vogue.
The completeness of a physical examination
need not be judged by the amount of time a
medical exajniner spends with the applicant for
a job. It makes little difference who asks the
questions, be it doctor, nurse, social worker, or
clerk, provided the information gleaned is nega-
tive. In cases where the information is of a
positive nature, it then becomes the duty of
trained personnel to determine the cause and ul-
timate effect on industry, if said individual be-
comes placed in industry. Suppose, for example,
the applicant states in his application blank that
he is short of breath. It then becomes the duty
of the interrogator or the medical examiner to
determine whether this is due to some peculiarity
of anatomy, i.e., hunchback with a marked scoli-
osis ; congenital or acquired cardiac pathology,
e.g., rheumatic heart in a young individual, or
heart muscle failure due to arteriosclerosis in an
older individual ; metabolic, such as one might
find in a condition of overweight or hyperthyroid-
ism ; infectious, such as tuberculosis of the lungs ;
or, nutritional or emotional fatigue due to faulty
dietary habits, shock, or overwork.
What we, as medical examiners, must attempt
to do are the basic, indispensable procedures.
These programs should not be intended to re-
ject the handicapped or submarginal worker;
rather, to suit the worker to his most produc-
tive job in industry and to minimize the defects
that the worker will attribute to industry when
this tremendous program once begins to be dis-
mantled. It then becomes the duty of the in-
dustrial physician and surgeon to learn to safe-
guard the worker in industry from machine and
material hazards ; to supervise environmental
working conditions ; to- conserve health and pre-
serve workability of the employe while at work ;
to restore speedily and properly the injured work-
er to his former earning capacity; and to be a
sympathetic yet unbiased appraiser of the amount
of an industrial disability, being neither for the
employer nor against the employe. In this posi-
tion, the surgeon becomes a sort of liaison of-
ficer between the worker and his job, and there-
by attempts to atttain 100 per cent efficiency with'
a minimum amount of risk and time lost.
It is particularly advisable at this time when
the relationship between the so-called “plant doc-
tor” and the injured employe is more than ever
likely to be strained, to redouble the effort to
bring the worker, management and the doctor
closer together. In order better to accomplish this,
it is the duty of the medical department to strive
to foster that feeling of confidence between the
staff and the worker to such a degree that there
will be no doubt in the mind of the worker that
nothing is left undone to speed the progress of
his return to his former earning capacity. As a
further aid in this direction, it is the duty of the
industrial organization to provide a competent
and well-trained medical and nursing staff, one
that becomes known for its ability to carry out
with dispatch the duties for which it has been
created. To this end, also, there must be spon-
sored a much closer co-ordination between the
industrial and the private physician. It is fully
realized that a system in industry can never be
devised to supplant the duty of the private physi-
cian. No matter how much industry attempts to
give the worker, it will be accused of cutting cor-
ners or being incomplete. Before this can any-
where near be accomplished, the worker must di-
vorce from his mind the idea of the “plant doc-
tor” as a disinterested physician. The worker
must be made to. feel that the physician has his
interests at heart — that it is the worker who is the
backbone of the organization.
Preplacement examinations are made to facili-
174
Minnesota Medicine
INDUSTRIAL INTEGRATION— RITT
tate orientation and advancement of the worker
in accordance with his own physical and mental
status ; to acquaint him with his own physical
shortcomings ; to guide him in improving and
maintaining good health ; to safeguard the health
■and safety of his associates ; to discover and to
control unhealthful exposure; and to assist in di-
recting the below-par or sick individual into the
hands of conscientious medical assistance. As
such, the examination must be accurate in ap-
praisal, unprejudiced in evaluation, and personal
in principle. The question naturally arises as to
the ability of the average worker to select a phy-
sician either to examine him preparatory to work
or to treat his industrial ills. True, the worker
has unlimited confidence in the physician of his
own choosing, and if he can only be made to ap-
preciate the effort behind the so-called “plant doc-
tor,” his familiarity with the operation of the
plant and materials involved, and the frequency
with which he sees the same or similar situations
repeated, he then, and then only, can begin to
appreciate that perhaps the “plant doctor” is, by
virtue of all this, somewhat better equipped to
treat and handle industrial ills. Further, the in-
dustrial physical examination is not intended to
be compared with the examination given in pri-
vate practice. Each has its purpose. The worker
must also understand that in industry he has the
right of appeal to his own physician. This should
be encouraged rather than denied.
When one considers that maladjustment in in-
dustry ranks along with accidents and discordant
interpersonal relationships in creating absentee-
ism, inefficient work, and low morale, it is easier
to understand why management might do well to
insist on proper placement in industry. This fact
takes on added importance when one further con-
siders that the average man loses 0.6 day per an-
num from occupational causes as against 8.8 days
per annum from non-occupational causes. Multi-
plying this figure by upward of fifty million peo-
ple employed, one readily arrives at the staggering
figure of lost production and lost time. In 1942
nearly four billion dollars were spent because of
illness and disability. This figure was slightly less
than 4 per cent of the total national income.
In setting up a physical examination program
with all of its restriction, industry is confronted
with four possible situations.
1. There are a sufficiently large number of
employes seeking employment so that industry
may be selective, selecting from only the com-
paratively small percentage of physically perfect
applicants.
2. Industry needs manpower to the point of
hiring some one for the job, with little regard for
defects.
3. Industry may try to be ultra-efficient and
set up a physical replacement examination that
loses itself in a multiplicity of wasted effort and
motions.
4. Industry may try to be practical, yet effec-
tive, in uncovering defects of body and mind so
that neither the employe nor the employer is pe-
nalized.
Obviously, Group 1 is neither feasible nor prac-
tical, nor is it a sign of effective preplacement in-
terviewing. Yet unless the industrial commissions
and industry get together it is that group to which
industry will turn in an attempt to protect itself.
In so doing, society will bear the burden of un-
employment and employment costs, and this again
in turn will be reflected in terms of higher mer-
chandise prices paid by the consumer.
Likewise, Group 2 is far from the answer; and
yet there are individuals in this group who can
be suited to industry.
Group 3 takes on the duties of “Mr. Citizen’s
private physician, and as such should not come
under the scope of industrial or preventive medi-
cine.
Group 4 then becomes the logical alternative.
Even here, one must learn to discriminate be-
tween the prospective employe (the applicant)
and the one already employed. It is the industrial
physician’s job to do those things listed elsewhere
in this paper. Proper preplacement interviewing
by trained workers therefore bridges one of the
large gaps in the industrial medical program.
Mantoux testing is valueless unless correlated
with an x-ray examination (approximately 60 per
cent of the adult population is Mantoux positive).
Wassermann testing is of value in bringing to the
fore the case of syphilis that is unknown to the
individual. It protects neither the individual test-
ed nor the employer and unless repeated may lull
the patient into a false sense of security.
In the light of the above there are certain func-
tions that are musts from the physician’s stand-
point. He must evaluate :
(Continued on Page 220)
February, 1947
175
CLINICAL-PATHOLOGICAL CONFERENCE
EPITHELIAL NEOPLASMS OF THE APPENDIX
ARTHUR H. WELLS, M.D., and HAROLD H. IOFFE, M.D.
Duluth, Minnesota
Dr. A. H. Wells : We wish to present briefly four
cases of epithelial neoplasms of the appendix and dis-
cuss the associated terms of carcinoid, mucoid carcinoma,
adenocarcinoma, adenoma, pseudomyxoma peritonei, and
mucocele of the appendix.
Case Reports — Clinical Aspects
Dr. S. W. Arhelger : (Case 37141) This eighty-
three-year-old retired housewife had been suffering with
pain about the umbilicus of two days’ duration. The
pain moved to the hypogastrium and later became con-
stantly severe and localized in the right lower quadrant.
She had vomited greenish material once and had noticed
mild constipation. Her past history included hospitali-
zation ten years ago for longstanding severe hyperten-
sive cardiovascular renal disease and toxic nodular
goiter. Her blood pressure at that time was 224/122.
At the time of the last admission it was 180/100; pulse,
120; respirations, 14; and temperature, 100.4° F. There
was severe tenderness and rebound tenderness with mod-
erate muscular spasm in the right lower quadrant. She
also had percussible enlargement of the heart to the
left and a systolic mumur, which was maximum at the
apex and transmitted to the left axilla, but no pulmonary
rales. The white blood cell count was 12,700 with 74
per cent neutrophiles. Her blood urea and creatinine
and urinalysis were essentially normal. An emergency
appendectomy was followed by an uneventful conva-
lescence. No further operation was considered advis-
able.
Dr. L. L. Merriam : (Case 3038) This sixty-eight-
year-old housewife claimed some abdominal discom-
fort since childhood. She had been admitted to the hos-
pital one year before her death with blood in her stools,
at which time small ulcers in the rectum were de-
scribed as the source of the blood. Eight weeks before
her last admission and three months before her death,
she had an attack of abdominal cramps and diarrhea.
She noticed loss of weight, poor appetite, abdominal
"bloating,” and belching. On admission, 4,750 c.c.
of ascitic fluid was removed from her distended abdo-
men. Carcinoma cells were found in this fluid. She
became gradually weaker during her last two months.
Dr. W. N. Graves : (Case 26912) This thirty-seven-
year-old forester suffered from pain in the right side
of the abdomen for twenty-four hours. It began at
the time of a long auto ride over a rough road. The
From the Department of Pathology, St. Luke’s Hospital, Duluth,
Minnesota, Arthur H. Wells, M.D., Pathologist. Clerical As-
sistance by Miss Faith Gugler.
pain was aggravated by walking, and his abdomen
became sore. Physical examination revealed muscular
spasm and tenderness in the right lower quadrant of
Fig. 1. Serosal and cut surfaces of an appendix with mucoid
carcinoma.
the abdomen, and tenderness to the right on rectal
examination. He had a white blood cell count of 15,000
with 70 per cent neutrophiles and a temperature of
98.4° F. An appendectomy was followed by a rapid
return to normal activity.
Dr. A. N. Collins: (Case 37213) This twenty-one-
year-old steelworker had a steady dull pain in the
lower right quadrant of the abdomen for forty-eight
hours. Physical examination revealed mild tenderness
in the same area of the abdomen, and his white blood
cell count was 13,850. An emergency appendectomy was
followed by a rapid convalescence.
Pathological Aspects
Dr. A. H. Wells: (Case 37141) This appendix (F’ig.
1) measured 7 cm. long and from 1 to 1.5 cm. in diam-
eter. There was a perforation, 4 mm. in diameter, at
the distal end at a localized site of suppuration. The
remainder of the lumen was filled with mucus-form-
ing anaplastic epithelial cells (Fig. 2) which invaded
the muscularis. At the proximal end the mucosal glands
had a papillary adenomatous alteration without invasive
properties.
(Case 3038) There was a rather highly anaplastic
adenocarcinomatous infiltration (Fig. 3) of the walls
of a swollen (1 cm. in diameter, 6 cm. in length) ap-
pendix, with an obliterated lumen and an irregular dis-
tribution of muscle fibers suggestive of a congenital
170
Minnesota Medicine
CLINICAL-PATHOLOGICAL CONFERENCE
Fig. 2. Typical mucoid carcinoma of the appendix.
Fig. 4. Typical carcinoid of the appendix.
Fig. 3. Highly anaplastic adenocarcinoma of the appendix.
Fig. 5. Papillary adenoma of the appendix.
anomaly of the appendix. The malignancy had extended
to regional retroperitoneal lymph nodes and both peri-
toneal and pleural surfaces. Terminally, she developed
intestinal obstruction due to malignant adhesions about
loops of small intestines.
(Case 26912) This man’s appendix had small clumps
of highly hyperchromatic, uniformly small, epithelial
cells (Fig. 4) with both simple glandular arrangements
and small clumps with palisaded peripheral cells. These
carcinoid cells were located primarily in the obliterated
lumen of the distal 1 cm. of the appendix, and a few
cells had extended into the muscularis. In addition,
the proximal appendix had a very mild neutrophilic
infiltration of all layers.
(Case 37213) This appendix, 7 cm. in length and
0.7 cm. in diameter, had no unusual gross appearance.
However, histologic sections from near the middle
revealed a small area of mucosa with a slightly papillary
adenomatous proliferation of the mucosal glands, of
neoplastic proportions without malignant invasion (Fig.
5). There was no inflammatory change.
In conclusion, these four cases are illustrative of dif-
ferent forms of epithelial neoplasms of the appendix :
mucoid carcinoma, adenocarcinoma, carcinoid, and
adenoma.
Carcinoid
Although there is no general agreement as to classifi-
cation of epithelial malignancies of the appendix, it is
obvious that carcinoids (enterochromaffin, basi-granular,
February, 1947
177
CLINICAL-PATHOLOGICAL CONFERENCE
Nicolas, Kultschitzky, Schmidt and Ciaccio cell tumors)
should be set in a class by themselves. They have been
described as often as one in every 200 appendectomies4
and have been studied in great detail, so that the prac-
tical aspects of their nature are well known. Carcinoids
are found 50 per cent of the time in the appendix,
and the remainder in the ileum, jejunum, stomach, gall-
bladder, duodenum, Meckel’s diverticulum, cecum, colon,
and rectum. They most likely develop from the Kults-
chitzky cells found sparsely scattered in the bases of
Lieberkuhn’s crypts along the intestinal tract. The
physiologic function of these cells is not settled. It
is significant that approximately 25 per cent of the
recorded1'2’11 carcinoids of the small intestines metas-
tasize, and some are the cause of death due to their
malignant nature. Nearly all of those found in the
stomach and colon tend to metastasize. The same
tumor in the appendix is much less likely to extend
beyond this organ. Less than twenty had been reported
as metastatic by 1942.5>10 Even when it does reach a
regional lymph node, it is very likely to remain there
for many years without harm to the patient.8 Con-
sequently, for all practical puropses, the surgeon can
consider carcinoids of the appendix as essentially be-
nign. However, if recognized at the time of the oper-
ation, local extensions should be sought for and re-
moved.5 One should avoid postoperative x-ray ther-
apy and mental disturbances of the patient concerning
“cancer.”
Adenocarcinoma
Other types of carcinoma of the appendix represent
only about 10 per cent of the total malignancies of
this organ and are much more serious than the relatively
common carcinoids. They are more likely to occur
in the fifth and sixth decades rather than in the third,
as is the case in carcinoids of the appendix.6 Unques-
tionable examples of this smaller group, which is some-
times called adenocarcinoma, are rare and should be
reported in the medical literature for future group
study, reference, and clarification of the subject. Uih-
lein and McDonald14 divide their seventeen cases (from
thirty-one years of appendectomies at the Mayo Clinic)
into “cystic” and “colonic” types. Although the Lieber-
kuhn’s glands of the appendix undoubtedly have the
same potentialities for varieties of epithelial malig-
nancies as the same glands in the colon and rectum,
there appears to be a decidedly increased tendency to-
ward mucoid carcinoma in the appendix. These malig-
nant cells form mucin and pseudomucin (chemical and
tinctorial variants of mucus).10 The extension of this
malignancy to peritoneal surfaces may lead to pseudo-
myxoma peritonei or “jelly belly.” The abdominal cav-
ity may become filled with gelantinous material.
Benign Epithelial Lesions
Simple mucoceles of the appendix most often result
from an inflammatory process obliterating the proximal
lumen. Subsequent secretion of mucus by lining epi-
thelial cells in the distal lumen may in time rupture
the atrophic appendix walls and produce pseudomyxoma
peritonei.13 The condition can kill as the result of
intestinal obstruction.9 Whether or not this non-neo-
178
plastic lesion (mucocele) becomes malignant, as has
been theorized,15’16 needs further confirmation. Fur-
thermore, it may be very difficult to rule out mucoid
carcinoma in an apparent case of ruptured mucocele.
Pseudomyxoma peritonei is most often due to mucin
secreting, benign or malignant ovarian cysts.
It is thought that some of the adenocarcinomas have
their origin in benign papillary adenomas of the ap-
pendix.14 There is much proof of this relationship in
the colon. Furthermore, the tendency toward multiple
papillary areas in the colon makes it imperative that
x-ray studies of the colon be performed in patients
with adenomas in their appendix, such as in our Case
37213. Benign papillary adenomas may form mucus
and distend the appendiceal lumen with this product
to the point of rupture. Their differentiation from a
low-grade mucoid carcinoma may be extremely difficult,
if not impossible.
Clinical Manifestations
“It is futile to attempt to make a preoperative diag-
nosis” of appendiceal tumors.12 The odds favoring
common lesions with the same manifestations are too
great. In a review of ninety-six cases7 of carcinoma
of the appendix, 83 per cent of the patients suffered
from symptoms of appendicitis and 28 per cent had
symptoms for one year or more. In another report
of twenty-eight patients10 with appendiceal cancer, the
chief complaint was pain in the right lower quadrant
of the abdomen. The associated appendicitis so fre-
quently found will of course produce all of the signs
and symptoms of this disease. Rarely a tumor mass
or blood in the stool may be evident.14 A chronic recur-
ring ill-defined pain in the appendiceal region is a fre-
quently mentioned symptom of carcinoid. In many cases,
this lesion is entirely clinically quiescent and is described
as an incidental finding in laparotomies performed for
other lesions.
Summary
1. We have presented four case studies of patients
with different epithelial neoplasms of the appendix, in-
cluding mucoid carcinoma, adenocarcinoma, carcinoid,
and papillary adenoma.
2. A very brief review of the nature and interrela-
tionships of these neoplasms, and of mucocele and
pseudomyxoma peritonei, is given.
References
1. Ariel, Irving M. : Argentaffin (carcinoid) tumors of small
intestine. Arch. Path., 27:25-52, (Jan.) 1939.
2. Blumgren, J. E. : Malignant carcinoid tumors of small
intestine; report of two cases. Minnesota Med., 27:620-623,
(Aug.) 1944.
3. Hobart, M. H., and Nesselrod, J. P. : Primary carcinoma
of appendix with gelantinous spread. J.A.M.A., 100:1930-
1931, (June 17) 1933.
4. Hopping, Richard A.; Dockerty, Marcolmn B., and Mas-
son, Tames C. : Carcinoid tumor of appendix; report of case
in which extensive intraabdominal metastases occurred, in-
cluding involvement of right ovary. Arch. Surg., 45:613-
622, (Oct.) 1942.
5. Latimer, Earl O. : Malignant argentaffine tumors of the
appendix. 54(N.S.) :424-430, (Nov.) 1941.
6. Leonardo, R. A.: Primary carcinoma of appendix versus
carcinoid. Am. J. Surg., 22:290-294, 1933.
(Continued on Page 223)
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
♦
♦
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester, Minnesota
(Continued from’ January issue)
A. O. Heiberg, who was born at Christiania (Oslo), Norway, in November,
1855, received his primary education at Ouam’s Latin School in that city and
his more advanced schooling at the Latin School at Trondjem. He was pre-
paring to enter the Fredericiana University to study medicine, but changed
his plan and instead took a course of two years at the Stenkjaer Apothecary
under Mr. A. J. Hoegh.
In April, 1873, Mr. Heiberg came to America and to southern Minnesota,
which was to be his permanent home. In his first year he worked for a drug-
gist, Mr. Pilzer, in Winona, and then settled in Rushford, Fillmore County,
where he was associated as a pharmacist in different drugstores, first with
K. Olson for four years, subsequently with Elling P. Kierland, a pioneer
medical practitioner, and finally with A. E. Hazard, with whom he bought
the Corner Drug Store, which the two men operated until the partnership
was dissolved by mutual consent in 1902.
On August 30, 1887, in Rushford, Mr. Heiberg was married to Bertha
Anderson; five children were born to this marriage.
In 1889, returning to his original intention of becoming a practicing phy-
sician, A. O. Heiberg entered Rush Medical College, in Chicago, where he
spent two years before going on to the Jefferson Medical College, in Phila-
delphia-, from which he was graduated in 1893. Again in Rushford, the pos-
sessor of state medical license No. 346, under the act of 1887, he entered
on- ten years which brought him deservedly a large and successful medical
practice, in which his scientific skill, together with his cheerful manner and
sympathetic understanding, won him confidence and esteem. Among his
professional affiliations were memberships in the Winona County Medical
Society and the Southern Minnesota Medical Association.
When, in 1903, symptoms of bulbar palsy appeared, and skilled physicians
in the East told Dr. Heiberg that the months of his life were numbered, he
decided to move his family to Northfield, Minnesota, where the children could
obtain excellent educational advantages, and he made the change during
the early summer. He died in Northfield on March 18, 1904, survived by
Mrs. Heiberg and the five children.
. About Ole T. Hoftoe, little information has come to light except that he
was born in New London, Kandiyohi County, Minnesota, in 1854, was grad-
uated from Rush Medical College on February 17, 1885, and within a month,
February, 1947
179
HISTORY OF MEDICINE IN MINNESOTA
on March 13, received state certificate No. 1012 (R) to practice medicine in
Minnesota. For a year or so, in 1885 and 1886, he was resident in the village
of Fountain, Fillmore County, and in the next year in the larger, near-by town
of Lanesboro. In the following year it appears that he had moved to Da-
kota Territory (North Dakota) where, on March 30, 1888, Dr. O. T. Hofte
[sic] was registered as being in practice in Abercrombie, Richland County,
and there, according to a gazetteer and business directory, he remained well
into the nineties. After an undetermined period of time, but certainly prior to
1907, Dr. Hoftoe returned to his native place of New London. After 1909
his name did not appear in the official medical directory.
Robert Hoyt, who became one of the earliest of physicians in Fillmore
County, was born at Hesper, Iowa. It is said that soon after his graduation in
medicine, probably in 1859 or 1860, he settled in the village of Lenora, and
there for two years was a confrere of Dr. James M. Wheat, who had come
in 1856. From Lenora he moved to Beloit, Wisconsin, the home of his wife’s
parents, where he followed his profession for many years. In an early history
of Fillmore County he was mentioned, it is believed erroneously, as a charter
member of the Fillmore County Medical Society, which was founded in 1866.
Robert W. Hoyt, almost certainly a relative of Dr. Robert Hoyt, the pioneer
physician already mentioned, was born at New Haven, Addison County, Ver-
mont, on February 14, 1852. When he was eight years old he moved with his
parents to Fillmore County, Minnesota, where he spent his boyhood and at-
tended the local schools. In 1875 he was graduated from Rush Medical Col-
lege of Chicago and immediately afterward began to practice medicine in
the community of Lenora. It is said that in the next year he moved to Wal-
nut Grove, Redwood County, where he remained for a considerable number
of years, into the eighties. In June, 1880, he was married to Myra E. Tester,
of New Lisbon, Wisconsin. By 1890, Like Dr. Robert Hoyt before him, Dr.
Robert W. Hoyt had moved to Wisconsin, the home of his wife’s people,
and was established in medical practice in New Lisbon, where he still was
in 1912; his name did not thereafter appear in the medical directories.
Dr. Huffman, apparently a medical nomad, was in Preston early in 1863,
exhibiting, according to the Preston Republican, “much skill in the way of
restoring loss of sight and hearing. Those afflicted with diseases of the eye
and ear would do well to call at the Minnesota House and consult him.”
Another clue to this practitioner lies in the statement that Dr. Huffman, an
eye and ear specialist from St. Louis, practiced in Austin, Mower County,
for a few months in 1863.
Thomas W. Hunt, a graduate of the Jefferson Medical College in 1894,
was licensed in Minnesota on July 10, 1894, receiving certificate No. 456,
under the “Act to Regulate the Practice of Medicine in the State of Minne-
sota” as approved in 1887. He was then a resident of Douglas County.
Not long afterward he presented his license in Fillmore County, and in the
issue of 1896-1897 of a state gazetteer and business directory he was listed
as being in practice in Lanesboro. In the official register of physicians of
Minnesota of 1883-1909, his name appeared without post office address.
His name was not included in the first (1907) issue of the directory of the
American Medical Association.
180
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
Johan Christian Hvoslef (sometimes seen Hooslef), who became one of the
distinguished citizens and physicians of Fillmore County, was born at F0rde,
S^ndfjord, Norway, on August 24, 1839, a member of a family which gave
several outstanding men to the political and professional history of Norway.
Well-trained in academic subjects at the Latin School and in general
sciences at the University of Norway, both at Christiania, Johan C. FIvoslef
came to America in 1872 and continued his studies at Rush Medical College,
from which he was graduated in 1876. In the same year he was married to
Karen Anderson of Wisconsin and came with his wife to Lanesboro, then
a village of about 1500 people, where he lived and continuously practiced
his profession until his death on October 11, 1920. Dr. and Mrs. Hvoslef
had one child, a daughter, who died in Lanesboro at the age of six years. Dr.
Hvoslef was survived by his wife and his sister, Mrs. Thorvold Klavanae, of
Christiania. A brother, Nils C. V. L. Hvoslef, a state official of Trondjem,
Norway, had died earlier.
Dr. Hvoslef’s life in Lanesboro was that of the country doctor, able, faith-
ful, overworked, unsung. It is a matter of record that in 1882, working with
the State Board of Health, Dr. FIvoslef as health officer dealt efficiently
with the local outbreak of smallpox. Under the Medical Practice Act of
1883 he received state certificate No. 466 (R) on December 28, 1883, which
he filed in Fillmore County on October 28, 1889. He was a member of the
official local and state medical societies and of the American Medical Asso-
ciation.
A quiet, modest, retiring man of distinguished ability, Dr. Hvoslef was not
so well known in the state as he should have been. Besides being a skilled
physician and surgeon who served his community well, he was a naturalist
of distinction. Thomas S. Roberts, M.D., in his masterly work, The Birds
of Minnesota, recognized Dr. Hvoslef’s ability as a physician and paid tribute
to him as a naturalist :
Perhaps no one man did so much to develop a knowledge of the bird-life of a single
locality in the state as did Dr. Johan C. Hvoslef. . . . He was a well-trained man and,
possessing an intense interest in natural history and a methodical and painstaking type of
mind, he was well fitted to make an intelligent, careful study of the region in which he
passed the greater part of his life. Throughout the entire fifty-four years, he kept a detailed
diary in which he recorded all his observations, covering the whole field of natural history,
though birds and plants were his first interests. There are fifty-four volumes of these journals,
with three additional general notebooks. The year following Dr. Hvoslef’s death, Mrs.
Hvoslef very generously presented, in complete form, this life-work of her husband to the
Museum, where it is now one of the most valued possessions. Dr. Hvoslef, during his life,
had given to the Museum his collection of bird-skins, numbering some four hundred, and
after his death, his wife donated a small collection of birds’ eggs, among which were those
of the blue-winged warbler, unique specimens for Minnesota.
No part of these diaries have ever been published, but from them were taken the bird-
migration records that Dr. Hvoslef sent to the United States Biological Survey at Wash-
ington over a series of years, and concerning which Mr. Wells W. Cooke, in one of the
Survey bulletins, stated that the information from Lanesboro was the most satisfactory that
had been received from any source. There is also on file at the Museum a considerable series
of letters from Dr. Hvoslef, relating almost entirely to the bird-life of Minnesota, received
by Thomas S .Roberts, M.D., Fellow of the American Orinthologists’ Union, Professor of
Orinthology and Director of the Museum of Natural History of Minnesota. Dr. Hvoslef’s
great modesty prevented his publishing at first hand the results of his work. This explains
the absence of his name from the Minnesota bibliography. But he generously and freely
supplied information to others, and thus he is quoted, second hand in many connections, as
authority for original and valuable records. All the records from Lanesboro in this work
February, 1947
181
HISTORY OF MEDICINE IN MINNESOTA
are from Dr. Hvoslef’s work. Fortunately he recorded carefully and accurately everything
that came under his notice, and the Minnesota bird-students owe no small debt of gratitude
to this retiring but accomplished and hard-working man of science.
George E. Jackson for many years a practicing physician of Minnesota,
was a graduate of Rush Medical College in 1880, and under the Medical Prac-
tice Act of Minnesota of 1883 received state certificate No. 9 (R) on October
11 of that year. He then was living in Fergus Falls, in Otter Tail County.
Strangely, it has been impossible thus far to discover more than isolated bits
of information concerning this well-qualified physician.
On June 9, 1885, George E. Jackson, M.D., a graduate of Rush on February
20, 1880, registered in Dakota Territory as in practice at Lakota, Nelson
County; during his residence in Dakota he was appointed County Super-
intendent of Health.
Dr. Jackson returned to Minnesota probably in the late nineties, and by
1899 he had settled in Chatfield, Fillmore County; in that year at a meeting
of the Southern Minnesota Medical Association in Owatonna, in Steele Coun-
ty, he was elected to membership. Dr. Jackson remained in Chatfield at
least into 1912. His name did not appear in the issue for 1914 of the directory
of the American Medical Association.
Charles H. Jacobson was born in Norway on May 17, 1856, received his
early education in the schools of his native place and, in 1871, at the age of
fifteen years, came to America and settled in southern Minnesota. After
working for five years in the drug store of Albert Weiser in Preston, he
decided on the study of medicine and entered the Bennett Electic College
of Medicine and Surgery, from which he received his degree of doctor of
medicine in March, 1879. Immediately after his graduation, Dr. Jacobson
improved his medical knowledge by taking a special course at the Chicago
College of Ophthalmology and Otology before returning to establish himself
as a physician in Preston. In 1881 and 1882, at least, he was in active prac-
tice, and that he used his specialty is evidenced by the following item in the
National Republican of Preston of December 29, 1881 : “Lost by Dr. Jacobson:
A myopodiartotican, used in cases of myopia.”
The fact that, subsequent to 1883, Dr. Jacobson’s name did not reappear
in the state gazetteer which had carried it previously is inconclusive evidence
that he had gone elsewhere. It is significant, however, that he was not listed
in the official directory of physicians in Minnesota of 1883-1890, nor in the
edition next following.
J. Ross Johnson was born on July 18, 1855, at Oak Leaf, Ontario, Canada,
the son of Mr. and Mrs. Samuel Johnson, who were farmers. In 1883 he
was graduated from the Medical School of McGill University, and shortly
afterward came into the Middle West of the Lbiited States, to settle in
Spring Valley, Minnesota, at the suggestion and request of friends from
Canada who already had established themselves in that community. On
October 13, 1883, under the new Medical Practice Act of the state he re-
ceived license No. 150 (R). That he at once identified himself with the medi-
cal profession of the state is evidenced by his election to membership in the
Minnesota State Medical Society at the annual meeting held at Minneapolis,
in Market Hall, on June 19, 1883. At this same meeting, one of his senior
colleagues, who had been in Spring Valley since 1871, Dr. Russell L. Moore,
182
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
became third vice president of the association. Dr. Johnson allied himself
with the local group of physicians in Fillmore County and, in 1904, on or-
ganization of the Houston-Fillmore County Medical Society, became an
active member.
J. Ross Johnson was married on August 30, 1882, to Jennie Green, a Ca-
nadian, and brought his wife with him to Spring Valley. They had three
children, Florence, Charles Harcourt, and Harry H. Johnson. When Mrs.
Johnson died in 1894, her body was taken back to Canada for burial. In
1897 Dr. Johnson was married to Martha Banks; there were no children
of this marriage.
Dr. Johnson belonged to a family of which two other members who were
physicians came into southern Minnesota. His brother, Dr. Charles Har-
court Johnson (1859-1917), newly graduated from McGill University, settled
permanently in Austin, Mower County, in 1884. His half-brother, Dr. Wil-
liam Nassau Kendrick (1872-1936), also a graduate of McGill, in 1896, in
that year began practice with him in Spring Valley; from 1898 to 1905 Dr.
Kendrick was in Austin in partnership with Dr. C. H. Johnson, but in 1905,
on the death of Dr. J. Ross Johnson, he returned to Spring Valley to carry
on his half-brother’s practice.
Dr. J. Ross Johnson is recalled as a fine man and citizen, a physician and
surgeon of unusual knowledge and skill, whose favorite diversion was fishing
and whose love of horses was a distinguishing quality. In those pre-auto-
mobile days, he kept, like many of his confreres, from six to eight excellent
driving horses most of the time, and although he drove them hard, he handled
them with skill and consideration and gave them the best of care. Only
ten days before his death in February, 1905, he drove sixty miles in a cutter.
His son, Dr. C. H. Johnson, has recalled that Dr. Johnson in his heavy
and widespread practice used to consult on occasion with his near-by col-
league, Dr. Albert Plummer, of Flamilton (later of Racine), and that he was
“a great admirer” of Drs. William J. and Charles H. Mayo, who sometimes
were called in consultation into the community.
The death of Dr. Johnson on February 27, 1905, at the height of his useful-
ness, was a sorrow and loss to Fillmore County. Dr. Johnson was survived
by his wife, who in 1943 was living in Austin, Texas; by his two sons, Harry
H. Johnson, a jeweler of Spring Valley, and Charles H. Johnson, who has
been a physician since 1912, in Spring Valley since 1916; and by his daughter
Florence (Mrs. Claude W. Rossman, of Minneapolis). Mrs. Rossman’s
death occurred in the nineteen thirties.
In speaking of his father, Dr. Charles FI. Johnson commented on the ad-
vances and conveniences in medical practice of later years of which the older
man could not know. In his times calories and vitamins were not recognized
factors in nutrition, the value of roentgen rays in medicine had not been
fully realized, and the sulfa drugs were unknown. “It seems too bad that he
was born too soon and died at the age of forty-nine, just a young man.”
Henry Jones was born on March 13, 1845, on a farm near Nashville, Ohio,
the son of William Jones, who was of Welsh blood and a native of Steuben-
ville, Ohio, and Sarah Collier Jones. His mother was descended from an
English family who had come to America early in the eighteenth century;
her grandfather twice was sent to Congress from Ohio when the state was
young. Henry Jones had seven brothers and sisters : William, Sylvester and
February, 1947
183
HISTORY OF MEDICINE IN MINNESOTA
Samuel, Mollie Wright, Sue Rose, Elizabeth Hunter and Evangeline (Mrs.
Warner, of Morrison, Illinois, the only member of the family living in 1941).
Henry Jones grew up on his father’s farm, receiving his early education
in the schools of Nashville. In his nineteenth year he enlisted in Company
B of the Sixtieth Ohio Regiment of Volunteer Infantry and with it served
at the front until he was wounded at the battle of Petersburg; on his release,
after ten months in a hospital in Philadelphia, he received his honorable dis-
charge from the army and returned home. Before continuing his formal
education, he worked for a time, loading lumber on the first trains to pass
through Ohio. During 1866 and 1867 he was a student at the Franklin In-
stitute in Prophetstown, Illinois, and for a year studied medicine under Dr.
J. H. Mosher of that city in preparation for enrolling at Rush Medical College
in 1869. Graduated from Rush in February, 1871, he began his medical career
in the village of Granger, Bristol Township, Fillmore County, Minnesota,
but in September of the following year, because of superior financial oppor-
tunity, he moved to the larger place of Preston, in Preston Township. He
was succeeded in Granger by Dr. Don J. Lathrop, who arrived in the spring
of 1872. In Preston, Dr. Jones remained in active practice for forty-six years,
during which he numbered among his fellow physicians Lafayette Redmon,
James H. Phillips, John A. Ross, Lyman Viall and George A. Love, as well
as many others who came and sooner or later passed on. And during these
years, like all the other physicians of the period and region, he met the dis-
comforts and hazards of carrying on a country practice in all weathers and
over all roads. Excerpts from old records and newssheets give glimpses of
him at work: assisting Dr. Ross “in the presence of Mr. Love, a medical
student,” to perform an autopsy on the body of a child who had died from
cerebrospinal meningitis ; refusing, after he had been called on a case which
proved to be one of smallpox, to see other patients or to appear in public
until danger of conveying the disease to others had passed ; performing an
operation, with Dr. Lathrop, for removal of a ruptured eyeball, under chloro-
form anesthesia, on an old gentleman who lived near Granger.
On December 24, 1874, Henry Jones was married to Bertha A. Loomis of
Preston. The only child of the marriage, Charles Henry, died in infancy ;
Mrs. Jones died in 1878. Dr. Jones in 1881 was married to Ella Gray of
Decorah, Iowa, and to this marriage were born three children: Mabel, who
died young; Rodney C., who became a musician, at one period living in
Wallace, Idaho, and in later years in Minneapolis; and Millie M. (Mrs. L
Hasten, of Chicago).
In 1882, to meet the conditions of practice of the times, Dr. Jones took up'
the study of dentistry and thereafter was both dentist and physician, but
especially dentist. There were many items in the local newspaper of those
years which mentioned his skill and fine equipment or which stated that Dr.
Jones, Preston’s popular dentist, had just returned from a successful tour
and would remain in his home office for about two weeks.
On December 31, 1883, under the new ruling of medical practice in the
state, Dr. Jones received certificate No. 668 (R). From 1872 to 1877 his pro-
fessional card appeared in Western Progress, the newspaper of Spring Valley,
as well as in the local papers, and his name was listed in Polk’s gazetteer
almost continuously from the late seventies for many years. From January
6, 1889, to January 6, 1891, he was coroner of Fillmore County.
(Continued on Page 186)
184
Minnesota Medicine
President s £ette>i
Physicians Obligated to Remedy Conditions in State Institutions
THE responsibility for the health of the citizens of Minnesota rests squarely on the
shoulders of its physicians, and it is the purpose of every member of the Minnesota
State Medical Association to discharge this obligation in an efficient, humanitarian and ethical
manner. We take pride in the standards of medical care in rural and urban communities.
We are proud of our state program for the control of contagious disease, of our public
health activities, of our record in the military service and at home during the war. How-
ever, in one field, one in which we find the largest number of patients, conditions exist
which are far from desirable. I refer to the mentally ill who inhabit our state institutions
and who constitute a profound responsibility of the physicians as well as of other citizens
•of the state.
More than 50 per cent of hospital beds in Minnesota are occupied by patients who suffer
with mental disease. Such patients in the state reach the astonishing total of almost 11,000,
and in this number are not included those individuals who are registered in the school for
the feeble-minded at Faribault and the epileptic colony at Cambridge. The fact that these
individuals represent such a large proportion of the families of the state proves that care
of the patients in many instances constitutes a serious social problem.
The publicity which recently has been directed against certain hospitals for patients suf-
fering with mental disease has aroused much adverse criticism. It should reveal the great
responsibility which falls on all reliable citizens of this nation. In physical equipment and
proportionate size of professional staffs, Minnesota institutions compared favorably with
those of most other states twenty years ago, but this condition does not exist today. No
longer can we coast along on such an illusion. There is more good fortune than merit
in the fact that the institutions of this state escaped the humiliating glare of recent investi-
gations.
A survey of state hospitals conducted in 1939 and 1940 revealed that too few physicans
were engaged in caring for patients suffering with mental disease. Specifically, it was
learned that in Minnesota there was only one physician for every 435 patients in our state
institutions. At this time I believe that the national average is one physician for every
250 patients. The ratio of attendants and ward personnel in 1940 was one for every fifteen
patients. The standard approved by the American Psychiatric Association is one physician
for every 150 patients and one attendant for every 5.6 patients.
The responsibility for these conditions is not that of the superintendents of the institutions.
I am reliably informed that the service which they have rendered, with their limited pro-
fessional and attendant staffs, has been heroic. This is especially true in Minnesota where
problems have been presented to the legislature repeatedly through the Director of Public
Institutions, who acts as the intermediary agent of the superintendents of the institutions.
Their requests for facilities sufficient to insure standard, adequate care of their patients
often have been sidetracked until other demands have been satisfied, and what has been
left of the budget has been sufficient to afford only a custodial level of patient care. Min-
nesota now ranks very low among the states of the nation in per capita expenditure for
the mentally ill.
Apparently, the chief interest evinced by our legislature has been in the housing of patients.
Undoubtedly, this phase of the problem has been, and is, serious. Today almost 11,000
patients are crowded into space which originally was intended for not more than 8,000. In
certain institutions, overcrowding runs as high as 30 per cent and conditions exist which
run counter to regulations of the State Fire Marshal as well as those of the State Board
of Health. These statements are no doubt unpalatable, and what makes them peculiarly
so is the fact that it is impossible to refute them.
In spite of the obvious need for funds for physical equipment, I doubt that this phase
of the problem is nearly as serious as that which exists because of lack of other facilities
for the care of patients. Measured in terms of human values and in the light of our
responsibility to the citizens of the state, we have a great duty. We must provide adequate
programs of therapy in order that patients may be returned to productive life. We must
use every means to prevent recurrence of illness and to provide facilities for counsel and
guidance in order to prevent the development of additional mental disorders in the com-
munity.
It is important that conditions pertaining to a form of illness which afflicts half the
patients in hospitals of the State of Minnesota should be understood by our legislators. If
these patients are to receive adequate medical care, the cost during the next few years
will be great. It should be great. It is a justifiable expense. It is an appalling fact that
the per capita per day cost in our state institutions barely exceeds one dollar. It is almost
February, 1947
185
PRESIDENT’S LETTER
unbelievable The standards set up by the American Psychiatric Association are $5 00 per
capita per day for patients who suffer with acute conditions and $2.50 per capita per day
for those who are chronically ill. Evidently, these facts are not well known to our
legislators. It is the responsibility of the physicians of the state, as well as of other
responsible citizens, to make it known that our goal is adequate treatment and comfortable
housing for every patient in our state hospitals for the mentally ill. This must be done with-
out further delay, in order that we may look forward to a decreasing, rather than an ever-
increasing, custodial population in our state hospitals.
President, Minnesota State Medical Association
HISTORY OF MEDICINE IN MINNESOTA
(Continued from Page 184)
Dr. Jones was an independent voter, was well read and tolerant. He was
a member of the Presbyterian Church; of the Underwood Post No. 122
of the Grand Army of the Republic, and its commander for many terms ; of
the Independent Order of Odd Fellows and of the Masonic Blue Lodge of
Preston, the latter of which he joined on December 17, 1S73. An avocation
which he made profitable for a number of years was the keeping of bees.
After forty-six years in Preston, “highly esteemed . . . respected for his
virtues, attainments and labors,” Dr. Jones moved to the town of Bethel,
Anoka County, where he practiced medicine six years before retiring to Cali-
fornia to make his home. He died in Monrovia on June 30, 1931, from the
infirmities of old age. Mrs. Jones survived him, and until her death, on Febru-
ary 3, 1943, at the age of eighty-five years, resided with her daughter, Mrs.
Kasten, in Chicago.
About J. R. Jones only one note has been gleaned. In an historical atlas of
Minnesota, of 1874, of which he was a patron, there appears the entry that
J. R. Jones was a physician, was born in Monroe County, New York, came
to Minnesota in 1861, and in 1874 (and earlier, obviously) was living in
Lanesboro, Fillmore County.
Of the career of Emma Adeline Keeney only an outline is presented.
Emma Adeline — was born in 1876 (the surname is lacking, as is the
date of her marriage). She was graduated from the College of Homoeopathic
Medicine and Surgery of the University of Minnesota in 1897, and in April
of 1898 received her license to practice in the state. There is evidence that
she began her professional career in Spring Valley, Fillmore County, and
practiced there for possibly a year ; in a business directory of 1898-1899 ap-
peared the name of “Mrs. E. A. Keeney” in the list of physicians of the town.
From Spring Valley Dr. Keeney moved to Austin, Mower County, where
for a time she was in partnership with Dr. Fannie K. Fiester, who in 1893
had been graduated from the Woman’s Medical College of Northwestern
University. Evidently desirous of improving her professional knowledge, Dr.
Keeney took graduate work, and in 1904 was graduated from the Hering
Medical College of Chicago. Presumably she settled soon afterward in Albert
Lea, Freeborn County, where she was practicing in 1907. In 1909 she was
licensed to practice in the state of Oregon, and into 1914, after which further
entry did not appear, she was in active practice in The Dalles.
(To be continued in March issue)
Minnesota Medicine
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
STREPTOMYCIN
TREPTOMYOIN is now available to the
profession, and reports indicate its great
value in a limited number of infections. Its high
cost will necessarily limit its use. The fact, too,
that various strains of the same bacterial species
differ widely in their sensitivity to streptomycin,
and that its absorption by individuals differs so
greatly, has made evaluation of its usefulness
difficult.
Streptomycin has been found of value in the
treatment of a number of infections due to both
Gram-negative and Gram-positive bacteria. Per-
haps the most important are urinary tract in-
fections due to Gram-negative organisms, in-
fections due to certain strains of Escherichia coli,
Proteus vulgaris, and Aerobacter aerogenes, as
well as Salmonella pneumonia due to Friedland-
er’s bacillus, and Hemophilus influenzae infec-
tions and tularemia.
Streptomycin is administered in much the same
fashion as penicillin. However, it is more likely
to produce toxic symptoms than is penicillin. In
larger doses it sometimes affects the eighth nerve,
producing deafness or dizziness or both, which,
though usually temporary if the drug is with-
drawn, may become permanent. Urticaria is not
uncommon as a side effect.
The new antibiotic can be given orally, intra-
muscularly, intravenously or intrathecally. The
intramuscular route is preferable, with 1,000,-
000 to 3,000,000 units being given daily. Recent-
ly the metric system has bden adopted in defining
dosage, 1 mg. of streptomycin being equal to
about 1,000 units. Solutions containing 0.1 to
0.2 gram (100,000 to 200,000 units) per c.c. may
be used intramuscularly, but for intravenous ad-
ministration the twenty-four hour dosage of 1,-
000, 000 to 3,000,000 units should be diluted in
1 or 2 liters of isotonic salt solution. Single in-
jections of as much as 0.1 gram (100,000 units)
have been given intrathecally in 5 to 10 c.c. of
normal saline. Concentrations of the drug as high
as 50,000 units in 1 c.c. of isotonic saline solu-
tion have been used for insufflation by a nebulizer
for bronchiectasis, without evidence of irritation.
The routine use of streptomycin for urinary
tract infection has been disappointing, according
to Nichols and Herrell.2 When the urinary infec-
tion was due to Proteus ammoniae or Aerobacter
aerogenes, the best results were obtained. It
seems important that the urine be alkaline and
that urinary stasis be overcome before favorable
results can be expected.
If treated early in the disease, tularemia seems
to respond well to streptomycin.1 Influenzal men-
ingitis is another infection which responds well to
this new antibiotic. Experience with its use in
tuberculosis is thus far insufficient to establish
its value in this disease.
A point that deserves consideration is that
streptomycin should be given in effective dosage
from the start, for it has been found that some
strains of bacteria develop resistance to the drug.
Experience with this new antibiotic has been
sufficient to prove it a valuable addition to the
relatively short list of specific drugs we possess.
1. Howe, Calderon, et al. : Streptomycin treatment in tula-
remia. J.A.M.A., 132:195, (Sept. 28) 1946.
2. Nichols, Donald R., and Herrell, Wallace E. : Streptomy-
cin. J.A.M.A., 132:200, (Sept. 28) 1946.
FLUIDS IN HEART DISEASE
CcOALT-FREE” diets and restriction of fluids
^ in the presence of edema have been in
vogue for a number of years. Only recently has
it been learned that it is the sodium, whether it
be in sodium chloride or sodium bicarbonate,
which should be restricted in the presence of
edema, from whatever cause, and that limitation
of fluids is wrong.
According to theory, the normal interchange of
fluid between the circulation and the body tis-
sues depends on hydrostatic pressure and osmosis.
With the pressure in the precapillary vessels
greater than the osmotic pressure in them, fluid
escapes into the tissues. Since pressure in the
postcapillary vessels is less than that in the pre-
capillary vessels and is also less than the osmotic
pressure in the postcapillary vessels, there is a
withdrawal of fluids from the tissues. A lower-
ing of the plasma contents of the blood would
February, 1947
187
EDITORIAL
result, according to this theory, in a greater
diapedesis of fluid from the precapillary vessels
into the tissue spaces, and would also cause a
lessened absorption of fluid from these spaces
into the postcapillary vessels, as a result of the
lessened osmotic pressure-effect of the plasma.
In the presence of cardiac decompensation, with
diminished cardiac output and increased venous
pressure in the postcapillary vessels as well as
in the rest of the venous system, the return of
fluid to the postcapillary vessels from edema-
tous tissue spaces is hindered. Edema fluid con-
tains salt, among other elements, corresponding
to the blood content. Along with venous con-
gestion, then, the kidney output is diminished in
quantity, and its sodium chloride content is low-
ered.
Theoretically then, the reduction of edema
should be favored by any factor which improves
circulation and relieves venous congestion, by
the restriction of salt in the diet and thus in the
circulation, and by diuresis, whether it be from
increased water intake and elimination through
the kidneys or from the administration of mer-
curial diuretics. This has been found to be the
case.
While the value of salt restriction in the pres-
ence of edema has been recognized for some years,
Schemm was the first to call attention to the
fact that if sodium, in the form of sodium chlor-
ide and sodium bicarbonate, is eliminated as far
as possible from the diet, fluids not only need not
be restricted but are beneficial in reducing edema
if given in large amounts. While a “salt free”
diet is unpleasant for the cardiac patient, the
recognition by the physician of the needlessness
of thirst in the treatment will he most welcome
by the cardiac patient.
MORE NURSES NEEDED
h I ’ HERE is still a great need for more nurses,
both trained nurses and practical nurses. In
publicizing the need and the advantages of train-
ing in the profession of nursing, a publicity cam-
paign has been undertaken, and informative
material has been sent to the Federated Women’s
Clubs throughout the state and to the members of
the Hospital Auxiliary. The subject is one of
timely importance and might well be taken up
by the Woman’s Auxiliary of the Minnesota
State Medical Association.
Representatives of the state nursing, hospital
and medical associations have been meeting to
formulate a bill agreeable to all three interested
professions, providing for legislative action for
the licensing of practical nurses by the the present
legislature. It is to be hoped that agreement as to
details will be reached, so that provision will be
made for this licensing of practical nurses, a
procedure which should stimulate recruiting of
young women for the short course in training.
At the special meeting of the House of Dele-
gates of the Minnesota State Medical Associa-
tion on December 22, 1946, in Saint Paul, ap-
proval was given for the establishment of ten
more schools of nursing with a three-year course
leading to the title of registered nurse, and for
twenty additional schools providing one-vear
courses for the training of practical nurses.
It seems that action will be taken by the present
legislature providing for “licensed practical
nurses.” In anticipation of this outcome and in
view of the great need of registered nurses and
practical nurses, physicians can render a service
by referring young women to the headquarters of
the Minnesota Nurses’ Association, 2642 Univer-
sity Avenue, Saint Paul 4; to the Franklin Hos-
pital School for Practical Nursing, 501 West
Franklin Avenue, Minneapolis 5 ; or to the Voca-
tional Hospital, 5511 Lyndale Avenue South,
Minneapolis 9, for detailed information as to re-
quirements and opportunities for training in
nursing.
CONSUMERS COOPERATIVE MEDICAL
CARE
THERE is every evidence that Consumers Co-
operatives are going to submit legislation to the
present legislature to enable them to provide medi-
cal service for their members. They propose to
furnish this service through the employment of
physicians to care for co-operative members and
their families. Such services are to be consumer
controlled, in contrast to the various plans being
promulgated by the various medical associations,
and medical care is to be sold like other com-
modities such as food and merchandise.
One fundamental difference between the Con-
sumers Cooperative plan and types of sickness
insurance, a vital difference in the minds of the
public as well as the medical profession, is that
in co-operative supplied medical care there is no
188
Minnesota Medicine
EDITORIAL
free choice of physician. The co-operative mem-
ber receives his medical care from the employed
physician or surgeon whether he be good, bad
or indifferent. If there is one prerogative of which
the American citizen is jealous, it is that when he
is ill he can obtain what in his mind is the best
available medical advice. Physicians, too, have
insisted on the importance of maintaining the free
choice of physician whenever possible, in order
not to abrogate the stimulating effect of free com-
petition on the quality of medical care.
Assuming that co-operatives may be able to em-
ploy first-class physicians, it seems quite probable
that such physicians, being employes, will of ne-
cessity be dictated to in the matter of what services
they may give their, patients in the way of hospital
care, medicines and the like. The holders of the
purse strings must of necessity be largely inter-
ested in costs, and freedom of medical care is sure
to be hampered.
MOBILE SPEECH CLINIC UNDERTAKES SURVEY
A concerted effort is under way to ferret out the
speech and hearing handicaps among Minnesota’s
school-age children — handicaps which may hold them
back in their classwork or contribute to making them
social behavior problems.
A complete survey of the speech and hearing needs
of 400,000 school children is the goal of the Mobile
Speech Clinic of the University of Minnesota, staffed
by the University and financed by tthe Minnesota As-
sociation for Crippled Children and Disabled Adults,
Inc., from funds derived through sale of Easter Seals.
Directed by Miss Laila L. Larsen of the University,
manned by Miss Larsen and two experienced clini-
cians and equipped with two pure tone audiometers and
a Sound Scriber, the station-wagon-clinic will tour the
state for three to five years on a project which both
university and Minnesota Association officials hope will
do much to waken the general public to the needs of
the mentally competent but physically handicapped.
They see the whole problem as a continuous one, not
one which can be solved by a traveling clinic in three
or four or five years.
They foresee the time when, partly as a result of this
initial project, public opinion will support long-range
plans to give every child, no matter how remote his
home or school, the opportunity to receive expert ex-
amination and early treatment of his handicap.
They hope to see the time when more and more special
teachers and clinicians will be trairied to staff permanent
clinics set up to serve given areas of the state.
For purposes of research, the clinic, under the gen-
eral administration of Dr. Bryng Bryngelson of the
University, will gather data regarding such important
questions as the effects of foreign language background
on speech.
It will attempt to correlate the speech and hearing
difficulties of children with behavior problems and with
failures in school, especially in spelling and reading.
Still another aim is to compare the effectiveness of
testing with pure tone audiometers with that of screen-
ing with group test audiometers.
Although the Minnesota survey is not the first of its
kind in the United States — others are in progress in
Indiana, Iowa, Illinois, Oregon, Pennsylvania, Michigan
and California — it is the first ever to use the pure tone
machine which tests in all ranges of sound rather than
in the speech range only. Every child is examined in-
dividually.
Since the staff of three — Miss Larsen, Gertrude Rus-
sell, hearing clinician, and Virginia Worthington, speech
clinician — set out in their station wagon last September,
they have covered two counties, surveyed sixty-seven
schools, given 20,398 survey tests.
Through January 20, they had examined 10,866 school
children in Washington and Stearns Counties, and had
found that one of every five or six had some speech
defect, while one of every fourteen or fifteen had a
hearing handicap in need of special attention.
Of 9,208 children tested for speech, 614 had marked
and 1,034 had slight defects. Of 11,190 tested for hear-
ing, 519 had marked and 261 had slight disabilities.
Every disability, however minor, discovered in the
screening test is followed up with a private conference
with the child and his parents or teacher. While the
first test requires about two minutes, an interview may
last from fifteen minutes to an hour while the clini-
cian investigates the background of the handicap.
Individual reports are forwarded to parents and
teachers, summary reports and recommendations to the
State Board of Education and the clinic’s sponsor, the
Minnesota Association for Crippled Children.
The clinic concentrates on diagnosis, not prescrip-
tion, and parents are informed that the individual re-
ports should be passed on to the family doctor to
whom the child is taken for treatment.
However, when the clinicians’ tests indicate that a
child may respond to certain treatment, a recommen-
dation to that effect is enclosed with the routine report.
Results in other states reveal that 20 to 40 per cent
of handicaps uncovered in surveys actually do receive
follow-up medical care.
Greater co-operation between parents and doctors can
raise this percentage, Miss Larsen believes, but fre-
quently the doctor must go out of his way to make
up for parents’ lack of initiative in bringing their chil-
dren for treatment.
Often, she believes, the doctor takes it for granted
that parents of course will return to him if an infected
ear for which he has prescribed does not improve; or
if a child, brought for consultation because he has not
learned to talk at a normal age, does not overcome his
retardedness in a reasonable length of time.
And too often, she continues, parents assume that be-
cause the doctor did not specifically request to see the
(Continued on Page 222)
February, 1947
189
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl. M.D., Chairman
AMA HOUSE OF DELEGATES AGENDA
INDICATE ASSOCIATION'S GROWTH
Several topics were under discussion at the
midwinter session of the House of Delegates of
the American Medical Association, held in Chi-
cago, December 9 to 11 — topics which give evi-
dence of the amazing rapidity with which the as-
sociation has grown and the multiplicity of its
functions.
On the agenda were such important subjects
as improving health conditions in the coal mining
areas, the possible significance of the new United
Mine Workers’ Health Fund, and ways and
means whereby the medical profession can help
the nation successfully realize the maximum
benefits from the broad features of the Hill-Bur-
ton Hospital Construction Program.
Other matters taken up were the establish-
ment of representation for the Veterans Admin-
istration in the fellowship of the association and
in the House of Delegates ; continued progress
in the development of prepayment medical care
plans; membership for general practitioners on
hospital staffs ; certain revisions in the constitution
and by-laws ; and plans for the observance of the
association’s one hundredth birthday at the 1947
annual meeting in Atlantic City.
Delegates Meet in "Free Atmosphere"
In a brief address before the assembly, the
president, Dr. Harrison H. Shoulders, declared
that this meeting “was being held in a different
atmosphere from that which existed in July and
from that which has been in existence for quite
some time.” He told the delegates that today’s
atmosphere “approaches freedom — the freedom
to go forward in the accomplishment of the great
mission of medicine.”
Dr. Shoulders said that the AMA is a strong
organization — an organization with a past of
which it can be justly proud and a future of
which it can be hopeful.
Dr. Olin West, president-elect, added a firm
second to Dr. Shoulders’ remarks and voiced his
confidence in the continued progress of the as-
sociation in its efforts to promote the art and
science of medicine. He called on physicians to
do their utmost toward what he termed “the
development of new financial techniques which
will make medical care more available— the fin-
ancing of it at least — to people of moderate
means.”
Conditions in Mining Areas Discussed
Much interest and attention at the conference
centered on medical care and sanitary conditions
among mine workers and their families. Present
to report was Rear Admiral J: T. Boone of the
U. S. Navy Medical Corps, who, as medical ad-
visor to the Federal Coal Mines Administrator,
organized and has been directing a survey of
medical, hospital and general health facilities and
sanitary conditions in the areas where bituminous
coal is mind.
As a preface to his report of the situation in
mining communities, Admiral Boone noted that
the war years have been accompanied by “changes
and dangers of a legislative nature” and that the
medical profession has been confronted with a
welter of new laws, bills and regulations bearing
directly on public health and medical and hos-
pital care. He reasoned that such proposals as
have received so much public support stem from
real as well as imagined needs of the people.
They are symptoms, he said, of dissatisfaction
with the medical profession as it practices its
art today; and he declared that “physicians them-
selves should be the first to recognize these symp-
toms, diagnose the cause and prescribe the reme-
dies, which will not merely allay the complaint,
but produce the cure.”
190
Minnesota Medicine
MEDICAL ECONOMICS
Mine Workers' Plight Is Vital Problem
While Admiral Boone recognized the fact that
substandard health and sanitary conditions among
coal miners is only one of the problems facing
the medical profession, he said that it was none-
theless of vital importance.
Admiral Boone went on to describe the sur-
vey of mining communities which, under his
direction, is now rapidly drawing to a close. The
survey, initiated some six months ago by the
Federal government and the miners’ union when
the government was operating the mines, Admiral
Boone said, called for a review of conditions
which would serve as a basis for providing miners
some day with medical, housing and sanitary
facilities conforming to recognized American
standards.
Since the survey report was not yet complete,
Admiral Boone did not feel he could reveal any
specific and official results or conclusions to the
delegates. However, he did present some personal
observations, and he called to the attention of the
House of Delegates, as a representative group
of American doctors, what he said “would seem
to be of major concern to organized medicine.”
“The apparent weakness in public health pro-
grams in the nation’s coal mining regions are
deeply disturbing,” Admiral Boone pointed out.
He had observed, as a general rule, such inade-
quacies as poor water supply controls, improper
sewage and garbage disposal, lack of “reasonable
safeguards” against contamination from human
and animal wastes, lack of protection in food and
milk handling, and poor insect and rodent control.
The number of mining communities with ade-
quate facilities, he added, were too few in num-
ber to stand out as exceptions to this rule.
Lack of Public Health Work
It had been very disappointing, Admiral Boone
said, to note what he called “a schism between cur-
ative medicine and preventive medicine.” To
explain this point, he said that, in the communi-
ties he visited, he inquired into the public health
work done by “company physicians,” and he
found that very little was done beyond the usual
school health programs of immunization. He
found physicians so busy with their practice of
curative medicine that they were reluctant to
concern themselves with assuming leadership in
public health, especially when there was so little
to work with in the way of understanding and
willingness to understand on the part of the
miners themselves.
Admiral Boone said he believes that not only
does this condition exist in coal mining communi-
ties but it exists “far too generally.” “I be-
lieve,” he said, “that organized medicine can
perform a noble task in closing the gap between
curative medicine and preventive medicine.” And
he added, “Public health is not exclusively the
concern of government.”
“What we have seen,” said Admiral Boone, re-
ferring to the subhealth standards uncovered by
his investigations, “should rightly be the concern
of every doctor, from the specialist in Chicago
and New York to the general practitioner in the
Appalachians. The health problem in the coal
fields cannot be dismissed as a matter affecting
less than 2 per cent of the population of the
country or merely a few hundred physicians.
“As you well know, since diseases can become
epidemics . . . since illness and disease in one
segment of the population can and does affect
the health and welfare of the entire nation, I am
sure that you agree with me when I say that if
we can help raise the health standards of coal-
mining communities, we can contribute to the na-
tional well-being.”
Background of United Mine Workers'
Health Fund
Admiral Boone then turned to a discussion of
the background and probable implications of the
recent establishment by agreement between Secre-
tary of the Interior J. A. Krug and the United
Mine Workers’ head, John L. Lewis, of the
UMW Health Fund, which has been “highly
disturbing” to physicians who practice in the coal-
mining communities and to other physicians
as well. . .
This fund, which is to be administered by
trustees appointed by the president of the UMW,
is to be accumulated from wage deductions of
mine workers and is to be used for medical, hos-
pital and related purposes “at the discretion of
the trustees of the fund.”
Collections for the fund, according to Ad-
miral Boone, have not yet started, but what
changes in the present system of medical prac-
tice will follow its establishment, no one, except
possibly a few persons inside the UMW, can
foretell.
Said Admiral Boone : “The mine physicians,
February, 1947
191
MEDICAL ECONOMICS
I understand, are not so much concerned about
their economic security as they are about the
maintenance of their professional status. That is
the concern of all medical men, because the
establishment of this particular medical fund may
be the precedent for similar funds in other in-
dustries.”
What changes this new departure, which may
inject third parties between physicians and pa-
tients, will tend to bring about in medical prac-
tice, no one knows, said Admiral Boone. It is
evident, however, he added, that the AMA has
been handed a problem which cannot and is not
overlooking.
‘‘The views which organized medicine takes in
handling such problems will help to fashion the
pattern that is eventually evolved,” Admiral
Boone concluded. “Organized medicine must
dissipate any emotionalism that beclouds sound
reasoning and must assume leadership in the for-
mulation and establishment of reasonable and
practical programs that will benefit the people.”
Delegates Act on Admiral's Advice
After hearing the Boone report, the Council on
Medical Service made definite recommendations
with regard to action which the AMA should
take. In its report to the House of Delegates, the
Reference Committee on Medical Service ap-
proved of the action suggested by the council,
that the council shall continue to follow closely
the developments of the bituminous coal situation.
The report said that “it is recognized in these
proposals (the UMW Health Fund) a new type
of economic philosophy, one with far-reaching
implications and concerns, which well may in-
fluence and possibly change the whole basic pat-
tern of medical practice.
“The manner in which these funds ultimately
will be administered, and the instrumentalities
through which medical care will be delivered,
will require our careful study and guidance.
Such plans as these doubtless will occupy a prom-
inent place in any collective bargaining of the
future. ... We shall have to project ourselves
into this developing situation and play a leading
role in the evolution of these plans for medical
care.”
Need for "Planned Co-operation" in
Hill-Burton Program Stressed
How the Council on Medical Service is trying
to impress all state medical societies with the im-
portance of planned co-operation to the success-
ful carrying out of the provisions of the Hill-
Burton law, was reported to the delegates by
that body. As a service to state societies it is
preparing a set of principles as a guide to such
co-operation, and a set of minimum standards for
diagnostic clinic facilities.
In addition, the medical profession, through
its state and county societies, is being encouraged
by the council to participate actively in all plans
or programs formulated under the bill. Each
state medical society, the council recommends,
should have good representation in the agency
charged with the responsibility of carrying out
the provisions of the law in its particular state.
The council’s report to the delegates drew at-
tention to the fact that it is up to the state medical
societies to see that facilities are placed only where
a specific need for them is shown, and that
diagnostic clinic facilities are erected only with
the sanction of the county medical society con-
cerned.
Formation of Health Councils Recommended
Among the other recommendations of the
Council on Medical Service was one regarding
the establishment of a National Health Congress,
proposed in January of last year. The report
favored “formation of state or local health coun-
cils to meet local needs and enlist the co-operation
of their interested bodies,” and said that the
council will continue to work on such a program
by calling a meeting of local health councils and
other interested groups to discuss the value and
scope of such councils and to draw up a model
outline for their formation.
The council reported that after much study
it feels that the setting up of a National Health
Congress as a permanent body would not be ad-
visable. Such a body, it pointed out, “would be
bound to duplicate the efforts, and to a certain ex-
tent usurp the prerogatives, of this House of
Delegates and other AMA bodies.”
“In the opinion of the Council,” the recom-
mendation read, “it would be far better for the
Board of Trustees, the Council on Medical Serv-
ice and other AMA Councils to call conferences,
whenever deemed advisable, on subjects on which
the advice and co-operation of their bodies is
desirable. In this way, different groups could be
called on in matters pertaining to their specific
fields ; and there would not be one set group to
192
Minnesota Medicine
MEDICAL ECONOMICS
consider every subject.” Therefore, the council
asked specifically to have its previous instruc-
tion for the establishment of a National Health
Congress rescinded.
Delegates Act on Variety of Questions
Several important decisions were made by the
House of Delegates, specifically :
1. An admendment to the by-laws was voted,
making it possible for general officers and dele-
gates in the association to be nominated to the
presidency without first having to resign from the
position held.
2. The delegates passed an amendment per-
mitting admission to fellowship in the AMA,
without payment of dues, to members of the
permanent corps of the Veterans Administration,
for so long a time as they should remain with the
Administration.
3. A resolution turned over to the Board of
Trustees for “serious consideration” was one
intended to promote closer co-operation between
the medical and dental professions by the ap-
pointment of a committee of five AMA members
to work with a similar committee set up by the
American Dental Association, “inasmuch as phy-
sicians and dentists have a common interest in
the extension of health service.” It was recom-
mended that this move be carried through on the
state level also.
4. Another resolution called for the establish-
ment of general practice sections in approved hos-
pitals, specifying that these appointments should
be made by hospital authorities “on the merits and
training of the physician,” and that “membership
on a hospital staff should not be dependent on
certification by the various specialty boards or
membership in special sections.”
5. The establishment of a certifying board to
determine the qualifications for general practice
was the subject of a related resolution, asking
that the Section on the General Practice of Medi-
cine of the AMA give consideration to a plan for
the establishment of such a board, and that the
section make a preliminary report to the House
of Delegates in June at Atlantic City.
6. As a result of deliberations at this session
of the House, there is now at association head-
quarters a Division of Public Relations, under
an executive assistant to the general manager,
which will handle public relations activities for
all councils, bureaus, publications and other agen-
cies and operations of the association.
7. The delegates approved a resolution direc-
ting the Council on Medical Service and the
Council on Industrial Health to “continue close
co-operation with mine physicians in an effort
to improve and maintain the high standards of
medical practice.”
Bureau of Medical Economics Reorganizes
It was announced by the Bureau of Economic
Research (formerly the Bureau of Medical
Economics) that under the leadership of its new
director, Professor Frank G. Dickinson, it plans
to reactivate and expand, with the emphasis on
research.
A current job of this bureau is an extensive
survey of medical services in each state. Ques-
tionnaires are being sent to county medical society
secretaries, asking them to draw on a state high-
way map a line around the area served by phy-
sicians located in each county medical center.
The bureau is also assisting with the tabulating
and1 analyzing of the completed questionnaires
now pouring in from the thousands of returned
medical officers. Reporting that the response in
this survey has been remarkable, the bureau
promises to study the some 20,000 questionnaires
and will file a report with the Committee on Na-
tional Emergency Medical Service, which is di-
recting the survey, some time in April.
Elaborate Plans for Centennial Announced
Elaborate plans for the AMA centennial cele-
bration in Atlantic City, June 9 to 13, which
promises, according to the skeleton outline
presented to the delegates, to be “the high point
in the assemblages of physicians anywhere in the
world,” were announced. Plans include a ban-
quet honoring leaders in industry and the va-
rious occupations associated with medicine, at
which time distinguished speakers will comment
on the influence of American medicine on the
nation’s progress.
A religious service on Sunday, June 8, present-
ing three great religious leaders who are to speak
on the spiritual aspects of medicine and health,
will be broadcast from Atlantic City. Plans are
to invite ministers throughout the nation to join
the observance by speaking on similar topics.
The outline promises that the annual meeting
will present the largest technical and scientific ex-
hibit ever developed by the AMA, and will in-
clude a public exhibit set up on the boardwalk,
February, 1947
193
MEDICAL ECONOMICS
depicting the progress of scientific medicine. Gen-
neral and special sessions are scheduled ; distin-
guished foreign guests are being invited, and a
motion picture program is planned which will in-
clude, among other special showings, a film on the
evolution of the scientific medical motion picture.
Washington's “New Political Flavor" Reviewed
Delegates heard a review of the complexion
of the new Congress in a report from the Bureau
of Legal Medicine and Legislation, in which the
names of new committee chairmen were listed
and predictions were made as to what the “new
political flavor” in Washington would mean in
the way of medical legislation.
Plans were announced at the session for a
Second Annual National Conference on Rural
Health to be held February 7-8 in Chicago, in
order to provide farmer and doctor with another
opportunity to exchange views regarding the
many questions which are of vital importance
in developing better health service in rural areas.
The Council on Industrial Health reported
that it is watching closely developments in the
World Health Organization, noting in its re-
port that “information is not yet available, par-
ticularly regarding the status of industrial hy-
giene in the proposed organization.” It was ob-
served that there will probably be a mixed com-
mittee of public health experts, representatives
of the International Labour Office and the World
Health Organization itself, to consider matters
of social insurance and industrial hygine. Mean-
while, the council reported, the United Nations
organization is establishing itself in New York
and is setting up a health program for its em-
ployes, who will probably number about 2,000.
Included in the industrial health report was an
interesting bit relative to this “Atomic Age.” The
council is deeply interested in the organization of
the Board of Consultants on Atomic Energy,
being set up under the sponsorship of the Council
on Physical Medicine. The report says that
“since it is proposed to use nuclear energy in in-
dustry as a source of power, the question of oc-
cupational risk is of considerable importance.”
A symposium of atomic energy in industry and
medicine, under the joint auspices of the Council
on Physical Medicine and the Council on Indus-
trial Health, was an event of the recently held
Seventh Annual Congress on Industrial Health.
MINNESOTA STATE BOARD OF MEDICAL
EXAMINERS
230 Lowry Medical Arts Bldg., Saint Paul, Minnesota
Julian F. DuDois, M.D., Secretary
Minneapolis Woman Sentenced to Three-year Term
for Criminal Abortion
Re. State of Minnesota vs. Clara Olga Anderson,
Irene E. McFarland and Isadore Abramovich.
On December 28, 1946, the Hon. Levi M. Hall, Judge
of the District Court of Hennepin County, sentenced
Clara Olga Anderson, forty-eight years of age, 1142
Emerson Avenue North, Minneapolis, to a term of
three years at hard labor in the Woman’s Reformatory
at Shakopee. The defendant, Anderson, had pleaded
guilty on that date to an information charging her with
the crime of abortion, and also with having had a pre-
vious conviction for a similar offense in 1943. A plea
by the defendant’s attorney for a suspension of sen-
tence and an opportunity for the defendant to leave the
State, was denied by Judge Hall. On the same date
Irene E. McFarland, forty-six years of age, 1514 Sixth
Street North, Minneai»lis, and Isadore Abramovich,
twenty-four years of age, 706 Elwood Avenue North,
Minneapolis, entered pleas of guilty to an information
charging them with the crime of abortion in the same
case with the defendant, Anderson. Judge Hall sen-
tenced the defendant, McFarland, to a term of one year
in the Minneapolis Woman’s Detention Home, suspended
the sentence and placed the defendant on probation.
The defendant, Abramovich, was sentenced to a one-
year term in the Minneapolis Workhouse, the sentence
being suspended and the defendant placed on probation.
The three defendants were arrested on December 12,
1946, by Minneapolis police officers, following the ad-
mission of a twenty-three-year-old young woman to
Minneapolis General Hospital suffering from the after-
effects of a criminal abortion. The investigation dis-
closed that the defendant, Anderson, attempted to abort
the patient by means of a catheter, on December 10,
1946, at the home of the defendant, McFarland. The
patient paid the defendant, Anderson, $150 for the
criminal abortion of which sum $25. 00 was given to the
defendant, McFarland, for the use of her home while
the abortion was being done. The defendant, Abramo-
vich, employed as a “bouncer” at a Minneapolis bar, was
arrested when it was disclosed that he was the contact
man for the criminal abortion.
The defendant, Anderson, has a previous conviction
for criminal abortion, having pleaded guilty in the Dis-
trict Court of Hennepin County, on March 25, 1943, to
an indictment charging her with the crime of abortion.
In that case Mrs. Anderson was sentenced to a term of
not to exceed four years at Shakopee, but was placed
on probation after serving one year in the Minneapolis
Woman’s Detention Home. None of the defendants has
a license to practice any form of healing in the State
of Minnesota.
GLOMUS TUMORS
(Continued from Page 160)
References
1. Dockerty, M. B.: Personal communication to the authors.
2. Love, J. G. : Tumor of a subcutaneous glomus or tumor of
the neuromyoarterial glomus: report of a case. Proc. Staff
Meet., Mayo Clin., 10:593-595, (Sept. 18) 1935.
3. Love, J. G. : Glomus tumors: diagnosis and treatment.
Proc. Staff Meet., Mayo Clin., 19:113-116, (Mar. 8) 1944.
4. Love, J. G., and Kernohan, J. W. : Glomangioma or glomus
tumor. In Allen, E. V.; Barker, N. W., and Hines, E. A.,
Jr.: Peripheral Vascular Diseases. Philadelphia: W B.
Saunders Company, 1946.
5. Mason, M. L„ and Weil, Arthur: Tumor of a subcutaneous
glomus; tumeur glomique ; tumeur du glomus neuromyo-
arteriel; subcutaneous painful tubercle; angio-myo-neurome;
subcutaneous glomal tumor. Surg., Gynec. & Obst., 58:
807-816, (May) 1934.
194
Minnesota Medicine
Minneapolis Surgical Society
Stated Meeting Held November 7, 1946
The President, Thomas J. Kinsella, M.D., in the chair
POSTOPERATIVE ANURIA
Complicated by Duodenal Ulcer, Hemorrhage,
Bilateral Pneumonia and Toxic Urticaria
L. A. STELTER, M.D.,
Minneapolis, Minnesota
The term oliguria, meaning deficient secretion of
urine, and the word anuria, meaning scanty urine, may
be used interchangeably, as they represent symptoms of
some critical urinary disease. They represent the failure
of the kidneys to excrete urine, and the longer the
condition exists the more rapidly the state of uremia is
approached.
The term uremia, introduced by Piory in 1848 to
denote a state of intoxication due to resorption of urine,
has now come to include all the toxic states which
develop as a result of renal insufficiency. Uremia may
be acute or chronic, the acute type arising from rapid
suppression of urine ; and the chronic type occuring
from diseases which cause a slowly developing state
of intoxication.
In 1821, Prevost and Dumas discovered that urea ac-
cumulated in the blood of a dog following removal
of both kidneys. Bright, in 1836, knew that people
suffering from nephritis had an increase in blood urea.
According to Musser, severe intoxication may be mani-
fest from 60 to 100 mg. per cent of urea; while in
more chronic processes, where there is a gradual ac-
cumulation, mild symptoms may appear only after
values higher than 100 mg. per cent. Values have been
observed as high as 1,000 mg. per cent.
Creatinine values, normally 1 to 3 mg. per cent, may
rise as high as 60 mg. per cent, but values above 5
mg. may have a serious prognosis, suggesting a fatal
outcome. Recoveries have been recorded when creatinine
has risen as high as 12 mg. per cent.
Rehberg and Holten calculated that 100 to ISO c.c. of
fluid must filter through the glomeruli of the kidney
per minute to accomplish the usual excretion of creatin-
ine. Calculations were based on investigations of Vim-
trup that the human kidney contains 2,000,000 glomeruli
with a total surface of approximately 1.6 square meters.
The effective pressure for filtration through the glomer-
ular membrane is the difference between the glomeruli
blood pressure and the force opposed by the osmotic
pressure within the Bowman’s capsule. If the num-
ber of glomeruli are reduced by disease, the filtration
must necessarily be reduced. Similarly, fluctuations in
the plasma protein have a direct effect upon the degree
of filtration which is decreased if the protein content is
increased.
Dr. Stelter appeared on the program by invitation.
February, 1947
Causes of Oliguria and Anuria
The causes of oliguria and anuria are numerous, and
the most important may be listed as follows :
1. Kidney diseases in the terminal state; nephritis
and nephrosis.
2. Toxic manifestations due to poisons, drugs, in-
travenous fluids or medications, and eclampsia.
3. Mechanical obstruction due to calculi, bilateral
tumors including the ureters, surgical ligation of the
ureters. Papin cited five cases of carcinoma of the
rectum with anuria as the initial symptom. Nephroptosis
has also been given as a mechanical cause.
4. Hysteria. Gordon reported a case of an hysterical
woman with anuria which lasted two days and was
cured by suggestion. Grenier saw an hysterical woman
through five attacks of anuria lasting two, four, six,
seven and fifteen days, respectively.
5. Surgical anuria resulting from shock, sympathetic
trauma, and anuria from unknown cause following
surgery.
Little has been written about this unfortunate dis-
aster following a surgical procedure on the urinary
tract or following a general surgical operation. Most
authors stress the catastrophe as being due to varying
blood pressure levels during an operative procedure
or the result of blood transfusions (incompatible blood)
in combating shock, where the blood pressure is definitely
lowered and where a surgical procedure had been of
long duration accompanied by fluctuating blood pres-
sure.
Coller found that continuous inhalant anesthesia over
long periods of time may affect the output of urine,
but he was unable to find any evidence of either ether
or cyclopropane causing any gross effect on glomeruli
permeability.
Sturmia states that when incompatible blood is in-
jected intravenously, rapid hemolysis occurs with the
clinical symptoms of a chill,' nausea, vomiting, lumbar
pain, tightness and constriction of the chest, and elevated
temperature following almost at once. There may be
additional symptoms of abdominal pain, bladder pain
and the urge to defecate. Transient hemoglobinuria
with scant reddish brown urine appears, followed in
a few hours by jaundice. The jaundice reaches its
peak in twenty-four hours. The oliguria may improve
and the patient may recover rapidly but more often it
leads to uremia and death.
Sturmia lists as possible causes of oliguria (1) block-
age of the renal tubules, (2) anaphylaxis, (3) ischemia
of the kidneys from vasomotor constriction, and (4)
nephrotoxic substances released by hemolysis. The first
three he refutes but believes the fourth more feasible
as there is a strong similarity pathologically between
post-transfusion nephrosis and chemical nephropathies.
195
MINNEAPOLIS SURGICAL SOCIETY
Bywaters showed in crushed muscle necrosis, causing
shock, in the early blitz of London, that patients seemed
to do well for several days, only to develop elevated
blood pressure and die as a result of suppressed renal
function. Two-thirds of the patients died at the end of
the first week, the majority on the sixth day. About
one-third of the cases recovered because urinary out-
put was maintained.
Treatment
The treatment is chiefly preventive. Proper blood
grouping and cross-matching are necessary before trans-
fusions are given. It is well to establish alkaline diuresis
by large doses of sodium bicarbonate by mouth until
the urine is alkaline. The alkalinity should be main-
tained. If the patient is vomiting, a fresh solution of
1.4 per cent sodium bicarbonate may be given intra-
venously. Isotonic sodium lactate may be given intra-
venously. Fluid intake should be kept up to 2 to 3 liters
a day, with sufficient saline to keep up the chloride
level. If renal failure occurs, the treatment is identical ;
the addition of mercurial diuretics may be introduced,
and decapsulation of the kidney considered.
Case Report
G. L., No. 1327311, aged thirty-six, white, an en-
gineer by occupation, entered Fairview hospital at
2:00 p.m. on February 28, 1945, complaining of pain
in the right lower abdomen and flank. He had become
acutely ill at 2:00 a.m. and ascribed his illness to a few
highballs and a heavy meal at a banquet the night be-
fore. During the night the pain became more intense,
radiating down the right side and towards the back.
There was nausea but no vomiting. He had no urinary
disturbance, no nocturia, and no testicular pain, but felt
some discomfort in the scrotum.
His past health had been good except for some in-
digestion ; he had intolerance to fried and fatty foods
and rare meats. Cabbage and oranges always gave him
distress. For the past year or two, he had had some
pain in the right side. Six months prior to the present
illness he had a similar attack, at which time he went
to another clinic where gastrointestinal, gall-bladder and
colon studies revealed nothing abnormal. He was ad-
vised to have his appendix removed on the basis of
a probable retrocecal location. This he refused to have
done and returned to his home and work.
Physical examination revealed a robust, well-developed
male, acutely ill. Except for the abdomen, physical
examination revealed nothing abnormal. His pulse was
76, temperature 99.4° F. ; blood pressure was 124
systolic and 75 diastolic, in millimeters of mercury. The
contour of the abdomen was normal. The muscles were
spastic. Palpation revealed no tumor nor masses, but
the muscles of the right side were held rigid and he
complained of tenderness in the right lower quadrant.
There was also tenderness in the right lumbar region
on Murphy percussion. There was no rebound tender-
ness and the testicles were not sensitive. The extremi-
ties and reflexes were normal. Rectal examination re-
vealed nothing of note. A tentative diagnosis of acute
appendicitis or some right-sided nephritic disease, ure-
teral stone or perinephritis, was made.
Laboratory tests showed a hemoglobin of 91 per cent.
There were 11,900 white blood cells in each cubic milli-
meter of blood. Differential examination showed, seg-
mented neutrophiles 82 per cent, lymphocytes 16 per
cent, monocytes 2 per cent. Urinalysis was normal ex-
cept for two red cells and three pus cells in the high
dry field. Specific gravity of the urine was 1.022. A
scout film of the abdomen revealed nothing abnormal.
In spite of the above findings, I decided against sur-
gical intervention, and on March 1, 1945, rechecked the
laboratory procedures and found the urine normal ex-
cept for four pus cells in a high dry field. The leukocyte
and differential counts were normal. On March 2, 1945,
an intravenous pyelogram revealed a marked hydrone-
phrosis of the right kidney. The condition was dis-
cussed with the patient and he was advised to have a
cystoscopic examination and a retrograde pyelogram
made. He elected to have this done at a future date
and returned to his home.
On March 7, 1945, he returned to Fairview hos-
pital, and repeat laboratory examinations were within
normal limits. On March 8, a cystoscopic examination
was performed by Dr. R. T. Soderlind, who noted
that “prostate, bladder and meatus were normal. Indo-
carmine appeared in normal time from the left meatus.
No dye appeared from the right meatus although
urine was spurting. A catheter was passed to the right
pelvis and 50 c.c. of urine aspirated. A No. 6 catheter
was left indwelling. A pyelogram revealed marked hydo-
nephrosis of the right kidney.”
Operation was advised and the patient was pre-
pared for operation. His blood was grouped, matched
and cross-matched for blood transfusions; fluids were
forced, -and sulfadiazine and sodium bicarbonate given.
On March 11, an indwelling catheter was passed into
the right ureter to reduce the size of the hydrone-
phrosis. Urine from the right ureter showed three pus
cells in a high dry field. No tubercle bacilli were found.
The blood urea was 13 mg. per cent, creatinine 1.2
mg. per cent.
On March 14, 1945, the right kidney was removed
under cyclopropane anesthesia. Operating time was one
hour thirty-four minutes. Extensive adhesions and
induration around the entire capsule made the procedure
more difficult. The patient received 5 per cent glucose
in normal saline intravenously during the operation. His
pulse varied between 90 and 130 per minute, and his
blood pressure from 100 systolic, 70 diastolic, to 154
systolic and 90 diastolic, in millimeters of mercury. He
returned to his room in good condition.
Five hundred cubic centimeters of normal saline and
500 c.c. of citrated blood were given intravenously in
the afternoon following the operation. He made satis-
factory progress, and the blood pressure and pulse were
normal. At 9:30 that night he was catheterized and
400 c.c. of urine obtained. At midnight he tolerated
1,000 c.c. of 5 per cent glucose in distilled water, and
had a fair night. At 6:00 a.m., March 15, he com-
plained of severe chest pain, generalized distress, dysp-
nea, and a faint feeling. His pulse became thready,
weak and rapid ; the rate rose to 150 per minute. The
blood pressure was 80 systolic and the diastolic could
not be heard. He was given neosynephrin, 250 c.c.
of plasma intravenously, 500 c.c. of normal saline, and
500 c.c. of citrated blood, after which he rallied from
shock and his blood pressure rose to 110 systolic and
70 diastolic, and his pulse stabilized at about 110. At
9:30 a.m., March 15, he was catheterized and 5 c.c. of
urine obtained. In the afternoon the patient became
confused and irrational, but this was only transitory.
An indwelling catheter was inserted in the bladder and
5 c.c. of urine obtained. Penicillin, 20,000 units, was
given every three hours. One thousand cubic centi-
meters of 5 per cent glucose in normal saline and 1,000
cubic centimeters of 5 per cent glucose in distilled
water were given intravenously morning and afternoon.
Copious fluids were given by mouth, with large doses
of alkalies, in an effort to establish diuresis. On March
16, nasal suction was instituted because of abdominal
distension. On March 17, the condition of the patient
was unchanged. The wound was inspected and the
drains removed. In spite of the large fluid intake and
the elevated metabolites, the condition of the patient
remained fairly good. He showed no gross evidence of
uremia. His skin, however, became deeply bronzed and
196
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
jaundiced, reaching its height on the fourth day. On
March 18, Dr. Soderlind passed a catheter into the left
ureter and also left a Foley catheter in the bladder.
Supportive treatment and forced fluid intake were con-
tinued. When the nasal suction could be clamped off,
alkalies were given in large amounts. In the evening the
patient began to doze a great deal; in waking intervals
he became very restless and irritable. His blood pres-
sure rose gradually up to 180 systolic and 78 diastolic.
His pulse slowed.
On March 19, Dr. Theodore Sweetser saw the patient
in consultation and recommended increase in fluid in-
take, hot packs and diathermy over the left kidney.
Decapsulation was suggested if the urine did not in-
crease in amount. On March 20, at about 8 :3Q a.m., he
became very restless and irritable. He was put in re-
straints, and he thrashed about. At 8:45 he had a
convulsion of several minutes’ duration, which, accord-
ing to the nurse, occurred after he lapsed into deep
coma. Dr. Sweetser advised decapsulation of the left
kidney under local and gas anesthesia.
The capsule of the left kidney was stripped completely,
anteriorly and posteriorly, the poles explored and found
normal, and the wound closed rapidly. He stood this
operation surprisingly well. In his room, saline and
another transfusion were started. At 4:30 p.m., the
ureteral catheter began to drip and by 7 :45, about
50 c.c. of urine had been collected. At 11 :45 p.m., 100
c.c. more had been excreted. However, the patient’s
condition was critical and he was placed under an
oxygen tent, which he constantly attempted to tear
off. His twitching and muscular jerkings were con-
trolled by sodium luminal.
His general condition from now on showed a gradual
improvement, though he remained unconscious. The
right wound was torn open by positioning on the oper-
ating table. By March 23, he was removed from the
oxygen tent. On March 25, he developed a very harsh
cough, elevated temperature and expectoration. X-rays
of his chest revealed nothing noteworthy. His cough
subsided and he again seemed to improve.
On March 27, following a hard coughing spell, dur-
ing which time he raised a great deal of thick purulent
mucus, he had a defecation of black stool, found to
be blood. On account of repeated positive findings of
blood in the stool, a diagnosis was made of bleeding
duodenal ulcer and he was treated by the Cook County
bleeding ulcer regime. He was kept on the diet, given
creamalin, vitamin K, thiamin chloride, vitamin C, liver
extract, and repeated blood transfusions, to which he
responded well.
He continued to improve, and on April 24, the
wound of the right side was completely debrided and
closed with interrupted silk sutures. It now healed
readily, and on Mav 1 he was allowed to sit up. At
11 :30 a.m. on May 2 the patient developed dyspnea and
pain in his left chest. His symptoms simulated those
of a pulmonary embolism and for a while it was feared
he would expire. X-rays on May 6, following a similar
attack in the right chest, revealed pneumonia on both
sides. He again responded to penicillin and an oxygen
tent, and roentgenograms on May 9 showed the pneumo-
nia to be subsiding on the left side. On May 13, when
he seemed well on his way to recovery, giant urticaria
developed over his entire body! Penicillin was dis-
continued and the urticaria responded to epinephrine.
On May 15, the patient was allowed out of bed while
all attendants held their breath for fear of another
catastrophe. On May 19, he left the hospital in
ambulatory condition.
The surgical specimen showed a large kidney with
multiple abscesses, massive suppuration and liquefac-
tion. The infection was nontubercular. The diagnosis
was multiple carbuncles of the kidney.
Stomach x-ray studies on July 7, 1945, by Dr. J.
Kelby, verified the diagnosis of duodenal ulcer.
The patient’s health to date has been good. A recent
February, 1947
examination revealed normal blood and urinary findings,
and his last weight was 197 pounds.
Comment
It is my opinion that this patient had a postoperative
anuria resulting from a transfusion reaction, the re-
action occurring about fourteen hours after the trans-
fusion. This delay I cannot explain. Ordinary routine
care, based on the treatment of uremia, failed to alter
the picture. Uremic convulsions ensued and, as a last
resort, decapsulation was done. It is possible that split-
ting the capsule and manipulating the kidney decom-
pressed the glomeruli sufficiently to permit the ex-
cretion of urine. A biopsy of the kidney would have
given valuable information. The numerous complica-
tions of wound disruption, bilateral pneumonia, bleeding
duodenal ulcer, and urticaria were coincidental to the
illness, and only added to the patient’s discomfort and
the attendants’ grief.
Discussion
Dr. Clarence Dennis : I have nothing to contribute,
but I would like to ask a question for my own informa-
tion. There is evidence to believe that alkalinzing urine
does not have any benefit in preventing renal damage:
I am curious.
Dr. L. A. Stelter : Alkalinization has been suggested
in the literature to help prevent reactions in blood trans-
fusions.
Dr. Edmund Flink : There are a few comments
which I would like to make regarding the problem of
reaction of the urine in relation to renal damage from
hemoglobinuria. I carried out some experiments, caus-
ing hemoglobin solution in dogs which had. a strongly
acid urine and in dogs which had alkaline urine, and ob-
tained renal biopsy thereafter. Renal damage with
uremia resulted whether the urine was acid or alkaline.
The number of dogs was not great. At the time when
the urine was strongly alkaline as well as when the
urine was acid, hemoglobin precipitated in the tubules,
toxic changes occurred, and one couldn’t distinguish the
kidneys of the dogs that had acid and alkaline urine.
The dogs which developed renal damage had the high-
est plasma hemoglobin levels, regardless of urine re-
action. No renal damage developed when relatively
lower hemoglobin levels were found.
One bit of evidence is presented in black water fever
which results in anuria in quite a number of cases. The
mortality rate in a large series of patients whose urine
was alkalinized as soon as hemoglobin appeared in the
urine is the same as in an even longer series of patients
to whom alkalies were not given.
There has been recent work which would support the
idea that alkalinization has benefit. Yulie has clamped
both renal arteries in rabbits for fifteen to twenty
minutes and injected small amounts of hemoglobin
solution. The animals that had alkaline urine suffered
no kidney damage at all, and those that had acid urine
had severe kidrley damage, similar to transfusion re-
action kidneys. His idea was based on the fact that
transfusion reaction is often accompanied by shock-
like state, renal anoxia, et cetera, and he was trying to
simulate that condition. Thus, there may be some evi-
dence that alkalinization is of use. The original basis
of alkalinization was on rather flimsy ground. The
work of Baker and Dodds, who used very few rabbits
for their experiments, gives very little pertinent data
and their conclusions are not convincing. DeGowin, who
carried out a large number of experiments on dogs, still
left the question open. I don’t know what the answer
is. If one is going to accomplish anything, however,
alkalinization before transfusion, or at least immediately
197
MINNEAPOLIS SURGICAL SOCIETY
after demonstrating a hemolytic reaction, should be
carried out promptly. One must be certain the urine
becomes alkaline too. A great deal of harm can re-
sult from the indiscriminate administration of a large
volume of alkali to a patient with anuria or oliguria.
I am quite certain that attempts to alkalinize the urine
once anuria has developed will not be of the slight-
est value and may be harmful.
There are several other ideas. Those patients re-
ceived sulfadiazine at the time of anuria. Sulfadiazine
possibly contributed to kidney damage. Another thing,
whenever one has a transfusion reaction, it is well to
find out immediately whether or not there is a hemo-
lytic reaction. One easy way is to obtain a specimen
of plasma or serum immediately. If the serum or plas-
ma is obtained carefully, there will be no hemoglobin
visible normally, but if there has been a hemolytic
reaction, there will always be hemoglobin present in
sufficient quantity to color the plasma red. Normal
appearing plasma or serum will ease one’s mind that
a febrile reaction is not a hemolytic reaction. On
the other hand, absolutely essential information will
be obtained when a true hemolytic reaction has oc-
curred.
THE USE OF CHEMICAL AGENTS IN THE
TREATMENT OF HYPERTHYROIDISM
EDMUND B. FLINK, M.D.
Minneapolis, Minnesota
In May of 1943, E. 13. Astwood of Boston1 published
a report on the reduction of basal metabolic rate and
the abolition of signs and symptoms of hyperthyroidism
in three patients using thiourea and thiouracil by
mouth.
In 1941, MacKenzie, MacKenzie and McCollum12 re-
ported a remarkable enlargement of the thyroid in
animals which had been fed sulfaguanidine. Two si-
multaneously published studies by MacKenzie and Mac-
Kenzie11 and Astwood, Sullivan, Bissell and Tyslo-
witz4 made clear the unique nature of the new goitro-
genic agents of which sulfaguanidine is the prototype
and thiouracil the best known example.
The goiters produced by these agents, unlike those
produced by the older goitrogens,10’15’17 viz. soy beans,
thiocyanate, cabbage and seeds of the Brassica family,
generally cannot be prevented or abolished by iodine ad-
ministration. The currently accepted viewi3’11’14 of the
action of thiouracil, as characteristic of the new thy-
roid drugs, is that it inhibits the uptake of iodine and the
formation of thyroid hormone by the thyroid gland, 3>8>
14>16 colloid typically being reduced or depleted,*4’11 and
basal metabolic rate falling. In the presence of normal
thyroid function, the pituitary is believed to overact, pro-
ducing hyperemia and epithelial hyperplasia of the thy-
roid ; this explanation of the thyroid hyperplasia is based
upon (1) the known action of the thyrotropic hormone of
the pituitary, (2) observable histologic changes in the
pituitary following sulfaguanidine administration, (3)
the ability of administered thyroxin to prevent or
abolish thiouracil-induced hyperplasia of the thyroid,
(4) the absence of thyroid hyperplasia in hypophysec-
tomized animals given the new goitrogens.4’11
Thiouracil (2-thiouracil) 2 was found to be the most
potent of the earlier substances tested. More recently,
ethyl and N-propylthiouracil have been found to be
more active than thiouracil. Thiourea, thiobarbital, and
various substituted ureas are active agents also.
More than 5,000 patients have been treated with thiou-
racil since 1943. We have had experience treating ap-
proximately sixty-five patients with thiouracil at the
University Hospital. Most of the patients were treat-
ed as a preoperative measure. Six patients, however,
were maintained for long periods on thiouracil. Two
patients have been lost from sight since discontinuing
the drug. One adolescent girl has been able to stop the
medication without recurrence of symptoms. Two
adults have repeatedly demonstrated that there is prompt
return of symptoms after discontinuing thiouracil, even
eighteen or more months from the time of starting
therapy.
The speed of response as measured by the basal
metabolic rate, by weight gain, et cetera, has com-
pared favorably to that obtained by other investigators.
The basal metabolic rate dropped to +20 per ceni
in from four to eight weeks. Patients who had iodine
before starting thiouracil responded more slowly than
those who had not had iodine previously. Most of the
patients had moderately severe to severe hyperthyroid-
ism.
Failure to control symptoms adequately has occurred
in three cases even after continued administration for
as long as three months. Perhaps longer trial would
have been successful, but thyroidectomy was carried
out in each instance, successfully in two but resulting
in death shortly after operation in one. All had had
iodine for varying periods before thiouracil therapy,
with very poor results and obviously were resistant to
further action of iodine. They had large nodular goiters,
had basal metabolic rates over +50 per cent, and had
at least some cardiac disability. Two were diabetics.
When the patients were in an approximately normal
state of metabolism, thyroidectomy was usually carried
out without event. In several instances thyroidectomy
presented some technical difficulties. When the
basal metabolic rate was normal before operation, the
postoperative convalescence was as uneventful as after
operations on a nontoxic goiter. The routine use of iodine
for several weeks before contemplated operation has de-
creased the technical difficulties appreciably.
The largest single group of patients treated for a
prolonged time is that of Williams.20 One hundred pa-
tients were followed for a period of many months.
Forty-nine patients have had remissions lasting from
three to twenty-one months, and fifty-one have had re-
lapses in from two weeks to five months (most of them
in one month). X-ray therapy, coincident thyroid ad-
ministration, type of hyperthyroidism and severity of
the hyperthyroidism had no significant effect on the
percentage of relapses. Males tended to have many
more relapses than females (fifteen out of nineteen
males). Patients with large glands tended to relapse
more frequently than others.
The most important consideration of all is the fre-
quency and severity of toxic reactions. The largest
198
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MINNEAPOLIS SURGICAL SOCIETY
collected series analyzed the records of 5,745 treated
patients. 1S Thirteen per cent had some toxic reactions.
Granulocytopenia occurred in 2.5 per cent of cases, and
80 per cent of these occurred by the twelfth week. A
mortality rate of 0.4 per cent has been reported and all
deaths have been attributed to agranulocytosis. There
is no evidence that folic acid, pyridoxine or any vita-
min influences the course or prevents the complication.
By controlling infection, penicillin appears to be the
best therapeutic agent for agranulocytosis. Other im-
portant toxic reactions include fever, rash, arthralgia,
delirium, purpura, salivary gland enlargement, neuritis,
headache, and jaundice. Reports of smaller series of
cases have indicated an incidence of 10 to 16 per cent
toxicity.13
The recommended dose is from 0.4 to 0.6 gm. per
day in divided doses until the basal metabolic rate ap-
proaches normal, after which the dose can be reduced
to 0.1 to 0.4 gm per day. It is well to administer iodine
in full doses for ten to fourteen days before con-
templated surgery. If iodine has been administered
within a month, it is not advisable to stop iodine dur-
ing the course of treatment.
Because of serious toxic reactions, thiouracil prob-
ably should be used only in patients who have one of
the following conditions: (1) thyrotoxic heart disease
with or without auricular fibrillation, (2) organic heart
disease complicated by coincident hyperthyroidism, (3)
severe hyperthyroidism treated with iodine for a variable
period without adequate response, and (4) patients re-
fusing surgery or other treatment. Careful follow-up
must be possible. Leukocyte counts three times a week,
frequent check for fever, skin rashes, other symptoms,
and observations of the bleeding mechanism must be
made. After several months vigilance can be relaxed
somewhat but leukocyte counts should be determined
every week then.
Danowski, Man and Winkler7 have recommended the
use of small doses of thiourea along with iodine as a
form of maintenance therapy in hyperthyroidism. They
have treated fifty-four cases successfully. Two patients
developed fever shortly after starting thiourea. The
dose used ranged from 0.07 gm. to 0.28 gm. of thiourea
and 15 drops of strong solution of iodine a day. The
response was more prompt in almost every case than
in the usual experience with thiourea or thiouracil
alone.
N-propyl thiouracil is a recent addition to the group
of goitrogenic drugs. In animals it is effective in 1/6
to 1/10 of the dose of thiouracil. Astwood3 reported the
treatment of thirty-five patients without any toxic
effects. Now over 600 cases have been treated but there
are instances of drug fever, leukopenia, skin rashes
and other similar complications. Doctors Bieter and
Troxil of the Department of Pharmacology have been
supervising its use here at the University of Minnesota.
Fifteen cases have been treated. Two patients developed
fever and leukopenia (and one a severe rash also).
Propyl thiouracil may not have been the cause in either
case. One patient developed a severe rash and fever
from phenobarbital. Satisfactory response has occurred
in eleven cases, no response in one case and toxic re-
actions in two cases. The period of observation was too
short in one. The responses have been comparable to
the ones observed when thiouracil is administered. Pro-
pyl thiouracil has been administered in doses of 75 mg.
per day, but more recently up to 200 mg. have been
recommended. It appears to have definite advantages
over thiouracil but still is not without dangerous toxic
complications.
The use of radiation therapy in hyperthyroidism is
well known. It is effective in a fairly high percentage
of cases. The idea of the use of “internal radiation,”
using various radioactive isotopes of iodine, has been
current for about ten years, but the unavailability of
radioactive iodine and various other factors have limited
its application.
Hertz and Roberts9 reported the results of treatment
of twenty-nine patients with radioactive iodine, and
Chapman and Evans6 reported the treatment of twenty-
two additional patients. Both groups used I130 (with a
small amount of I131). I1,30 has a half life of twelve
hours, and I131 has a half life of eight days. Both
substances emit beta rays in the process of decompo-
sition. The calculation of dose of isotope used depended
on the following data: (1) fractional uptake of radio-
active iodine by the thyroid, (2) the known energy
of the radiations from I130 and I,131 (3) the clinical
estimation of the weight of the thyroid of the patient,
and (4) the known pattern of uptake and retention of
radioactive iodine by hyperplastic thyroid gland of hyper-
thyroidism.
Hertz and Roberts9 used from 1.5 to 28 m.c. of I130
giving an estimated 500 to 2,500 roentgens (plus or
minus 50 per cent) to the thyroid. Of twenty-eight
patients whom they felt had received adequate dosage
(questioned by Evans and Chapman6, five patients un-
derwent subtotal thyroidectomy partly as a means to
evaluate therapy. Twenty patients are not thyrotoxic,
and three patients must be considered failures, three or
more years after therapy. Every patient who had a sub-
total thyroidectomy developed myxedema or hypometab-
olism, indicating continued progress of involution after
the thyroidectomy.
Chapman and Evans6 used much larger doses — from
0.5 to 1.2 m.c. per gm. of estimated thyroid weight.
In a series of twenty-two patients so treated, twenty
are either nontoxic or myxedematous, and only two
failed to show a return to normal metabolic state. The
decline in basal metabolic rate to normal occurred over
an average period of sixty days. Five patients had
multiple doses. It is apparent that this last series of
cases 'from the Massachusetts General Hospital re-
sponded more promptly and completely than those of
Hertz and Roberts.
In order to carry out such therapy adequately, it is
imperative that a competent physicist be able to follow
the treatment, measuring carefully the amount excreted,
the calculation of dose, et cetera.
One patient has been treated with I1?1 (half-life of
eight days) at the University Hospital. Doctor Stem
strom and the staff of his laboratory have carried out
the necessary calculations of dosage, excretion, and
uptake by the gland, in terms of roentgen equivalents.
The patient is a twenty-nine-year-old woman with very
severe hyperthyroidism of about six months’ duration.
February, 1947
199
MINNEAPOLIS SURGICAL SOCIETY
Her basal metabolic rate at time of hospital admission,
after taking iodine for three weeks, was -j-65 per cent.
Her condition has been precarious. Propyl thiouracil
was started, but a generalized skin eruption, leukopenia
and fever developed shortly afterward. This actually
proved to be due to phenobarbital rather than propyl
thiouracil. Too short a time has elapsed since giving
the radio-iodine to determine what the response will be,
but she has improved quite definitely now.
Conclusions
The mode of action, effectiveness, dangers and indi-
cations of the thiouracil group of drugs have been re-
viewed. These agents have added a great deal to our
understanding of the physiology of the thyroid gland
and have proved to be of very real value in the control
of hyperthyroidism. The thiouracil compounds do not
supplant thyroidectomy, but merely supplement it at the
present time.
Radioactive iodine gives promise of being an impor-
tant tool in the medical therapy of hyperthyroidism.
Since its use depends on fairly elaborate equipment and
a thorough knowledge of physics, for the present only
a few clinics and hospitals are able to use radioactive
materials.
Bibliography
1. Astwood, E. B.: Treatment of hyperthyroidism with thiou-
rea and thiouracil. J.A.M.A., 122:78-81, (May 8) 1943.
2. Astwood, E. B.: Chemical nature of compounds inhibiting
the thyroid gland. J. Pharmacol. & Exper. Therap., 78:79,
(May) 1943.
3. Astwood, E. B., and Bissel, Adele: Effect of thiouracil on
the iodine content of the thyroid gland. Endocrinology,
34:282-296, (April) 1944.
4. Astwood, E. B.; Sullivan, J.; Bissel, Adele, and Tyslowitz,
R. : Action of certain sulfonamides and of thiourea upon
the function of the thyroid gland of the rat. Endocrinology,
32:210-225, (Feb.) 1943.
5. Atwood, E. B., and Vanderlaan, VV. P. : Thiouracil deriva-
tives of greater activity for the treatment of hyperthyroidism.
J. Clin. Endocrinology, 5:424-430, (Dec.) 1945.
6. Chapman, E. M., and Evans, R. D. : Radioactive iodine in
hyperthyroidism. J.A.M.A., 131:92-95, (May 11) 1946.
7. Danowski, T. S. ; Man, E. B., and Winkler, A. W. : Addi-
tive effects of iodine and thiourea in hyperthyroidism. J.
Clin. Investigation, 25:597-604, (July) 1946.
8. Franklin, A. L. ; Lerner, S. R., and Chaikoff, I. L. : The
effect of thiouracil on the formation of thyroxine and di-
iodotyrosine by the thyroid gland of the rat with radioactive
iodine as indicator. Endocrinology, 34:265-275, (April)
1944.
9. Hertz, S., and Roberts, A.: Radioactive iodine in .thyroid
physiology. J.A.M.A., 131:86-92, (May 11) 1946.
10. Kennedy, T. H., and Purves, H. D. : Studies on experi-
mental goiter. I. The effect of brassica seed diets on rats.
Brit. J. Exper. Path., 22:241-244, (Oct.) 1941.
11. MacKenzie, C. G., and MacKenzie, Julia B. : Effect of sul-
fonamides and thiourea upon the function of the thyroid
gland of the rat. Endocrinology, 32:185-209, (Feb.) 1943.
12. MacKenzie, J. B.; MacKenzie, C. G., and McCollum, E. V. :
Effect of sulfanilylguanidine on the thyroid of the rat.
Science, 94:518-519, (Nov. 28) 1941.
13. Moore. F. D. : Toxicity of thiouracil. J.A.M.A., 130:315-
319, (Feb. 9) 1946.
14. Rawson, Rulon W. ; Evans, R. D.; Means, J. H.; Peacock,
W. C. ; Lerman, J., and Cortell, R. E. : The action of thiou-
racil upon the thyroid gland in Grave’s disease. J. Clin.
Endocrinology, 4:1-11, (Jan.) 1944.
15. Rawson, R. W. ; Hertz, S., and Means, J. H.: Thiocyanate
goiter in man. Am. Int. Med., 19:829, 1943.
16. Rawson, R. W. ; Tanheimer, J. F., and Peacock, W. : The
uptake of radioactive iodine by thyroids of rats made goiter-
ous by potassium thiocyanate and by thiouracil. Endocrin-
ology, 34:254, (April) 1944.
17. Sharpless, G. R.; Pearsons, J., and Prato, G. S. : Produc-
tions of goiter in rats with raw and with treated soybean
flour. J. Nutrition, 17:545-555, (June) 1939.
18. VanWinkle, W. ; Hardy, S. M.; Hazel, G. R.; Hines, D. C.;
Newcomer, H. S. ; Sharp, E. A., and Sisk. W. N.: Toxicity
of thiouracil. J.A.M.A., 130:343-347, (Feb. 9) 1946.
19. Williams, R. H., and Clute, H. M.: Thiouracil in the treat-
ment of thyrotoxicosis. New England J. Med., 230:657-667,
(June 1) 1944.
20. Williams, R. H. : Thiouracil treatment of thyrotoxicosis.
I. The results of prolonged treatment. J. Clin. Endocrin-
ology, 6:1-22, (Jan.) 1946.
EXTERIORIZATION PROCEDURES FOR
COLON INJURIES
U. SCHUYLER ANDERSON, M.D.
Minneapolis, Minnesota
In addition to well-established principles which are
followed in the management of intra-abdominal trauma,
exteriorization procedures for large bowel injuries have
been found extremely valuable. For the purpose of
discussion, exteriorization procedures may be considered
to include not only the actual exteriorization of the
damaged segment of bowel but also colostomies formed
proximal to the site of injury in a part of bowel which
cannot be brought outside the abdominal cavity. How-
ever, it is important to note the distinction between
exteriorization of a wounded segment of bowel and the
construction of a colostomy for the purpose of defunc-
tionalizing the distal segment. At times both purposes
may be accomplished by one and the same procedure,
but a clear understanding of the purpose of the operation
is necessary to the selection of the techniques involved.
While stationed at army general hospitals, one in this
country, and one overseas, the author became impressed
with the usefulness of exteriorization, when about fifty
patients with colostomies which had been made in the
treatment of battle injuries of the colon and rectum at
overseas army medical installations came under his care.
The management of these colostomy patients and a par-
tial review of the literature constitute the basis of this
paper. The author has had no experience with the initial
treatment of battle injuries in the forward areas. It is,
therefore, with understanding and realization of the diffi-
culties encountered by surgeons in the front line regions,
and the knowledge that hindsight is easier than fore-
sight, that certain critical observations are made.
The wisdom of exteriorization of wounds of the colon
was emphasized repeatedly during the late war. Ogil-
vie,9 in reviewing the results of surgery in the western
desert, contended that the principle of exclusion of all
damaged parts of the large intestine until repair is com-
plete, applies to all injuries, even suspected ones, and
to all parts of the bowel, particularly the extraperitoneal
portion of the rectum. From directives and bulletins
issued by the Surgeon General’s Office, in which broad
policies and guiding principles on the care of the
wounded were presented, it can be learned that exteri-
orization of the injured bowel was considered the estab-
lished procedure. Proximal colosotomy was regarded as
mandatory in the treatment of wounds of the rectum.
Primary closure of wounds of the unprepared colon,
as found in battle casualties, was deemed unwise and
unsafe.
Ogilvie9 cited a case which is illustrative. Primary
suture of a retroperitoneal tear of the descending colon,
with drainage of the retroperitoneal region, was ac-
complished. Later a fecal fistula developed, and the
patient died on the ninth day. Autopsy showed the
wound of the colon to be broken down over a large area.
Fecal matter lay free in the retroperitoneal tissues, and
a severe general peritonitis was present. Comment by
the surgeon was : “Suture alone seemed adequate ; a
proximal colostomy should have been made.”
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MINNEAPOLIS SURGICAL SOCIETY
The following case, which was among those observed
by the author, also serves to illustrate the probable un-
wise choice of primary suture of a perforated colon
rather than exteriorization.
The patient incurred a gunshot wound of the abdomen
with the point of entrance in the right lumbar region
and the point of exit in the left lower quadrant of the
abdomen. At laparatomy ten hours after injury, a per-
foration 3 centimeters in diameter was found in the
upper portion of the sigmoid colon. The perforation was
closed. On arrival at an overseas general hospital, a
fecal fistula was present in the lower left quadrant
.of the abdomen. The external opening of the fistula
was the original wound of exit. At this hospital a loop
colostomy of the transverse colon was made and mul-
tiple bone fragments were removed from the left ilium.
After admission to a general hospital in this country,
it was found that the patient had the following condi-
tions : a fecal fistula, a poorly functioning loop colostomy
of the transverse colon, compound comminuted fractures
of the left ilium and sacrum with osteomyelitis of these
bones, an atonic bladder, anal sphincter incompetence and
partial paralysis of the left lower extremity. It was
determined by x-ray examination, after lipiodal injec-
tion, that the fistula communicated with the upper sig-
moid colon. Since the loop colostomy did not completely
divert the fecal stream and therefore did not defunction-
alize the distal bowel, revision of the transverse colos-
tomy with separation of the stomata was done. Later,
the perforated portion of the sigmoid colon and the
fecal fistula were excised, and end-to-end anastomosis
accomplished. The chronic osteomyelitis required drain-
age and sequestrectomy. The transverse colostomy was
permitted to remain because of the incompetent anal
sphincters. It is believed that exteriorization of the per-
forated portion of the sigmoid colon and the formation
of a double-barrel colostomy at the time of the first
laparotomy would have been the better procedure for
this patient. Exteriorization would have prevented the
formation of the fecal fistula and might well have les-
sened the severity of the osteomyelitis.
In reviewing the literature, it was found that authors
who had had first-hand experience with battle injuries
were almost without exception in favor of some type of
exteriorization of all battle injuries of the colon. Hors-
ley6 stated that there is no dispute concerning exteriori-
zation of the wounded bowel. Mason8 followed the dic-
tum, “exteriorize all colon injuries.” Such strict adher-
ence to the principle of exterioration of all colon in-
juries may be debatable in civilian-type injuries. Hoffert
reported at this society two cases of civilian-type injury
to the colon in which exteriorization was employed with
successful results in both cases.
Although there appears to be little or no argument
concerning the value of exteriorization of battle injuries
of the colon, there is considerable controversy over the
methods of accomplishing the exteriorization, such as
the technique involved and the type of colostomy to be
employed. It is believed by some surgeons that the
simple tube or loop colostomy, when properly performed,
will completely shunt the fecal stream and defunction-
alize the distal segment, while it is considered by others
that the loop colostomy is inefficient and that complete
defunctionalization of the distal bowel can only be ob-
tained by forming a colostomy with separated stomata.
It is felt by the latter that fecal material is bound to
get into the distal bowel if the colostomy is covered by
the same dressing. In observing the colostomies of
those patients which came under the author’s manage-
ment, it did not seem that there was always a clear un-
derstanding of the purpose of the operation at the time
the colostomy was made. This was particularly true of
proximal colostomies whose apparent intended purpose
was to defunctionalize the distal bowel but, because of
the technique used, could at best only decompress the
bowel. Many of these patients arrived at the general
hospital with the distal colon and rectum filled with
feces. This was especially troublesome in those patients
suffering from wounds of the buttocks and perineum
which communicated with the rectum and which fre-
quently were associated with compound fractures of the
pelvic bones.
In order that a better understanding of the purpose
of the operation can be acquired, Mason8 has grouped
trauma of the colon as follows: (1) perforations of the
antemesenteric portion up to one-half the diameter of
segment ; (2) perforations of the mesenteric and ante-
mesenteric border larger than one-half of the diameter;
(3) severely torn segments necessitating resection of
a segment; (4) complete transections ; (5) injuries to
the mesentery producing nonviable segments; (6) the
first five groups occurring in the rectosigmoid above the
pelvic floor; (7) the same five groups occurring between
the pelvic peritoneum and anus; and (8) injuries neces-
sitating right colectomy or cecectomy. Using a classi-
fication of this type, the exteriorization of the bowel
should be planned and the colostomy constructed, bear-
ing in mind not only the simplest and easiest closure
later but, what is more important, the real purpose of
the exteriorization.
Ordinarily two types of colostomies are employed :
(1) the tangential, simple, no-spur loop or tube colos-
tomy and (2) the long, double-barrel colostomy with or
without separation of the stomach. According to Ma-
son,8 injuries of the colon fall in groups as stated above;
and Groups 1, 6, and 7 should be treated by the simple,
no-spur, loop colostomy. There is no question con-
cerning the Group 1 injuries, since a loop colostomy will
handle adequately the small antemesenteric or lateral
perforations and lacerations. One questions that a loop
colostomy, no matter how performed, will completely
defunctionalize the lower bowel and rectum in Groups
6 and 7 injuries. It is believed that the time would be
well spent, providing the patient’s condition permits, in
constructing a colostomy which will completely defunc-
tionalize the lower segment. This can only be accom-
plished by the formation of a colostomy with separated
stomata, whether this be the Devine type or a no-spur
colostomy with separated stomata necessitating end-to-
end closure later. The usual double-barrel colostomy
with approximated stomata will permit feces to gravitate
from the proximal stoma to the distal stoma. Exclu-
sion-type colostomies should be constructed, particularly
for large intraperitoneal perforations or lacerations of
rectum, where it is obvious a long time will elapse be-
fore healing and where secondary closure of the rectal
wound will be necessary. Extensive damage to lower
bowel segments, associated injury of bladder and ure-
thra, and rectal injuries with compound fractures of the
pelvis are examples of injuries which require a pro-
longed and complete defunctioning artificial anus. Un-
February, 1947
201
MINNEAPOLIS SURGICAL SOCIETY
der these circumstances, the exteriorized loops should be
made sufficiently long to allow for complete transverse
section and some separation of the stomata. As ulti-
mate closure will be by end-to-end suture, the forma-
tion of a spur is undesirable. The formation of a
skin bridge between the arms of the loops might, in
fact, be preferable.
The loop colostomy may be used for small perfora-
tions of the rectosigmoid, suspected perforations of the
rectum, or when the patient’s condition is such that
the additional time required to construct a completely
diverting type would greatly add to the risk of the
operation. However, certain details in the formation
of the loop colostomy, as recommended by Horsley,6
Mason8 and Fallis,3 should be observed. For exteriori-
zations or loop colostomies in the lower quadrants of
the abdomen, short, laterally placed incisions which fol-
low the direction of the fibres of the external oblique,
similar to the McBurney incision, should be used. For
colostomy of the transverse colon, a transverse incision
through either rectus muscle, as advocated by Fallis,3
is indicated. The transverse incision will obviate the
necessity of rotating the loops or twisting the bowel in
its axis to permit delivery. Adequate mobilization with-
out tension is extremely important in preventing retrac-
tion. It should be recalled that about one-half the diam-
eter of the right colon, both flexures, and a portion of
the rectosigmoid lie retroperitoneally, and that the lateral
mesenteric attachments are for the most part avascular.
Lateral incisions in the mesocolon can be made with im-
punity in procuring mobilization. Even with adequate
mobilization there is a tendency for loop colostomies to
retract. For this reason, a glass rod or rubber tube
should be placed under the loop to be maintained in
place for several weeks if necessary. Retraction causes
the colostomy to degenerate into a useless fistula, which
may be difficult to repair or may lead to intraperitoneal
sepsis or abdominal wall abscess. The loop colostomy
should be opened as soon as it is made, in the long axis
of the antemesenteric border of the bowel, not neces-
sarily in a longitudinal band. About two-thirds of
the incision should be over the proximal loop and one-
third toward the distal loop. The mesenteric border
of the bowel will be undisturbed and will rest against
the glass rod or tube. Often this type of colostomy can
simply be closed by suturing the longitudinal incision
transversely. The closed loop can then be placed extra-
peritoneally or intraperitoneally as seems most desirable.
Injuries of the colon falling in Groups 2, 3, 4 and
5 of Mason’s8 classification should be treated by the
construction of a double-barrel spur colostomy, accord-
ing to Mason. This type of colostomy and exterioriza-
tion would permit extraperitoneal closure after crush-
ing the spur. It was Mason’s belief that exteriorization
of these injuries without formation of a spur would
result in a complicated procedure in re-establishment
of the continuity of the bowel. This is contrary to the
opinions of Keene7 and Hamilton and Cattanach,4 who
prefer excision of the colostomy and end-to-end intra-
peritoneal closure as a one-stage procedure rather than
the spur-crushing, extraperitoneal two-stage procedure.
The author has, on several occasions, closed colostomies
intraperitoneally with excellent results and no untoward
effects. As has been emphasized by Coller and Vaughn,3
Pemberton and Black,10 the ]>eritoneal cavity will stand
the contamination of intraperitoneal closure of a colos-
tomy or open end-to-end anastomosis better than the
abdominal wall tissues at the site of the colostomy.
Injuries of the ascending colon and cecum are ex-
tremely difficult to manage. Various exteriorizations
procedures have been recommended. Tangential per-
foration of the cecum may be treated by tube cecostomy
but preferably by exteriorization. Cecostomy, even when
necessary because of direct injury, should never be used
as a substitute for a proximal colostomy when indi-
cations are present for the latter. Extensive injuries
necessitating resection of the cecum and ascending
colon were treated by a number of different methods.
In one method, after resection, a terminal ileostomy was
created in a separate incision in the right lower quad-
rant, and the distal end of the colon was exteriorized
below the costal margin. Occasionally an ileocolostomy
was done and the distal end of the colon exteriorized as
a colostomy. The formation of a double-barrel colos-
tomy, one limb of which is the distal colon and the other
limb the terminal ileum, has been suggested as another •
way of handling these injuries.1 Such a combined prox-
imated ileostomy and colostomy could be closed extra-
peritoneally after crushing the spur.
It would seem a simple matter to close a colostomy.
However, the fairly large number of papers written on
the closure of colostomies by authors with large ex-
perience attests to the fact that difficulties are encoun-
tered. It was the author’s experience to find that a
large number of colostomies were attended with com-
plications or problems such as retractions, herniation
of the bowel subcutaneously, interposed foreign bowel
or mesentery between the colostomy loops, varying de-
grees of rotation of one limb of the colostomy around
the other limb, secondary perforations or fistulae ad-
jacent to the colostomy, and inflammatory or granulom-
atous masses involving the colostomy. These complica-
tions prohibited or precluded the use of the Paul-
Miculicz technique or spur-crushing extraperitoneal
closure. Excision of the colostomy, followed by intra-
peritoneal, open or closed, end-to-end anastomosis, was
accomplished in these cases, with excellent results.
Where a well-defined spur is present, the usual spur-
crushing extraperitoneal closure can be used. Whatever
method of closure is used, the contamination of the
abdominal wall tissues should be handled either by de-
layed closure, as used by Coller and Vaughn3 and Pem-
berton and Black,10 or by subcutaneous drainage.
Summary
The value of exteriorization procedures for colon
injuries is emphasized.
The techniques involved and the indications for the
various methods of exteriorization are discussed.
When the intended purpose of the exteriorization pro-
cedure is defunctionalization of the distal bowel it is
believed that a formal type of colostomy with sepa-
rated stomata should be made, rather than a simple loot)
colostomy.
202
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MINNEAPOLIS SURGICAL SOCIETY
Bibliography
1. Colcock, B. P. : Perforating wounds of the colon and rec-
tum. Am. J. Surg., 72:343-351, (Sept.) 1946.
2. Coller. F. A., and Vaughn, H. H. : Treatment of carci-
noma of the colon. Ann. Surg., 121:395-411, (Apr.) 1945.
3. Fallis, L. S. : Transverse colostomy. Surgery, 20:249-256,
(Aug.) 1946.
4. Hamilton, J. E., and Cattanach, L. M.: Reconstruction of
war wounds of the colon and rectum. Surgery, 20:237-239,
(Aug.) 1946.
5. Hoffert, H. E. : Acute nor.malignant perforations of the
colon. Minnesota Med., 29:935-939, (Sept.) 1946.
6. Horsley, G. W., and Michaux, R. A.: Surgery of the
colon as seen in an overseas hospital. Surgery, 19:845-854,
(June) 1946.
7. Keene, C. H.: Colostomies. Bull. U. S. Army M. Dept.,
86:115-117, (Mar.) 1945.
8. Mason, J. M.: Surgery of the colon in the forward battle
area. Surgery, 18:534-541, (Nov.) 1945.
9. Ogilvie, \V. H. : Abdominal wounds in the western desert.
Surg., Gynec. & Obst., 78:225-238, (Mar.) 1944.
10. Pemberton, J. J., and Black, B. M. : Delayed closure of
incisions made at closure of colonic stomas. Surg., Gynec.
& Obst., 76:385-390, (Apr.) 1943.
Discussion
Dr. Robert J. Tenner: Dr. Anderson has presented
a very interesting and excellent discussion of the problem
of colostomy and exteriorization procedures for colon
injuries.
I would like to emphasize the importance of an ex-
clusion type of colostomy. My experience in an Army
General Hospital was very similar to Dr. Anderson’s,
and I saw several cases of chronic fecal fistulas which
I believe would have been prevented if the colostomies
which were established had completely diverted the fecal
stream.
When it is deemed advisable to make a colostomy,
whether for decompression in the case of an obstructing
carcinomatous lesion or for protection of the sutured
colon after repair of an injury, I feel the fecal stream
should be diverted completely. I have seen colostomies
which only partially diverted the fecal current, and I
believe these were so constructed, in part at least, to
facilitate the later closure of the bowel in a retroperito-
neal or so-called aseptic manner. This aid to later
closure of the stoma is no longer necessary, in my
opinion, in that with the aid of chemotherapy plus the
immunity present in these cases there is little or no
risk or danger to the procedure of colostomy closure.
At our hospital we closed over fifty colostomies. These
closure cases were prepared for five days preoperatively
with IS to 20 gm. of sulfasuccidine daily, and then
the stoma was closed and the wound sutured in layers.
In some instances an extraperitoneal closure was done,
but more often the colon was put back into the perito-
neal cavity, free on its mesentery. All cases healed well
and with no further difficulty. Therefore, I feel it is im-
portant to establish a completely exclusion type of colos-
tomy in order to accomplish the main purpose at hand,
in those cases where for any reason a colostomy is
indicated.
There is a point I would like to mention in con-
nection with the construction of a transverse colostomy
when such a procedure is indicated. I feel it is advis-
able to make use of the protective properties of the
omentum in these cases. An opening should be made
in the omentum distal to its attachment to the trans-
verse colon and by reaching through this opening, a
loop of the colon can be delivered which will be sur-
rounded by a collar of omentum. After the colon has
been exteriorized and the wound closed, the omentum is
in direct contact with the peritoneum of the anterior
abdominal wall and thus seals off the peritoneal cavity
from contamination and protects against possible hernia-
tion of the small intestine through the wound. Also
when the colonic stoma is later closed, the omentum
affords excellent protection against possible leakage
which might occur at the suture line.
Dr. Hamlin Mattson: Colon injuries constituted 22
per cent of all intra-abdominal visceral injuries in World
War I. At Wakeman Hospital Center, most of our
February, 1947
colon surgery consisted in closing colostomies made
overseas. We saw loop colostomies. I do not recall
seeing one with separated stomata. We did end-to-end
sutures and dropped the colon back into the peritoneal
cavity. By this method better repair of the fascial
hiatus is possible. The peritoneum is much better able
to cope with infection than is the abdominal wall. The
abdominal wall was drained. With chemotherapy and
suction tubes in the lower small bowel, we are permit-
ted greater boldness in colon surgery than heretofore.
We saw posterior colonic fistulas from bullet wounds
through the ascending and sometimes descending colon
where no mesentery is present. In the former it seemed
best to do right hemicolectomy, while in fistulas from
the descending colon the preferable procedure seemed to
be repair of the colon after rotation, followed by a tem-
porary transverse colostomy, Devine type.
Dr. Nathan C. Plimpton : I was very much inter-
ested in Dr. Anderson’s paper and the comments. These
men were at one end of the line while I was at the
other. We often wondered what happened tp the men
we operated on, and my only follow-ups were a few
scattered letters from some of my patients.
It is evident from what was presented here tonight
that some colon injuries would have been better treated
by an exclusion type of colostomy. In the European
Theater of Operations, by directive, we did loop colos-
tomies, and I think it is a good operation for most of •
the cases it was done on. Our group was about evenly
divided between repairing the injuries to the colon and
doing a proximal colostomy, and by exteriorizing the
injured segment. I used to prefer the former when
possible because I could delay the opening of the
colostomy a day or so, thereby saving the wound from
some contamination. Also, I preferred bringing my
colostomies through a separate wound, usually a trans-
verse incision when a transverse colostomy was done.
One trick we employed when there was a single hole in
the colon was to exteriorize that particular part of the
bowel and repair it, with the hope that it would hold.
Of course, it never did, but the wound was spared sev-
eral days contamination. It was our feeling at the time
these colostomies were done that, because the distal loop
of the colon was already full of feces, it would not
make much difference if there was some drainage from
the proximal loop into the distal loop as long as we had
performed a decompression.
Another argument for this procedure is that it is
quick and simple, which is quite a . factor when there
is a backlog of ten to fifteen men in the preoperative
tent who need abdominal and chest operations. I
quite agree that all retroperitoneal wounds of the colon
should be drained directly to the outside, in addition to
the proximal colostomies. One thing we learned was
that in the rather severe wounds of the rectum it is bet-
ter to do a proximal transverse rather than a sigmoid
colostomy, because in the final repair it might be neces-
sary to mobilize enough sigmoid to anastomose it with
the lower rectum, and if the latter procedure is done,
it would add to the difficulty of the final operation.
Dr. U. S. Anderson : Before this meeting, I tried
to find someone who had served in a field or evacuation
hospital to tell of his experiences in making these colos-
tomies. I was unable to find anyone, and I am there-
fore glad that Dr. Plimpton has told us something about
his experiences. All of us who were in general hospitals,
both in this country and overseas, marveled at the
excellent work of the surgeons in the field and evacua-
tion hospitals. I did not wish to give the impression
that all of the colostomies were made incorrectly.
Many of them were made correctly, subsequently closed
and the patients returned to duty. As I stated in my
paper, I had had no first-hand experience with battle cas-
ualties, but believe I could understand and appreciate
the many difficulties under which the surgeons in the
forward areas worked.
203
^ Reports and Announcements ♦
MEDICAL BROADCAST FOR FEBRUARY
The following radio schedule of talks on medical
and dental subjects by William O’Brien, M.D., Di-
rector of Postgraduate Medical Education, University
of Minnesota, is sponsored by the Minnesota State
Medical Association, the Minnesota State Dental Asso-
ciation, the Minnesota Hospital Service Association in
co-operation with the Minnesota Hospital Association
and the Minnesota Nurses Association, and the Uni-
versity of Minnesota School of the Air.
1
11:30 A.M.
KUOM-
KROC-
KFAM
Medicine in the News
4
4 :45 P.M.
WCCO
Hospitals for Mental Disease
5
11 :00 A.M.
KUOM
Your Body Needs Regular Ex-
ercise
7
4:45 P.M.
WCCO
Social Hygiene
8
11:30 A.M.
KUOM-
KROC-
KFAM
Medicine in the News
11
4:45 P.M.
WCCO
The School Nurse
12
11 :00 A.M.
KUOM
Rest and Sleep Renew Our
Bodies Daily
13
4:45 P.M.
WCCO
National Heart Week
IS
11:30 A.M.
KUOM.
KROC- ,
KFAM
Medicine in the News
18
4:45 P.M.
WCCO
Progress in Maternal and In-
fant Care
19
11:00 A.M.
KUOM
Your Nervous System Directs
Your Life
20
4 :45 P.M.
WCCO
Cause of Accidents
22
11.30 A.M.
KUOM-
KROC-
KFAM
Medicine in the News
25
4:45 P.M.
WCCO
On Becoming a Nurse
26
11:00 A.M.
KUOM
We Can Grow Old and Be Well
27
4 :45 P.M.
WCCO
Injuries of Mouth and Teeth
AMERICAN CONGRESS ON
OBSTETRICS AND GYNECOLOGY
The program of the Third American Congress on
Obstetrics and Gynecology', to be held September 8-12,
1947, in St. Louis, will feature general sessions for all
groups making up the congress as well as smaller in-
dividual group meetings and round-table discussions.
The morning sessions will be panel-type presentations
of the following subjects: September 9, Anesthesia and
Analgesia; September 10, Cancer; and September 11,
Cesarean Section.
The afternoon meetings of the medical section of
the congress will consider on September 9, Psychoso-
matic Aspects of Pregnancy; on September 10, Preg-
nancy Complicating Cardiac Disease, Diabetes and
Tuberculosis; and on September 11, Recent Advances
in Endocrinology.
Round-table discussions from four to five o’clock
daily will consider such topics as etiology of abortion,
asphyxia, fibroids, prolonged labor, infertility', early
ambulation, adolescence, treatment of abortion, genital
relaxation, ovulation, the menopause, the cystic ovary,
uterine bleeding, nutrition in pregnancy, geriatric gyne-
cology, endometriosis and erythroblastosis.
Concurrent sessions and round tables for nurses, hos-
pital administrators and public health workers are be-
ing arranged.
The popular forceps and breech demonstrations, that
attracted so much attention at the second congress in
1942, will be increased in number so that eighteen
demonstrations per day will be held, six each at nine,
one and five o’clock daily.
A large scientific and educational exhibit is being
set up under the direction of Dr. J. P. Pratt of De-
troit, and a comprehensive motion picture program
is being arranged by Dr. John Parks of Washington,
D. C. The committees assisting these doctors will re-
view applications by prospective participants late this
spring. Anyone wishing to make application for space
in the scientific exhibit or for time on the motion pic-
ture program may obtain the proper blanks from the
office of the congress at 24 West Ohio Street, Chicago
10, Illinois.
SECOND SOUTH AMERICAN CONGRESS
OF NEUROSURGERY
The second South American Congress of Neurosur-
gery will be held in Santiago, Chile, April 21-27, 1947.
Subjects which will receive special attention include Hy-
drocephalus, Histology in Brain Tumors (Gliomas and
Paragliomas) in Relation to Clinical Findings, and
Brain Abscess.
As the meeting is sponsored by the Chilean govern-
ment, embassies and consulates of Chile have been in-
structed to grant free visas to those wishing to attend
and to extend maximum facilities for obtaining the
necessary travel permits.
The registration fee of $18.00 (United States) in-
cludes the cost of a copy of the Proceedings of the
Congress.
Copy of the program and further information may be
obtained from Dr. Carlos Villavicencio, Instituto de
Neurocirugia y Neuropatologia, Casilla 70, Santiago,
Chile.
EXAMINATIONS FOR APPOINTMENT
TO REGULAR CORPS, USPHS
Competitive written examinations for appointment to
the Regular Corps of the USPHS to fill some seventy-
five vacancies will be held on April 14 and IS, 1947,
at various locations. The oral examinations will be
held from February 13 to April 9 in strategically located
cities. One of these is Minneapolis and the date set
is February 27.
Commissions are available to scientists trained in bac-
teriology, mycology, parasitology, entomology, biology,
chemistry, physiology', physics, psychology, et cetera.
Salary for assistant scientists is $3,811, and for senior
assistant scientists, $4,351 with allowance for depend-
ents.
Application forms and additional information can be
obtained from the Surgeon General, USPHS, Wash-
ington 25, D. C.
(Continued on Page 206)
204
Minnesota Medicine
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(7H gr. of Searle Aminophyllin*).
Supposicones are unlike all suppositories known heretofore — the
specially prepared base results in prompt disintegration in the
rectum at body temperature, yet no refrigerated storage is necessary.
Aminophyllin Supposicones are nonirritating to the rectal
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sized and shaped for easy insertion and retention.
In boxes of 12.
* Searle Aminophyllin contains at least 80% of anhydrous theophyllin.
Supposicones is the registered trademark of G. D. Searle & Co.,
Chicago 80, Illinois.
SEARLE
RESEARCH IN THE SERVICE OF MEDICINE
February, 1947
205
WOMAN’S AUXILIARY
WOMAN’S AUXILIARY
STATE BOARD MEETING
The fall board meeting of the Woman’s Auxiliary
to the Minnesota State Medical Association was held
at the University Club in Saint Paul, Friday, Decem-
ber 6, 1946.
Mrs. Jesse D. Hamer, Phoenix, Arizona, president of
the Auxiliary to the American Medical Association, was
present and brought a very interesting message to the
board members. A luncheon followed the business meet-
ing.
Hennepin County
On December 6, 1946, the Hennepin County Auxiliary
held its annual Christmas tea in the Medical Arts
lounge. Mrs. Jesse D. Hamer, Phoenix, Arizona, na-
tional president, and Mrs. Melvin S. Henderson, Roches-
ter, state president, were guests of honor.
Mrs. Leonard Arling read “The First Christmas
Tree,” and Mrs. Elmer O. Dahl and Mrs. Arthur A.
Wohlrabe were tea hostesses.
A luncheon was given at the Radisson Hotel, January
3, 1947.
Mr. E. C. Peterson of the Baker Peterson Floral
Company gave a demonstration of floral arrangements.
Mrs. Gerald M. Koepke made the luncheon arrange-
ments and Mrs. C. A. Boreen was hospitality chair-
man.
Mower County
The Mower County Auxiliary met Monday, Decem-
ber 30, 1946, at the home of Mrs. J. K. McKenna, with
eleven members present.
Mrs. H. B. Allen presided as Mrs. P. C. Leek gave
an interesting outline of the Christmas seal work. She
traced the progress of the seal from its origin in 1903
in Denmark to its present date. She told how in 1904
the National Tuberculosis Association was organized to
study tuberculosis in all its forms, to spread knowledge
as to its causes, treatment and prevention.
The Auxiliary voted to purchase a $5.00 tuberculosis
bond.
Luncheon followed the meeting.
Red River Valley
The Red River Valley Medical Auxiliary met Tues-
day evening, January 7, 1947, at the home of Mrs.
O. K. Behr, Crookston. Mrs. M. O. Oppegaard, presi-
dent, presided at the business meeting which was fol-
lowed by several tables of bridge.
Mrs. J. P. Anderson of Red Lake Falls was the
high-score prize winner. The out-of-town guests were
Mrs. W. E. Anderson of Clearbrook and Mrs. C. H.
Holmstrom and Mrs. M. J. Bechtel of Warren.
Refreshments were served by Mrs. Behr.
The meeting followed the annual banquet held in the
Red and Gold room of Hotel Crookston, attended by
members of the Red River Valley Medical Associa-
tion and the Auxiliary.
Waseca County
Dr. and Mrs. Clifford Wadd of Janesville entertained
the members of the Waseca County Medical Society and
their wives at a dinner at Hotel Waseca, January 7,
1947.
At the business meeting of the auxiliary, held after
the dinner, the following officers were elected : Presi-
dent, Mrs. B. J. Gallagher, Waseca; Vice President,
Mrs. Ray Hottinger, Janesville; Secretary-Treasurer,
Mrs. R. D. Davis, Clearbrook.
Winona County
Winona County Auxiliary members attended a din-
ner with their husbands Monday evening, January 6,
1947, at the Winona Hotel, Winona, Minnesota. A busi-
ness meeting followed the dinner.
REPORTS AND ANNOUNCEMENTS
(Continued from Page 204)
MINNESOTA PATHOLOGICAL SOCIETY
The regular meeting of the Minnesota P'athological So-
ciety was held in the Medical Science Amphitheater of
the University of Minnesota Medical School on Jan-
uary 21, at 8:00 p.m. The featured address, “Rehabili-
tation Following Semi-starvation in Man,” was given by
Dr. Ancel Keys.
UNIVERSITY GRADUATES AVAILABLE
FOR ASSISTANTSHIPS
The University of Minnesota Medical School is grad-
uating a senior class on August 29, 1947. Some of
these young physicians have expressed an interest to
engage in further training on a preceptorship basis or
to serve as office assistants for periods of from three
to nine months pending the beginning of regular intern-
ships.
Any physician in Minnesota or in the midwest who is
interested to discuss such an arrangement with students
at the University of Minnesota Medical School may
correspond with Dr. M. M. Weaver, Assistant Dean and
Secretary of the Committee on Internships, University
of Minnesota Medical School.
WASHINGTON COUNTY
The Washington County Medical Society was ad-
dressed at its January 14, 1947, meeting by Dr. Karl
H. Pfuetze, director and superintendent of the Mineral
Spring Sanatorium. Chest x-rays of some eighty-eight
high school students, teachers and janitors who had
had positive Mantoux reactions were interpreted.
Medicine is the only profession that labors incessantly
to destroy the reason for its own existence. — Lord
Bryce.
206
.Minnesota Medicine
IN MEMORIAM
In Memoriam
HARRY WINSLOW ALLEN
Dr. H. W. Allen of Minneapolis passed away on
December 28, 1946, following a year’s illness.
Dr. Allen was born at Bath, Maine, on July 10, 1872.
He lived in Red Wing, Minnesota, before attending
the University of Minnesota, from which he received
B.S. and M.S. degrees in 1895 and his M.D. degree in
1900.
He was a member of the Hennepin County Medi-
cal Society, the Minnesota State and American Medical
Associations, and a staff member of St. Barnabas Hos-
pital. For many years he was medical examiner for
the Claim Department of the Minneapolis and St.
Louis Railway.
Dr. Allen is survived by his wife and a sister, Mrs.
George Murfin, Lake Minnetonka.
GEORGE RALPH CHRISTIE
Dr. George Ralph Christie, of Long Prairie, died in
Asbury Hospital in Minneapolis on January 20, 1947,
in his eighty-seventh year.
Dr. Christie had practiced medicine at Long Prairie
for sixty years. He was born in 1858 and graduated
from the University of Illinois, in 1882. Although he
retired some years ago, he continued to be prominent in
local business and civic affairs and was well known in
Minneapolis.
His immediate survivors are three sons ; Dr. Robert
of Long Prairie, George W., editor of the Red Lake
Falls Gazette; and Donald R., of P'erham.
Funeral services were held on Wednesday, January
22, at 2 p.m. and interment was at Long Prairie.
DONALD MICHAEL DECOURCY
Dr. Donald Michael DeCourcy was born in Saint Paul,
on March 3, 1902, and died suddenly on May 28, 1946.
He was buried in St. Mary’s cemetery, Minneapolis.
He attended St. John’s grade school on Dayton’s
Bluff and 'later graduated from St. Thomas Military
Academy, Saint Paul. While at St. Thomas College,
where he took his pre-medical course, he played half-
back in football, played hockey, was Minnesota
State collegiate singles champion in tennis. In 1919
he won the Colonel Perkins silver tennis trophy and
was Saint Paul city tennis champion in 1922 and 1925.
He graduated from Marquette Medical School in 1929,
and while there he played defense on Marquette’s un-
defeated hockey teams of 1927 and 1928, who were the
Northern Collegiate Champions. He earned a place for
himself in Marquette’s Hockey Hall of Fame.
He interned at St. Joseph’s Hospital, Saint Paul,
from 1929 to 1930. He maintained an office on Day-
ton’s Bluff since his graduation and was affiliated with
the Veterans Hospital, where he served in the capacity
of orthopedic surgeon. He was on the staffs of Mounds
Park, St. John’s and St. Joseph’s Hospitals. He was
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207
IN MEMORIAM
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ST. PAUL MINNEAPOLIS
a member of the Minnesota State and American Medi-
cal Associations, and the Ramsey County Medical
Society. He was also a member of the Phi Chi
medical fraternity.
He is survived by his wife, Elizabeth Talbot De-
Courcy, whom he married on June 19, 1937, and two
sons, Donald Michael, Jr., and Michael Talbot DeCour-
cy, who was born about one hour after his father’s death.
James Wilson, M.D.
DOMINICK PATRICK DEMPSEY
Dr. Dominick P. Dempsey of Wabasha died Novem-
ber 30, 1946, at the age of seventy-six.
He was bom at Clermont, Iowa, on September 9,
1870. After receiving a B.S. degree from Valparaiso
University in 1903, he obtained his medical education
at Creighton Medical School in Omaha, graduating in
1906. He interned at St. Mary’s Hospital in Minneapolis
and opened an office in Kellogg, Minnesota, and in
Wabasha in conjunction with Drs. Lester and Doherty
in 1907.
Dr. Dempsey was a member of the Wabasha County
Medical Society, the Minnesota State and American
Medical Associations.
He is survived by a sister who lives in Dubuque,
Iowa, and several nephews and nieces in Iowa and
Nebraska.
JOHN JOSEPH EDERER
Dr. John J. Ederer, formerly of Mahnomen, Min-
nesota, passed away December 11, 1946, in Minneapolis,
following a heart attack, after an illness of almost two
years.
He was born at Morton, Minnesota, on March 9, 1905.
After attending North Dakota University for two years,
he took his medical course at the University of Min-
nesota, graduating in 1930, His internship was served
at the United States Marine Hospital in New York.
At one time he practiced in Morris and Bellingham,
Minnesota, and was an army physician from 1934 until
1936.
Dr. Ederer owned and operated the Mahnomen Hos-
pital at Mahnomen, Minnesota, for four years before
retiring in 1944. He was a member of the Red River
YTalley Medical Society and served as examining physi-
ciain for the Selective Service for a period of four
years in Mahnomen County. He was elected president
of the Mahnomen Golf Club in 1939.
Dr. Ederer is survived by his wife, Celeste, and two
sons, John H. and Paul F. Ederer.
HENRY B. GRIMES
Dr. H. B. Grimes of Madelia, Minnesota, died July
18, 1946, at the age of sixty-nine.
He was born in Mansfield, Ohio, on September 8,
1877. He received his medical degree from the Univer-
sity of Michigan in 1903 and interned at St. Mary’s
Hospital in Rochester, Minnesota.
After practicing at Lake Crystal, Minnesota, from
1904 until 1911, he moved to Madelia. In 1918 and
1919 he served as captain in the Medical Corps of the
army and later was a major in the army medical
reserve.
208
Minnesota Medicine
IN MEMORIAM
Dr. Grimes was a member of the W atonwan County
Medical Society, the Minnesota State and American
Medical Associations, and the Southern Minnesota Medi-
cal Association.
ELEANOR JANE HILL
Dr. Eleanor J. Hill of Minneapolis, one of the first
women graduates of the University of Minnesota Medi-
cal School, died December 12, 1946, at the age of
seventy-eight.
Dr. Hill was born at Rockwood, Ontario, August 1,
1868. She received her M.D. degree in 1902 and in-
terned at the State Hospital for the Insane at James-
town, North Dakota, staying there from 1902 until 1907.
She was head of the prenatal clinic at the North-
east Neighborhood House, school physician for the
Minneapolis Board of Education, and was a member
of the staff at Asbury and Northwestern Hospitals. She
was also a member of the Hennepin County Medical
Society, the Minnesota State and American Medical
Associations.
Dr. Hill is survived by a sister, Mrs. Abbie A. Pearce
of Minneapolis, and two brothers, Charles F. Hill,
Ontario, and George A. Hill, Jersey City, New Jersey.
ARNOLD PLANKERS
Dr. Arnold Plankers of Saint Paul died December
26, 1946, at the age of sixty-two.
He attended Central High School and Hamline Uni-
versity, Saint Paul, and the University of Minnesota,
where he played football. He received his medical de-
gree from Creighton University in 1910, and a few
years later began practice in Saint Paul.
CHARLES E. REMY
Dr. Charles E. Remy, superintendent of the Minne-
apolis General Hospital from 1930 to 1937, died Decem-
ber 16, 1946, at the Wesley Memorial Hospital in Chi-
cago.
After leaving Minneapolis in 1937, Dr. Remy was
associated with the Knickerbocker Hospital in New
York.
JESSE LYNN MACBETH
Dr. J. L. Macbeth of St. Clair, Minnesota, died No-
vember 19, 1946, at the age of sixty-six, following a
lingering illness.
Dr. Macbeth was born in Tivoli township, Minnesota,
June 20, 1880.
He received his medical education at Fort Wayne
Medical College, graduating in 1905, and began practice
in St. Clair in 1906. In 1920 he married Sadie Eaton
of Mankato.
Dr. Macbeth was a member of the Blue Earth County
Medical Society and the Minnesota State and American
Medical Associations.
He is survived by his widow, by three brothers, Walter
and George, of Mankato, and Dr. A. H. Macbeth, Fort
Wayne, Indiana, and by three sisters, Mrs. Nellie Red-
ner and Mrs. Mary Britt, of North Dakota, and Mrs.
Carrie Britt, Eagle Lake.
February, 1947
"EUREKA! I THINK
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Said A Doctor When Shown
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209
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COMMUNICATION
BROWN & DAY, INC
St. Paul 1, Minnesota
VICTOR E. VERNE
Dr. Victor E. Verne, brother of the late Dr. Paul
C. Verne of Minneapolis, died December 1, 1946.
Dr. V. E. Verne was born in Minneapolis, March 2,
1883. He graduated from the University of Minnesota
Medical School and was a member of the Nu Sigma
Nu medical fraternity.
He began practice at Parkers Prairie in 1906 and be-
came associated with Dr. O. J. Hagen in Moorhead,
Minnesota, in 1910. In 1914 he established his own of-
fice. In 1918 he joined the Medical Corps of the army
and was later discharged as a captain.
In 1922 Dr. Verne moved to Long Beach, California,
where he had since practiced.
Dr. Verne is survived by his wife and two children.
Communication
St. Cloud, Minnesota
November 27, 1946
Re : Our Forgotten Children
Dear Dr. Drake :
I am writing to you, the editor of Minnesota Med-
icine about a matter which I feel is important If,
when I get through telling you my story, you too feel
that it is worthwhile, perhaps you would like to write
an article for your Minnesota Medicine regarding it.
Minnesota has many good public, private and paro-
chial schools which take care of the educational needs
of most of the children of our state. There is, how-
ever, a group of children, which up until now, has re-
ceived very little attention. 1 refer to the homebound
crippled children of our state. The reason for this
neglect, I believe, is not that people have not been in-
terested in them, but rather, because the cases are
scattered and people have not known about them. It is
therefore up to some of us who do know what the
situation is, and what the possibilities are, to do what
we can to see that life is made as normal and satisfying
as possible for these deserving children. This, among
other things, includes the opportunity to get an edu-
cation.
St. Qoud has been the pioneer in this field of effort,
and is the only city in Minnesota which has in opera-
tion at the present time Home School for Shut-in
Crippled Children, conducted through its public schools.
Minneapolis has just recently begun operations to pro-
vide Home School for its shut-in crippled children.
As long as 1935, the school authorities of St. Cloud
recognized the needs and rights of physically handi-
capped children of our city and mapped out a pro-
gram of education for them. The work was first car-
ried out through a WPA project, which was planned
and supervised by the public schools, with the actual
home school work being carried out by WPA teachers.
When WPA was discontinued, interested members of
the St. Cloud Public Schools Administration collected
information from other states concerning the opera-
tion of classes for their physically handicapped children
and finally, in 1943, wrote a hill which they presented
before the Minnesota State Legislature. It was sup-
ported by many interested civic and education groups.
The bill was passed and became a law. Ever since that
time our home classes for physically handicapped chil-
dren have operated under the new law, with expenses
of operation being bom by the state. Though this
law has been in operation in Minnesota since 1943, no
other school district outside of St. Cloud, and now
Minneapolis, has availed itself of its opportunities.
210
Minnesota Medicine
COMMUNICATION
The question is, should there not be many more
classes for home-bound physically handicapped children
in operation in various public school systems scattered
throughout the State of Minnesota, to care for our
handicapped children? Included in this group are heart
cases, spastic cases, rheumatic fever cases, polio cases,
and crippled children. Could not a little teamwork
and publicity work on the part of doctors, school super-
intendents, and our State Department of Education bring
education to these deserving children? The machinery to
do the job is already set up and ready to go, but it isn’t
being used. Can’t we do our bit to give these deserving
youngsters the same break that normal children have?
Why add a mental handicap to the physical handicap
which they already have to bear?
Would you care. Dr. Drake, to bring this problem to
the attention of the doctors of the state, through
your Minnesota Medicine, urging them to call to the
attention of their superintendents of schools the physi-
cally handicapped children of their town, who are being
denied an education, just because they can’t go to school
and get it? I am also at this time writing to the Editor
of our Minnesota Education Journal, in an effort to
bring this matter to the attention of the superintendents
and teachers of our state. They seem not to know that
a law has been passed to take care of these children.
All we need is a little understanding and teamwork
and the job can be done. If the doctors will report
the cases to the school superintendents and the school
superintendents will write to the State Department of
Education for permission to set up Home Teaching, the
State of Minnesota has already said it would pay
the bill. Simple, isn’t it?
Thank you very much for anything you may care
to do about the matter. Sincerely
Martha Van Brussel,
Grade Supervisor
* * *
Editor’s Note: The above letter from Miss Van
Brussel calls attention to the provision, by the state,
for free home instruction of crippled children of school
age unable to attend school or the special public school
classes. In Minneapolis the Dowling School and in
Saint Paul the Lindsay School for crippled children
provide special instruction and free transportation for
handicapped children who are able to take advantage of
these special schools. In the cities and country districts,
there are many additional youngsters who are confined
to their homes and, therefore, unable to acquire an edu-
cation. These children are known to physicians.
If physicians would report the names of such chil-
dren to the Board of Education of the local school dis-
trict, and the Board in turn would report to the Special
Class Section of the State Department of Health the
names of five or more children living near enough to
each other to make visiting by a teacher practical, some-
thing might be accomplished.
In order to qualify for such home instruction, each
child must be provided with a certificate from a quali-
fied physician, stating the nature and extent of the dis-
ability and that the child is one so “deformed or im-
paired in body or limb” as to be unable to attend special
school classes with other children. As home enrollment
has a tendency to increase each year, the state re-
serves the right to require yearly examination of those
enrolled.
St. Cloud was the instigator of this worthy move-
ment, and Minneapolis has just recently taken ad-
vantage of the provisions of the 1943 law. The rest
of the state might well get in line.
February, 1947
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211
Of General Interest
#>
Dr. James J. Kolars opened offices for the practice
of medicine and surgery in Faribault on January 1.
* * *
“Recent Advances in Medicine’’ were discussed by Dr.
Martin O. Wallace, Duluth, at a recent meeting of the
local Kiwanis Club.
H*
Dr. Allan G. Janecky, formerly in practice at Thief
River Falls, but more recently located at Monroe,
Louisiana, has entered general practice at Warroad.
sjc sj: sj:
Announcement has been made of the termination of
the partnership of Dr. James A. Sanford and Dr.
Anthony H. Field, in Farmington, effective Tanuary 1,
1947.
* * *
Dr. Edward H. Juers, of Red Wing, was guest speak-
er at the December meeting of the Saint Paul Surgical
Society held at the University Club. Dr. J uers’ sub-
ject was “Pulmonary Thrombosis of the Axillary Vein.”
* * *
Dr. Hugh Patterson, of Slayton, is holding office hours
three forenoons during the week at Lake Wilson — Tues-
day, Thursday and Saturday — in order to provide the
residents with at least partial medical service.
* * *
Dr. Gordon R. Kamman, of Saint Paul, was the
featured speaker at the meeting of the Webster County
Medical Society held at Fort Dodge, Iowa, on January
16, 1947. Dr. Kamman’s subject was “Psychomatic
Diagnosis.”
* * *
Dr. Dean Affleck, formerly of Grand Rapids, has
resumed his practice at Twin Falls, Idaho, where he
had been located for nine years prior to entering military
service. Dr. Affleck took his medical degree at the
University of Minnesota.
* * *
The practice of the late Dr. G. B. Cross at Lakeville
has been taken over by Dr. Paul Wagner, effective
January 6. Dr. Wagner was only recently released
from military service. He is a graduate of the Univer-
sity of Minnesota School of Medicine.
* * *
Recent experimental use of streptomycin in the treat-
ment of tuberculosis was discussed by Dr. Horton C.
Hinshaw, of the Mayo Foundation, in the auditorium
of the Natural History Museum at the University of
Minnesota on Tuesday evening, January 14.
^ ^ ^
CORRECTION
Due to a typographical error, the wrong dosage was
given in the last line in the case summary of the article
on Epilepsy which appeared on Page 50 of the January
issue. The line should read: Dilantin sodium, 0.1 gm.
twice daily, was prescribed.
Dr. Hartvig Roholt, son of Dr. and Mrs. Christian L.
Roholt, of Waverly, received his medical degree at the
mid-year commencement at the University of Minne-
sota. Dr. Roholt is completing his internship at the
Milwaukee County Hospital, Milwaukee, Wisconsin.
* * *
Dr. Haddow M, Keith, of the Mayo Clinic, has been
in New York City for a meeting of the American
League Against Epilepsy and the Association for Re-
search in Nervous and Mental Disease. Dr. Keith, who
has been vice president of the League, was elected
president for the current year.
* * *
Dr. Charles E. Turbak has taken over Dr. Charles E.
Baker’s offices and practice in Herman.
Dr. Baker, who moved to Fergus Falls some months
ago, had been holding office hours in Herman several
days each week until a permanent medical practitioner
could be secured.
* * *
A portrait in oils of the late Dr. Franklin Raiter, of
Cloquet, has been hung in the local hospital. The un-
veiling, which was held on December 24, was witnessed
by men, women and children from all walks of life,
representative of the patients to whom Dr. Raiter had
given a devoted service.
* * *
Dr. Marland R. Williams, Cannon Falls, has been
joined in practice by Dr. Harold J. Anderson, formerly
of Saint Paul. Dr. Anderson, a graduate of the Uni-
versity of Minnesota Medical School, was recently dis-
charged from military service, where he was a surgeon
in the Army Air Corps.
* * *
Dr. W illiam B. Halme is now associated in practice
with Drs. Reino H. Puumala and Marie K. Bepko at
the new Cloquet Medical Center. Dr. Halme, who is
a former resident of the Kettle River-Automba com-
munity, was recently appointed a member of the cour-
tesy staff of St. Luke’s Hospital, Duluth.
* * *
Dr. Allan E. Moe has completed his three-year fel-
lowship in Internal Medicine at the Mayo Foundation
and received an M.S. degree in science from the Uni-
versity of Minnesota at the December commencement.
After February 1, 1947, Dr. Moe will be associated
with the Fargo Clinic at Fargo, North Dakota.
* * *
Dr. Frank Falsetti, of Rochester, who was recently
released from the Army Medical Corps, is taking post-
graduate work at the University of Minnesota School
of Medicine. At the time of his induction into military
service in 1944, Dr. Falsetti had an orthopedic residency
at St. Vincent’s Hospital in Toledo, Ohio.
( Continued on Page 214)
212
Minnesota Medicine
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OF GENERAL INTEREST
(Continued from Page 212)
Dr. James Chessen, formerly of Duluth, has been
awarded a fellowship by the American College of Sur-
geons. Dr. Chessen, who is in practice in Denver,
Colorado, is a member of the faculty of the University
of Colorado School of Medicine and consultant to the
Denver University Student Health Department.
* * *
Mid-year commencement at the University was a
very special occasion for Dr. and Mrs. Denton Eng-
strom, of Minneapolis. Dr. Engstrom, who has been
studying under the Army Training Program and in-
terning at St. Barnabas Hospital, received his medical
degree, and Mrs. Engstrom received a B.S. degree as a
medical technician.
* * *
The Minnesota Society of Neurology and Psychiatry
held a regular monthly dinner meeting at the Saint Paul
Town and Country Club on January 14 at 6:30 p.m.
The guest speaker was Dr. Barnard J. Alpers, professor
of neurology at Jefferson Medical College. Dr. Alpers’
subject was “The Correlation, by Pathological Studies,
of Retinal and Cerebral Arteriosclerosis.”
* * %
Dr. Alfred H. Wolf, Harmony, has taken over the
Minneapolis practice of his brother, the late Dr. William
W. Wolf, and will locate there permanently. Until an-
other physician can be secured for Harmony, Dr. Wolf
will keep office hours there every Saturday afternoon
and evening.
Dr. William Wolf died unexpectedly on December 14.
* * *
Dr. Howard Gray, of the Mayo Clinic, has returned
from the East where he attended the meeting of the
American Board of Surgery in Philadelphia and ad-
dressed the Luzerne County Medical Society at Wilkes-
Barre on “Problems Associated with Surgery of the
Biliary Tract.” While away Dr. Gray attended the
Clinical Congress of the American College of Surgeons
in Cleveland and participated in a panel discussion on
surgery of the stomach.
* * *
Dr. Paul Gamble was elected president of tbe Free-
born County Medical Society at the annual meeting
held at the Hotel Albert in Albert Lea in December.
Other officers elected at this time were : vice president,
Dr. Leo Prins; treasurer, Dr. Ernest S. Palmerston;
secretary, Dr. Paul Persons.
The business meeting, which was conducted by Dr.
Daniel L. Donovan, the retiring president, was preceded
by dinner at 7 :00 p.m.
* * *
Announcement has been made of the following fel-
lowship awards by the American College of Surgeons
to Minnesota men : Drs. Everett B. Coulter, Earl H.
Dunlap, Paul N. Larson, Reinhold M. Erickson, John
R. Paine and Wesley G. Schaefer, all of Minneapolis ;
Dr. David P. Anderson, Jr., Austin; Dr. Rochfors W.
Kearney, Mankato; Dr. Donovan McCain, St. Paul;
Dr. Anthony J. Spang, Duluth; and Drs. William H.
Bickel, George T. R. Fahlund, Fred Z. Havens, Paul
Z. Kiernan and Howard H. Lander, all of Rochester.
With his resignation as city health officer and county
coroner in January, Dr. James H. Haines, Stillwater,
terminated more than thirty years of public service.
Dr. Haines, who is a graduate of Rush Medical Col-
lege, Chicago, came to Stillwater in 1895, shortly after
receiving his degree. He served as superintendent of
the City Hospital for two years, then entered private
practice, in which he continued until forced to retire
recently because of ill health.
* * *
Dr. Robert Elman, associate professor of surgery,
Washington University, St. Louis, Missouri, was guest
speaker at the meeting of the Hennepin County Medical
Society on Monday, January 6, in the Medical Arts
Building. Dr. Elman appeared under the joint auspices
of the Medical Society and the Afinneapolis Surgical
Society.
The business session included nomination of officers
for 1947-48.
% Jjs %
Dr. \\ il f red M. Akins, now of Red Wing but for-
merly associated with the Afore Hospital and Clinic at
Eveleth, was guest of honor at a dinner for 150 Min-
neapolis YMCA campers and their fathers given at
the Y’s year-round camp— Camp Iduhapi— at Lake In-
dependence.
Dr. Akins, who was located in Eveleth for many
years, served as camp doctor at Camp Warren which
was operated by the YA1CA south of Eveleth.
:Je % %
Dr. Paul Reed has joined the Lenont-P'eterson Clinic
at Virginia, Minnesota. Dr. Reed, who is a native of
Virginia, is a graduate of the University of Minnesota
School of Afedicine. Following the completion of his
internship at the Afinneapolis General Hospital in 1937,
he entered practice at Langdon and Rolla, North Dakota,
where he remained until enlisting in the U. S. Navy in
1942. Dr. Reed was in service for four years and at
the time of his separation was lieutenant commander.
* * *
Dr. Duncan E. Luth, Duluth, was guest speaker at a
recent meeting of the West Duluth Women’s Club. Dr.
Lutli’s subject was India and Burma, on which he is
qualified to speak, having been on military assignment
in the China-Burma-India Theatre for fourteen months.
Dr. Luth, who was in the Army Afedical Corps for al-
most four years, served as group flight surgeon and
chief of obstetrical service of the Romulus Air Base.
Later Dr. Luth was assigned as surgeon for the Bengal
Wing in Burma and was placed in charge of all medi-
cal activities at the Ninth Air Base.
* * *
Dr. Jay A. Myers, professor of Public Health and
Medicine at the University of Minnesota, is now as-
sociated with five major health groups concerned with
the study and treatment of tuberculosis. He is general
chairman of the Research Council of the American
Chest Physicians; a committee member of the National
Tuberculosis Association ; a member of the recently
established subcommittee of the National Research
Council ; a member of the committee in the Division
214
Minnesota Medicine
OF GENERAL INTEREST
of Tuberculosis, U. S. Public Health Service, and a
member of the Tuberculosis Therapy Study Section
of the National Institute of Health.
* * *
Dr. H. H. Perman, formerly of Moorhead, has pur-
chased Dr. P. W. Demo’s practice at Wells, taking over
about the middle of January.
Dr. Perman took his medical degree at Washington
LTniversity in St. Louis. On the completion of his in-
ternship at the Minneapolis General Hospital, he entered
the U. S. Navy Medical Corps. Since his separation
from service six months ago, Dr. Perman has been
house surgeon at Abbott Hospital in Minneapolis.
Dr. Demo has re-entered the navy medical service
and is now on assignment at the Naval Hospital at
Bainbridge, Maryland.
* * *
Dr. Lawrence F. Richdorf, Minneapolis, has been
appointed co-chairman with Douglas Misfelt, Saint Paul,
of the American Legion Child Welfare program.
A major activity of this committee will be a cam-
paign to raise funds for a permanent professorship in
rheumatic fever and research to operate in conjunction
with the projected Variety Club Heart Hospital at the
University of Minnesota.
Dr. Richdorf attended the Legion’s Area D Child
Welfare Conference held in Omaha, January 9 through
11, when an appeal was made to other Legion organi-
zations throughout the country for assistance in estab-
lishing the proposed professorship.
Dr. G. Arvid Hedberg, superintendent of Nopeming
Sanatorium, has announced the appointment of Dr. Reno
W. Backus as associate medical director to succeed Dr.
Robert Davies, who resigned to take a position in Seattle.
Dr. Backus is a graduate of Rush Medical College,
Chicago. He was superintendent of the Methodist Hos-
pital in Peking, China, for fourteen years and while
there organized a 100-bed tuberculosis sanatorium. Re-
turning to the United States in 1941, he joined the staff
of McGregor Sanatorium in New York. Later he was
associated with Glen Lake Sanatorium in Minneapolis,
and has been on the staff at Nopeming since July 1, 1943.
* , * *
Dr. Ralph Larson, who has been associated in prac-
tice with Dr. Marvin R. Williams at Cannon Falls
for the past year, has opened offices at Anoka and pur-
chased a home there.
Dr. Larson is a 1940 graduate of the University of
Minnesota Medical School. He served his internship
at the Orange County, California, General Hospital,
then entered private practice. A short time later he
was inducted into the Army Medical Corps. As a bat-
talion surgeon he served in England for two years and
took part in the invasion of Normandy, where he was
wounded and evacuated to England. At the time of his
discharge, Dr. Larson had completed fifty-two months
of military service.
* * *
Dr. Ernest F. Cowern, North Saint Paul, was guest
of honor at an “appreciation party” sponsored by Fel-
lowship Lodge, AF and AM, and members of the East-
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February, 1947
215
OF GENERAL INTEREST
ern Star during the Christmas holidays in recognition
of Dr. Cowern’s forty-three years of service to the
community. Among the 400 persons who attended were
many of the 1,360 babies Dr. Cowern has delivered
since coming to North Saint Paul in 1903.
Dr. Cowern graduated from Dartmouth in 1902 and
practiced for a short time in Vermont and New Hamp-
shire before coming to North Saint Paul. He has
been local school physician for many years and still is
“on the job.”
* * *
Dr. Kenneth A. Peterson, formerly of Saint Paul, has
opened offices in association with Dr. Frank D. Gray,
of Marshall.
A graduate of the University of Minnesota Medical
School, Dr. Peterson interned at the Minneapolis Gen-
eral Hospital and was resident physician at the Midway
Hospital in Saint Paul for the two years prior to his
entry into the army. His military assignments included
duty at Northington General Hospital in Tuscalusa, Ala-
bama— a neurosurgical, orthopedic and plastic surgery
center — and the Regional Hospital at Fort McClellan,
Alabama, where he was chief of the outpatient depart-
ment. Dr. Peterson was separated from service last fall.
* * *
Eighteen new members, fourteen of them veterans of
World War II, were admitted to the Hennepin County
Medical Society at the meeting on January 6.
The veterans were: Drs. Eugene Edward Aherne,
Evrel Arthur Larson, Howard Martin Frykman, How-
Cook County
Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY — Two-week intensive course in Surgical
Technique starting January 20, February 17, March
17.
Four-week course in Genera] Surgery starting Feb-
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Two-week Surgical Anatomy & Clinical Surgery start-
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One week Surgery of Colon & Rectum starting March
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Two weeks Surgical Pathology every two weeks.
GYNECOLOGY — Two-week intensive course starting
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One-week course in Vaginal Approach to Pelvic Sur-
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OBSTETRICS — Two-week intensive course starting
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MEDICINE! — Two-week intensive course starting April
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One month course Electrocardiography & Heart Dis-
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TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar, 427 S. Honors St., Chicago 12, 111.
ard Hoffman Groskloss, Donald Ernest Often, George
Werner, Gordon Strom, Vincent Frances Swanson,
John Patrick Kelly, Donald Richard Reader, John Low-
ell Stennes, Eric Kent Clarke, Stanley Guy Law and
Clifford Orvis Erickson.
Other new members are Drs. Helen Robertson Ha-
berer, John Jacob Kaplan, Raymond E. Buirge, and
Donald John Erickson.
5*S 5}=
Dr. T. S. Eberley, formerly of Anoka, has entered
practice at Benson. A 1937 graduate of St. Olaf Col-
lege, Northfield, Dr. Eberley took his medical degree
at the University of Minnesota in 1941. He served his
internship at the Minneapolis General Hospital, then
entered the Army Air Force, where he was made a flight
surgeon. His assignments during four years in service
included twenty-eight months in Europe, with duty in
England, France, Belgium, Holland, Luxembourg, Ger-
many, Austria and Switzerland.
At the expiration of his terminal leave on February
15, 1946, Dr. Eberley enrolled at the University for a
six months’ postgraduate course. Recently he had been
practicing in association with Dr. James J. Warner
at Perham.
* * *
Eight oil paintings which included Rochester scenes
and California landscapes, the work of Dr. John E.
Crewe, were exhibited in a downtown Rochester store
during the first week of January.
Dr. Crewe, who is seventy-four and has been in medi-
cine for half a century, started painting as a hobby
about fourteen years ago, but he has never had any in-
struction. Most of the work has been done during
the past few years when his health was such that he
had to take things easier.
In all, Dr. Crewe has completed about twenty paint-
ings, some of them in water color, his first media. The
work is notable for a fine sense of color. Except for a
showing of a few paintings at a physician’s hobby show,
this is the first time Dr. Crewe has exhibited his work.
* * *
Effective January 1, 1947, Dr. Luveme H. Domeier,
formerly of Sleepy Eye, began practicing at New Ulm
in association with Dr. Otto J. Seifert, whom he had
been assisting for the past several months.
Dr. Domeier is a graduate of St. Thomas College,
Saint Paul, and took his medical degree at Loyola Uni-
versity, Chicago, in 1939. Following the completion of
his internship at St. Joseph’s Hospital in Saint Paul, he
took postgraduate work at Wayne University, Detroit,
Michigan, where he was granted a fellowship in the De-
partment of Pathology in 1940. He has also been pathol-
ogist in hospitals in Pontiac and an instructor at Wayne.
His army service includes three years as director of
laboratories and internal medicine in hospitals in Florida.
At the time of his discharge, Dr. Domeier was a major.
* * *
After an absence of five years, Dr. Charles Vander-
sluis has resumed his practice at Bemidji. Dr. Vander-
sluis is a graduate of the University of Minnesota Medi-
cal School and interned at the city hospitals in Balti-
more and St. Louis. He entered practice at Bemidji in
216
Minnesota Medicine
OF GENERAL INTEREST
1935 and for the four years immediately preceding his
entry into military service in 1942 was coroner of Bel-
trami County.
Dr. Vandersluis’ military assignments included nine-
teen months in New Guinea and the Philippines. He
was returned to this country for separation from serv-
ice in November, 1945. For the past year he has been
engaged in postgraduate work at the University of
Minnesota — six months’ study in pathology and six
months in disease of the heart and blood cells. Dr.
Vandersluis is limiting his practice to internal medicine.
During the doctor’s absence from Bemidji, Mrs. Van-
dersluis and their two children remained at home there.
* * *
Dr. Frank W. Quattlebaum and Dr. Jane E. Hodgson
have opened offices at 511-512 Lowry Medical Arts
Building, Saint Paul, for the practice of surgery, gyne-
cology and obstetrics.
Dr. Quattlebaum is a graduate of the University of
Georgia School of Medicine, Class of ’39. His intern-
ship and an assistant residency at the Medical Center,
Jersey City, New Jersey, were followed by a fellow-
ship in obstetrics and gynecology at the Mayo Clinic.
Dr. Hodgson took her medical degree at the Uni-
versity of Minnesota in 1939 and also served her intern-
ship and an assistant residency at the Jersey City
Medical Center. While there she was married to Dr.
Quattlebaum.
For the past year and a half Dr. Hodgson has been
practicing at New Smyrna Beach, Florida, and Dr.
Quattlebaum was stationed with the Army Medical
Corps at Daytona Beach, nearby.
*
New and expanding plans for the Mayo Memorial
on the University of Minnesota campus now under con-
sideration call for a 19-story structure which would
include a new cancer research institute, a wing for the
University’s School of Public Health, medical admin-
istrative offices, an addition to the University Hospitals,
a medical and biological library and a large auditorium.
The estimated cost of the Memorial under the original
plans was $2,000,000, of which the legislature had ap-
propriated $75,000 and the rest was to be raised by
private subscription. If the new plans are adopted,
considerably more money must be raised, and the
Founder’s Committee is studying possible new sources.
Among them are a Federal grant, and another appro-
priation from the Minnesota Legislature. The Minne-
sota Cancer Society is considering a separate campaign
to raise the necessary funds for the Cancer Institute.
Dr. Donald J. Cowling, Saint Paul, is chairman of
the committee, and Dr. George S. Earle, Saint Paul, is
secretary.
* * H*
Dr. Henry W. Meyerding, of Rochester, has returned
from a European trip during which he attended a
number of medical meetings and gave several addresses.
While in Amsterdam, Dr. Meyerding addressed the
Society for Furtherance of Physics, Medicine and Sur-
gery, which was established in 1820 and is the oldest
medical society in Holland. He was introduced to the
gathering by Dr. Peter Formijne, general president of
the society, who was a graduate student in medicine at
the Mayo Foundation in 1929 and 1930.
In Paris Dr. Meyerding attended the Congress Fran-
caise de Chirurgie, and was elected an honorary member
in the Academie de Chirurgie Francaise, which recently
celebrated its one hundredth anniversary. He also spoke
at a meeting of the Societe Francaise d’Orthopedic and
was elected to honorary membership in this organization.
While in Brussels Dr. Meyerding attended the In-
ternational Society of Orthopedic Surgery and Trau-
matology as delegate for the United States, and present-
ed a paper on the “Surgical Treatment of Malignant
Tumors of the Bone.” He was honored by being elected
president of the next Congress of the Society, which will
be held in Amsterdam in the fall of 1948.
Dr. Meyerding also assisted at the dedication of a
Practical Nursing Course
Nine months' course open to high school
graduates or women with equivalent
education.
For further information
write
Mrs. Lydia Zielke, Supt. of Nurses
FRANKLIN HOSPITAL
501 Franklin Avenue Minneapolis 5, Minnesota
The Birches Sanitarium, Inc.
2391 Woodland Avenue
Duluth 3, Minnesota
A hospital for the care and treatment of
Nervous and Mental disorders. Quiet, cheer-
ful environment. Specially trained personnel.
Recreational and occupational therapy.
Psychiatrists in Charge
L. R. Gowan, M.D. L. E. Schneider, M.D.
February, 1947
217
OF GENERAL INTEREST
monument to Antonius Matthysen, the discoverer of
plaster-of-Paris bandages.
* * *
Among those receiving their medical degrees at the
December commencement at the University of Minnesota
were: Dr. Melvin Reeves, of Brainerd ; Dr. William H.
Ryan, of Little Falls; Dr. James H. Kelley, of St.
Paul; Drs. John Watson, Peter Habein, Charles Conley
and Mark Anderson, Jr., all of Rochester.
Dr. Ryan is serving his internship at the Almeda
County Hospital in Oakland, California, and will be
there until June.
Dr. Reeves, who has been at the Sheltering Arms
Hospital in Minneapolis, serving a junior internship for
the past year, will take his senior internship at the Good
Samaritan Hospital in Portland, Oregon, and St. Bar-
nabas Hospital in Minneapolis.
Dr. Watson will intern at the Robert Packer Hospital
in Sayer, Pennsylvania.
Dr. Habein, who is the son of Dr. Harold C. Habein,
Rochester, has accompanied his mother to Tucson,
Arizona, where they will spend the winter.
Dr. Anderson, son of Dr. Mark J. Anderson, has
gone to California with his parents and will serve his
internship at the Orange County Hospital in Los
Angeles.
* * *
Twenty-one Rochester physicians were awarded de-
grees for work done at the Mayo Foundation at the
December Commencement of the University of Min-
nesota, and ten physicians received degrees, in ab-
sentia, for work performed in the various fields of the
Foundation.
M.S. degrees in surgery were conferred on Drs. John
A. Evert, Ellis E. Fair, Robert F. Golden, Chester L.
Holmes, Charles S. Joss, Cecil G. McEachern, Wen-
dell L. Nielsen, John H. Remington, F. H. Smith and
John Zaslow.
Drs. David T. Carr, Edgar A. Haunz, Mary C. Long,
Allan E. Moe and Irwin M. Vigran, received M.S.
degrees in medicine.
Dr. John R. Hodgson received an M.S. degree in
radiology ; Dr. J. J. Hinchey, in orthopedic surgery ; Dr.
John T. Robson, in neurology and psychiatry; Dr. J.
W. Pender and Dr. William N. Hardman, in anesthesi-
ology, and Dr. W. S. Green, in dermatology and syphilol-
ogy.
Those who received the degrees in absentia were Dr.
Brown M. Dobyns, Ph.D. in surgery; Drs. A. F. Cast-
row, Leonard C. Hallendorf, Jack A. Killins, Henry
R. Thomas, M.S. in surgery ; Drs. Natalie M. Briggs,
Richard N. Kent, Paul V. Morton, and A. S. Mann,
M.S. in medicine; and Dr. L. Williams, M.S. in neuro-
surgery.
:|e
ERRATUM
Attention is called to an error which occurred in the
Slyd-Rul sent to physicians recently by Ciba Pharma-
ceutical Products, Inc., on which the conversion of
0.49 grains reads 0.25 grams when it should read 0.025
grams. Slyd-Ruls with this error corrected will be
sent in replacement as soon as possible.
HOSPITAL NEWS
Staff members and associate members of St. Joseph’s
Hospital, Mankato, held their annual banquet and elec-
tion of officers at the hospital on December 12.
All the incumbent officers retained their positions
for the ensuing year by unanimous vote. They are :
president, Dr. H. Bradley Troost ; vice president, Mar-
shall I. Howard; secretary-treasurer, Dr. Anthony A.
Schmitz. The members of the executive committee are
Dr. Alphonse E. Sohmer, chairman ; Dr. Roger G. Has-
sett and Dr. George E. Penn.
* * *
Dr. Viktor O. Wilson, Division of Child Hygiene,
State Department of Health, in collaboration with an
advisory committee of twenty-three members appointed
by former Governor Thye, is taking an inventory of
existing hospitals and making a study of the total hos-
pital needs for the state. The survey is being made
in order to qualify for a share of the $75,000,000 an-
nual appropriation for construction of hospitals which
is expected to be authorized by Act of Congress.
* * *
The management of the More Hospital at Eveleth
has announced the addition of two members to the staff.
They are Drs. Carleton W. Leverenz and Lloyd H. Klef-
stad, both veterans of World War II.
Dr. Leverenz, who is a graduate of the University of
Illinois Medical School, interned at Ancker Hospital in
Saint Paul. He served in the Army Medical Corps
for five years and was in Japan when the war ended.
Dr. Klefstad, a native of Duluth where he grew up,
took his medical degree at Western Reserve University,
Cleveland, Ohio. He was in the U. S. Navy for three
years, his assignments taking him practically around the
world.
* * *
Dr. L. Kenneth Onsgard, who recently joined the
staff of Grandview Hospital in La Crosse, Wisconsin, is
still practicing at Houston, where he makes his home.
ZEMMER pharmaceuticals
A complete line of laboratory controlled ethical pharmaceuticals.
Chemists to the Medical Profession for 44 years.
THE ZEMMER COMPANY • Oakland Station • PITTSBURGH 13, PA.
218
Minnesota Medicine
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
CHECK and TROUBLE CHECK on SICKNESS INSUR-
ANCE. T. Wesson Walrh. Price 25 cents; Special prices in
quantity. New York: Public Relations Bureau, Medical Society
of the State of New York (292 Madison Avenue, New York
17, N. V.), 1046.
“Check and Double Check on Sickness Insurance” is
a new pamphlet published December 15 by the Public
Relations Bureau of the Medical Society of the State
of New York. The subject is covered in 133 questions
and answers with a complete index. By use of this index
any speaker or writer can find, in a few minutes’ time,
material for a 15-minute talk or an editorial a column
in length.
The author, J. Weston Walch, is instructor in
Economics and Business Law, Portland (Maine) High
School, and manager of the Platform News Publishing
Company. He studied the subject of sickness insurance
while preparing a handbook for use by participants in
nation-wide high school debates. Here he gives what
he thinks are the outstanding points in the controversy,
from the standpoint of a plain American citizen, just
as they impressed him in the course of his own work
on the handbook.
Mr. Walch was asked to do the job because this
question will ultimately be decided in the forum of
public opinion. He is thinking here of what would hap-
pen to him under compulsory sickness insurance. As an
average citizen, he doesn’t like it. Legislators already
know the doctors don’t like it. Here is the evidence
that the J. Weston Walches of the country don’t like
it, either. The last question propounded by the book-
let is, “Mr. Walch, in your study of this subject what
point strikes you most forcibly?” The author answers
as follows :
“I am most interested in my own health and well-
being and that of my family. I have tried to examine
every important point on the subject of sickness in-
surance on the basis of how I thought my own in-
terests would be affected. I feel that there are other
ways of improving the medical care of the American
people without resorting to government compulsion.
“You, the reader, should apply the same test — what
will happen to you — personally. Don’t take anybody's
say-so, not even mine.
“For your own sake, check and double check all the
facts on this vitally important subject.”
Says the foreword to this pamphlet :
“Free of large masses of statistics, and written in a
colloquial style, the author’s aim is simplification with-
out distortion. This painstaking work is offered as a
handbook for community leaders. For this purpose, a
ready-reference index is provided. The pamphlet is
intended for editorial writers, radio commentators, min-
isters, teachers, lawyers and members of Chambers of
Commerce, Parent-Teachers’ Associations, Women’s
Clubs, Labor Unions and Granges, as well as doctors
called upon to speak on the subject.”
CHILDREN IN THE COMMUNITY. The Saint Paul Ex-
periment in Child Welfare. U. S. Children’s Bureau, Social
Security Administration, Federal Security Agency, Washing-
ton, D. C. : Children’s Bureau, 1946. Free upon request.
An experiment that has challenging implications for
communities in dealing with boys and girls with be-
havior problems is described in this recent publication of
the U. S. Children’s Bureau. It tells of the work done
and the results obtained in Saint Paul, Minnesota, in
bringing all community resources to bear in a “first
aid” program for youth in trouble.
This experimental project, which was initiated by the
Bureau and developed with the co-operation of social
agencies in Saint Paul, and carried on from 1937 to
1943, was confined to a neighborhood of 20,000 per-
sons. The neighborhood was small enough for study
purposes and yet large enough to provide a good cross-
section of a metropolitan community. It represented a
wide range of nationality and of family income. The
children involved were typical of those to be found
anywhere, their behavior problems presenting the usual
run of truancy, pilfering, school failure, inability to
get along with other children, and the like.
The idea back of the Children’s Bureau undertaking
was to see what might be done “early in the game” to
get a child and his family the help the community had
to offer. The schools, the churches, and youth organiza-
tions, such as Boy and Girl Scouts and the like, were
involved. So were social and law-enforcement agencies,
and the community’s health services. All were drawn
into a plan which called for their referring to the proj-
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INSTRUMENTS ■ TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494
February, 1947
219
BOOK REVIEWS
ect — The Community Service for Children — boys and
girls they knew to be in trouble of one kind or another.
Altogether some 700 children were given individual
assistance. For some the project’s role was largely that
of referring the parents or the teachers or some other
interested person to a place or person who could help.
The referral, in most such cases, followed upon a di-
agnosis by the project. But, for some 400 boys and
girls much more was done and in many cases over
a long and difficult period. In four out of five cases,
an improvement was brought about and in a high pro-
portion, almost 70 per cent, a change for the better
was made in the situation causing, or affecting, the
child’s behavior, thus giving promise of a long-run
improvement. Significantly, although the juvenile de-
linquency rate for the city rose, in the section in which
the project was operating a decline took place.
The value of the project, the Children’s Bureau re-
ports, lies in the fact that nothing was done in St.
Paul that could not be done in other communities.
Those directing the project simply went into the com-
munity to try to make a better use of what was at
hand in the way of services for children. What de-
veloped that was new was the setting up of a referral
center to serve as a “first-aid station,” as it were,
for boys and girls in trouble. Any community, the
Bureau points out, could bring about such a co-ordi-
nation of its services for children. In small communi-
ties, it adds, the child welfare worker or some other
person in a strategic position might well serve as the
co-ordinator.
Lacking such a central place, or person, informed
about all community resources, those dealing with the
youngsters — parents, teachers, clergymen, welfare offi-
cials, court officials and police officers — are thrown back
upon their own resources. They often do not know
how to go about seeking help. The Saint Paul project
showed how they could get help, and, as a result, many
children were benefited.
Pcdna+ti^e Ousi /IdUieSiti^enA
Industrial Integration
(Continued from Page 175)
1. Abnormal chest sounds.
2. Abnormal heart sounds.
3. Abnormal blood pressures.
4. The presence of hernia.
5. The nervous system’s stability without go-
ing into the field of psychiatric medicine.
Finally, either as the result of information
gained during a pre-employment examination, or
as the result of an industrial illness or accident,
the physician must create confidence in the appli-
cant or injured worker. Ideally, the medical in-
dustrialist should write to the applicant’s per-
sonal physician and acquaint him with any patho-
logical processes found. He should attempt to
appraise disability in terms of days or weeks or in
the degree of loss of function to expect. He
should neither undertreat nor overtreat. The in-
dustrial physician and surgeon must have a defi-
nite objective: to return the injured employe to
his former employment as speedily as is in keep-
ing with sound medical and surgical practices.
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vision of skilled personnel.
Catalogue on request.
G. H. Marquardt, M.D. Barclay J. MacGregor
Medical Director Registrar
26 Geneva Road, Wheaton, Illinois
(Near Chicago)
220
Minnesota Medicine
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
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Radiological and Clinical
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MURPHY LABORATORIES
Minneapolis: 612 Wesley Temple Bide- - - At. 4786
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If no answer, call - -- -- -- -- Ne. 1291
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Fire - Tornado - Automobile Insurance Service
REPRESENT ATIVE-S. E. STRUBLE, WYOMING, MINN.
February, 1947
221
MISCELLANEOUS
Classified Advertising
PHYSICIAN WANTED— Prefer one interested in
x-ray and internal medicine. Salary to start and part-
nership in small group, if congenial. Address E-6,
care Minnesota Medicine.
FOR SALE — First selection hang-up mounting skeleton.
Price quoted by instrument dealer, $155.00. What am
I offered? E. Sydney Boleyn, M.D., Stillwater, Min-
nesota.
WANTED TO BUY — Binocular microscope. Contact
Dr. C. W. Freeman, Pathology Department, Univer-
sity of Minnesota, Minneapolis 14, Minnesota. Tele-
phone Main 8551 — Ext. 251 or Bridgeport 0919.
FOR SALE — Pavex machine, like new. Sacrifice,
$85.00. Address E-5, care Minnesota Medicine.
FOR SALE — Large assortment of surgical instruments,
practically new. One OB retraction forceps. Address
Mrs. James E. Arnold, 2840 Humboldt Avenue South,
Minneapolis 8, Minn.
DOCTORS’ OFFICES FOR RENT— Choice established
location in Minneapolis. Address E. B. Freeman, 2706
East Lake Street, Minneapolis 6, Minnesota. Tele-
phone Drexel 0311.
PHYSICIAN WANTED — To associate with or be-
come partner of resident physician, or to buy very
good practice in thriving town twenty-five miles from
Twin Cities. Address E-7, care Minnesota Medicine.
OFFICE SPACE FOR RENT— Downtown Saint Paul.
Two rooms with adjoining waiting room, shared by
two physicians. Laboratory and x-ray available.
Low overhead. Excellent opportunity. Address E-8,
care Minnesota Medicine.
MOBILE SPEECH CLINIC
UNDERTAKES SURVEY
(Continued from Page 189)
patient again, there is no need for further consultation.
So after the prescribed medicine is gone, the infected
ear is ignored until the child’s hearing is impaired; or
parents who were advised to “give your child time” to
learn to talk give him years while his disability grows
more and more impervious to treatment.
But University and Minnesota Association officials are
convinced that public education can alert the general
population to the vital necessity for early diagnosis and
correction of such handicaps. And that, in the long
run, is exactly what the Mobile Speech Clinic hopes to
accomplish.
BOMBAY TO BROOKLYN
Nature’s medicine chest is a worldwide reservoir.
From Bombay to warehouses in Brooklyn come the
hard, bitter seeds of the nux vomica tree, used as a
stimulant and general tonic. The fruits are collected in
India by tribal natives, who clean, dry and sort the
nux vomica seeds in crude trays before shipment.
Ipecac, the dried roots of the ipecacuanha, a low
struggling shrub with emetic and expectorant properties,
comes from the moist, woody areas of Brazil, Bolivia
and Colombia.
^ Thyme, the aromatic herb, dots the fields of Italy,
France and Spain. Its leaves and flowertops produce
a soothing oil used in some proprietary medicines in
connection with bronchitis and whooping cough.
The Alps, Pyrenees and Vosges of Europe are
speckled with the greenish-white flowers of sweet-
smelling angelica and the yellow gentian, or felwort.
The seed of the former becomes a carminative and
tonic. The gentian root, pulled up in summertime and
heaped on. the ground to ferment, is a bitter tonic.
Also flourishing in these mountains is the poisonous
monkshood, prescribed under the name of aconite for
fevers and heart conditions.
Purgative plants have similar backgrounds. Senna,
a constituent of some laxative preparations, is the
sun-dried leaflets of a flowering yellow shrub, knee
high, which thrives on the heat of the Nile Valley as
well as in India. Arabian senna leaves are picked twice
a year, crammed into large palm leaf sacks and trans-
ported across the desert by camel back to the market
places of Port Sudan and Alexandria.
Aloe, a cathartic whose succulent pale green leaves
are snipped open and drained into kettles to produce a
dried juice, is shipped in gourd shells from Socotra
Island, Africa, and from Curacao.
Jalap, the potent purgative, is the dried, tuberous
root of a plant grown 6,000 feet above sea level
near the city of Jalapa in Vera Cruz. The roots,
having been dried out over the hearths of native
Indian huts, have a distinct smoky taste.
Agar-agar, a bulk-producing agent as well as a
bacteria culture medium in research laboratories, is
cultivated by Japanese deep-sea divers fathoms beneath
the ocean surface. This peculiar seaweed produces a
mucilaginous substance which is carried up into the
dry-cold air of the Japanese mountains to be dehy-
drated and extruded into long, flat strands.
Frangula, the bark of the European buckthorn shrub,
irritant psyllium seeds from the Mediterranean and
cassia pulp of the pods from the puddingpipe tree in
the East Indies are among other laxative herbs from
distant sources.
Cloves, a good mixer with drugs, is a spice made
of the dried flower buds of the evergreen clove tree in
the Philippines and Molucca Islands. In Zanzibar,
natives secure the pungent buds by thrashing the trees
with bamboo rods. The cloves are spread out on mats
to dry in the sun before being baled for export.
Many of these roots, leaves, seeds and flowers are
also used in flavoring foods, as condiments, and in per-
fumes. Aromatic myrrh, for instance, the sweet-scented
gum drawn from myrrh trees in Somaliland, has triple
duty: as a flavoring extract, as a perfume and as an
antiseptic in dentifrices and mouth washes. — O.P.I.
Bulletin, August, 1946.
VlathmaL filaaumnL ShmIol. . . . for hospitals -
PART TIME— TEMPORARY— PERMANENT
When in need of a PHYSICIAN, DENTIST, OFFICE NURSE, TECHNICIAN, MEDICAL SECRETARY, or
OTHER PERSONNEL for medical and dental offices, clinics, and hospitals contact —
Minneapolis, Minn. — GE. 7839 The Medical Placement Registry St. Paul, Minn. — GA. 6718
OLIVE H. KOHNER, Director
222
Minnesota Medicine
MISCELLANEOUS
Epithelial Neoplasms of the
Appendix
(Continued from Page 178)
7. McWilliams, C. A. : Primary carcinoma of vermiform ap-
pendix: a study of 90 cases, three previously unpublished.
Am. J. M. Sc., 135:822-850, 1908.
g. Mallory, Tracy B.: Cabot Case 22511; carcinoid of appen-
dix with metastasis to a retroperitoneal lymph node. New
England J. Med., 215:1176-1178, (Dec. 17) 1936.
9. Masson, J. C., and Hamrick, R. A.: Pseudomyxoma peri-
tonei originating from mucocele of the appendix. Surg.,
Gynec. & Obst., 50:1023-1029, 1930.
10. Norment, William B. : Tumors of appendix. Surg., Gynec.
& Obst., 55:590-596, (Nov.) 1932.
11. Pennington, R. E., and Priestley, J. T. : Multiple carcinoid
tumors of the small intestine. Proc. Staff Meet., Mayo Clin.,
18:49, (Feh. 2.4) 1043
12. Schuldt, F. C. : Primary adenocarcinoma of appendix and
carcinoid tumors. Minnesota Med., 23:791-794, (Nov.) 1940.
13. Timoney. Francis X. : Ruptured mucocele of appendix with
pseudomyxoma peritonei. Am. J. Surg., 64:417-419, (June)
1944.
14. Uihlein, Alfred, and McDonald, John R. : Primary car-
cinoma of appendix resembling carcinoma of colon. Surg.,
Gynec. & Obst., 76:711-714, (June) 1943.
15. Waugh, Theodore R., and Findley, David: Mucocele with
peritoneal transplantation in adenocarcinoma of appendix.
Am. J. Sure-. 37(N.S.) :518 5?5. 1937,
16. Woodruff, Robert, and McDonald, John R.: Benign and
malignant cystic tumors of appendix. Surg., Gynec. &
Obst., 71:750-755, 1940.
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INDEX TO ADVERTISERS
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Anderson, C. F., Co
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Benson^ N. P., Optical Co
Bilhuber-Knoll Corporation
Birches Sanitarium, Inc
Borcherdt Malt Extract Co
Borg, George W., Corporation
Bristol Laboratories, Inc
Brown & Day, Inc
Buchstein-Medcalf Co
Burroughs Wellcome & Co
Camel Cigarettes
Camp, S. H., & Co
Ciba Pharmaceutical Products, Insert facing
Classified Advertising
Cleartone Hearing Aid
Coca-Cola Co
Cook County Graduate School of Medicine .
Dahl, Joseph E., Co
Danielson Medical Arts Pharmacy, Inc. . . .
Druggists Mutual Insurance Co
147
221
207
140
151
142
146
217
148
208
141
210
223
127, 143
128, 129
132
208
222
211
146
216
221
219
221
Ewald Bros.
Inside Back Cover
Franklin Hospital 217
Glenwood Hills Hospital 137
Glenwood-Inglewood Co 210
Griggs, Cooper & Co 150
Hall & Anderson 221
Homewood Hospital 148
Human Serum Laboratory 211
Kalman & Co., Inc 208
Kinney, H. W., & Sons, Inc 130
Kroll, August F 221
Laboratory Ramsey County Medical Society 138
Lilly, Eli, & Co., Insert facing 152
Maico Co 148
Massachusetts Indemnity Insurance Co 122
Mead Johnson & Co 224
Medical Placement Registry 222
Medical Protective Co 126
Milwaukee Sanitarium Back Cover
Mounds Park Sanitarium Back Cover
Murphy Laboratories 221
National Dairy Products Co. Inc 139
North Shore Health Resort 150
Parke, Davis & Co Inside front cover, 121, 135
Philip Morris & Co. Ltd., Inc 134
Physicians Casualty Association 142
Physicians & Hospitals Supply Co 213, 219, 221
Pogue, Mary E., School 220
Rest Hospital 215
St. Croixdale Sanitarium 124
Schering Corporation 133
Schmid, Julius, Inc 144
Schusler, J. T., Co 223
Searle, G. D., & Co 205
Smith-Dorsey Co 142
Smith, Kline & French Laboratories 152
Spencer, Inc 209
Stearns, Frederick, & Co 145
Upjohn Co 149
Varick Pharmacal Co. Inc 136
Vocational Hospital 215
Wander Co 125
White Laboratories, Insert facing 136
Williams, Arthur F 221
Winthrop Chemical Co. Inc 131
Zemmer Co 218
February, 1947
223
SHOULD VITAMIN D BE
GIVEN ONLY TO INFANTS
9
ITAMIN D has been so successful in preventing rickets during in-
fancy that there has been little emphasis on continuing its use after
the second year.
But now a careful histologic study has been made which reveals
a startlingly high incidence of rickets in children 2 to 14 years old.
Follis, Jackson, Eliot, and Park* report that postmortem examina-
tion of 230 children of this age group showed the total prevalence
of rickets to be 46.5 % .
Rachitic changes were present as late as the fourteenth year, and
the incidence was higher among children dying from acute disease
than in those dying of chronic disease.
The authors conclude, “We doubt if slight degrees of rickets,
such as we found in many of our children, interfere with health
and development, but our studies as a whole afford reason to pro-
long administration of vitamin D to the age limit of our study, the
fourteenth year, and especially indicate the necessity to suspect and
to take the necessary measures to guard against rickets in sick
children.”
*R. H. Follis, D. Jackson, M. M. Eliot, and E. A. Park: Prevalence of rickets in children
between two and fourteen years of age, Am. J. Dis. Child. 66:1-11, July 1943.
MEAD'S Oleum Percomorphum With Other Fish-Liver Oils and Viosterol
is a potent source of vitamins A and D, which is well taken by older
children because it can be given in small dosage or capsule form. This
ease of administration favors continued year-round use, including
periods of illness.
MEAD'S Oleum Percomorphum furnishes 60,000 vitamin A units and
8,500 vitamin D units per gram. Supplied in 10- and 50-c.c. bottles and
bottles of 50 and 250 capsules. Ethically marketed.
MEAD JOHNSON & COMPANY, Evansville 21, Ind., U.S.A.
224
Minnesota Medicine
the champing teeth, the tonic and
clonic contractures, the incontinence— all may yield to
DILANTIN SODIUM. The E.E.G. can trace the pathologic brain wave,
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DILANTIN SODIUM KAPSEALS
( diphenylhydantoin sodium), containing 0.03 Gm.
(Y2 grain) and 0.1 Gm. (D/2 grains), are supplied in
bottles of 100, 500 and 1000. Individual dosage is
determined by the severity of the condition.
♦Trademark Reg. U. S. Pat. Off.
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MINNEAPOLIS 2, MINNESOTA
i vrnal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
olume 30
March, 1947
No. 3
Contents
cute Intussusception in Infancy and Childhood.
F. H. Magruey, M.D., F.A.C.S., Duluth, Minnesota. 257
inancing the Establishment of a Small
Hospital.
James A. Hamilton, Minneapolis, Minnesota 261
. Short Commentary on the History of the
Circulation.
F. A. Willius, M.D., Rochester, Minnesota 264
uodenal Diverticulum.
Arthur N. Collins, M.D., F.A.C.S., Duluth,
Minnesota
.268
'ffice Proctology.
A. H. Borgerson, M.D., Long Prairie, Minnesota. .272
etting the Most from a Pathologist.
Charles W. Vandersluis, M.D., Bemidji, Minnesota 276
Finical-Pathological Conferences :
Kimmelstiel-Wilson Syndrome.
A. J. Hertsog, M.D., and W. D. Hayford, M.D.
Minneapolis, Minnesota 280
Diagnostic Case Study.
Arthur H. Wells, M.D., Olin W. Rowe1, M.D.,
and Harold H. Joffe, M.D., Duluth, Minnesota. 282
Iase Report:
Adenocarcinoma of the Sweat Glands with Metas-
tases.
A. E. Benjamin, M.D., Minneapolis, Minnesota. .286
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. (Continued from February
issue).
Nora FI. Guthrey, Rochester, Minnesota 289
President’s Letter :
Minnesota Medical Service, Inc., to Begin Opera-
tion Shortly
Editorial :
Calorie Intake and Industrial Output 296
Use of Dimercaprol (BAL) 296
Vagotomy for Peptic Ulcer 297
The Nursing Problem 298
Medical Economics :
1947 National Health Bill 299
Minnesota Health Legislation 300
Cancer Fight Intensified 301
Veterans Medical Service 302
Minnesota Academy of Medicine:
Meeting of November 13, 1946 303
Periarteritis Nodosum — Treatment with Penicillin.
S’. Marx White, M.D., Minneapolis, Minnesota. .303
The Treatment of Hysteria by Narco-Hypnosis.
Heivitt B. Hannah, M.D., Minneapolis, Min-
nesota 305
Minneapolis Surgical Society :
Meeting of December 5, 1946.
.310
295
Surgical Management of Chronic Fistulas of the
Rectum Following Penetrating Wounds.
Robert J. Tenner, M.D., F.A.C.S., Minneapolis, Min-
nesota 310
Pulmonary Decortication for Infected Organized
Hemothorax.
H. P. Harper, M.D., Minneapolis, Minnesota. .. .312
Criteria for Choledochostomy Tube Removal.
R. W. Utendorfer, M.D., Minneapolis, Min-
nesota '■ 315
Massive Gastric Hemorrhage .Due to Hemorrhagic
Gastritis Necessitating Gastric Resection.
G. FI. Hall, M.D., Minneapolis, Minnesota 317
Reports and Announcements 320
Woman’s Auxiliary 324
In Memoriam 326
Of General Interest 328
Book Reviews - 340
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in flection 1103, Act of October 3, 1917, authorized July 13, 1918.
March, 1947
227
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committer
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
C. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — $3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions — $3.50.
The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
ST. CROIXD ALE ON LAKE ST. CROIX
PRESCOTT, WISCONSIN
MAIN BUILDING— ONE OF THE 5 UNITS IN “COTTAGE PLAN”
A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous, Mental and Medical Cases
Located on beautiful Lake St. Croix, eighteen miles from the Twin Cities, it has the advantages of both
City and Country. Every facility for treatment provided, including recreational activities and occupational
therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
CONSULTING NEUROPSYCHIATRISTS
RESIDENT PHYSICIAN Hewitt B. Hannah, M.D. SUPERINTENDENT
Howard J. Laney, M.D. Joel C. Hultkrans, M.D. Ella M. Mackie
Prescott, Wisconsin 511 Medical Arts Building Prescott, Wisconsin
Tel. 39 Minneapolis, Minnesota Tel. 69
Tel. MAin 4672
228
Minnesota Medicine
Clinical results — not laboratory units — are the true measure of
estrogen therapy. And Squibb Amniotin, a truly natural estrogen
of known safety and effectiveness, is backed by more than seven-
teen years of extensive clinical use. Amniotin is well tolerated
and rarely causes distressing side effects.
Available in a wide range of potencies and dosage forms,
Amniotin is excellently adapted to precision dosage.
Squibb
MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858
TRADEMARK
March, 1947
229
r oi
Mo
Minds
His diet is balanced, yet he is a borderline vitamin defi-
ciency case. Like many others whose occupations are
sedentary and who take little exercise otherwise, his
caloric requirements and appetite are so small that he
simply does not eat enough food to supply adequate
quantities of the protective factors. As a result his case
record has taken its place in his physician’s file along
with those of all of the other varieties of dietary delin-
quents: the ignorant and indifferent, patients “too
busy” to eat properly, those on self-imposed and badly
balanced reducing diets, excessive smokers, alcoholics,
and food faddists, to name but a few. First thought in
such cases is dietary reform, of course. But this is often
more easily adv ised than accomplished. Because of this,
an ever-growing number of physicians prescribe a \ ita-
min supplement in every case of deficiency. If you're
one of these physicians — or if you prescribe vitamins
only rarely — consider the advantages of specifying an
Abbolt vitamin product: Quality — Certainty of potency
— A line which includes a product for almost every vita-
min need — And easy availability through pharmacies
everywhere. Abbott Laboratories, North Chicago, 111.
230
Minnesota Medicine
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PHYSICIANS & HOSPITALS SUPPLY CO., INC.
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Lightest and Strongest
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March, 1947
231
Zrauma and Nitrogen Equilibrium
Recent recognition of the direct relationship between trauma and
protein loss has greatly improved the prognosis in postsurgical
and post-trauma patients.
Striking and hitherto unsuspected protein loss has been ob-
served in patients with fractures. Excessive urinary nitrogen ex-
cretion reaches its maximal point about a week after the injury is
sustained, and thereafter slowly diminishes in extent, so that
nitrogen balance is restored in approximately four weeks.1
In patients sustaining severe burns, the daily protein loss may
be equivalent to 400 cc. of plasma.2
In a study embracing 2.3 burned patients, nitrogen balance
determinations revealed excessive urinary nitrogen excretion.
Nearly all patients were in negative nitrogen balance which was
most marked during the first ten days.3
It thus appears that protein destruction and loss are prominent
and potentially detrimental sequelae of trauma, and that every
effort must be made to restore nitrogen equilibrium as quickly as
possible to prevent the many deleterious consequences of protein
depletion. The recommendation has been voiced that “whenever
possible, protein losses or deficiencies should be corrected by oral
feeding.”4
Among the protein foods of man, meat ranks high not only be-
cause of the generous supply of protein it provides, but also be-
cause its protein supplies all the essential amino acids, making it
applicable for every protein need — growth, tissue maintenance,
and tissue repair.
1 Howard, J. E.: Bull. Johns Hopkins Hosp., 74:313 (May) 1944.
2 Co Tui, C.; Wright, A. M.; Mulholland, J. H.; Barcham, T., and Breed,
E. S.. Ann. Surg. i/9: 815-823 (June) 1944.
3 Hirshfeld, J. W.; Abbott, W. E.; Pilling, M. A.; Heller. C. G.; Meyer, F.;
Williams, H. H.; Richards, A. J., and Obi, R.: Arch. Surg. 50:194 (Apr.) 1945.
4 Lund. Chas. C, and Levenson, S. M.: J. A. M. A. 128: 95 (May 12) 1945.
The Seal of Acceptance denotes that the nutri-
tional statements made in this advertisement
are acceptable to the Council on Foods and
Nutrition of the American Medical Association.
AMERICAN MEAT INSTITUTE
MAIN OFFICE, CHICAGO ... MEMBERS THROUGHOUT THE UNITED STATES
I
232
Minnesota Medicine
from PZI
to
BIN INSULIN
When protamine zinc insulin treatment is
complicated by post-prandial hyperglycemia,
nocturnal insulin reaction, protamine sensitivity,
or other difficulties, a change to Globin Insulin
often results in the desired improvement. The
change is achieved in three steps :
I. THE INITIAL CHANGE-OVER DOSAGE: The first
day, 30 minutes or more before breakfast, give
a single dose of Globin Insulin, equal to Vi the
total previous daily dose of protamine zinc
insulin or of protamine zinc insulin combined
with regular insulin. The next day, dose may
be increased to I. 2A former total.
3. adjustment OF DIET: Simultaneously adjust
carbohydrate distribution of diet to balance
insulin activity; initially 2/10, 4/10 and 4/10.
Any midafternoon hypoglycemia may usually
be offset by 10 to 20 grams carbohydrate at
3 to 4 p.m. Base final carbohydrate adjustment
on fractional urinalyses.
Most mild and many moderately severe cases
maybe controlled by one daily injection of ‘Well-
come’ Globin Insulin with Zinc. Vials of 10 cc.;
40 and 80 units per cc. Developed in The Well-
come Research Laboratories, Tuckahoe, New
York. U.S. Pat. 2,161,198. Literature on request.
2. ADJUSTMENT TO 24-HOUR CONTROL: Gradually
adjust the Globin Insulin dosage to provide
24-hour control as evidenced by a fasting blood
sugar level of less than 150 mgm. or sugar-free
urine in the fasting sample.
BURROUGHS WELLCOME & CO. (U.S.A.)
'Wellcome' Trademark Registered
INC., 9 & II EAST 4IST STREET, NEW YORK 17. N.Y.
March, 1947
233
► He ’phoned the druggist
for the little girl’s impetigo.
to send an ounce of "mild chloride of mercury ”
► The druggist thought he said "bichloride of mercury." The child has recovered,
but her parents are suing the doctor for malpractice.
► Yet this doctor would lose neither time, money nor reputation if protected
by our policy and service (as are thousands of other doctors, for about the cost
of 2 packs of cigarettes a week).
► The confidential service of our legal staff of malpractice experts (the world’s
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pay judgments, if awarded, as provided in our policy.
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Professional Protection exclusively. . . since 1899
234
MINNEAPOLIS Office: Robert L. McFerron, Manager, 816 Medical Arts Building, Telephone Atlantic 5724
Minnesota Medicine
WHY THIS PORTABLE X-RAY il FOR YOUR OFFICE PRACTICE?
The fact that thousands of physicians are today using
G-E X-Ray’s Model F Portable is perhaps the most
convincing evidence of its recognized value.
You too, would soon conclude that for office x-ray
examinations, the Model F Portable atop your desk or
table greatly simplifies matters; also that the inambu-
lant patient is grateful for this service right in
his home.
Within the practical range of service for which this
unit is intended, the quality of radiographs it is ca-
pable of producing is second to none, regardless of
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workmanship throughout.
The moderate investment required, and the poten-
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justify your investigation. Mail this coupon today.
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March, 1947
235
\
There can be no middle course between the ethics of the medical profession and the
temptations of the market place in the field of anatomical supports. Here the stand-
ards of the businessman must be elevated to the standards of the doctor because the
customer of the businessman is the patient of the doctor. Anything else is "merchan-
dising quackery." We at Camp have for many decades controlled our distribution
throughout the recognized retail institutions which, like the doctor have earned the
respect and confidence of their home communities. No appeal is used in our adver-
tising approach to the consumer which fails to meet the precepts of the profession.
We serve the physician and surgeon by living up to our chosen function of supplying
scientific supports of the finest quality in full variety at prices based on intrinsic
value. We try to insure the precise filling of prescriptions through the regular
education and training of fitters. In cooperation with medical and edu-
cational public health authorities we play the role our resources
permit in promoting better posture and body mechanics.
That is our idea of the practical ethical standards which
permit the businessman to solicit the recommen-
dation of the doctor. Camp Anatomical Sup-
ports have met the exacting
^ test of the profession for four
decades. Prescribed and recom-
mended in many types for prenatal, post-
. » natal, postoperative, pendulous abdomen, vis-
— — _ ' ceroptosis, nephroptosis, hernia, orthopedic and
other conditions . If you do not have a copy of the
Camp “Reference Book for Physicians and Surgeons”,
it will be sent upon request.
ANATOMICAL SUPPORTS
S. H. CAMP & COMPANY • Jackson, Michigan • World’s Largest Manufacturers of Scientific Supports
Offices in CHICAGO • NEW YORK • WINDSOR, ONTARIO • LONDON, ENGLAND
Minnesota Medicine
PLANNING • NOT LUCK
Planning— not luck— is responsible for
the pure, crystal-clear solution of
NEO-IOPAX for urography. Every pre-
caution known for obtaining a sterile fluid,
completely free from foreign particles, is
taken with this contrast medium during its pro-
duction. And when NEO-IOPAX is ampuled it must
pass before a corps of specially trained inspectors whose
sole task is to detect and reject any solution containing the least
visible trace of extraneous matter.
A final inspection by the physician himself before intravenous or
retrograde injection is invited by the water-clear glass ampule in
which NEO-IOPAX is dispensed.
Trade-Mark NEO-IOPAX-Reg. U. S. Pal. Off.
NEO-IOPAX, disodium N-methyl-3,5-diiodo-chelidamate, is supplied as a
stable, crystal-clear solution in 50 and 75 per cent concentrations.
CORPORATION • BLOOMFIELD, N. J.
IN CANADA, SCHERING CORPORATION LIMITED, MONTREAL
p ' p
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KNOW
WHAT
THESE
SYMBOLS
STAND
FOR?
The barber pole is a relic of the middle ages,
when barbers professed also to be surgeons
and dentists. The pole was originally a red
staff, wrapped with removable bandages, hung
with dentai instruments and topped by a brass
lathering bowl. Later, as a concession to sani-
tation (or possibly to prevent theft), bowl, band-
ages and instruments were replaced by a
painted replica.
The familiar blue and white Rexall sign is a
modern symbol of superior and dependable
pharmacal service. There are more than 10,000
independent, reliable drug stores, conveniently
located throughout the country, which display
this sign. It assures you of drugs laboratory-
checked for purity and uniformity under the
rigid Rexall system of controls— and of selected
pharmacal ability in compounding them.
REXALL DRUG COMPANY
DRUGS
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Minnesota Medicine
ELECTRO-CARDIOGRAPHY
Portable , rugged , electrically o per*
ated without batteries. Cardiotron is
available with or without stand .
The first successful
'Detect- IQeccncluty
Electrocardiographs
With more than 1 200 now in use throughout the
world, the Cardiotron has established the principle
of instantaneous recording in general clinical elec-
tro-cardiography.
The Cardiotron is fast, accurate and sensitive. It
makes an immediate black and white cardiogram-
on permanent chart paper. It is free from skin re-
sistance errors. It reveals more information than any
other electrocardiograph instrument.
IMPORTANT: Factory-supervised installation and service
are available in most parts of the world. Good deliveries
are scheduled. Cardiotron is sensibly priced.
Send for 1 2-page descriptive booklet.
CafuUcthm
ELECTRO- PHYSICAL LABORATORIES, INC., 298 Dyckman St., New York 34, N. Y.
ELECTROCARDIOGRAPHS, ELECTROENCEPHALOGRAPHS, SHOCK
THERAPY APPARATUS, AND SPECIAL ELECTRONIC EQUIPMENT
Distributed by
C. F. ANDERSON CO.. INC
901 MARQUETTE AVENUE
MINNEAPOLIS 2, MINN.
March. 1947
239
KOROMEX JELLY
• Fastest Spermicidal Time
measurable under Brown and Gamble technique
• Proper Viscosity
for cervical occlusion
• Stable Over Long Period of Time
pH consistent with that of the normal vagina
# and in addition
time-tested clinical record
ACTIVE INGREDIENTS: Boric acid 2.0%, oxyquinolin benzoate
0.02% and phenylmercuric acetate 0.02% in a base of glycerin,
gum tragacanth, gum acacia, perfume and de-ionized water.
Prescribe Koromex Jelly with Confidence
, . . send for literature
HOLLAND-RANTOS COMPANY, INC., 551 FIFTH AVENUE, NEW YORK 17, N. Y.
240 Minnesota .Medicine
PROTEIN SPARER
Carbohydrates as protein sparers have
particular significance in infant nu-
trition, which requires a high order
of efficient utilization of protein for
an active metabolism.
CARTOSE* is well tolerated; its
content of dextrins in association with
maltose and dextrose minimizes gas-
trointestinal discomfort due to an
excessive concentration of readily
fermentable sugars in the gastro-
intestinal tract.
CARTOSE is liquid, facilitating
rapid, exact formula preparation. It
is compatible with any formula base
— liquid, evaporated, or dried milk.
SUPPLIED: In clear glass bottles
containing 1 pt. Two tablespoonfuls
( 1 fl. oz.) provide 120 calories. Avail-
able through recognized pharmacies
only.
CARTOSE
Mixed Carbohydrates
*The word CARTOSE is o registered trademark of H. W.
Kinney & Sons, Inc.
H. W. KINNEY & SONS, INC.
COLUMBUS, INDIANA
March, 1947
241
Stubborn cases call for PHOSPHALJEL
Phosphaljel is unexcelled in the treatment
of marginal ulcer. It provides quick relief
from pain . . . lays a protective coating
over the inflamed mucosa . . . safely buffers
gastric acidity with no danger of alkalosis
or "acid rebound.” Phosphaljel permits a
liberal bland diet — patients are more con-
tented during treatment, gain strength
and weight more quickly.
Phosphaljel provides excellent prophy-
laxis against seasonal recurrences, as well
as protection against marginal ulcer fol-
lowing surgery. It is highly valuable in
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Request a showing for your medical society.
Address Professional Service Department.
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242
Minnesota Medicine
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243
CLAIM
vs.
DIFFERENCE
WHAT value have claims of superiority unless there is a
difference in formula or process to justify such claims?
Take cigarettes for example.
Philip Morris Cigarettes are made differently. In the
clinic as well as in the laboratory, the advantages of Philip
Morris have been repeatedly observed, repeatedly reported
by recognized authorities in leading medical journals. Yes,
Philip Morris claims superiority . . . and that superiority
has been proved *
May we suggest that your patients suffering from irrita-
tion of the nose and throat due to smoking change to Philip
Morris — the one cigarette proved definitely less irritating.
Philip Morris
Philip Morris & Co., Ltd., Inc.,
119 Fifth Avenue, N. Y.
* Laryngoscope , Feb. 1935, Vol. XLV , No. 2, 149-154 Proc. Soc. Exp. Biol, and Med., 1934, 32, 241
Laryngoscope, Jan. 1937, Vol. XLV (I. No. 1, 58-60 N. Y. State Journ. Med., Vol. 35, 6-1-35, No. 11, 590-592 .
TO THE DOCTOR WHO SMOKES A PIPE: We suggest an unusually fine new blend — Country
Doctor Pipe Mixture. Made by the same process as used in the manufacture of Philip Morris Cigarettes.
244
Minnesota Medicine
Furunculosis ... . second in the series: "FACIAL EXPRESSIONS OF SICKNESS"
From a practical standpoint, the use of penicillin orally should be limited to infections in which low doses of
parenteral penicillin have proved adequate, for prophylaxis, and for the convalescent stages of such acute infections
as furunculosis. Here, when the crisis is past and the fever receded, the administration of 100,000 units of penicillin
orally at two or three hour intervals, day and night, for 48 hours is a tested safeguard against relapse. For such
prophylaxis, tablets of calcium penicillin, 50,000 units each, are available in hollies of 12.
PENICILLIN TABLETS ORAL by
March, 1947
245
PYOKTANIN SURGICAL GUT
Plain and Jcmatijed
Manufactured Since 1899 by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia.
• • •
Price fait
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE C NONBOILABLE
Sizes 000 — 00 — 0—1 — 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
9 9 9
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FDR SALE BY SURGICAL DEALERS AND DRUGGISTS
246
Minnesota Medicine
Yes, and experience is the best teacher in smoking too!
p JJ he wartime cigarette shortage is only a memory now, but that’s
when millions of people — smoking any brand they could get — learned
the differences in cigarette quality.
And, significantly, more people are smoking Camels than ever before in
history. But, no matter how great the demand:
Camel quality is not to be tampered with. Only choice tobaccos, properly
aged, and blended in the time-honored Camel way, are used in Camels.
According to a recent Nationwide survey*.
More Doctors
smoke Camels
f/ian any ot/ier cigarette
R. J. Reynolds Tobacco Company, Winston-Salem. N. C.
March, 1947
247
Both systemic and topical penicillin administrations have been
found valuable in the treatment of infections of the mouth, nose and
sinuses, pharynx, tonsils, larynx, and tracheobronchial system.1- 2
Since respiratory infections often show a tendency to relapse,
it is all-important to adhere to the principle established
by clinicians widely experienced in penicillip therapy:
give enough-soon enough-tong enough
(1) Menefee, E. E., Jr., and Atwell, R. J.: South. M. J. 39:726 (Sept.) 1946.
(2) Woodward, F. D„ and Holt. T.; j.A.M.A. 129-589 (Oct. 27) 1945.
PENICILLIN SCHENLEY. Suggested dosage: Intra-
muscular, 20,000 to 40,000 units every three hours,
continued until the patient has been symptom-free
for forty-eight to seventy-two hours. Topical,
instillation of 3 to 5 cc. of a solution containing
5,000 to 10,000 units percc., repeated as frequently
as indicated in the judgment of the physician.
PENICILLIN TABLETS SCHENLEY. Suggested dosage:
2 tablets (50,000 units each) every two or three
hours day and night until all signs of infection
have been absent for at least forty-eight hours.
This treatment is suitably employed after
initial parenteral therapy, and as an adjunct to
topical administration.
Specialized skills devoted to the control of
bioculture processes insure the dependability of
all penicillin products bearing our label.
EXECUTIVE OFFICES: 350 FIFTH AVE., NEW YORK CITY
248
Minnesota Medicine
“1
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enuuooc
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DSD
ita
NEW AND MODERN HOSPITALS
beautifully located amid the rolling hills of Golden Valley.
Only 10 minutes from the Minneapolis loop, the hospitals have all
the advantages of the rural setting. The spacious and convenient
arrangement of physical plant makes the proper classification of
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SCHOOL OF PSYCHIATRIC NURSING
A CAREER IN NURSING OFFERS:
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A one-year course in our School of Psychiatric Nursing is available to eligible applicants.
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Class pin and diploma awarded on completion of course. Write for particulars.
Director, School of Nursing, Glenwood Hills Hospitals
June Class now being organized
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Candidates for the June
class should make reser-
vations at this time.
School and health records
must be reviewed and
correspondence complet-
ed prior to acceptance.
Classes begin
January , June,
September.
Seven : Minneapolis,
Minn.
March. 1947
249
( rOLD THERAPY in Rheumatoid Arthritis
THE consensus of clinicians who have
had considerable experience with
aurotherapy is that gold, despite its
recognized toxicity, is the most effective
agent available for the treatment of
active rheumatoid arthritis.
The following statements, quoted
from the article entitled, "The Use
And Abuse Of Gold Therapy In Rheu-
matoid Arthritis,” by Bernard I.
Comroe, M. D. ( J.A.M.A . 128:848-
851, July 21, 1945), constitute an ex-
cellent summary of the present position
of gold therapy in arthritis:
1 Gold is of no value in any form of joint
disease except rheumatoid arthritis.
2 Gold does not benefit all patients with
rheumatoid arthritis.
3 Gold is not the final answer to the treat-
ment of rheumatoid arthritis.
4 Toxic symptoms may appear at any time
during this form of therapy.
5 From 10 to 20 per cent or more of pa-
tients who have received gold therapy re-
lapse after stopping the drug.
6 Extreme care must be used during gold
therapy, and the physician must be familiar
with the details of such treatment before
undertaking this.
7 Injections of certain gold salts in proper
dosage may be followed by subjective and
objective evidence of improvement in the
majority of selected patients with rheuma-
toid arthritis.
Literature on request
MYOCHRYSINE
GOLD SODIUM THIOMALATE MERCK
for the treatment of rheumatoid arthritis
MERCK & CO., Inc. RAHWAY, N. J.
250
Minnesota Medicine
depression characterized by
\
"chronic fatigue"
Depressed patients . . suffering from psychomotor inhibition com-
plain of feeling tired, of not being able to get started on their daily tasks,
and of an abnormal inclination to procrastinate. They make up their
minds that they are going to do a certain thing but they never seem to
get to it. Everything seems too big for them . .
In the above quotation, Kamman emphasizes "chronic fatigue” as a
dominant symptom in the type of depression most frequently en-
countered in daily practice.
Benzedrine Sulfate is particularly valuable in the presence of "chronic
fatigue”. It will, in most cases, help to overcome the depression and
thus enable the patient to make a sincere and constructive effort to
surmount his difficulties.
♦Kamman, G. R.: Fatigue as a Symptom in Depressed Patients, Journal-Lancet 65:238 (July) 1945.
Tablets and Elixir
benzedrine sulfate
( racemic amphetamine sulfate, S.K.F.)
Smith, Kline & French Laboratories, Philadelphia , Pa.
March, 1947
251
PRESCRIPTION PACKET
1 Extensive clinical experience
• has established that the com-
bined use oi an occlusive dia-
phragm and a spermatocidal
jelly affords the optimum in pro-
tection to the patient.
2 A comprehensive report
• shows an overwhelming
preference for the diaphragm-
jelly technique of conception
control. In a survey comprising
36.955 cases, clinicians pre-
scribed this method for 34,314
or 93 per cent1
3 Warner,2 in a study of 500
• cases in private practice,
concludes that the combined
technique is the most efficient
method; there was no case of
unexplained failure.
4 For the optimum of protec-
• tion and simplicity in use
we suggest the "RAMSES" Pre-
scription Packet NO. SOI ... a
complete unit, containing a
"RAMSES" Patented Flexible
Cushioned Diaphragm of pre-
scribed size, a "RAMSES" Dia-
phragm Introducer of corre-
sponding size, and a large tube
of "RAMSES" Vaginal Jelly.t
Available through all prescrip-
tion pharmacies. Complete lit-
erature to physicians on request
'Human Fertility 10: 25 (Mar.) 1945.
iWarner. M. P.: J.A.M.A. 115: 279 (July
27) 1940.
JULIUS SCHMID, INC. 423W.55thST..NEWYORK19,N.Y.
/S83
The word "RAMSES" is a registered trademark ot Julius Schmid. Inc.
fActive ingredients: Dodecaethyleneglycol
monolaurate 5%; Boric Acid 1%; Alcohol 5%.
NO. 501
Minnesota Medicine
Your Job— And Ours:
To Build Baby’s Weight
We’re glad to share a little of that re- Nestles Evaporated Milk. We’re also
sponsibility, and proud of our record in glad to promise that you’ll always be able
helping babies to a fine start in life with to place full confidence in Nestle’s.
NestlI’x
nestle’s MILK PRODUCTS, INC.
New York, U. S. A.
Nestle’s Has the "Know-How" to
Produce a Good Product
• For 75 years, Nestle’s milk products have been best
known, most used for babies ’round the world.
• Nestle’s was the first evaporated milk fortified with
400 USP units of genuine Vitamin D3 per pint.
© Nestle’s accepts milk only from carefully inspected
herds. As further assurance of quality, rigid controls
check Nestle’s Milk every step of the way. We even
take the plant apart every day and wash it!
Nestles
•MW
Uiifl
No wonder so many doctors
recommend NllTLEx Milk by name
• . .
March. 1947
253
Premature, but promising
To the premature struggling for existence, intestinal distention, colic
or diarrhea may be insurmountable obstacles. Good care and good
nutrition, however, offer promising prospects for life and health.
In the feeding of premature infants, 'Dexin' has proved an excellent
"first carbohydrate." Because of its high dextrin content, it (1) resists
fermentation by the usual intestinal organisms, (2) tends to hold gas
formation, distention and diarrhea to a minimum, and (3) promotes
the formation of soft, flocculent, easily digested curds.
Readily soluble in hot or cold milk, or other bland fluids, 'Dexin' brand
High Dextrin Carbohydrate is well taken and retained. 'Dexin' does
make a difference.
HIED DEXTRIN CARBOHYDRATE
BRAND
Composition — Dextrins 75% • Maltose 24% • Mineral Ash 0.25% • Moisture
0.75% • Available carbohydrate 99% • 115 calories per ounce • 6 level packed
tablespoonfuls equal 1 ounce • Containers of twelve ounces and three pounds •
Accepted by the Council on Foods and Nutrition, American Medical Association.
‘Dexin* Reg. Trademark
Literature on request
BURROUGHS WELLCOME Sc CO. (U.S.A.) INC., 9 & 11 East 41st St., New York 17, N.Y.
254
Minnesota Medicine
...
highly potent
To these advantages may be added the emotional uplift or feeling of well-being which is so often
encountered in the patient following therapy with "Premarin." This aspect is being favorably
commented upon by an increasing number of clinicians.
To permit flexibility of dosage and enable the physician to fit estrogenic therapy to the particular
needs of the patient, "Premarin" is supplied in two potencies:
Tablets of 1.25 mg. — bottles of 20, 100 and 1000.
Tablets of 0.625 mg. — bottles of 100 and 1000.
Liquid; containing 0.625 mg. in each 4 cc.
(one teaspoonful) — bottles of 120 cc.
CONJUGATED ESTROGENS
(equine)
Ayerst, McKenna & Harrison Limited
22 EAST 40TH STREET, NEW YORK 16, N.Y.
March, 1947
255
Dose: 1 daily or
is prescribed
by physician.
PER CAPSULE
Auorbic
DOSE. To bo dotomiiood by
nood» of thf
STABILIZED AQUEOUS SOLUTION
Per CC.
THIAMINE HYDROCHLORIDE (B,) 5 Mg.
DOSAGE: X M. D R.
INFANT 3 Drop* 400X
CHILD 1-6 Yr*. 6 Dropi 400X
CHILD 6-12 Yrj--9 Drops 400X
ADULT 12 Drops 400X
MORE AS DIRECTED »Y PHYSICIAN
DROPS MAY BE ADDED TO MILK. FRUIT
JUICES OR FOOD
DROPPER SUPPLIED DELIVERS APPROX.
15 DROPS PER CC.
ASCORBIC
ACID
(VITAMIN C)
WA
ASCORBIC 1
VITAMIN PI
ACID
Mount Verr
(VITAMIN C>
lOO MG.
15 cc.
WALKER’S
To be used only
by, or on prescrip-
tion of physician.
WALKER VITAMIN PRODUCTS
Dose. 1 daily
as prescribed
by physician
WALKER VITAMIN PRODUCTS.il
WALKER
1 VITAMIN PRODUCTS, INC.
p.,f» Mount Vernon, New York
RIBOFLAVI
IOO TABLETS j
THIAMINE
5 MG.
HYDROCHLORIDE
(VITAMIN B->
lO MG.
Caution :
for therapeutic use
only To be used only
by or on prescription
Of a physician.
50 MG.
To be used only
by. or on prescrip-
tion of physician.
WALKER VITAMIN PRODUCTS.INC.
WALKER VITAMIN PRODUCTS, INC.
CONCENTRATED
OLEO VITAMIN
A-D DROPS
WALKER
CON FI DENCE
The hallmark of Walker manu-
facture is its uncompromising
emphasis on quality. Rigid con-
trols at every stage of produc-
tion, from raw materials to the
finished products, insure their
dependability. Physicians know
that Walker vitamin products can
be prescribed with confidence.
To be. used only
by. or on prescrip-
tion of physician.
IOO CAP8ULE8
WALKER’S
saaa
PH
Dose: 1 daily or
as prescribed
by physician.
50 MG.
VITAMIN PRODUCTS, INC.
MOUNT VERNON, NEW YORK
2S6
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30
March, 1947
No. 3
ACUTE INTUSSUSCEPTION IN INFANCY AND CHILDHOOD
Report of Fifty-Eight Cases
F. H. MAGNEY, M.D., F.A.C.S.
Duluth, Minnesota
T^HIS study is based on the cases of acute in-
tussusception coming to operation in St.
Mary’s and St. Luke’s Hospitals during a period
of twenty-five years, or from 1921 to 1945 in-
clusive. There were fifty-six patients who under-
went fifty-eight operations. The condition re-
curred in two cases, necessitating a second opera-
tion. Both of these patients survived. The high
mortality universally reported indicates that there
is a field for further study in order that there
be a more general early recognition of this con-
dition, as well as a more early resort to surgery.
Only by doing so can we reduce the mortality
rate.
No attempt has been made here to determine
the etiological factor in each case. Theoretically
many factors may play a part, but Ladd and
Gross in their series of 484 operated cases were
able to determine the cause in only 5 per cent.
Smith, in thirty-five cases including all ages, re-
ported that the cause was found in seventeen.
It must be noted that it is much easier to find
the cause in an adult than in an infant or young
child, as in the adult it is usually brought about
by some mechanical abnormality or pathologic
condition. In infants its occurrence is most prev-
alent between the ages of four and ten months,
which is the time their diet is being shifted from
a liquid to a solid one, so it is thought that this
is an etiological factor. Its appearance is quite
often during or shortly after a siege of acute
enteritis. The disturbed intestinal peristalsis at
this time may produce the mechanical inbalance
Presented before the Duluth Surgical Society and the Duluth
Pediatric Society.
that causes the bowel to invaginate. Meckel’s di-
verticulum is accepted as a causative factor. This
was found in two of the cases.
The youngest child in this series was seven
and a half days old and the oldest twelve years.
Seventy-four per cent were less than one year
old, and the highest incidence came at six months.
All but three were less than three years old. Sixty
per cent were boys and 40 per cent girls, which
is approximately the ratio found in other sur-
veys. Ladd and Gross report 62 per cent males
and 38 per cent females.
There are only three main or cardinal symp-
toms, and there being only three, every physician
having to do with infants and children should
keep these in mind. They are namely, inter-
mittent colicky pain, vomiting and bloody stools.
Seventy-three per cent of the children showed
all of these symptoms, and all had at least one
of them. If on examination an abdominal mass
can be felt, the diagnosis is certain. If in addi-
tion to this, a mass is felt by a rectal examina-
tion, there should be no doubt that one is dealing
with an intussusception. In 60 per cent an ab-
dominal mass was felt, although only in 20 per
cent was a mass felt rectally. The latter condi-
tion can be found only if the intussusception has
advanced well down in the large bowel, which
in most cases would indicate that the condition
has existed for some time.
Even the early symptoms are severe enough
to indicate that the child is seriously ill, and they
should suggest the correct diagnosis. I am sure
that many physicians have made the diagnosis by
having the mother relate the child’s actions over
March, 1947
257
ACUTE INTUSSUSCEPTION— MAGNEY
TABLE I. INCIDENCE OF INTUSSUSCEPTION
ACCORDING TO AGE
Age
Cases
7 days
i
1 month
1
2 months
0
3 months
2
4 months
6
5 months
4
0 months
10
7 months
4
8 months
5
9 months
5
10 months
4
1 1 months
1
12 months
4
13 months
2
14 months
1
15 months
0
16 months
0
17 months
0
18 months
0
19 months
0
20 months
0
21 months
1
22 months
0
23 months
0
24 months
1
2 to 3 years
3
3 to 4 years
0
4 to 5 years
0
5 to 6 years
1
6 to 7 years
0
7 to 8 years
0
8 to 9 years
0
9 to 10 years
0
12 years
2
the telephone. In most cases the onset was sud-
den and consisted of colicky abdominal pain
lasting only a few seconds and occurring every
ten to thirty minutes. Usually the patient is so
young that he cannot describe his pain but the
parents will note that the child becomes inter-
mittently pale, draws up its legs and cries out.
It may utter a grunt during the paroxysms. It
may appear well between these spells and even
go back to its play. Vomiting is sometimes the
first symptom and almost always an early one.
As the intussusception progresses and the ob-
struction becomes more definite, there is pallor,
sweating, dehydration, and later, shock. In this
series, vomiting occurred in 88 per cent of the
cases. Blood in the stool or on the examiner’s
finger was present in 63.3 per cent although it
was noted that it was less likely to be present if
the case was seen early. Ladd and Gross report
blood passed by 85 per cent of their patients ;
Gibbs and Sutton report 70.9 per cent. Accord-
ing to our findings the mortality was 30.8 per
cent when blood was present and 15.8 per cent
when absent, or nearly twice as high in the
presence of blood. This differs from the findings
of Gibbs and Sutton who report a mortality of
22.5 per cent with melena and 42 per cent without.
Intussusception does not seem to appear espe-
cially in a child that is below par or with a history
of nutritional disturbances, but rather in a healthy
Fig. 1. The frequency of characteristic signs and symptoms
of intussusception in infancy.
and well-nourished one. There may be one or
two normal bowel movements followed in most
instances by bloody mucus resembling current
jelly. The pulse is usually rapid and there is
evidence of pain the lower right quadrant. Even
when in a state of shock, the child will thrash
around, cry, and show other evidences of having
pain. An elevation of temperature was observed
in twenty-two cases or 38 per cent. It is some-
times difficult to palpate a mass in a well-nour-
ished child even though a mass is present. It may
be necessary to give a general anesthetic to relax
the abdominal muscles. If this is done, the oper-
ation room should be set up so that the operation
can be carried out under the same anesthesia. The
mass is sausage shaped, but may be rather ill de-
fined. If the invagination is small it may be lo-
cated under the edge of the liver and be hard to
palpate.
The intussusception may advance through the
whole length of the large bowel and even pro-
trude through the anus and look like prolapse of
the rectum.
The laboratory findings were not of much
value in this series, as the history and physical
findings were so convincing in the majority of
the cases that the laboratory was not called upon
for assistance. This may have been a time-saving
factor as the taking of laboratory specimens,
their examination, and the interpretation would
tend only to delay the operation. Three cases
not reported in this series were supposed to have
been reduced by enemas. The majority of the
Duluth physicians are of the opinion that treat-
ment is strictly surgical, and the so-called con-
servative methods were not attempted. No evi-
dence was found in the records that the hydro-
static method of Hipsley was used. In the very
few cases in which reduction was attempted by
methods other than surgery, a barium enema was
used under fluoroscopic observation. Surely no
method of this nature should be used if the
258
Minnesota Medicine
ACUTE INTUSSUSCEPTION— MAGNEY
TABLE II. OPERATIVE PROCEDURE USED
AND ASSOCIATED MORTALITY
Operation
Number
Mortality
Per Cent
Reduction:
31
23
00
Reduction only
Fixation
D
Appendectomy
10
Fixation and appendectomy
3
00
Not reducible (tissues necrotic)
1
100
Not reducible (ileostomy tube)
1
100
Resection:
Primary anastomosis
4
25
i00
Double enterostomy
1
Single enterostomy
1
Not reduced-serus surfaces sutured at the
1
100
beginning of intussusception
symptoms have been present for some time, as
the series showed instances of gangrenous or
near gangrenous bowel and in one case a gan-
grenous Meckel’s diverticulum. The latter was
resected and the patient recovered. Hipsley does
not use his method if the symptoms have been
present more than twelve hours.
If a pediatrician is not already in charge of the
case or is in consultation, one should by all
means be called without delay. There is no one
more qualified by learning or experience to evalu-
ate the child’s condition and to treat the dehy-
dration, acidosis, toxicity, and even shock, if
present, by administering fluids and restoring the
electrolytic balance. Blood and plasma may be
needed. The dosage of the pre-operative medi-
cation should be left to the decision of the pedi-
atrician. In this series, the mortality rate with
a pediatrician in attendance was 23.5 per cent as
compared with 29.1 per cent without.
Drop ether was the anesthetic of choice, which
conforms to the experience of all other studies.
Apparently it is safest and gives the best relax-
ation. All but five children were given ether.
Three had local anesthesia plus ether. Two had
local anesthesia plus gas and eight had a com-
bination of gas plus vaporized ether.
Only operative cases in which the pathologic
condition was verified are included in this study.
Most operators used a right rectus incision, no
doubt due to the fact that it gives the best ex-
posure to the region of the ileocecal valve, where
the most difficulty is encountered in reduction.
The most favorable results are obtained if the
duration of the symptoms is short, as the bowel
is in better condition and the patient is in better
condition to stand the operation. The average
duration in this series was 34.4 hours. Ladd and
TABLE III. DURATION OF SYMPTOMS AND
MORTALITY RATE
Duration of
Symptoms
Number of
Cases
Deaths
Mortality Rate
(Percentage)
Less than 24 hours
28
5
18
24 to 48 hours
13
3
23
2 to 3 days
4
2
50
3 to 4 days
5
0
00
4 to 5 days
5
3
5 to 6 days
3
2
67
TABLE IV. TYPE OF LESIONS AND
RELATIVE MORTALITY
Type
Number
Deaths
Per Cent
Mortality
Ileo-ileal
5
2
40 0
Ileo-colic
49
12
24.7
C olo-colic
4
1
25.0
Gross report thirty hours, Peterson and Carter
thirty-two hours and Robbins forty-five hours.
Extreme care and gentleness must be used in
handling the bowel, due to its friability. Several
figures are passed into the left side of the ab-
domen to locate the head of the intussusception.
It is pushed back along the colon. Good progress
is usually made until reaching the neighborhood
of the ileocecal valve. The bowel must then be
brought outside of the abdomen. If there is
much edema, this can be reduced by warm com-
presses. The reduction is continued by a gentle
milking process, using the whole hand and
squeezing the invagination out. It may be neces-
sary to hold the bowel below between the fore-
finger and the thumb to steady it. The difficulty
encountered near the valve is due to the edema
of the gut and mesentery. Perseverance and a
prolonged gentle pressure seems to reduce the ede-
ma, and in most cases where the situation seems
most hopeless, success is achieved. At this point,
caution must be exercised and traction avoided.
Some operators advise the injection of some gly-
cerin between the two serous layers due to its
hydroscopic action on the edematous tissue. After
the intussusception has been reduced, the bowl
must be observed carefully for tears and via-
bility. Small serous tears can be ignored, but
if the tear extends into the muscularis it should
be repaired. There is always edema, swelling,
discoloration and some degree of hemorrhage, but
if observed for a few minutes it will be found to
improve in color, especially if a warm saline pack
is applied. Immediately following reduction the
appendix may appear to be acutely inflamed due
March, 1947
259
ACUTE INTUSSUSCEPTION— MAGNEY
to edema, but most authors advise against its
removal as it adds to the operative trauma and
shock. However, in this series, there was only
one death among the eleven who were submitted
to an appendectomy. In thirty-one (55.2 per
cent) of the cases the operative procedure was
limited to the reduction of the intussusception,
with eight deaths or a mortality of 28.8 per cent.
In one case no attempt at reduction was made
as the bowel was gangrenous. The patient died
on the operating table. In five cases some method
of fixation was done with the idea of prevention
of recurrence with no deaths. In one case re-
duction plus appendectomy and fixation was done
without mortality.
A resection of the bowl was done in seven
cases, five of which had a primary anastomosis.
There were two deaths, or a mortality of 40 per
cent. One had a double enterostomy and one a
single, following resection, both resulting in
death. Both of these patients were in poor con-
dition before the operation, so the outcome was
anticipated. The mortality in all resection cases
was 57 per cent which is considered very low.
Most reports show a mortality rate of 70 to
100 per cent.
In one case where the reduction was found to
be impossible, the serous surfaces were sutured
at the beginning of the intussusception and an
enterostomy tube inserted. The patient died. A
gangrenous Meckel’s diverticulum was resected
in one case and the patient recovered. No at-
tempt was made to fix the bowel by exterioriza-
tion of the appendix as reported by Masson and
Judd. Most authors advise against any method
of fixation as it only adds to the operative pro-
cedure without preventing recurrence. In some
cases of recurrence, the invagination of the bowel
occurs at a new site the second time.
While it is wise to limit the procedure to a
simple reduction, even though it may tax the
patience of the operator carrying it out, there
are cases in which a resection must be done. In
these cases a primary anastomosis was accom-
panied by the lowest mortality, probably due to
the fact that the child cannot stand the loss of
the succus entericus. Woodhall has reported the
doing of a lateral anastomosis in the Mikulicz
operation, thus establishing an immediate con-
tinuity of the bowel and preventing the loss of
the enteric contents. No such procedure was at-
tempted in this series.
The fifty-eight operations were followed by
fifteen deaths, or an overall mortality rate of
25.9 per cent. It is interesting to note the great
improvement that has been made in the manage-
ment of these cases during the last fifteen years.
TABLE V. MORTALITY RATES REPORTED
BY DIFFERENT AUTHORS
Author
Per Cent Mortality
Gribsby and Kaplan
20.0
Gordon
22.7
Mayo and Woodruff
23.6
Duluth
25.9
Gibbs and Sutton
30.4
Ladd and Gross
31.2
The first ten years showed a mortality of 46.7
per cent as compared with 18.1 per cent during
the last fifteen years. In the last five years seven-
teen cases were operated upon with only two
deaths, or a mortality of only 11.8 per cent.
Gibbs and Sutton report a mortality rate of
30.4 per cent over a sixteen-year period, Ladd
and Gross 31.2 per cent, Grigsby and Kaplan
22.0 per cent, Gordon 22.7 per cent and Mayo
and Woodruff 23.6 per cent.
The improvement in the results during the
more recent years is due to many factors. The
early diagnosis and surgery without delay are
without doubt of most importance. The improve-
ment in surgical technique plays a great part. The
part played by the pediatrician in preparing the
patient for operation and caring for him post-
operatively is so important that every case should
have the benefit of this co-operation. The more
recent adjuncts to surgery, such as whole blood,
blood plasma, the Wangensteen decompression
tube, et cetera, are vital in bringing down the
death rate in intussusception.
(Continued on Page 302)
260
Minnesota Medicine
FINANCING THE ESTABLISHMENT OF A SMALL HOSPITAL
JAMES. A. HAMILTON
Hospital Consultant and Professor of Hospital Administration, University of Minnesota
Minneapolis, Minnesota
OUR discussion is concerned with the estab-
lishment of a small hospital, about 50 to 100
beds, in a rural area. It is true many of the prin-
ciples likewise apply to a hospital of larger size
located in an urban center. Recent studies of
population indicate that, approximately 45 per
cent of hospitals in the United States are classi-
fied as rural. However, a sizable portion of the
rural population is located in areas surrounding
urban centers and is not occupied with farming
activities. Likewise, the studies are indicating
that the rural population would utilize hospital
service to the same degree as the urban resident
if more facilities were readily available and the
cost of such service could be properly financed.
Undoubtedly, much of the hospital construction
in the next few years will occur in the rural areas.
Launching the Project
For the purpose of this discussion we will as-
sume that there has been sufficient interest in the
local community to have resulted in the formation
of a small committee requested by the citizens to
investigate the possibility of creating a small hos-
pital.
The first step would be to have a survey of
the population, health, social and economic char-
acteristics of the area to determine whether there
should be a hospital and, if so, what should be
the extent of its functions, how large should it
be, what facilities are needed to perform the func-
tions as determined, and finally, how can it be
integrated with the other hospital facilities of
the state program.
A statement of such facts, together with their
interpretation on the light of hospital trends, and
some analyses of the probability of continued
operating support, constitute a real necessity for
the launching of a successful project. It tends
to keep the local enthusiasm intelligent and within
rational bounds. Also, it tends to balance the
pressure of local pride with realistic endeavor.
If money must be raised for the construction of
such an institution, the donors ask very significant
Presented at the annual meeting of the Minnesota State Medi-
cal Association, St. Paul, Minnesota, May 22, 1946.
March, 1947
questions which cannot be answered without the
above data, and such donors usually desire an
outside reliable opinion. Therefore, not only is it
advisable for intelligent planning, but it also may
be considered to be good business in terms of the
success of the project.
Such a survey could be conducted by a nearby
hospital administrator or a person devoting full
time to such consulting services. The nearby
administrator usually has the disadvantage of local
prejudice, and his recommendations are not so
easily accepted, even though he may be a very
capable person. The expert consultant who has
the benefit of objective distance, also can bring
to bear the experiences and conclusions which
other communities have experienced outside of
the local area. It must not be assumed that such
a consultant would always recommend in favor
of the construction of a hospital. In fact, I am
just completing a survey where we are recom-
mending that no additional facilities be con-
structed.
The cost of such a survey, including profes-
sional fees, will naturally vary with the size of the
area, the complexity of the local problem, and the
availability of facts. Therefore it may run from
$1,000 to $3,000 for a relatively small communi-
ty. The funds for this purpose can be secured
from a local organization such as a lodge, legion,
or Rotary Club ; from a single individual in the
community vitally interested in health affairs, or
from local government public funds. The secur-
ing of such funds has the additional advantage
of giving to the community the first real evidence
that the interest for a hospital is deep-rooted — -
a very necessary fact for the future success of the
project.
The next step usually is the formalizing of an
organization to serve as trustee in receiving
funds and carrying out the objectives. In most
cases this is of nonprofit character, and it is well
to secure a local lawyer to' give advice in the
formation of this unit, in order to take advantage
of existing state laws which will give freedom
from taxation and other privileges. The cost of
such assistance is very low. Likewise, it is im-
261
ESTABLISHMENT OF A SMALL HOSPITAL— HAMILTON
portant to secure some hospital advice as to the
best forms of by-laws for the operation of such
an institution. Here the American Hospital As-
sociation has several suggestions, and again the
consultant can be helpful in interpreting these in
the light of the local conditions.
The third step in launching the project is the
raising of capital funds. The amount necessary
will be estimated by the consultant in co-opera-
tion with an architect. In these days of high
construction costs, it is advisable not to conceive
of less than $10,000 per bed. In some rare in-
stances it is possible to do this at the present time
for $8, '000 per bed. In a few situations the cost
may even be higher. Such amounts will con-
struct and completely equip the hospital. In-
cluded is an architect’s fee which usually amounts
to between 6 and 7 per cent of the total construc-
tion and fixed equipment cost, and a hospital con-
sultant’s fee which ranges from 2 down to 1 per
cent depending upon the size of the project.
The capital fund campaign usually includes
three phases :
1 . A public relations phase which involves the
telling to the right people the facts relating to the
need and the objectives of the, proposed hospital.
2. The securing of promised contributions
from a selected group of individuals with means,
and from corporations located in the area who
will be benefited by the new hospital.
3. The conduct of a general campaign in which
everyone in the area may have some opportunity
of contributing. Normally the larger portion of
the funds comes from large givers in corporations.
The general campaign usually yields a very small
portion of the total amount.
Many communities have found it worth while
to employ outside fund-raising experts. There
are several very reliable firms who conduct such
campaigns with excellent results. They do not
raise the money, but assist the local people in do-
ing so. Many of the theoretical objections to
the use of such outside units are so much buga-
boo and are unrealistic. They do not use high
pressure ; they have the benefit of the experiences
of many communities ; they do guide the local
effort and keep it continuously in line with the
necessity of activity which is not usually possible
through normal voluntary effort. They are
trained in developing successful techniques. They
usually work on a fixed fee basis, which together
with the total costs amounts to about 2 to 3 per
cent of the total amount raised. They do not
undertake a project unless there is reasonable
assurance it will be successful. Most communities
feel that “now is not the best time” to raise money,
whatever time that may be. If one follows that
philosophy, no money would ever be raised for
welfare projects. Therefore, this barrier should
be overcome from the very beginning.
A considerable portion of funds for recent
hospital construction is contributed by corpo-
rations. Contrary to the general belief, most cor-
porations in rural areas are not soulless, but re-
flect the attitude and humanitarian instincts of
the human beings who direct them. I could give
you many illustrations of corporations who have
responded enthusiastically and generously to such
hospital effort.
If desirable, it is possible to raise some of these
capital funds from tax sources — not only from
local, county, and state sources, but from Federal
funds available under the new Hill-Burton Act,
with which I believe you are acquainted. It is
possible to secure about a third of the capital
from the funds available under the new Hill-Bur-
ton Act. However, it is necessary that the local
project be integrated into a state program and that
the state authority indicate its approval and prior-
ity status.
Construction of the Hospital
This is a period of high construction costs.
With the uncertainty of labor costs, contractors
are padding their bids. Even then it is advisable
to leave additional allowances for a possible rise
in cost during the construction period. It is the
hope that even though labor rates will not be re-
duced, that the productivity of labor will be in-
creased. It is also hoped that labor’s demands
will be stabilized, thus making it possible for the
contractors to remove the additional padding.
No guess is reliable as to when this will take place.
Also, it is difficult in these days to secure suit-
able materials with sufficient regularity to pro-
duce the kind of hospital one desires. It is hoped,
with the removal of priorities and the increased
productivity of labor, that materials will be avail-
able within a reasonable length of time.
In the meantime, many communities are mak-
ing specific architectural plans for the develop-
ment of their hospitals. It is well that a rela-
tively long time be available for such procedure
262
Minnesota Medicine
ESTABLISHMENT OF A SMALL HOSPITAL— HAMILTON
in order that ideas may mature, and that with new
thinking, the plans can be revamped as many times
as necessary until finally satisfactory. It is ad-
visable to hold in mind that the unit is to be used
over a long span of years and that errors in the
planning will have a serious effect upon later op-
eration.
Most communities, therefore, are employing
not only an architect, but a hospital consultant,
and it is my belief that both are necessary to give
an economic result. No architect, whether he
has done several hospitals or not, is in a full posi-
tion to keep abreast with changes in hospital op-
eration which may effect a big saving in later
operating costs. The qualified hospital consultant
is in the best position to reflect such results in
the architect’s plan.
Operating Funds
In the planning of a new hospital, it is very
advisable to plan for the financial operation of the
institution in advance of its construction. The
most potent influence on the net financial result
will be the percentage of occupancy of the pro-
posed institution. Studies have indicated that the
smaller the hospital, the lower the percentage of
occupancy, which is usually the result of the in-
creased proportion of segregation of patients
which is imposed upon the smaller units. There-
fore, it is very favorable in the planning of the
hospital itself to assure as much flexibility in bed
utilization as possible, thus insuring as high a
percentage of occupancy and income as can be
realized.
Current operating capital should be anticipated
to carry the loss of operation for at least six
months and perhaps better, for a year. In addi-
tion it will be necessary to have some funds for
current operating purposes. Therefore it is ex-
ceedingly advisable that a budget be prepared in
advance. Here again the consultant with his
knowledge of hospital operation is in the best
position, not only to advise the new Board of
Trustees in the operating organization of the
hospital, but also to aid in the preparation of the
budget.
Normally, it is not possible for the hospital
which desires to give some free service to the
community to secure its complete income from pa-
tients solely. There is an increasing tendency for
third parties to pay for patients’ bills. In many
institutions this is as much as two-thirds of their
total load. Such third parties may take the form
of the voluntary Blue Cross movement, commer-
cial insurance, and local government authorities.
Therefore great care should be taken in making
financial arrangements with these third parties
which will yield a sufficient income to operate the
institution. All of these endeavors are possible in
the small community as well as the large. Nor-
mally, a hospital of the size we are discussing has
as a cost of service about $8 per patient per day.
With increased labor costs, the chances are that
this amount will increase, and within a relatively
short time will amount to $10 per patient per day.
Usually it is necessary for the community hos-
pital to secure some outside financial assistance
in its operation. If it is possible to secure en-
dowment funds at the same time as one is raising
construction funds, such a situation is ideal.
However, this is very rarely possible. Therefore,
the raising of operating funds usually takes place
after the construction of the institution. For the
first few years of its existence, the hospital may
secure some of these funds from local govern-
mental sources in the form of an annual subsidy
in order that the institution may exist at all. Like-
wise a local annual drive for the operating con-
tributions may be conducted. Many hospitals
have existed on these two sources alone for many
years before they were able to secure bequests
for endowment purposes.
Summary
The successful establishment of a new hospital
must depend upon the possibility of giving good
service to the community, primarily through de-
veloping a good professional staff, and upon
sound planning. If this is done, usually the finan-
cial needs are met, provided the facts are prop-
erly interpreted to the community as a whole.
To accomplish such results, however, the local
people should proceed slowly, and with the ad-
vice and guidance of persons experienced in the
hospital field.
I am informed by leaders in the rural areas
in this country that many communities realize the
need for hospital facilities and are prepared to
put forth the effort and the sacrifices necessary
to secure such community service. Therefore,
I have every confidence that the majority will
proceed along intelligent lines and that the rural
population will eventually have available those
hospital services vitally necessary to their full life.
March, 1947
263
A SHORT COMMENTARY ON THE HISTORY OF THE CIRCULATION
Modem Addenda
F. A. WILLIUS, M.D.
Rochester, Minnesota
rT'< HE casual student of medical history asso-
ciates two famous and well-known historic
names with the discovery of the circulation of the
blood. He knows that the martyr, Michael Serve-
tus, generally has been regarded as the discoverer
of the pulmonary circulation and that William
Harvey conceived and described both the systemic
and pulmonary circulation, suggested the exis-
tence of the capillary circulation and described
the essential functions of the heart. Most phy-
sicians today consider that Harvey discovered the
circulation. I have no intention to deprecate the
monumental contribution of Harvey but rather
to maintain the accuracy of historical documen-
tation.
In order to do this it is necessary to present
the facts as they are inscribed in the records of
the past and to supplement the older records with
more recent biographic research. In such re-
examination of historical data several less prom-
inently mentioned contributors are brought to at-
tention, and particularly one who was introduced
to readers only eleven years ago. In presenting
this commentary it is not my intention to become
involved in the futile controversy relative to pri-
ority which is currently being carried on among
various medical historians. It is, however, my
desire to present certain evidence to the reader
which may enable him to conclude that the cur-
rent concepts regarding the circulation are the
product of several noteworthy historic personages
living in different eras and in different localities.
According to recent disclosures, the first re-
corded concept of the pulmonary circulation was
that of a famous Arabian physician, Ibn an-Nafis
(circa 1210-1288 A. D.). The important infor-
mation which he contributed became available
largely through the recent researches of Meyer-
hof and of Haddad and Khairallah. Meyerhof
learned that a young Egyptian physician, Muhyi
ad-Din at-Tatawi presented a thesis on Ibn an-
Nafis for his doctorate degree before the Medical
Faculty of Freiburg in 1924. This thesis was not
published and in all probability would have re-
mained in obscurity had it not been for the in-
From the Section on Cardiology, Mayo Clinic, Rochester,
Minnesota.
terest and continued investigations of the three
aforementioned medical historians.
Ibn an-Nafis will be discussed more fully than
the other contributors owing to the relatively
recent appearance of information concerning him
in historical writings even though he is the most
ancient oi all. He was reared in Damascus but
no information is available regarding his parents,
his childhood or his early education. Ibn an-Nafis
studied the medical sciences under the brilliant
teacher and scholar, Muhadhdib ad-Din ’Abd ar-
Rahim ibn ’Ali.
Ibn an-Nafis was said to have been a tall man
of slender stature, dignified, polite, austere and
lefined. The biographies of this man, according
to Meyerhof, indicate that he was a master of
the art of healing and that he had no peer in
tlie acuity of his investigations. He remained
unmarried and devoted most of his time to study
and writing. Ibn an-Nafis was a prolific writer
and did not confine his writing to medical sub-
jects but also wrote extensively on logic, phil-
osophy, theology, jurisprudence, applied law, the
Arabic language, tradition and rhetoric.
As was the custom of the day, Ibn an-Nafis
wrote numerous commentaries on the works of
others but, in addition, wrote three books on
medicine. “Kitab ash-Shamil fi’t-Tibb” (The
comprehensive book on medicine) was an exten-
sive encyclopedia which was never completed and
no copy of this work is known to exist today.
Another work, “Kitab al-Muhadhdhab fi’l-Kuhl”
(The well-arranged book on ophthalmology), is
also nonexistent but references to it were found
in later works on the subject. The third book,
“Kitab al Mukhtar min al-Aghdhiya” (The choice
of aliments) was said to be of relatively little im-
portance. A manuscript of this work was known
at one time to be in the Berlin State Library.
Ibn an-Nafis’ most important work was his
commentary on Avicenna’s (Ibn Sina; 980-1037)
“Sharh Tashrih al-Qanun li-’bn Sina” (Anato-
my) because this document contained the first
known description of the pulmonary circulation.
The exact time of its inscription is not known
but Meyerhof believes it to have been about the
264
Minnesota Medicine
HISTORY OF THE CIRCULATION— WILLIUS
middle of the thirteenth century. At least four
manuscripts of this voluminous work have been
preserved. Ibn an-Nafis’ manuscript, therefore,
antedates Servetus’ work by approximately three
centuries.
Ibn an-Nafis’ conclusions regarding the pul-
monary circulation were based on indirect ob-
servation, speculation and remarkably correct de-
duction. In the preface of the commentary he
stated that the prevailing religious laws and his
own innate charity had prevented him from per-
forming anatomic dissections and therefore, he
was obliged to study the forms of anatomic struc-
tures from the works of others, especially those
of Galen. Galen’s concepts regarding the heart
and circulation were fallacious but were generally
accepted as being true for nearly fourteen and a
half centuries.
It is most plausible, as contended by Temkin,
that Servetus’ conclusions regarding the pulmo-
nary circulation were original, for it would have
been an unusual coincidence for him to have
known of this earlier work. The separation in
the space of time by nearly three centuries, the
widely separated geographic localities and the
great differences in language, strongly support
the contention that Servetus was entirely unaware
of Ibn an-Nafis’ contribution.
Ibn an-Nafis described the pulmonary circula-
tion five times in his “Commentary” and dis-
cussed the general physiologic principles of res-
piration. Man was classified as an air-breathing
creature in whose lungs the blood was aerated.
He mentioned the alveoli of the lungs which were
first actually demonstrated by Marcello Malpighi
in 1660.
The following quotations from Ibn an-Nafis’
work in translation from Meyerhof’s article are
of importance: “Therefore, the blood, after hav-
ing been refined, must arise in the arterious vein
to the lung in order to expand in its volume and
to be mixed with air so that its finest part may
be clarified and may reach the venous artery in
which it is transmitted to the left cavity of the
heart.” Disclaiming Galen’s false concept regard-
ing the existence of invisible pores in the ven-
tricular septum, Ibn an-Nafis stated : “ But there
is no passage between these two cavities; for the
substance of the heart is solid in this region and
has neither a visible passage, as was thought by
some persons, nor an invisible one which could
have permitted the transmission of blood, as was
alleged by Galen.” Ibn an-Nafis also stated that
the heart was nourished by its own vessels and
in this statement at least implied a very early
concept of the coronary system.
Ibn an-Nafis’ important contribution was, be-
yond dispute, the one outstanding highlight in
the medical accomplishments of the Medieval
Era and, owing to its relatively recent disclosure,
merits emphasis in historical documentation deal-
ing with the circulation.
The life of Michael Servetus (1509-1553) of
Villanueva de Sigena, Spain, has received con-
siderable historical comment and therefore a full
account of his tragic existence and death would
entail much repetition.4’9 He was a self-styled
theologian, in addition to being a physician, an
author, a linguist and a translator, and his re-
ligious rebellion found expression during the
troubled years of the Reformation.
Servetus was judged to be a heretic by many
of his contemporaries and he acquired more
enemies than friends. The accusations of heresy
were based on the confused and bigoted reli-
gious doctrines of his day and his ideas con-
cerning religion certainly would not be consid-
ered heretic according to modern, or even semi-
modern, religious standards. Nevertheless he was
convicted of heresy at the insistence of Calvin
after an unfair trial, met his death on the pyre
after having experienced many humiliations and
cruel suffering and became one of medicine’s
first and most prominent martyrs.
The description of the pulmonary circulation
by Servetus was embodied in his famous, con-
troversial, religious work “Christianismi Resti-
tutio” which generally was presumed to have ap-
peared first in 1553. However, Mackall found
evidence that this work was written and in cir-
culation by 1546. The “Restitutio” in essence
was a disquisition of Servetus’ religious philos-
ophy and an outspoken criticism of prevailing
theologic views. His description of the pulmo-
nary circulation was used only to illustrate and
emphasize a point in discussing the nature of the
Holy Spirit. Servetus described the circulation
of the blood from the right chambers of the heart
through the vessels of the lungs where it was
mixed with the air and thence back to the left
chambers of the heart. This was his only im-
portant medical contribution.
Thus, two entirely unrelated discoveries deal-
ing with the basic and correct concept of the pul-
March, 1947
265
HISTORY OF THE CIRCULATION— WILLIUS
monary circulation are now known to exist in
early medical annals. The first occurred approx-
imately in the middle of the thirteenth century
and the second, approximately three centuries
later. Each contribution, without a doubt was
original and Ibn an-Nafis’ discovery in no meas-
ure detracted from the importance of Servetus'
later work.
An Italian anatomist of the Renaissance who
described the pulmonary circulation almost cor-
rectly deserves mention. He was Matteo Real-
do Colombo (Columbus; 1516 ?-l 559) of Cremo-
na, who became Vesalius’ (1514-1564) successor
at Padua.2,5 In his work, “De re anatomica,”
published in 1559, Colombo described the pul-
monary circulation but did not explain the de-
tails correctly because he accepted certain beliefs
of the ancients. He held the view that the veins
carried the nutritive blood throughout the body
and he also perpetuated Galen’s fallacious idea
that the liver was the central organ of the cardi-
ovascular system.
By means of vivisection, Colombo demonstrat-
ed that the pulmonary veins contain blood but
held the erroneous belief that the blood becomes
cooled during the process of respiration. He,
however, disagreed with Galen regarding the
mythical notion that the ventricular septum con-
tains invisible pores and in discarding this be-
lief, Colombo was enabled to understand the gen-
eral scheme of the pulmonary circulation.
Colombo’s work appeared six years after the
death of Servetus and some historians are of the
belief that Colombo plagiarized the work of the
martyr. Colombo was also accused of plagiariz-
ing Vesalius’ “De fabrica humani corporis,”
which was published in 1543. He imitated the
title page of Vesalius’ work and utilized so many
other characteristics of “De fabrica” that from
the records of history it has been impossible to
clear these suspicions.
Still another important contributor to the dis-
covery of the circulation was the celebrated
Italian anatomist, Andrea Cesalpino (1519 or
1524-1603), professor of medicine at Pisa and
physician to Pope Clement VIII. Cesalpino’s first
published work which contained a description of
the circulation appeared in the volume “Peri-
pateticarum quaestionum Libri V,” which also
contained discussions of a philosophic nature.
It was published in Venice in 1571 and again in
1593. It is stated, however, that Cesalpino used
the term “circulation” in its physiologic sense as
early as 1559. Thus, his first publication with
reference to the circulation of the blood pre-
ceded Harvey’s work by fifty-seven years.
For many years a bitter controversy has been
waged among medical historians regarding Cesal-
pino’s priority and his rightful place among the
discoverers of the circulation. The Italian his-
torians have been particularly irate, not without
considerable justification. It is not my desire to
enter this controversy but rather to present his-
torical evidence which supports the Italian side
of the argument. In a recent interesting and im-
portant monograph, Arcieri, who asserts that he
has read and studied all the Cesalpinian works
carefully, brings forth convincing evidence that
Cesalpino had comprehensive knowledge of the
circulation. The records of history undisputedly
prove the priority of the publication. Corwin, in
a relatively recent publication, also emphasizes
the importance of Cesalpino’s work.
It is important that the following evidence
clearly presented by Arcieri be examined care-
fully. Cesalpino observed the difference in both
the structure and the function of the pulmonary
artery and vein. His observations also contained
a description of the origin, course and size of the
aorta and vena cava and the recognition of a
difference in the structure of arteries and veins
in general. Cesalpino explained that communi-
cations exist between the portal veins and the
vena cava, he observed the reciprocal relation of
cardiac contraction and vascular dilatation, and
predicted that an anastomosis (capillaries) exists
between arteries and veins. When these various
observations made by Cesalpino and his use of
the term “circulation” are considered it would be
strange if this learned physician had not him-
self integrated these various observations and
understood at least the general scheme of the
circulation of the blood.
In 1628, William Harvey (1578-1657) of
Folkestone and London, published his famous
“Exercitatio anatomica de motu cordis et san-
guinis in animalibus.11’12” Notes made by Harvey
as early as 1616 which are in the possession of
the British Museum indicate that even at that
time he possessed a clear understanding of the
structure and function of the heart and circula-
tion.
It is not known whether Harvey knew of Ces-
alpino’s work. Cesalpino is not mentioned in
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HISTORY OF THE CIRCULATION— WILLIUS
Harvey’s disquisition while frequent reference is
made to Galen, Aristotle, Fabricius and others.
Harvey studied at Padua from 1600 to 1605 and
during the first three years Cesalpino was still
alive. Harvey studied anatomy under the cele-
brated Hieronymous Fabricius of Aquapendente
and it would seem strange if this learned teacher
was not acquainted with the writings of a native
contemporary in his own field. If Fabricius knew
of Cesalpino’s work it would seem stranger yet
if he had not imparted this knowledge to his
students. The problem of language was no bar-
rier to Harvey because he was unusually pro-
ficient in the knowledge and use of Latin and his
monumental work appeared in faultless Latin.
The important question of whether Harvey knew
of Cesalpino’s work may always remain unan-
swered.
Harvey’s work was not accepted universally
by his contemporaries so it is little wonder that
the earlier contributions of others failed to either
interest or instruct the medical profession of his
time. Such celebrated contemporaries as Riolan-
us, Gassendi and Wormius refused to accept
Harvey’s clear exposition which was based on
dissections, vivisections, observations and lucid
reasoning. As already emphasized, the fallacious
teachings of Galen endured for nearly fourteen
and a half centuries and so deeply were they im-
pressed on physicians that unprejudiced, dear
vision regarding the new and correct ideas seemed
impossible. Riolanus is credited with the state-
ment that if dissections and observations dis-
agreed with those of the great Galen, then any
discrepancies should be attributed to the fact that
nature had changed since the day of the great
master.
At this point of this commentary it is appro-
priate to reiterate the generally accepted con-
cepts regarding the heart and circulation which
prevailed at the time of Harvey. Earlier physi-
cians accepted the belief that a movement of the
blood occurred but, like Galen, they believed
that this movement took place in the veins by a
process of ebb and flow. Some still held the view
that arteries contained air (spirits) while only
the veins contained blood. Circulation of the
blood had not been universally understood, al-
though as previously pointed out, the general
scheme of the circulation was certainly known
by Cesalpino. The liver, rather than the heart,
was considered to be the central organ of the
March,' 1947 . • •
cardiovascular system, and it was in the liver
that the production of blood was said to occur.
The prevailing idea was that two kinds of blood
were present; one kind flowed from the liver to
the right chambers of the heart and to the lungs
and then returned to all parts of the body by
the veins ; the other kind flowed from the left
chambers of the heart to the various parts of
the body by means of the arteries. One of the
crucial fallacies of Galen’s beliefs was that in-
visible pores existed in the septum of the ven-
tricles. Hence, a small amount of blood from the
right ventricle was permitted to trickle through
to the left ventricle. No definite knowledge of
the heart as a propulsive organ designed for the
conveyance of blood from the heart and ulti-
mately back to the heart was extant. It was
even debated whether the heart is muscular and
it was not until 1664 that Niels Stensen (Nicho-
las Steno; 1638 to 1686), definitely proved that it
is. The early physicians considered the pulsa-
tions of the heart and arteries to be the result of
the alternate contraction and expansion of the
air (spirits).
Harvey’s exposition was clear, convincing and
based on actual proof and offered an intelligible
explanation for those who were willing to accept
new ideas. His proof was perfect and his dis-
quisition appeared in an era of greater medical
enlightenment so that its universal acceptance
was only a matter of time. These have been the
factors which have stamped this great English-
man as the discoverer of the circulation.
Harvey proved that contraction, not dilatation,
of the heart is synchronous with the pulse, that
contraction of the ventricles squeezes out the
blood and propels it into the aorta and pul-
monary artery, that the expansion phase of the
pulse is produced when the arteries become filled
with blood, that no invisible pores exist in the
septum of the ventricles (also proved by several
predecessors) and that the only means whereby
blood from the right chambers of the heart can
reach the left chambers is through the pulmo-
nary circulation. Harvey completed his descrip-
tion of the circulation of the blood when he stated
that blood from the left side of the heart is
conveyed by the arteries, reaches the veins by
small communicating vessels (capillaries) and is
then returned to the heart. He could not visualize
the small communicating vessels but he postulated
( Continued on Page 285)
26?
DUODENAL DIVERTICULUM
ARTHUR N. COLLINS, MD„ F.A.C.S.
Duluth, Minnesota
T N an effort to emphasize the importance of duo-
denal diverticulum, the writer has undertaken
to report a case of his own, to review similar cases
from the records of local hospitals, and to call
attention to the symptomatology and surgical
treatment.
In 1710, Chomel first described duodenal diver-
ticulum in a woman dead from apoplexy. The
diverticulum contained twenty-two gallstones.
Case described it first from the x-ray standpoint
in 1913, while Forsell and Kay described the
first surgical treatment for it in 1915.
Incidence
In one of our x-ray departments in Duluth,
duodenal diverticulum was noted forty times in
1,744 gastrointestinal studies (2.3 per cent). At
Stanford University Hospital, during 6,000 gas-
trointestinal roentgen examinations, it was noted
seventy times (1.16 per cent). This is not com-
mon, to be sure, but at the same time is not a
rarity.
The roentgenologist during gastrointestinal
studies not infrequently observes and makes notes
of duodenal diverticulum but more often coin-
cidently with other intra-abdominal findings, such
as gall-bladder abnormalities, peptic ulcer, car-
cinoma or other epigastric disorders. Occasion-
ally, duodenal diverticulum stands alone as the
single finding to account for the patient’s symp-
tom-complex.
Its clinical importance is perhaps not sufficient-
ly recognized. Undoubtedly, many diverticula
exist without causing symptoms. Many, unsus-
pected before death, have been found at autopsy.
A diverticulum, small to begin with, probably does
not cause symptoms until it attains a size suffi-
cient to develop retention within or mechanical
pressure to adjacent structures without.
What relationship, then, has a duodenal diver-
ticulum to the symptoms of the patient? What
should be done if it is decided a relationship
■ exists between the lesion and the complaint? The
■ question of its clinical significance has formed
the basis of much discussion during the last dec-
Presented before the Duluth Surgical Society December 26,
1946.
ade. Groups of cases are being reviewed in the
literature, and experiences compared, in a con-
structive effort to command more exactness. No
doubt operations have been done for gall-bladder
disease or ulcer when, in essence, a missed diver-
ticulum was at the root of the patient’s trouble.
Beals, in a study of forty-one cases of duodenal
diverticulum seen in his x-ray work, found that
about 36 per cent had received surgical treatment
for gall-bladder disease or had x-ray evidence
thereof.
Diagnosis begins with a careful review of the
patient’s history, his complaints and the length
of time involved. The following case is presented.
Case Report
A man, aged fifty-seven, a construction worker, pre-
sented himself complaining that for the past two years
he had had epigastric distress after eating, which had
been gradually becoming worse. It seemed to him to be
gas pressure, for he obtained some relief by belching.
Some foods distressed him more than others. Onions,
potato chips, cabbage or fried foods were the worst of-
fenders. The distress seemed worse at night. No relief
was obtained by taking milk or alkalis, and he found
no food which relieved the burning and boring pain.
He had experienced no hematemesis or bloody stools.
He had lost about ten pounds in weight in the preced-
ing eight months.
On examination he was found to be a man of strong
muscular build. Heart and lungs were essentially nor-
mal. The blood pressure was 120/80 and his pulse
was 68. No tenderness was elicited over the epigastrium
or elsewhere in the abdomen, and no mass was pal-
pated. There was a small reducible left inguinal hernia.
The extremities were not abnormal. Laboratory findings
included essentially normal urine, a hemoglobin value
of 89 per cent, erythrocytes numbering 4,640,000, and a
white blood cell count of 7,850.
The x-ray studies of the gall bladder and gastro-
intestinal tract revealed (Fig. 1) “a poorly functioning
gall bladder, no evidence of stones, and a negative
stomach and duodenal cap. A diverticulum of the sec-
ond portion of the duodenum was demonstrated, which
had an area of decreasing density due either to retained
food from a previous meal or to a polypoid growth
within the diverticulum. It should be kept under ob-
servation, especially if there is blood in the stool, and
the advisability of surgery should also be considered
in view of these findings. A single film of the abdo-
men, forty-eight hours after ingestion of the barium
meal, shows no evidence of any barium remaining in
the diverticulum. Most of the barium has been expelled.”
268
Minnesota Medicine
DUODENAL DIVERTICULUM— COLLINS
Fig. 1. The x-ray shows a normal stomach and duodenal cap
with a large diverticulum of the second portion of the duodenum.
In the absence of positive diagnostic findings to account
for the man’s persistent complaints, aside from the
diverticulum, exploration was advised. At the operation,
there was found a soft gall bladder and no palpable
lesion of the stomach. After considerable search in the
second portion of the duodenum, the sac of the diver-
ticulum was found posteriorly. It was rotated anteriorly,
clamped at its neck, and removed with a cautery. The
stump was sutured and then overcast with interrupted
silk sutures.
Postoperatively, a naso-gastric tube was used for
decompression of the stomach. A transfusion of 500 c.c.
of whole blood was given, supplemented by saline with
glucose or by distilled water with glucose. On the
fourth day the naso-gastric tube was discontinued, and
water in small amounts was allowed by mouth.
The laboratory reported the diverticulum to be lined
with normal mucosa without significant inflammatory
change.
The man took a vacation and at the end of eight weeks
returned to his regular duties. He has worked steadily
up to the present time, about six months after the opera-
tion. He feels fine, has no pain, and his old trouble has
ceased. He is on an unrestricted diet without discom-
fort. He has gained 20 pounds in weight. An x-ray
check-up and report six months after operation was
as follows (Fig. 2) : “Films of the stomach following
the ingestion of the barium meal show the stomach
and duodenal cap to be within normal limits. The large
diverticulum of the second portion of the duodenum
has been resected and the duodenum appears to func-
tion normally.”
Review of Cases
If it is true, as has been stated, that divertic-
ulosis is noted on roentgen examination with
relative frequency, we are faced then with the
problem of sorting out and fixing our attention
upon those cases in which a duodenal diverti-
Fig. 2. This x-ray, taken six months after the removal of the
duodenal diverticulum, shows a normal appearing duodenum.
culum is accountable for symptoms disabling to
the patient. These diverticula are not all harm-
less by any means. Malignancy, ulceration, and
perforation of a diverticulum have been found
to be serious complicating factors. A case of
spontaneous rupture of a duodenal diverticulum
was described by Beaver in 1938, and similar
episodes were described by Boland and Monsur-
rat. Gallstones have been found within a diver-
ticulum. Hare and Cattell discuss the subject of
duodenal diverticulum simulating gall-bladder
colic. Sinister factors, therefore, are sometimes
linked with this condition, and a differentiation
is called for.
Twenty-three cases of duodenal diverticulum
have been collected from the records of St. Luke’s
and St. Mary’s hospitals in Duluth, and these in-
volved thirteen males and ten females. There was
one child, three years of age, who on x-ray
examination showed a diverticulum of the second
portion of the duodenum. The rest of the patients
ranged in age from thirty-seven to eighty-eight
years. Twenty of the twenty-three patients were
fifty years of age or older. Ten were over sixty
years of age. The overwhelming majority were
in the older age group.
Nineteen of the twenty-three patients com-
plained of epigastric pain. Of the remaining four,
one patient, aged fifty-one, had aching pain in
the left chest and left upper quadrant, worse after
eating, with a history extending back fifteen years.
The x-ray study was not typical of ulcer, and the
patient was not treated surgically.
One patient, aged seventy, had sharp pain in
March, 1947
269
DUODENAL DIVERTICULUM— COLLINS
the upper right quadrant, and the history ex-
tended back many years, with nausea and vomit-
ing and diarrhea by spells, and with weight loss.
X-ray examination showed a duodenal diverticu-
lum in the second portion. The patient was not
treated surgically.
One patient, aged seventy-eight, had constant
severe pain in the umbilical region for a period
of one month, with tenderness, vomiting and loss
of weight. X-ray showed a duodenal diverti-
culum in the first portion. No operation was per-
formed. At autopsy, cholelithiasis and carcinoma
of the pancreas were found.
The fourth case without epigastric pain was
that of the child referred to above.
As to the nature of the pain, three patients
complained of burning pain, three of cramp-like
pain, three of sharp pain, and seven of dull ach-
ing discomfort. Gas was mentioned as distressing
in nine cases, and bloating or fullness in six
cases. In eleven cases, the history extended back
one year or more. In nine cases, the history ex-
tended back “for years.” One patient, a man,
seventy-two years of age, had attacks for thirty-
five years of epigastric burning pain and, at times,
nausea, vomiting and constipation, but no local
tenderness. On x-ray examination a large duo-
denal diverticulum was visualized, and six-hour
retention was observed in the diverticulum. No
operation was done. This was the longest history
in the group.
Fifteen of the twenty-three patients had tender-
ness in the epigastrium. One of the fifteen, a man
aged sixty-seven, stated the right upper quadrant
was the site of his tenderness. He was an obese
miner who was admitted for cardiovascular dis-
ease, but who on gastrointestinal study showed a
duodenal diverticulum. On the other hand, one
man of sixty, had no complaint of tenderness but
had epigastric distress. His x-ray study re-
vealed a normal gall bladder and a diverticulum
in the second portion of the duodenum with six-
hour retention. He stated that Sal Hepatica made
his pain worse. No operation was done.
Nausea was listed in the group ten times, and
vomiting eleven times. Five of the eleven had
intercurrent conditions, such as gallstones, ulcer,
or carcinoma, as complications.
The diverticulum was localized by x-ray in the
first portion of the duodenum in two instances.
One of these two patients also had a carcinoma
of the pancreas, and the other had had multiple
operations on the stomach. The diverticulum was
found in the second portion of the duodenum in
nineteen cases. When the third portion was in-
volved, the diverticula were multiple. There were
three of these, one in a diabetic with cirrhosis
and cardiovascular disease, one associated with
an inoperable carcinoma of the pancreas, and one
with diverticula also in the second portion. In
five cases, cholelithiasis was a complicating factor
found either at operation or on x-ray report.
Operation was done to ablate the diverticulum
in three of the twenty-three cases. One has been
described in the case report. One diverticulum,
3.5 cm. in diameter, was clamped, removed, and
the stump inverted. X-ray follow-up showed a
good result. The third was located in the region
of the ampulla close to the ducts and was turned
in by plication. X-ray follow-up in this case also
showed a favorable result.
Etiology
In Guys Hospital reports of 1893, Perry and
Shaw were of the opinion, as quoted by Edwards,
that the pylorus is largely responsible for a rise
in pressure within the duodenum. That is to say,
when there is a peristaltic contraction in the lower
duodenum with the pylorus closed, there is pro-
duced an abnormal pressure within the inter-
vening loop. Weak areas in the wall, therefore,
may be subjected to greater pressure than they
can withstand, and a point of local dilitation re-
sults. Adhesions and traction in some instances
seem to play a part in causation.
Symptoms
Prominent in the symptoms outlined by Ed-
wards and quoted by Nagel is flatulent dyspepsia
of a vague type, with a sense of oppression in the
epigastrium. The histories often run back many
years. There is a dull distress or a burning sensa-
tion in the epigastrium frequently following food
ingestion. Nausea and vomiting may be accom-
panying symptoms, with relief of distress. Pearse
observed that if there is retention in the diver-
ticulum and at the same time local tenderness,
the diverticulum is probably the cause of the pa-
tient’s symptoms.
Diagnosis
The duodenal diverticulum can be demonstrated
by x-ray, and the roentgenologist therefore pro-
nounces the ultimatum. The location of the diver-
270
Minnesota Medicine
DUODENAL DIVERTICULUM— COLLINS
ticulum, as to its position in the first, second or
third portion of the duodenum, can likewise be
stated by the roentgenologist. The size of the
diverticulum also should be noted, inasmuch as the
large pouches cause most symptoms. A six-hour
film to detect retention in the diverticulum is
valuable. The presence, location, size, and six-
hour retention of a duodenal diverticulum are,
therefore, valuable points of interest to the sur-
geon.
Surgery
These diverticula are not easy of access to the
surgeon. Those in the first portion are rare and
are most likely the ones removed at the time of
pyloric resections or are the ones which become
symptomless thereafter. Those in the second por-
tion are the most common and are the ones which
may cause difficult surgical problems.
Lawson found that, of fifteen cases in which
there was exploration of the abdomen, the sur-
geon did not attempt to locate the diverticulum
in seven because of other findings regarded as
the cause of symptoms. In eight cases where
search was made for the pouch, it was found in
six. Lahey states they have learned from ex-
perience that those diverticula which burrow into
the head of the pancreas can be dissected only
with the greatest difficulty. Pearse describes a
method whereby he slits the diverticulum in order
to insert the finger into it and thus help in the
dissection, and he uses strong illumination to be
sure the common duct and pancreatic duct are
avoided. Neil MacLean opened the duodenum
and through this opening inserted a finger into
the diverticulum to aid in separating it from the
pancreas. Nagel believes these diverticula should
be resected and not inverted. One has to contend
with the fact that these pouches may be collapsed
when the surgeon is searching for them, which
adds to the difficulty of locating them. Those
diverticula beyond the second portion are more
easy of access and may often be approached from
below near the ligament of Treitz.
Prognosis
While few of these diverticula require opera-
tion, it is encouraging that 80 per cent of those
treated, according to Morton, are relieved of their
symptoms. Beals makes the significant statement
that if duodenal diverticula were as accessible to
the surgeon as is the appendix, we should soon
learn more exactly the relationship between these
pouches and the attendant symptom-complex.
Summary
Surgical treatment is indicated for a small per-
centage of duodenal diverticula. The larger ones
are the chief offenders. Their clinical significance
should be given careful consideration. If a duo-
denal diverticulum is associated with a diseased
gall bladder or a peptic ulcer, it should be eval-
uated as to its possibile contributing nature in the
patient’s complaint.
The author reports a case treated, and twenty-
three hospital cases reviewed, most of them in
the age group over fifty. Three were treated
surgically with good results. In the roentgen
study, the presence, location, size, and six-hour
retention are important. The surgical experience
of various authors is herein discussed. The prog-
nosis is encouraging unless serious complications
exist.
Bibliography
1. Beals. T. .A.: Duodenal diverticulum. South. M. J., 30:
218-22, '(Feb.) 1937.
2. Beaver, J. L. : Acute perforation of duodenal diverticulum.
Am. J. Surg., 108:153-54, 1938.
3. Boland, F. K.: Acute perforation of duodenal diverticulum.
Surgery, 6:65-67, 1939.
4. Ceneno, A. M. • Duodenal diverticulum. Prensa med. ar-
gent., 32.1829, 1945.
5. Edwards, H. C. : Diverticula of the duodenum Surg.,
Ovneo. Obst.. 60:946-65, (Mav) 1935.
6. Hare, H. F., and Cattell, R. B. : Duodenal diverticulosis
simulating gall bladder colic. Surg. Clin. North America,
1944.
7. Lahey, F. H.: Surgery of the duodenum. New England J.
Med., 222:444-50, (March) 1940.
8. Lawson, J. D.: Duodenal diverticulum. Am. J. Roentgenol.,
34:610-16, (Nov.) 1935.
9. Mendillo, A. J., and Koufman, W. B.: Diverticulosis and
sarcoma of the duodenum. New England J. Med., 219:
432-33, 1938.
10. Morton, J. J.: The surgical treatment of primary diver-
ticula. Surgery, 8:265-74, 1940.
11. Pearse, H. E. : Surgical management of duodenal diver-
ticulum. Surgery, 15:705-12, (May) 1944.
12. Rankin, L. M.: Duodenal diverticulum. Amer. T. Roentgenol.,
47:584-87, (April) 1942.
13. Strobe, J. E. : Radical duodenopancreatectomy of duodenal
diverticulum with carcinoma. Surgery, 18:115-129, duly)
1945.
The enjoyment of the highest attainable standard of health is one of the fundamental rights of every
human being without distinction of race, religion, political belief, economic or social condition. — Constitution
of the World Health Organization.
March, 1947
271
OFFICE PROCTOLOGY
A. H. BORGERSON. M.D.
Long Prairie, Minnesota
npHE scarcity of hospital beds and the insistence
of patients who have no time to stay in hos-
pitals have combined to persuade us to undertake
an increasing amount of rectal surgery in the
office. Our methods of rectal treatment for am-
bulatory cases, and a new needle for retrograde
injection of combined hemorrhoids, were present-
ed to the Upper Mississippi Medical Society,
May 11, 1946. Credit should go to Drs. Buie and
Smith of Rochester, Drs. Fansler and Anderson
of Minneapolis, and Dr. Frank Yeomans of New
\ ork, whose techniques have been modified to
suit our purposes. These gentlemen have courte-
ously entertained me at their clinics, and their
publications have been freely consulted.
The rectal mucosa ends at the pectinate line
which is marked by the anal papillae, the pointed
upward extensions of the anal skin, above which
extend the columns of Morgagni and between
which lie the pockets of the anal crypts. Inner-
vation above this line is autonomic and insensi-
tive to ordinary pain stimuli. The skin below
this line is supplied by peripheral nerves and is
exquisitely sensitive. Branches of the internal
pudendal nerve leave Alcock’s canal as it crosses
the obturator internus muscle just above the
ischial tuberosity, and course medially through
the ischiorectal fossa to supply the anal skin and
the external sphincter. This makes it possible to
anesthetize the anus by a nerve block, using the
tuberosity as a landmark. As this does not block
the autonomic supply of the internal sphincter
it is also necessary to infiltrate, fanwise, on both
sides of the sphincter in cases requiring complete
relaxation. This thickened terminal portion of
the circular muscularis of the rectum is in con-
stant tone, except when reflexly relaxed during
defecation peristalsis, and is aptly dubbed the
“responsible” sphincter, in contrast to the ex-
ternal or “social” sphincter, loss of whose volun-
tary control results in musical and olfactory
phenomena at embarrassing moments.
Rectal treatment must be preceded by a com-
plete history and physical examination, with rou-
tine check on blood and urine. Carelessness in
this respect saves no time in the long run, but
invites disaster for the patient and embarrass-
ment to the surgeon. It is not pleasant to discover
rectal carcinoma in a patient who continues
to bleed after his piles have been eliminated, or
diabetes in a woman whose pruritis was not
alleviated by injection treatment, or tuberculosis
in one whose fistula has recurred. The treatment
of piles by any method in the presence of a
cirrhotic liver or an obstructing pelvic tumor is
a light occupation. They will promptly recur.
The next step is always a careful digital and
proctoscopic examination. Most rectal carcino-
mata can be felt with the lubricated finger, and
all lesions below the sigmoid flexure can be seen
through the proctoscope. Proctoscopy can be
done on any examining table by using the knee
chest position. The scope is introduced past the
sphincters with the obturator in place. When the
obturator is removed and replaced by the light,
the rectum will balloon up as a result of the
vacuum created by the falling toward the dia-
phragm of the abdominal viscera. This is safer
and simpler than bulb inflation, which is seldom
necessary. Next the instrument is gently ad-
vanced, under direct vision, past the valves of
Huston and the rectal ampulla, to the terminal
sigmoid. Although any lesion may be seen dur-
ing introduction, a systematic inch-by-inch survey
of the entire circumference is made as the instru-
ment is withdrawn. Long applicators are used
to wipe away any flecks of blood, stool or mucus,
as these cling more readily to diseased portions
than to the normally smooth and slippery mu-
cosa, and may conceal the very lesion being
sought. Biopsy may be taken with alligator for-
cepts or the diathermy loop. Bits of loose tis-
sue are picked up on a wet applicator. Bleeding
may be controlled by fulguration, applied with
discretion to the anterior rectum above the cul-
de-sac, where perforation can open the peritoneal
cavity. X-ray examination of the rectum is
superfluous and futile, but it is still our best
means of visualizing the rest of the colon.
Our patients are told that piles are caused
by standing upright on their legs. Since there
are no valves capable of supporting the vertical
column of blood in the erect trunk, the greatest
pressure falls on the veins in the lower rectum.
272
Minnesota Medicine
OFFICE PROCTOLOGY— BORGERSON
The straining and milking down effect of passing
hard stools blows up the weaker veins into bulb-
ous varicosities, which are piles. This expla-
nation promotes an understanding of the need
for periodic checkup to catch recurrences in
their early stages, and encourages co-operation
in the establishment of proper bowel habits. The
loose areolar tissue, containing the venous plexus,
beneath the rectal mucosa permits this lining
to move freely during defecation. If a large
varicosity is extruded beyond the sphincter, it
may be prevented by spasm from retracting.
Venous return is shut off, and passive conges-
tion is followed by edema, extravasation and pain-
ful inflammation, and there results a prolapsed
thrombosed internal hemorrhoid. In combined
piles, where the varicosities extend beneath the
pectinate line into the subcutaneous fat, the
thrombus may extend into the external portion.
Prior to thrombosis, the complaints are bled-
ing, protrusion, an aching but not severe pain,
or a continued sense of fullness after defecation.
The piles are better seen than felt, as submucous
varicosities just above the pectinate line which
elevate the mucosa into pink to purple, soft,
bulbous masses which bleed easily on abrasion.
Piles are best treated by injecting 5 per cent
quinine and urea hydrochloride in 2 per cent
procaine into the loose areolar tissue surrounding
the varicosity, not intravenously. Enough solu-
tion to distend the pile, without blanching, is
injected, usually 1 or 2 c.c. into each of one or
two hemorrhoids at a session. The pile is en-
gaged in a Hirschman speculum, wiped clean,
painted with antiseptic, and the solution injected
through a tonsil needle on a Luer-Lok syringe.
Much smaller amounts of 5 per cent phenol in
cottonseed oil are used in patients who react un-
pleasantly to quinine. The effect is to tighten
up the areolar tissue through fibrosis, thus oblit-
erating or supporting the veins and also fixing
the mucosa more tightly to the muscularis, an
effect which finds its further application in the
similar treatment of mucosal prolapse.
External piles are not injected because they
are not troublesome, unless thrombosed, and be-
cause injection through the perianal skin is a
very painful procedure. Their management calls
for an occasional incision to shell out a thrombus,
or the clipping off of a residual skin tag.
Combined piles may be injected with a retro-
grade needle (Fig. 1). These needles were first
made to the authors specifications by V. Mueller
of Chicago, in 1942. Subcutaneous varicosities
may be as successfully treated as those beneath
the mucosa. Tissue reaction to quinine and urea
Fig-. 1. Syringe and retrograde needle for injecting external
hemorrhoids.
hydrochloride is the same. The oily solution has
not been used in the subcutaneous fat for fear
of fat necrosis. Injection of external piles has
never become popular because of the pain inci-
dent to transcutaneous injection. The retro-
grade needle was designed to meet this objection.
Using a side-slotted speculum of the smaller
Fansler type, the needle is introduced, retrograde,
into the hemorrhoidal mass above the pectinate
line. This muco-cutaneous junction is freely
mobile over the varicosity, which extends beneath
it under the perianal skin. The submucous por-
tion is first distended, then the needle is advanced
outwardly, blowing up the tissue space beneath
the crypts and papillae as it progresses into the
subcutaneous portion of the pile, and finally
injecting there a quantity sufficient to distend mod-
erately the external portion of the hemorrhoid
One must be careful not to puncture the skin or
to raise an intracutaneous wheal, as this will
result in the painful reaction the technique is
planned to avoid. When the injection is com-
pleted, the needle is pushed back into the rectum
to disengage the point, keeping the needle in the
slot and the speculum farther within the rectum
than the needle point. The point is then rotated
away from the slot, where it may be easily with-
drawn without hooking up the mucosa.
A thrombosed pile may be easily treated in the
March, 1947
273
OFFICE PROCTOLOGY— BORGERSON
office under procaine block. If the sphincter is
adequately relaxed and dilated, a speculum is
rarely needed. The thrombosed mass is grasped
at its upper pole with Ochsner Forceps, pulled
down, and a ligature of fine chromic gut is passed
through the mucosa and about the submucous ves-
sels just above the proposed site of excision.
This suture is tied and left long. It should in-
clude all the tissue down to the sphincter but
should not bite into the muscle. An ellipse of
mucosa is excised, extending from just below
the ligature, over the clot, to the perianal skin
just without the anal verge. This extension is
important, as it insures drainage and guards
against the formation of infected pockets, perianal
abscesses and consequent fistulas. The thrombus
is cleaned out, the wound sprinkled with sulfon-
amide, and the long end of the ligature continued
downward as a hemostatic, locked suture, clos-
ing the wound to the anal verge but leaving the
lower end wide open. A vaseline gauze strip is
placed over the wound and secured by tying it
into the ends of the ligature. There is usually
no difficulty with bleeding, but if any spurting
vessels are encountered they should be separately
secured by mattress ligatures before starting the
closure. This avoids the accumulation of a hema-
toma which could be more distressing than the
original thrombus.
The patient cleanses the anus with soapsuds
after each stool and applies an external dressing
of sulfathiazole ointment. Hot sitz baths al-
leviate postoperative distress and promote clean
healing. On the third day, if there has been no
stool, an oil enema is given. The gloved finger
is inserted, the wound cleansed, loose sutures re-
moved, and the wound painted with gentian vio-
let. This is repeated twice weekly till healing
is complete, usually in about three weeks. The
remaining piles are injected during this healing
period. Usually no sedatives or anesthetic oint-
ments are required. Mineral oil is seldom used,
as the dilating effect of a soft, formed stool is
desired. A pint of water before breakfast and
a regular morning stool habit are insisted upon,
supplemented at times by such a bulk and jelly
producing preparation as agar, psyllium or
karaya. Any residual varicosities are treated
after a month’s interval, and a final checkup after
six months advised.
Rectal fissure should be suspected whenever
painful defecation is followed by a severe, tooth-
ache-like pain. The tormented victim postpones
the ordeal until the stool is inspissated and im-
pacted, when, finally, its passage is forced by a
cathartic or an heroic effort. These diamond-
shaped ulcers are usually found between an
external skin tag, the socalled “sentinel pile,” and
a hypertrophied papilla at the posterior anal mar-
gin. The older ones are indurated, all bleed
easily on abrasion, and their pink, inflamed
floors are covered with a yellow, viscid exudate,
unless it has been wiped off by a recent stool.
Sphincter spasm is so marked and sustained as
to make proctoscopic examination impossible
without anesthesia. Even digital examination
may be an agonizing ordeal. A cluster of sub-
mucous varicosities is usually found just above
the enlarged papilla. The stubborn persistence of
these ulcers in the presence of hemorrhoids sug-
gests comparison with varicose ulcers of the leg.
Permanent healing is more likely if the piles are
eliminated. Fissure occurs most often at this
site because the shelving forward of the posterior
rectal wall directs the impact of the descending
stool against the least elastic portion of the cir-
cumference, where the decussating fibers of the
sphincter are firmly attached to the fibrous coccy-
geal tendon.
Many recent rectal abrasions heal with no treat-
ment. A few recent fissures have healed after
digital stretching and the application of silver
nitrate. Few patients will permit such treatment
in a well-developed fissure. The first essential
in proper treatment is to secure sustained anes-
thesia and relaxation. One per cent Diothane
or such an oily anesthetic as Zylcaine is used
to block the sphincter on both sides. The sphinc-
ter is gently and gradually stretched as it relaxes,
taking care to tear neither muscle nor mucosa.
Mucosal lacerations and extravasations in or
about the sphincter cause anal stenosis with con-
sequent persistence of the fissure. The bivalve
retractor-type Smith speculum gives adequate
exposure. If the fissure is recent, soft, small and
elastic, excision is unnecessary. The internal
pile above is injected, and the granular, indolent
ulcer surface is pooled up to the point of blanch-
ing with the same quinine solution with the de-
liberate intent to produce a superficial slough
down to healthy, fresh tissue. The same result
may be achieved by diathermy coagulation, but
the author prefers to avoid this method. It is
very easy to cook the tissues a little too deeply,
274
Minnesota Medicine
OFFICE PROCTOLOGY— BORGERSON
and a well-baked sphincter tends to be replaced
by a fibrous, contracting scar.
If the fissure is large, chronic, or indurated,
it should be excised in an ellipse wide enough to
include both margins and extending from the
hemorrhoid above to just outside the anal verge.
The same preliminary ligature and continued
suture technique employed in treating thrombosed
piles is used, but the dissection must be carried
right down to the bare sphincter, where may be
seen or felt the so-called “pecten band,” an an-
nular zone of fibrosis caused by organization of
the inflammatory exudate in the lymph spaces
overlying the sphincter. This will not stretch,
and must be severed with the scalpel to expose
the healthy, meaty and elastic sphincter. The
incision is closed to the lower edge of the sphinc-
ter, where the mucosa may be tacked down with
a pair of interrupted sutures, leaving the lower
end open past the anal verge. Dressings and
after-care are the same as previously described.
One must be particular to maintain dilation until
healing is complete. The long-lasting anesthetic
may be repeated, if needed, in patients in whom
dilation is difficult to maintain.
Fistulas may sometimes be prevented by in-
cising an infected crypt. A bent malleable probe
or crypt hook is used to lift up the crypt wall,
which is then snipped off under the probe with
scissors. A persistent or neglected crypt infec-
tion may burrow along the lymphatics to the
ischiorectal space, where an abscess forms and is
incised, or finally breaks through the skin, estab-
lishing a fistulous tract extending from the crypt
to the external opening. Early incision is indi-
cated, as it prevents the extensive burrowing
which too often results in the extensive, multiple
branching fistulas, which are, indeed, a formidable
problem. So-called “expectant treatment” en-
titles one to expect only this unpleasant result.
Penicillin in procaine may be used if the abscess
is too deep for ethyl chloride refrigeration. Drain-
age is better promoted by cutting off a corner of
a crucial incision than by insertion of a gauze
pack. A single strip of vaseline gauze may be
inserted to the bottom o,f the abcess cavity. The
finger should be inserted to feel out and break
down any loculated pockets. The patient should
be told that only the first part of a two-stage
operation has been performed. Bleeding and
the spread of infection are minimized if incision
of the entire tract is delayed until inflammation
has subsided and the wound contracted. Hot
sitz baths are used after the first, large post-
operative dressing. Meanwhile, sulfamerazine
and a daily dose of penicillin in oil are useful.
Only the simpler and more superficial fistulas
should be treated in the office. If a malleable
probe can be guided all the way through the fis-
tula, it can be replaced by a grooved director, and
the entire tract laid open by a single, straight
incision onto the director. The operation is
completed by trimming off the overhanging edges
to form a gutter. The wound is sprinkled -with
sulfonamide and filled with vaseline gauze strips.
Frequent dressings prevent bridging over, and
must be continued until healing from the bottom
up is complete. A straight radial incision
through the sphincter is sometimes necessary, and
heals without incontinence. Severing the sphinc-
ter in more than one place at the same time or
cutting it obliquely invites this disaster.
Summary
Simple, proved methods for treating most piles
and fissures and some fistulae, in the office by
ambulatory methods, are described.
A new needle for retrograde injection of com-
bined piles is presented.
HANDICRAFT BOOKS VALUABLE AID TO PHYSICAL THERAPY AMONG PATIENTS
Self-instruction books in various handicrafts are prov-
ing more and more important in the mental rehabilita-
tion of hospitalized persons and those suffering from
nervous disorders.
The House of Little Books of New York City, pub-
lishers of a line of $1.00 and $1.50 arts and crafts books,
have made an outstanding contribution to this field.
Among their subject titles most widely received by hos-
pitals and mental institutions are : Fundamentals of Clay
Modeling by R. R. Fiore, Working in Leather by Mar-
garet Ickis, and Fundamentals of Wood Working by
Harry C. Helfman. These books show how to develop
satisfying skill in these crafts. Simply worded, with
easy how-to-go-about-it instructions — plus scores of il-
lustrations, sketches and examples — they afford hours
of relaxation for patients. As a hobby outlet, too, they
are highly recommended, for adults as well as for
children.
These books may be purchased at leading art, book,
and department stores throughout the world, or directly
from the publisher, House of Little Books, 80 East 11th
Street, New York 3, N. Y. Complete lists available on
request.
March, 1947
27 5
GETTING THE MOST FROM A PATHOLOGIST
CHARLES W. VANDERSLUIS, M.D.
Bemidji, Minnesota
I /VERY year a certain amount of money is
■^wasted on pathologic services. Some think
that hospital standards requiring routine patho-
logic examination of every appendix, gall bladder,
and fallopian tube are responsible for a good
deal of this waste, inasmuch as the main gain
usually is a written report by a disinterested party
after the operation has been done. Furthermore,
there is little evidence, from the type of tissues
submitted for examination, that the certain
knowledge of pathologic review acts as a deter-
rent to surgery. Admitting the questionable need
of some of this expense, there is, in addition, a
greater and more hidden waste — namely, that the
doctor is not always getting the information he
could get from pathological examination of his
tissues. In some cases, this is due to misinforma-
tion from the pathologist but more often to mis-
interpretation by the doctor.
For example, let us consider the appendix.
This vestigial remnant is responsible for a good
part of the income of the surgical pathologist,
and he sees a good many of them. If a smooth,
normal-appearing appendix is submitted to him
without a report of the clinical course and the
total and differential white cell counts, it is very
possible that he will get the impression that the
patient may have been operated upon by a hur-
ried doctor. Routinely, he will cut a block or
two for the record. When he reviews the micro-
scopic sections and sees nothing unusual, he will
have little compunction about making a diagnosis
of normal appendix or chronic appendicitis, de-
pending upon the sensitivity of the referring doc-
tor. Whichever diagnosis is made, it is apparent
that the intent is to indicate that the operation
was, at least, not a medical emergency. However,
if the specimen is accompanied by a history of
acute onset, rapid progress, and leukocytosis
with an increase in neutrophiles, the pathologist
will more likely view it with respect in spite of
its possibly benign appearance, will choose the
sites for his blocks with more care, and, in cer-
tain cases, make a smear of the contents of the
lumen. He is sensitive about being unable to find
Read before the Upper Mississippi Medical Society at Ah
Gwah Ching, Minnesota, October 5, 1946.
disease when there is good presumptive evidence
that it is present, but he is calloused to appendices
because he sees so many which appear harmless.
A good deal of abdominal surgery has fallen
into disrepute with the pathologist. Although he
is not a practicing clinician, he has been trained
in clinical diagnosis and knows its value. In cases
where pathological examination of tissue is not
conclusive, he can profitably use clinical facts
when making a decision because his record stands,
in many cases, as the final diagnosis. To deny
the pathologist clinical information is short-
sighted. He is usually in a better position to
correlate clinical facts with what he sees than
is the physician to correlate a description of what
the pathologist sees with his clinical finding.
That the pathological report is all-important with
government agencies and insurance companies in
judging the competence of surgical care is, in
some circumstances, unfortunate, but the fact re-
mains, nevertheless, that it does hold that posi-
tion. Apparent discrepancy between clinical di-
agnoses and pathologic reports is considerable.
Even though from 75 to 80 per cent of the in-
flammatory conditions in the abdomen are due
to appendicitis, almost 50 per cent of the appen-
dices submitted for pathologic examination (ex-
cluding those removed routinely in the course of
other abdominal surgery) are pronounced normal
or are given a comforting name. The surgeon
can partially correct this discrepancy by being
sufficiently specific in his indications for an opera-
tion to write them down for the pathologist.
Many studies have shown a fair correlation be-
tween clinical and pathological data in appendici-
tis. By making careful clinical records, the op-
erator will seldom have to shrug off a surprise
report.
Many uteri are submitted for examination.
Those which are normal in size and not accom-
panied by a clinical history are puzzling to the
pathologist. Money is often wasted upon an
examination of this type because the surgeon who
removes a normal-appearing uterus usually knows
more about it than the pathologist who sees it
postoperatively. Such an organ should be ac-
276
Minnesota Medicine
GETTING THE MOST FROM A PATHOLOGIST— VANDERSLUIS
companied by a history. To insure complete
fixation, it should be opened by the surgeon be-
forehand so that the endometrium will be ex-
posed to the formalin. It should be incised ex-
actly through the midline from front to back.
Larger uteri should also be cut open in this man-
ner, and tumor masses should be incised in order
to allow more complete fixation. A history of the
reason for removal, unless the pathologic condi-
tion is obvious, always brings a more careful
examination and a more considered diagnosis.
Nothing seems to provoke more remarks among
pathologists than the receipt of corpora lutea as
surgical specimens. Sometimes such an object
is the only one removed in a laparotomy, prob-
ably as a side excursion from a uterine suspen-
sion. As we all know, a corpus luteum is physi-
ological and harmless, and is easily diagnosed
grossly. It is rounded and firm and sometimes
measures more than an inch in diameter. The
wall is yellow and sometimes wavy in outline,
and the cavity contains bloody fluid. Its removal
is a surgical mistake, and its histological examina-
tion is a waste of time. The pathologist makes
his slide from a small part of it only for the
record. Many small, smooth-walled cysts of the
ovary are also removed. These are usually harm-
less. The distinction between follicular, luteal,
and endometrial types can usually be made only
on histological examination, and sometimes not
then.
Occasionally, thyroid glands are submitted for
examination. As a result of clinical study of the
patient the surgeon usually pretty well knows the
nature of every thyroid which he removes, but he
is often disappointed by the pathological report.
The main reasons for this diappointment are the
shortcomings of pathological examination and the
usual circumstance that the pathologist does not
have the clinical information which the surgeon
possesses. If the patient with a diffusely hyper-
plastic gland and symptoms of hyperthyroidism
has been treated with iodine for some time and the
symptoms relieved, the gland on pathologic ex-
amination may not be diagnostic of past diffi-
culty. Generally, there are remaining foci of lym-
phocytes, but the epithelial hyperplasia and re-
duction of colloid so characteristic of Graves’
disease may no longer be apparent. Without a
clinical history, the pathologist does not always
feel justified in making the diagnosis of treated
Graves’ disease. This is sometimes disconcerting
to the surgeon, in view of the incidence of con-
tinuation or recurrence of symptoms in this con-
dition. If a patient with a nodular goiter of some
years’ duration develops symptoms of toxicity
and undergoes thyroidectomy, the gland will show
mainly its adenomatous character. Histological
evidence of toxicity, at best present only between
the nodules and further diminished by iodine
treatment, is most often absent. This cannot be
taken as proof that the gland was not responsible
for symptoms. The pathologist usually makes a
diagnosis of nodular or adenomatous goiter, with-
out reference to toxicity. By observing the clin-
ical course, the surgeon must settle that question
for himself.
Of most direct service to the patient and physi-
cian is the correct interpretation of biopsies. The
most frequent specimens of this type are uterine
curettings. If only a few curettings are present,
the diagnostic probabilities lie between incomplete
curettage and postmenstrual or senile endome-
trium. Malignancy is not to be expected in a
small volume of curettings. If a great amount is
present, the gross conclusion is that either hyper-
plasia or carcinoma is the likely diagnosis. Micro-
scopic examination is made in every case, but
sometimes all fragments are not sectioned. In
order to keep the pathologist on his guard the
surgeon should make a thorough curettage and
submit all of the tissue free from blood. It is
much easier to separate the tissue from the blood
before the mixture has been put into formalin.
Then, if the pathologist receives a large amount
of curettings, he will be more on the alert for
malignancy. Along with the specimen, the refer-
ring doctor should send a summary of symptoms,
menstrual history, and, without fail, the age of
the patient.
It is not often that a pathologic examination of
endometrium gives the reason for uterine bleed-
ing. If a definite cystic hyperplasia or a carci-
noma is found, the answer probably lies here.
In most cases, however, the endometrium appears
normal and is described according to its stage of
development in relation to the menstrual cycle — -
either proliferative, secretory, or premenstrual.
If the endometrium is of the secretory or premen-
strual type, it may be assumed that the patient
ovulates normally and that a corpus luteum has
been formed. This knowledge is of some help
because anovulatory uterine bleeding is fairly
common in the early and latter parts of menstrual
March, 1947
2 77
GETTING THE MOST FROM A PATHOLOGIST — V ANDERSLUIS
life. Most endometrium removed, however, is
found to be in the proliferative stage. This is
because normal endometrium in women past the
menopause is normally of this type, ovulation no
longer taking place. A single curettage showing
proliferative endometrium in a cyclic woman ob-
viously does not prove anovulatory bleeding. A
second biopsy should be taken two weeks later.
Cystic and hyperplastic changes occur almost ex-
clusively in proliferative endometrium of women
just past the menopause and are signs of pro-
longed, unopposed estrogen activity.
Decidual transformation of endometrium is
sometimes found on histologic examination. If
chorionic villi are found with the decidual cells,
the diagnosis of intra-uterine pregnancy is estab-
lished. If chorionic villi are not found, how-
ever, evidence of intra-uterine pregnancy is not
complete because uterine endometrium undergoes
identical decidual change of pregnancy in 50 per
cent of cases of extra-uterine gestation. The find-
ing of advanced degenerative changes in decidua,
however, points to aborted intra-uterine preg-
nancy.
Oftentimes the real answer to the problem of
uterine bleeding lies outside the endometrium,
and the doctor must assure himself that there is
no leukemia, purpura, anemia, ovarian tumor or
uterine myoma. The question of a submucous
myoma cannot be settled by examination of the
endometrium, but the operator might be able to
feel a projecting fibroid with his curette. An
ovarian tumor, especially in obese women, oc-
casionally escapes earnest efforts at detection by
pelvic examination and will only be found by
laparotomy.
Cervical biopsies are frequently submitted. Ac-
companying histories should include the age of the
patient, notation of previous pregnancies and the
gross appearance of the cervix. If the biopsy
is made so that a normal portion of mucosa is
included, it may be possible for the pathologist
to pick up a precancerous or early cancerous le-
sion where otherwise he might not be able to say.
The specimen should be cut deeply enough to in-
clude some of the underlying tissue of the cervix
so that the degree of epithelial penetration can
be determined. It is of great importance that the
biopsy be taken perpendicular to the surface, so
that the resulting section will show the epithelium
in strict cross-section and not obliquely. The
possibility of a section of epithelium being ob-
lique is constantly kept in mind by the patholo-
gist when making a decision between malignant
and nonmalignant thickening. Oblique sections
are sometimes impossible to read reliably.
The decision between when to biopsy and when
to attempt removal of a lesion without knowing
its nature is important in many instances. In case
of a mass in the breast it seems best, as a general
plan, to limit initial surgery to its adequate local
removal, unless it is obviously malignant. Path-
ological examination is probably more useful in
saving benign breasts than in causing radical re-
moval of malignant ones. There is less harm in
leaving an operation temporarily unfinished in
the occasional case than in removing an entire
breast and possibly doing a radical operation for
a few cysts or fibroadenomata. If the removed
mass does prove to be cancer, a block dissection
can still be done. Before putting such a speci-
men into formalin it is desirable to dissect the
axillary lymph nodes from it. Finding these
nodes by palpation is much easier in the fresh
specimen than in a formalized one, in which case
the fixed fat and the nodes have about the same
consistency. Putting these nodes into a little
gauze sack will insure pathologic examination
of all of them and a much more accurate prog-
nosis.
The diagnostic procedure to be followed in
lesions of the lip depends to some extent upon the
treatment intended. Small carcinomas are very
satisfactorily treated with x-ray or radium, but
they should first be biopsied. It is the practice
of some men to biopsy without anesthesia, re-
moving only a little epidermis. Unforunately,
some of these specimens are not diagnostic be-
cause too little dermis is included for estimation
of epithelial penetration, and because so little
tissue is present that orientation for a truly per-
pendicular section is impossible. A lip biopsy
should be reasonably deep, even though narrow.
Since many early lesions might just as easily be
removed as biopsied and radiated, it is just as well
to dissect these out with normal tissue on all sides
and have them examined. If early cancer is
present and no cervical nodes are felt, it is per-
missible to let the matter rest. In case of a large
lesion, a biopsy should first be taken. If the re-
port is that of squamous cell carcinoma, a com-
plete dissection of the tumor and of the sub-
mental and subaxillary lymph nodes should be
carried out.
27K
Minnesota Medicine
GETTING THE MOST FROM A PATHOLOGIST— VANDERSLUIS
The failure to biopsy before removal has often
been regretted in tumors of the subcutaneous
tissue or muscle. All of these masses should be
biopsied as soon as discovered. If they are small
and discrete, they can be widely removed at the
first sitting. If they are large, however, a biopsy
should suffice for the first attack. Many tumors
thought to be simple fibromas are, in reality, fib-
rosarcomas or myxosarcomas with a marked ten-
dency for local recurrence. It is more economical
of the patient’s tissue to do a wide dissection of a
large malignant tumor after biopsy than to per-
form a routine removal with a practical certainty
of recurrence if examination proves the pres-
ence of malignancy.
Lymph nodes are often submitted for diagno-
sis. In case of a suspected lymphoblastoma, the
doctor should find out the duration of enlarge-
ment of the nodes, the location of those enlarged,
size of the spleen and liver, width of the medi-
astinum, presence or absence of pulmonary in-
volvement, and the nature of the blood picture.
Sometimes, in a single node there is poor histo-
logical distinction between lymphosarcoma, Hodg-
kin’s disease and leukemia. The physician who
wants this distinction made should supply the
pathologist with all of the information mentioned
above. Since there is a certain overlapping of
histological as well as clinical criteria for these
diagnoses, it is possible that the doctor will have
to be satisfied for the time being with a diagnosis
of malignant lymphoblastoma, which is an inclu-
sive term. Some pathologists are now distin-
guishing reticulum cell sarcoma within the group
of lymphosarcomas by the larger and more ir-
regular character of the cells.
In addition to the specific tissues referred to
above, which, with gall bladders and uterine tubes,
are the most numerous of the surgical specimens,
there are tumors of bone, rectum, skin, mouth,
ovary, vagina, parotid and intestine. Branchial
and thyroglossal duct cysts and fistulas, anal fis-
tulas, cutaneous ulcers and granulomata fairly
well round out the list. A history of the lesion
and the age and other pertinent facts about the
patient should accompany all of these tissues.
Detection of cancer cells in pleural and ascitic
fluid is sometimes possible by histologic methods.
If it is desired to submit such fluid for examina-
tion, a certain amount of preliminary work is
necessary. The entire amount should be centri-
fuged or the cells allowed to settle out in a re-
frigerator. The supernatant fluid is then poured
off and discarded. Smears are made from the
sediment and are air-dried. The remaining sedi-
ment is then collected and allowed to settle again,
or it is centrifuged in order to concentrate as
much as possible. The remaining supernatant
fluid is discarded and 10 per cent formalin is
added to the settled material, which is then sent
to the pathologist along with the smears.
Blood smears are often submitted for diagnosis,
and usually with too little data. A history of the
illness, the hemoglobin value and red and white
cell counts should be sent with thin, even blood
films on clean slides. Rinsing the slides in 95 per
cent alcohol and drying, before making the
smears, will add to the ease of making even films.
Slides which are stained immediately are always
better than those submitted unstained. Wright’s
stain and distilled water for dilution and washing
will usually produce good results. Glenwood-
Inglewood triple-distilled water, sold in gallon
bottles by a Minneapolis concern, or parenteral
flask water, are ideal.
While peripheral blood studies are indispen-
sible in many cases, they are not always diagnostic
of specific disease, and now some pathologists
want bone marrow to prove or disprove a condi-
tion suspected from study of the peripheral blood.
The diagnostic value of expert bone marrow ex-
amination in obscure anemias and in unexplained
chronic febrile conditions is gradually being ap-
preciated.
In his role of consultant, the pathologist is nat-
urally in a position to supplement the education
of every doctor. Most men in the field are will-
ing to return microscopic sections of material
studied to the referring physicians. Some doctors
profess histology to be out of their sphere and
do not consider their judgment or knowledge in
this field sufficient to enable them to gain anything
from a study of sections. With a good pathologic
report at hand, however, this is not the case, and
many will find the study of surgical sections a
refreshing departure from the routine of clinical
practice.
The press of time prevents the average doctor
from putting the acid test to much of his clinical
diagnosis, but here the pathologist can be of fur-
ther service. Post-mortem technique is not diffi-
cult, and any doctor can learn it from the obser-
vation of a few dissections, followed bv practice.
(Continued on Page 309)
March, 1947
279
CLINICAL-PATHOLOGICAL CONFERENCES
KIMMELSTIEL- WILSON SYNDROME
A. J. HERTZOG, M.D., and W.D. HAYFORD. M.D.
Minneapolis. Minnesota
Dr. William Hayford: (A-46-2190). This forty-nine-
year-old woman was first admitted to the Minneapolis
General Hospital in 1932, complaining of having had
diabetes mellitus for three years. Her blood pressure
was 138/80. A urinalysis showed 4 plus sugar and was
positive for acetone. The blood sugar at this time
ranged between 190 and 240 mg. per cent. A glucose
tolerance test showed a diabetic curve. She was dis-
charged on 25 units of regular insulin daily. She was
next seen in 1935. Her blood pressure was 136/90.
Blood sugar was 240 mg. per cent. She had not taken
insulin during the previous year for financial reasons.
Her diabetes was controlled and she was discharged on
40 units of regular insulin daily. Her final admission
was on August 15, 1946. She was complaining of
swelling of the legs and abdomen for the past two
years. Acute complaints were swelling of the upper
extremities and eyelids, and nausea and vomiting. For
the past few weeks she had blisters of the legs. When
they broke, they drained for long periods of time. She
was short of breath. The edema of the lower extremi-
ties gradually progressed upwards to involve the hips.
In the last few months her abdomen had begun to swell.
She required three pillows in order to sleep at night.
She urinated four times a day and only small amounts.
On physical examination, the blood pressure was
190/92. The pulse was regular and 80 per minute. The
patient was slightly dyspneic. There was edema of the
eyelids. The breasts were distended with fluid. The tis-
sues of the chest posteriorly pitted on pressure. Aus-
cultation of the lungs demonstrated moist rales bi-
laterally in the lower lung fields. The respiratory rate
was 32 per minute. Heart examination showed the point
of maximal impulse to be 11 cm. to the left of the mid-
sternal lines. There was a slight apical systolic mur-
mur. There was marked ascites and grade 4 pitting
edema of the lower extremities. There were small bullae
on the lower legs, some of which had broken and were
oozing fluid. There was two plus pitting edema of the
upper extremities and three plus pitting edema of the
sacral region.
Urinalysis showed a specific gravity of 1.034 with 3
plus albumin and occasional red and white blood cells.
The urine sugar varied with the amount of insulin.
Every urinalysis showed from 3 to 4 plus albumin with
many red cells and pus cells. A quantitative albumin
determination showed an excretion of 12 grams of
albumin in a twenty-four-hour specimen. Blood urea
nitrogen was 23 mg. per cent. Blood sugar was 140
From the Department of Pathology, Minneapolis General Hos-
pital, A. J. Hertzog, M.D., pathologist.
mg. per cent. Plasma proteins varied from 6.7 to 6.5
grams per cent. Quantitative determinations of plasma
proteins showed 3.93 grams of albumin and 2.73 grams
of globulin. On August 23, 1946, her venous pressure
was 21 cm. of citrate. The circulation time was 15 sec-
onds. She was given mercurial diuretics and subse-
quently voided 7,675 c.c. of urine. Thoracentesis was
done and several thousand cubic centimeters of fluid
were removed from her chest. The hemoglobin, white
blood count and differential blood count were within
normal limits. The prothrombin level was normal. Ser-
ology was normal. Blood chlorides and carbon dioxide
combining power were within normal range. The P.S.P.
test for kidney function showed a total excretion of
35 per cent in two hours.
On September 22, 1946, the patient had a sharp non-
radiating precordial pain and a pulse of 120 with a
gallop rhythm. The symptoms were relieved by nitro-
glycerine. On September 27, the venous pressure was
25 cm. of citrate. The anasarca persisted. On Novem-
ber 5, 1946 while sitting on the side of her bed, she
expired very suddenly.
Dr. Hertzog : Does anyone wish to explain the se-
vere generalized edema that occurred in this diabetic
woman ?
Intern : Kimmelstiel-Wilson’s syndrome.
Dr. Herman Koschnitzke: When a diabetic de-
velops generalized edema with a marked albuminuria,
we naturally think of Kimmelstiel-Wilson’s syndrome.
The plasma protein level in this case was not lower than
6.5 grams. She had hypertension and an enlarged heart.
She had an attack of cardiac pain relieved by nitro-
glycerine. An electrocardiogram showed low voltage of
the QRS complex, a slight ST depression, and tachy-
cardia with a gallop rhythm. Her venous pressure was
25 cm. of citrate. Hence she definitely had heart failure.
We thought that the edema, however, was out of pro-
portion to the degree usually seen in heart failure. It
is reasonable to believe that the lowered plasma pro-
tein may have been a contributing factor in her gen-
eralized anasarca.
Dr. Hertzog : Kimmelstiel and Wilson3 called our
attention to the so-called intracapillary glomerulo-
sclerosis of the kidneys in diabetes mellitus. They em-
phasized a nephrotic syndrome associated with this
renal lesion in diabetics. The Kimmelstiel-Wilson syn-
drome has been used very loosely to describe the edema
280
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CLINICAL-PATHOLOGICAL CONFERENCES
due to heart failure in diabetics. A restricted definition
would be edema in a diabetic resulting from albumi-
nuria and hypoproteinemia as a result of intracapillary
glomerulosclerosis of the kidneys. Hypertension occurs
because of the vascular changes in the kidneys. Most
of the cases give a history of a normal blood pressure
at one time. The hypertension as in this case is of
gradual onset. Porter and Walker4 describe the typical
events of a case of Kimmelstiel-Wilson syndrome as
shown by one of their cases. Diabetes mellitus was di-
agnosed in 1929 at the age of thirty years. In 1932,
albuminuria, mild edema, and hypoproteinemia were first
noticed. Blood pressure was 98/65. In 1937, edema was
marked. The blood pressure had risen to 160/80. Al-
buminuria was 3 plus. Total plasma proteins were 4.1
grams per cent. In 1938, blood pressure was 180/95.
Anasarca was marked. Renal insufficiency developed
and she expired. Dr. Bell2 has studied the kidneys of
606 diabetics at autopsy. He found the lesion of intra-
capillary glomerulosclerosis of both the nodular and
diffuse type in 22 per cent of males and 36 per cent of
females. One can diagnose about 20 per cent of cases
of diabetics at autopsy from the microscopic findings
in the kidneys alone. Allen1 believes because of the
high incidence and clear-cut character of the glomerular
lesion in diabetics, the kidneys offer the most reliable
histologic diagnosis of diabetes mellitus of the age group
over forty years. We can diagnose about 50 per cent
of diabetics from the changes in the islands of Lang-
erhans with the usual hematoxylin and eosin stain.
When the beta granules of the islands are studied with
the Gomori stain, this percentage goes up considerably.
In Dr. Bell’s series only about one-third showed ap-
preciable edema in spite of the renal lesion. The edema
when present appeared to be due to heart failure rather
than hypoproteinemia. Diabetics today die largely of
complications related to cardiovascular disease rather
than coma. The marked tendency of a diabetic to de-
velop arteriosclerosis at an early age appears to be un-
influenced by insulin therapy. Dr. Hayford will give
the autopsy findings.
Dr. William Hayford : The body was that of a
middle-aged female, measuring 161 cm. and estimated
to weigh 160 pounds. There was generalized anasarca
present with marked pitting edema of the lower ex-
tremities. The abdominal cavity contained approximately
3,500 c.c. of straw colored fluid. Each pleural cavity
contained approximately 800 c.c. of similar fluid. The
heart weighed 440 grams. There was moderate hyper-
trophy and dilatation of both ventricles. There was a
large fibrous scar resembling a healed infarct that in-
volved the greater part of the left anterior ventricular
wall. The coronary arteries showed grade 4 sclerosis
with complete occlusion of the anterior descending branch
of the left coronary. The cardiac valves appeared
normal. The lungs showed moderate generalized edema
and atelectasis as a result of the hydrothorax. The
liver was enlarged and weighed 2,350 grams. It had
the gross appearance of severe passive congestion. The
pancreas appeared to be of normal size and consistency.
The right kidney weighed 210 grams and the left 240
grams. Both kidneys were large, pale, and finely gran-
ular. The remaining organs showed nothing of note.
Dr. Julian Sether: The microscopic slides show
passive congestion of lungs and liver. The lungs con-
tain many macrophages filled with brown pigment as
found in the so-called “heart failure” cells. The myo-
cardium shows the picture of an old myocardial infarct
with a large fibrous scar. The pancreas with a hema-
toxylin and eosin stain shows partial hyalinization of
many islands. A Gomori stain shows marked reduction
of the beta cells of the islands. It is estimated that the
islands do not contain more than 10 per cent beta cells.
Our interest is naturally centered on the kidneys. The
afferent arterioles show marked subintimal hyaliniza-
tion and thickening of the walls. The hyaline ma-
terial extends from the arterioles into the glomerular
capillaries to cause a marked intercapillary thickening.
The hyaline material is deposited between the glomerular
capillaries. Most of the glomeruli show this lesion to be
diffusely distributed throughout the tuft. An occasional
one shows the hyaline material to be localized and cir-
cumscribed in distribution. There are some areas of
cortical atrophy present. The tubules show nothing of
note.
Dr. Hayford: The anatomical diagnosis then is (1)
diabetes mellitus, (2) intracapillary glomerulosclerosis
of the kidneys, (3) hypertrophy and dilatation of the
heart (hypertension), (4) coronary sclerosis with myo-
cardial fibrosis, (5) passive congestion of liver and
lungs, and (6) bilateral hydrothorax and ascites. We
considered the edema to be due largely to heart failure.
It is plausible to believe that the lowered plasma pro-
teins may have been a contributing factor to her gen-
eralized anasarca. In reviewing the literature on Kim-
melstiel-Wilson’s syndrome, one is impressed by the
lack of quantitative studies. Few cases record the plas-
ma protein level and extent of heart failure. Many
times the diagnosis was made on patients who were in
a moribund state on admission to the hospital and with-
out benefit of autopsy confirmation.
References
1. Allen, A. C.: So-called intercapillary glomerulosclerosis. A
lesion associated with diabetes mellitus. Arch. Path., 32 :33-
51, 1941.
2. Bell, E. T. : Renal Diseases. Pp. 373-387. Philadelphia: Lea
and Febiger, 1946.
3. Kimmelstiel, P., and Wilson, C.: Intercapillary lesions in
the glomeruli of the kidneys. Am. T. Path., 12:83-98, (Jan.)
1936.
4. Porter, W. B., and Walker, H.: The clinical syndrome as-
sociated with intercapillary glomerulosclerosis. J.A.M.A.,
116:459-464, 1941.
March, 1947
281
DIAGNOSTIC CASE STUDY
ARTHUR H. WELLS, M.D., OLIN W. ROWE, M.D., and HAROLD H. IOFFE, M.D.
Duluth, Minnesota
Dr. A. H. Wells: We have a most remarkable di-
agnostic problem of the dramatic and rapidly fatal type.
Dr. O. W. Rowe: I saw this fifteen-year-old school
boy in his home about forty hours before his death and
three days after he had developed abdominal distress,
fatigue, and difficulty in breathing. These symptoms
were first noted after the boy lifted a heavy boat anchor
out of the river. They gradually increased in severity.
He had been under my care since birth, and was in ap-
parent excellent physical and mental health at the time
of onset of his present illness. He was lying on his
left side, a little cyanotic and breathing rapidly. He
pointed to the mid upper third of the abdomen as the
seat of pain. The lung excursions were equal. Heart
sounds were faint. There were confused faint murmurs,
one of which was systolic, apical, and apparently not
transmitted. His pulse was 125 per minute, faint and
regular. I was unable to get his blood pressure. I he
abdomen was soft and not tender. My immediate di-
agnosis was that of acute cardiac condition, possibly
pericarditis with effusion.
At the time of admission to the hospital fifteen hours
before death, the physical examination revealed a robust
fifteen-year-old boy, measuring 67 inches and weighing
about 160 pounds, in acute distress with dyspnea and
cyanosis. He was very weak and tended to lie on his
left side. Circulatory collapse was continuous. His
pulse was 68, respirations 24, and rectal temperature
102.4° F. There was air-hunger type of respiration
with limited but equal expansion of the lungs. The
apical beat of the heart was not visible or palpable. 1 he
heart sounds were weak and distant. A diastolic apical
murmur was heard on one examination. A doubtful
pulsus paradoxus was noted and later pistol-shot sounds
were heard over the femoral arteries. There was some
tenderness in the epigastrium. Otherwise, the abdominal
examination was entirely normal. His distress had be-
come continuous and located much of the time in the
lower thorax.
Two consultants, Dr. F. J. Hirschboeck and Dr. S
M. White, could hear a pericardial friction rub the first
day of his illness which disappeared later. Aspiration
performed bv Dr. M. G. Gillespie failed to produce any
fluid from the pericardial sac. The consultants felt
that the patient had a circulatory collapse of unknown
etiology.
A portable film of the chest revealed no enlarge-
ment of the cardiac shadow or distortion of the shape
of the heart. There was slight congestion in both lungs
according to Dr. Arden L. Abrahams. Dr. S. H. Bo^er,
Sr., interpreted the electrocardiograms (Fig. 1) as fol-
lows : rapid rate and regular rhythm ; ST,, depressed,
From the Department of Pathology, St. Luke’s Hospital, Du-
luth, Minnesota. Clerical Assistance by Miss Faith A. Gugler.
rises with slight concavity to pointed apex ; T3
inverted, T4 upright, and ^ 1.2.i upright, do not ex-
ceed normal voltage. The diagnosis was that of auricular
tachycardia, T.f inversion. In the absence of other signs
and characteristic features of posterior infarction, such
Fig. 1. Electrocardiograms leads 1, 2, 3, and 4 in order.
inversion is normal to childhood and even in youth may
be accepted as of no significance unless later records dis-
prove this. ST, depression is sometimes seen in peri-
carditis. There was a white blood count of 17,500 with
57 per cent neutrophils, 41 per cent lymphocytes and
2 per cent monocytes.
He was kept on absolute bedrest with nasal oxygen to-
6 liters, coramine 2 c.c. every three hours, light diet,
fluids not to exceed 2,000 c.c., and one .hypodermic in-
jection of morphine, grains 1/8. He continued to com-
plain of abdominal and lower thoracic distress. He was
constantly cyanotic and his weakness was progressive
and severe. He vomited small amounts of bile stained
fluid twice during bis last fifteen hours. During the
last nine hours his body was cold and clammy. His
blood pressure and pulse rate were unobtainable. Res-
pirations increased to 40, and the temperature reached
105° F. He became restless and irrational during the
last two hours.
282
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CLINICAL-PATHOLOGICAL CONFERENCES
Dr. A. H. Wells : The case is open for diagnosis.
Physicians : Acute pericarditis, acute rheumatic pan-
carditis, Fiedler’s myocarditis, coronary thrombosis,
acute endocarditis with ruptured bicuspid aortic valve,
acute cor pulmonale of unknown origin.
Fig. 2. The rhabdomyosarcoma almost filling the right auricle
and ventricle.
Necropsy
Dr. A. H. Wells : The post-mortem examination re-
vealed a large, hemorrhagic, friable, pedunculated tumor
mass (Fig. 2) measuring 12 cm. long and 6 cm. in diam-
eter at its largest dimensions. It hung from a site of
attachment 2.5 cm. in diameter directly overlying the
usual site of the foramen ovale in the right auricle.
The mass filled the tricuspid orifice and extended into
and almost filled the right ventricle. There was not
more than a 3 mm. extension into the interauricular
wall. The cardiac cavities, valves, vessels, pericardium,
and myocardium were otherwise entirely normal. The
heart weighed 360 grams. There was no evidence of
chronic passive congestion, edema, metastases, congeni-
tal anomalies or significant change in other organs. The
brain was not examined.
Microscopic. — Possibly 95 per cent of the cardiac tu-
mor mass was necrotic and hemorrhagic. A few pre-
served areas were composed of a moderately cellular,
highly anaplastic lesion, characterized by a predominance
of long spindle-shaped cells, with occasional larger mul-
tinucleated, rounded, or elongated cells. A finely granu-
lar cytoplasm frequently contained longitudinal and
cross striations (Fig. 3). The nuclei tended to be oval
or elongated and had a hyperchromatic granular chro-
matin which on occasions appeared in ill-defined linear
arrangements. No “spider cells’’ of congenital rhabdo-
myoma could be found.
In conclusion, this otherwise normal fifteen-year-old
Fig. 3. (above) Phosphotungstic acid, hematoxylin stained
preparation with oxer-exposed prints revealing relatively faint
cross striations (indicated by arrows) in the cytoplasm of em-
bryonic muscle cells.
Fig. 4. (below) Enlarged view of a selected field of Figure
3 with the same over-exposure pf the print.
boy died as the result of tricuspid block caused by a
pedunculated rhabdomyosarcoma of the right interauricu-
lar septum.
Discussion
In spite of the rarity of primary tumors of the heart,
the subject has been reviewed3’6’14 repeatedly, so that
many facts concerning these lesions are well organized
and the controversial subjects clearly defined. The exact
frequency of these neoplasms has not been determined
at present since as many as 30,000 autopsies have been
performed13 without finding a single case. In other
March, 1947
283
CLINICAL-PATHOLOGICAL CONFERENCES
instances, 8,550 necropsies produced four primary tu-
mors,10 1,200 examinations revealed three cases,12 and
in our hospital one case was found in the last 3,000
autopsies. By 194513 primary heart tumors totaling 163
had been counted in the literature. There were sixty-
three “authentic” cases2 of rhabdomyoma and apparent-
ly only four cases7’8’9 of rhabdomyosarcoma of the
heart.
The primary tumors of the heart can be readily
classified into five groups : myxoma, fibroma, rhabdo-
myoma, sarcoma, and rare miscellaneous tumors. The
malignant varieties represent 29 per cent of the total.8
Pathology
The myxoma is the most frequent of the primary
cardiac tumors. Its benign, frequently pedunculated
nature, its usual site of attachment on the left inter-
auricular septum, and its occasional mitral stenotic
clinical syndrome, sometimes altered by the position of
the patient, make it the one heart tumor which might
be recognized and cured by operation. The exact na-
ture of this lesion has been debated. Some feel that it
is not a true neoplasm but a myxomatous change in an
edematous thrombus. The majority favor its neoplastic
nature. A poorly cellular, edematous, Wharton’s jelly
type of tissue bespeaks a slow-growing benign character.
Small, rounded or papillary, generally pedunculated
tumors composed of adult fibroblasts form the second
most common group of heart tumors (fibromas). These
have been found attached to some one of the heart
valves. They have been innocuous and consequently
innocent pathologic curiosities.
The benign rhabdomyomas are undoubtedly the most
intriguing of the cardiac tumors. Over half of the
cases occur in the first year of life, and only seven cases
have been described in patients over fifteen years of
age.2 In 50 per cent of the patients with this lesion,
there is an associated tuberous sclerosis of the brain.8
One is also very likely to find other congenital anoma-
lies, including cleft palate, harelip, cystic kidneys, mul-
tiple gliomas, hypernephroma, sebaceous gland adenomas,
embryonic rests in the kidney and malformations of the
pancreas. These frequently associated dysontogenetic
lesions are a strong argument in favoring the common
opinion that rhabdomyomas of the heart are not true
neoplasms but hematomas. They are described in three
gross forms2: single nodules usually near the apex;
multiple nodules scattered through the heart ; and, rare-
ly, diffuse involvement of the myocardium even to the
point of complete replacement. The cells composing
these nodules are tubular and similar to those found
in the embryonic heart muscle of the thirteenth week
of fetal life.5 Their large glycogen content results in a
typical “spider-cell” appearance. When cut at a right
angle to the length of the cell, strands of cytoplasm
suspend the centrally placed nucleus to the thick outer
wall. The cytoplasm may have cross striations. The
hollow spaces contain glycogen.2
Only one nonconvincing case of malignant transforma-
tion of a rhabdomyoma to a rhabdomyosarcoma has
been described.8 It is entirely possible that rhabdomyo-
sarcomas of the heart are a separate oncologic entity.
The finding of typical multiple rhabdomyomas, tuberous
sclerosis or other commonly associated lesions in a pa-
tient with a rhabdomyosarcoma seems essential before
relating the two conditions.
It is entirely possible that the last relatively large
group of primary cardiac neoplasms, the sarcomas, may
contain instances of rhabdomyosarcoma without the nec-
essary identifying striations. The majority of the sar-
comas described14 are simply designated as round cell,
spindle cell, giant cell, or myxosarcoma. They occur at
any age. They generally arise in the auricles, especially
on the right side, and often from the interauricular sep-
tum. Occasional metastases to other organs are re-
corded. At times they become huge before causing
death.
Secondary tumors of the heart are more frequent
than the primary neoplasms, occurring in approximately
7.3 per cent of all deaths due to malignancy.11 They
are metastatic from practically all sites of carcinomas,
sarcomas, melanomas, and the leukemias. The origins
of greatest frequency are the bronchogenic and breast
carcinomas.11 However, the incidence of heart involve-
ment in melanomas, reticulum cell sarcomas, and leuke-
mias may be over 50 per cent. They are found in any
part of the heart. Possibly because of the great pre-
ponderance (three fourths) of cardiac venous return
through the Thebesian venae minimae into the' right
ventricle (Kretz) most of the metastases are found in
its walls. It has become obvious through the years of
post-mortem examinations that those malignancies which
invade the heart usually are not inhibited by the other
tissues seldom involved by metastases, such as the
spleen, pancreas, thyroid, and voluntary muscle. They
generally have a very wide distribution of metastasis
and are quite embryonic in type. This obvious immunity
of specific tissues to metastases could be the clue lead-
ing to the discovery of an efficacious therapeutic extract
for the control of cancer.
Clinical Recognition
Primary or secondary heart tumors cause cardiac em-
barrassment by (1) mechanically blocking of a valve
(mitral and tricuspid), (2) interference with transmis-
sion of the electrical impulse, (3) pericardial effusion,
and (4) extensive destruction of myocardium by infiltra-
tion. These various lesions can give rise to almost
any sign or symptom of heart disease. However, there
are certain manifestations or cirumstances which have
aided in the recognition of neoplasms in the heart.9’14
The ball valve action of a tumor may cause a murmur
which changes or disappears with change of position
and the effect of gravity on the tumor mass. The
electrocardiogram1 may demonstrate a heart block or
bundle branch block which cannot be easily explained
because of lack of the other signs pointing to coronary
disease. The pericardial effusion is frequently hemor-
rhagic and occasionally contains demonstrable neoplastic
cells. Malignancies of the heart causing cardiac em-
barrassment are generally large and at times cause
distortion of the shape and size as best demonstrated by
roentgenologic methods. What intravenous radio-opaque
dyes can do in demonstrating these lesions needs further
elucidation. In any patient with known malignancy, the
sudden onset for cardiac symptoms may well be on the
284
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CLINICAL-PATHOLOGICAL CONFERENCES
References
1. Barnes, A. R. ; Beaver, D. C., and Snell, A. M.: Primary
sarcoma of heart; report of case with electrocardiographic
and pathological studies. Am. Heart J., 9:480-491, (Apr.)
1934.
2. Batchelor, T. M., and Maun, M. E. : Congenital glycogenic
tumors of the heart. Arch. Path., 39:67-73, (Feb.) 1945.
3. Farber, S. : Congenital rhabdomyoma of the heart. Am. J.
Path., 7:105-130, (Mar.) 1931.
4. Hillman, R. W. : Tuberous sclerosis; with congenital rhab-
domyomas of heart discovered in a child dying of acute
lead poisoning. Brooklyn Hosp. J., 3:181-195, (Oct.) 1941.
5. Hueper, W. C. : Rhablomyomatosis of heart in a negro.
Arch. Path., 19:372-379, (Mar.) 1935.
6. Labate, J. S. : Congenital rhabdomyoma of heart; report of
case. Am. J. Path., 15 :137-150, (Jan.) 1939.
7. Larson, C. P., and Lidbeck, W. L.: Rhabdomyosarcoma and
other myocardial tumors; report of 3 cases. West. J. Surg.,
Obst. & Gyn., 48:151-153, (Mar.) 1940.
8. Larson, C. P., and Sheppard, J. A.: Primary rhabdomyoma
of heart with sarcomatous extensions. Arch. Path., 26:717-
723, (Sept.) 1938.
9. Lisa, J. R. ; Hirschhorn, L., and Hart, C. A.: Tumors of
the heart; report of four cases and review of literature.
Arch. Int. Med., 67:91-113, (Jan.) 1941.
10. Lymburner, R. M.: Tumors of heart; histopathological and
clinical study. Canad. M. A. J., 30:368-373, (Apr.) 1934.
11. Scott, R. W., and Garvin, C. F. : Tumors of heart and
pericardium. Am. Heart J., 17:431-436, (Apr.) 1939.
12. Shelburne, S. A.: Primary tumors of heart; with special
reference to certain features which lead to logical and cor-
rect diagnosis before leath. Ann. Int. Med., 9:340-349,
(Sept.) 1935.
13. Straus, R., and Merliss, R. : Primary tumor of heart. Arch.
Path., 39:74-78, (Feb.) 1945.
14. Yater, W. M.: Tumors of heart and pericardium; pathology,
symptomatology and report of 9 cases. Arch. Int. Med.,
48:627-666, (Oct.) 1931.
HISTORY OF THE CIRCULATION
( Continued from Page 267)
that they exist. It must be recalled that Cesal-
pino also suggested that an anastomosis existed
between the arteries and veins. Harvey further
explained that both the arteries and the veins
contain blood and that movement of the blood
is progressive, not undulating. He also showed
that the functional center of the cardiovascular
system is the heart, not the liver.
In this rather brief review of the history of the
discovery of the circulation of the blood, facts
have been recorded as they are found in the
annals of history. After these many centuries the
primary concern is no longer with priority of
discoverers but rather with the importance of
observations and conclusions as recorded by the
contributors. History unmistakably inscribes the
chronology of events. Each is important and its
individual merit should be emphasized as we to-
day contemplate in retrospect on the progress of
history and the influence of these various con-
tributions on what is known at this time as
modern medicine.
References
1. Arcieri, J. P. : The circulation of the blood and Andrea
Cesalpino of Arezzo. 193 pp. New York: S. F. Vanni, 1945.
2. Castiglioni, Arturo: A history of medicine. (Translated
and edited by E. B. Krumbhaar.) pp. 435-436. New York:
A. A. Knopf, Inc., 1941.
3. Corwin, W. C. : William Harvey and the circulation of the
blood. Proc. Staff Meet., Mayo Clin., 12:668-672, (Oct. 20)
1937.
4. Cumston, C. G. : The biography of Michel Servetus, the
discoverer of the pulmonary circulation. Boston M. & S. J.,
156:451-461, (Apr. 1 1) 1907.
5. Garrison, F. H. : An introduction to the history of medi-
cine; with medical chronology, suggestions for study and
bibliographic data. Ed. 4, p. 222. Philadelphia; W. B. Saun-
ders Company, 1929.
6. Haddad, S. I. and Khairallah, A. A.: Forgotten chapter in
history of circulation of blood. Ann. Surg., 104:1-8, (July)
1936.
7. Mackall, L. L. : A manuscript of the “Christianismi Resti-
tutio” of Servetus, placing the discovery of the pulmonary
circulation anterior to 1546. Proc. Roy. Soc. Med., (Sect.
Hist. Med.) 17 (pt. 1-2) :35-38. (Oct. 17) 1923.
8. Meyerhof, Max: Ibn an-Nafis (Xlllth cent.) and his
theory of the lesser circulation. Isis, 23:100-120, 1935.
9. Osier, William: Michael Servetus. Bull. Johns Hopkins
Hosp., 21:1-11, (Jan.) 1910.
10. Temkin, Owsei: Was Servetus influenced by Ibn an-Nafis?
Bull. Hist. Med., 8:731-734, (May) 1940.
11. Willis, Robert: The works of William Harvey, M.D. 624 pp.
London; The Sydenham Society, 1847.
12. Willius, F. A and Keys, T. E. : Cardiac classics; a collec-
tion of classic works on the heart and circulation with com-
prehensive biographic accounts of the authors, pp. 12-79. St.
Louis; The C. V. Mosby Company, 1941.
basis of cardiac metastasis. Intractable myocardial in-
sufficiency without obvious cause may be on a tumor
basis.9’14
Although very few tumors of the heart have been
recognized as such prior to necropsy, the time should
come when a benign pedunculated myxoma of the left
interauricular septum will be clinically recognized and
surgically cured. More alert physicians are already
metastatic-cardiac-tumor conscious.
Summary
1. A fifteen-year-old boy developed abdominal and
thoracic distress, muscular weakness, and dyspnea,
progressing to circulatory collapse and death over a
five-day period.
2. Necropsy revealed a rhabdomyosarcoma of the
right interauricular septum with much necrosis and re-
cent hemorrhage which had blocked the tricuspid valve.
3. This appears to be the fifth rhabdomyosarcoma of
the heart in the world literature.
4. A very brief review of the more important facts
and theories concerning both primary and secondary
neoplasms of the heart is recorded.
March, 1947
285
CASE REPORT
ADENOCARCINOMA OF THE SWEAT GLANDS WITH METASTASES
A. E. BENIAMIN, M.D.
Minneapolis, Minnesota
MALIGNANT tumors of the sweat glands with
metastases are rare. Gates, Warren and Warvi1
reported thirty-five cases, four of them with metastases.
The case I wish to report is one of interest because of
the many areas and tissues involved and the associated
lesions present.
health had been quite good. Her weight was 120
pounds; she was 5 feet 5 inches tall. She had worn
glasses for about eight years. She stated she became
somewhat deaf in her right ear fifteen years before,
followed shortly by bilateral, nearly total deafness. She
had been wearing a hearing aid since.
She had quite a large growth involving the external
Fig. 1. X-ray of the abdomen on
August 11, 1943, before operation. The
density in the right abdomen suggests
a soft tissue mass. The operative
findings showed that this was probably
secondary to an intra-abdominai hemor-
rhage from a lesion in the liver.
Fig. 2. Lateral view of the skull.
The shadow of a dense tissue mass
may be seen about the right ear, with
erosion of the temporal bone about the
mastoid and eburnation which was
probably secondary to an infection in
the tumor mass. Several nodules in
the scalp could be seen in the original
film hut are lost in reproduction.
Fig. 3. X-ray of the chest on April
29, 1946, shows multiple rounded den-
sities in the left lung which are most
probably carcinomatous metastases.
Case Report
Mrs. C., aged 76, a widow for twenty years, was of
Irish descent. She had had the ordinary diseases of
childhood. Her tonsils had been removed in her earlier
years. Twenty years ago, she noticed a skin tumor in
front of the right ear. In two years time, this grew
quite large, and she had it removed. Apparently it was
malignant, for she had radium and x-ray treatments
following the operation. Her father died of cancer of the
mouth at seventy-nine years of age. Her mother died at
twenty-four following childbirth. Mrs. C. was married
at eighteen and at the time of examination had three
grown children, all healthy. Another child, a daughter,
died several years ago of tuberculosis. Her husband
died of cancer of the mouth twenty years ago. Her
menopause, when she was fifty, arrived with no particu-
lar disturbances.
When first seen by me in August, 1943, she com-
plained of pain in the upper right quadrant. This
pain had started one month previously. Her general
Read at the annual meeting of the Southern Minnesota
Medical Association, Faribault, Minnesota, September 9, 1946.
right ear and mastoid area, one involving the skin of
the right breast, several growths on the scalp, and some
on the arms, legs, and back, ranging in size from 1 to
5 cm. in diameter. These were dark in color and raised
above the skin. She had upper and lower plates. Her
mouth and throat seemed healthy. There was no thyroid
disturbance. She had no cough or bronchial trouble.
Her heart was normal. Her blood pressure was 140/72.
There was no lymphatic enlargement. The liver was
enlarged, the lower border extending 1.5 inches below
the costal margin. There was pain upon percussion over
the gall-bladder area and dullness over the upper right
quadrant and some over the whole abdomen. She had a
second degree prolapse of the uterus with a marked cys-
tocele. She had no hernia. The bones and joints seemed
normal. Her reflexes were normal. She had some vari-
cose veins of the lower extremities. Her hemoglobin was
64 per cent. The urine contained a trace of albumin.
Her bleeding time was 1 minute, 10 seconds; clotting time
was 4 minutes. The blood Wassermann test was nega-
tive. Her temperature was 100; pulse, 78; white cell
count, 11,800; and red cell count, 2, 970, 0(K).
The growths were thought to be malignant.
286
Minnesota Medicine
CASE REPORT
Fig. 4. Tumor of the right ear before
operation.
Fig. 6. Malignant growth of the scale
and forehead before operation.
Fig. 8. Malignant growths on the legs
before operation.
12, 1943, three tumors were removed from the right
lower leg, one from the right breast, and one from the
forehead for biopsy. These involved the skin alone.
The pathologist reported adenocarcinoma of the sweat
gland type.
March, 1947
Fig. 5. Photomicroscopic section of the
right ear shows malignant degeneration of
a cylindroma involving the ear.
Fig. 7. Photomicroscopic section of a
scalp cylindroma (turban tumor).
Fig. 9. Photomicroscopic section of a
skin cylindroma with characteristic cyt-
ology.
August 17, 1943, through the outer border of the right
rectus. The muscle was retracted and the peritoneum
opened back of the muscle. The abdominal cavity con-
tained a great deal of blood from a hemorrhage that
apparently had occurred from the under surface of the
Because of the severe pain in the upper right quad-
rant, a flat plate was taken, and a shadow in the vicinity
of the gall bladder was noticed (Fig. 1). On August
Because of the continuous pain in the right upper
quadrant and the possibility of a stone in the gall
bladder, an exploratory operation was performed on
287
CASE REPORT
liver, where there were a few greyish nodules. The
omentum was adherent to the nodules and liver. The
upper surface of the liver was smooth and the right
lobe was enlarged. The organ was congested and in-
flamed. The gall bladder and other abdominal organs
Fig. 10. The patient after removal of the growth of the ex-
ternal right ear and the growths on her forehead and scalp.
moved, we operated on May 2, 1946, removing all of
the external ear and the contiguous tissue involved.
The skull was not interfered with except to cauterize
it, as we removed the malignant tissue by means of the
electric knife. The pathologic report was basal cell
carcinoma (Fig. 5).
Her progress was very satisfactory, and inasmuch as
she seemed to improve after these various procedures,
she and her family were anxious to have all remaining
growths marring her appearance removed (Fig. 6).
We then, on May 10, removed, under local anesthesia,
three growths from the frontal region, one from be-
tween the shoulder blades, one from the left shoulder,
and one from the lumbosacral region. The pathologist
reported these growths to be basal cell carcinoma (Figs.
7 and 9).
There still remained the following smaller tumors ;
five growths on the lower left leg, seven on the right
leg (Fig. 8), three more on the back, two on the scalp,
and two on the upper right thigh. These we removed
under local anesthesia five days later.
The wounds all healed perfectly (Fig. 10), and the
patient seemed happy and well satisfied. There remained
a little drooping of her right upper eyelid because of
a nerve and muscle injury from the operation. The
denuded area where the external ear was removed has
now healed over, and she covers the defect with a lock
of hair.
There remains, however, at this lime, within the
external auditory canal a small granular mass which
probably is malignant, but which we will remove soon
with the electric needle.
She weighs 126 pounds. Her hemoglobin remains
about 70 per cent. Her general health is good, and she
gets about alone.
were apparently normal, and no stone was found. The
adhesions were separated and a portion of the border
of the liver including a nodule was removed for biopsy.
This was thought by the pathologist to be malignant,
but the specimen was reviewed by Dr. E. T. Bell and
others who believed it to be an angioma. A positive
diagnosis was not made.
Transfusions were given following the operations.
The patient made satisfactory progress. The bloody
drainage gradually ceased and she was allowed to get
up in a few days.
The patient did not require any special attention until
April 22, 1946, when she returned complaining of pelvic
distress and bleeding from the ear. She was weak and
her hemoglobin was 40 per cent. The uterus was pro-
lapsed and a cystocele was present. She had no growth
or signs of malignancy in the pelvis. Appropriate diet
and blood building remedies were employed. A pessary
to support the bladder and uterus was fitted. The bleed-
ing surface of the ear was treated. On April 29, 1946,
x-rays were taken of the skull (Fig. 2) and lungs
(Fig. 3). These showed invasion of the mastoid and
possibly cancer of the lungs.
Because of the large and bleeding tumor of the ear
(Fig. 4) which she had previously refused to have re-
Comment
This case is of particular interest because of the
numerous growths and metastases which have occurred
since she first noticed the tumor in front of her right
tar twenty years ago. This tumor may have been the
same malignant type of the sweat glands. There was
no recurrence until a number of years later when it
developed in the same location with involvement of the
ear and skull, a tumor in the liver with hemorrhages,
probable malignant growths in the lungs, and numerous
malignant growths of the sweat glands of the scalp and
skin of the body and extremities, these tumors being
considered similar in nature by the pathologists. It is
interesting to note that she has made improvement in
a general way since all of these growths have been
removed.
References
1. Gates, Olive, Warren, Shields, and Warvi, W. N. :
Tumors of sweat glands. Am. T. Path., 19:951,
1943.
I have never found a person who was merely a physical being. Most of us have minds and bodies and
souls, and you can’t treat just one part. — Margaret S. Taylor, R.N., Congress on Rehabilitation of the
Tuberculous, March 4, 1946.
288
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
♦
♦
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY .
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester. Minnesota
(Continued from February issue)
A Dr. Keller settled in Preston around 1882 and for a few years practiced
medicine and surgery there. It has been recalled by the daughter of an early
settler, Mr. Joseph Pickett, of Carimona, that in her father’s last illness one
of her two physician uncles (Dr. William C. Pickett, founder of Carimona,
and Dr. Plorace W. Pickett) called Dr. Keller in consultation, and that Dr.
Keller finally took the case alone.
Dr. Keller, although he possessed the confidence of many persons of judg-
ment, physicians and laity, who believed him to be a skilled member of the
medical profession, incurred the disfavor of others, as witness the following
broadsides, the first of which appeared in the local National Republican in
August, 1883 :
Quacks thrive by appropriating as their own the skill and knowledge of others. Dr. Love
is one of the sufferers by this too common practice. The sap-head reporter of the Lanesboro
Journal is doing what he can to give credit for service to others than those who perform it.
When either Dr. Love or Dr. Knowles has an accouchement case, he hastens to report that
Dr. Keller was the professional attendant. There are several such cases which exhibit the
retailer of lies as a scavenger worthy of the dirt he consumes.
And the second appeared in November, 1883 :
Dr. Keller, the quack, who deluded so many Prestonians into the belief that he was an
accomplished physician, and who left last fall to “follow his profession in Texas,” is in
Chicago trying to get a diploma from the Homeopathic Medical College. Will that relieve
him from the necessity of borrowing some other physician’s small hand?
A Dr. F. Keller practiced in Red Wing, Goodhue County, for a few years,
perhaps more, in the seventies. There is official record, which should be con-
sidered with the foregoing paragraphs, that on April 24, 1884, Dr. Francis
Keller, once of Goodhue County but “now Fillmore, as per certificate,” a
graduate from the Medical Department of the State University of Iowa, early
in 1884, was licensed by the Medical Examining Board of the State of Min-
nesota to pursue the practice of medicine in the state, and that on March
2, 1885, he formally filed his license with the clerk of the District Court of
Fillmore County, as required by law.
Ambitious to extend his scope of practice in a larger place, Dr. Keller left
Preston in the eighties, and some years later word came back to the village
that he had built up a large practice in Los Angeles.
March, 1947
289
HISTORY OF .MEDICINE IN MINNESOTA
Herbert Kendall, a graduate of Rush Medical College, was practicing medi-
cine in Spring Valley in 1880, and in that year, at the annual meeting of the
Minnesota State Medical Society which was held at Albert Lea on June 15,
he was elected to membership in the association. Other mention of him has
not been found.
William Nassau Kendrick was born at Athens, Leeds County, Ontario, Ca-
nada, on June 15, 1872, the son of Samuel Kendrick and Amelia McNish
Kendrick, both of English parentage and natives of Oak Leaf, Ontario. Samuel
Kendrick lived until 1903, his wife five years longer.
William Kendrick went to school in Athens, and subsequently was a stu-
dent at the Almonte Collegiate Institute, at Almonte, Canada, from which
he was graduated with honors in 1890, at the age of seventeen. Two years
later, having decided to become a physician, he entered McGill University,
from which he was graduated in 1896, again an honor student and the presi-
dent of his class, with the degree of M.D. C.M. ; among the awards for scholar-
ship which he had received during his course of four years were the Primary
Prize, the Prize for General Proficiency, and the Gold Medal for Proficiency
in Chemistry.
Immediately after taking his degree in medicine, Dr. Kendrick came to
Spring Valley, Minnesota, to join his half-brother, Dr. J. Ross Johnson, in
practice, and on June 9, 1896, was licensed as a physician in the state. In
Spring Valley, on October 14, 1896, he was married to Maud M. Lloyd,
daughter of L. M. Lloyd of that place. In 1898 a second half-brother, Dr.
Charles H. Johnson, of Austin, in neighboring Mower County, who was in
ill health, persuaded Dr. Kendrick to become his partner; the association
continued for eight years. During the period in Austin there were born to
Dr. and Mrs. Kendrick two children, Dorothy Gertrude, on December 8,
1899, and William Lloyd, on March 16, 1903.
In 1905, after the death of his half-brother, Dr. J. Ross Johnson, Dr. Kend-
rick returned with his family to Spring Valley, where he spent the remain-
ing thirty-one years of his life, a loved physician, high in the esteem and con-
fidence of his patients and fellow townsmen. Among his professional con-
temporaries in the village were Dr. John D. Utley, Dr. Cyrus B. Eby and
Dr. Eubert V. Simons, as well as others who were there for varying periods
of time. These men and their fellow practitioners, in the late nineties and
well after the turn of the century, experienced many of the difficulties and
inconveniences that their earliest predecessors in medical practice had met;
the scientific advances of the last two decades were then only visions in the
minds of a few research workers.
Always a student, Dr. Kendrick did much postgraduate work, visiting
clinics and hospitals, and twice taking courses at the Medical School of
Northwestern University. He was a general practitioner, with special interest
in diseases of the eye, ear, nose and throat, and he became well qualified in
treatment for these disorders. An expert optician as well as an oculist, he
fitted glasses for many of his patients. Dr. Kendrick early began to write
occasional original articles for the medical journals, of which one of the first
was a note on postpartum hemorrhage that was published in the Northwestern
Lancet in 1898. He served on the local board of health and was a member
of the local county medical society, the Minnesota Valley Medical Associa-
tion, and the Southern Minnesota Medical Association (as stated previously,
these two joined in 1911), and the state and the national medical associations.
290
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
Dr. Kendrick is recalled as a leader in every movement that had to do with
the betterment of his community. He was a member of the Spring Valley
Commercial Club, the Automobile Club, and the American Legion and of
the following fraternal orders: the Masons (A. F. and A. M. ; Grand Master
of Minnesota in 1918) ; the Ancient Order of LTnited Workmen, the Benevo-
lent and Protective Order of Elks, the Modern Woodmen of America and
the Modern Brotherhood of America. He was a Republican in politics, an
Episcopalian in religious affiliation. During World War I he was an examiner
of army recruits, local chairman of the Liberty Loan and Victory Drives,
and he aided the national department of justice in locating hidden grain and
in dealing with aliens. In October, 1918, he entered military service and was
stationed at Camp Pike, Arkansas, until his honorable discharge on De-
cember 23, 1918. His favorite diversions, when time permitted, were hunting,
fishing and golf.
Although Dr. Kendrick never fully recovered his health after an opera-
tion for ruptured appendix in 1912, and although he became the victim of
agranulocytic angina, he continued in medical practice until his death, at
Rochester, Minnesota, on January 21, 1936. He was survived by his wife,
a son and a daughter, and a sister, Mrs. William McNaughton, of Ottawa,
Canada. Three years later Mrs. Kendrick removed from Spring Valley to
Brainerd where, until she died, on September 28, 1944, at the age of seventy-
two years, she made her home with her daughter, Dorothy Gertrude (Mrs.
E. C.) Parsons. Late in 1944 there were living of Dr. Kendrick’s family, Mrs.
Parsons, William Lloyd Kendrick, his son, a mining engineer at Coleraine,
and three grandchildren.
Dr. Kendrick lives in the memory of all who knew him, distinguished for
his professional ability and his personal integrity and worth.
Elling P. Kierland, who was born at Kjerland Homestead, Hardanger, Nor-
way, on February 18, 1818, was educated in his native place, receiving his
general grounding in the schools and his special training, in pharmacy and
medicine, under a preceptor. As many another member of his family had
done before him, he became a druggist and, although not a graduate of a
medical school, a competent practitioner of medicine.
In 1839 Elling Kierland was married to Madli Hovlen, also a native of
Hardanger, a religious, conscientious woman who was a fine wife and thriftv
homemaker and a devoted mother to the seven children of the marriage. Dr.
and Mrs. Kierland in 1856 came with their family to America, settling first
on a farm in Winneshiek County, Iowa. After five years in Iowa they moved
to Rushford, Minnesota, where Dr. Kierland operated a drug store with his
sons, Thomas and Peter E. Kierland, the latter of whom subsequently became
a physician in Rushford, a graduate of Rush Medical College in 1869.
In 1877 Dr. E. P. Kierland temporarily discontinued his practice of medi-
cine to enter the hardware business with his son Louis in Canton, South
Dakota, but on giving up this enterprise after a few years, he returned to
Rushford where he resumed his preferred occupation. Not a graduate of a
medical school, as has been stated, he had received excellent training and
had improved his knowledge by study, as evidenced by his successful prac-
tice, so that on December 31, 1883, under the Medical Practice Act of that
year, he received exemption certificate No. 733-3. Until the time of his death
at the venerable age of ninety-four years he continued his work of caring
for the sick.
March, 1947
291
HISTORY OF MEDICINE IN MINNESOTA
Kind, generous, charitable, actively interested in the Lutheran Church and
in civic affairs, Dr. Kierland was one of Rushford’s most influential and up-
right citizens. He died on April 26, 1912, at Rushford, survived by three of
his children, twelve grandchildren and ten great grandchildren. His family
in 1943 was represented in the medical profession by three members : his
grandsons, Dr. Peter Ernest Kierland (son of Thomas Kierland), of Alex-
andria, Minnesota, who for ten years was a physician of Harmony, Fillmore
County, and Dr. George E. Hourn, of St. Louis, Missouri (son of Martha
Kierland Hourn) ; and his great grandson, Dr. Robert Richard Kierland (son
of Dr. Peter E. Kierland), of Rochester, Minnesota, since the entrance of the
United States into World War II absent on military service. (Dr. Kierland
returned to Rochester, where he is on the staff of the Mayo Clinic, in De-
cember, 1945.)
Peter E. Kierland, one of the seven children of Filing P. Kierland, phar-
macist and medical practitioner, and Madli Hovlen Kierland, natives of Har-
danger, Norway, was born in Hardanger in 1846 and when he was ten years
old came with his parents and his brothers and sisters to America, to a farm
home about ten miles east of Decorah, Iowa. Here in the country schools
his education was continued. Early in the sixties the family moved to Rush-
ford, Minnesota, where the boy, then fifteen, went to school and helped in
the drug store which was operated by his father and his brother Thomas.
Peter learned pharmacy from his father and, from 1862 to 1868, whenever time
afforded, studied medicine under Dr. Billington, of Decorah, Iowa. At the
end of that period he entered Rush Medical College, in Chicago, and from
it was graduated on February 3, 1869, with honorable mention for high
scholastic rating and with the degree of doctor of medicine.
The young physician, who is remembered as of medium build, with black
hair and gray eyes, returned to Rushford to begin his professional life in
the community in which the senior practicing physicians were his father, Dr.
Thomas H. Everts and Dr. Henry C. Grover, and in which Dr. H. W. Eldred
was a highly respected surgeon-dentist. Dr. Kierland was a Mason, a member
of the Lutheran Church and from the first a useful citizen.
In Chicago Peter E. Kierland was married to Louise Anderson, and on
his return to Rushford brought his wife home with him. Although she never
had lived outside of a city, Mrs. Kierland entered fully into the life of the
community and sought to share the hardships of a country doctor’s routine,
accompanying her husband in horse-drawn vehicles on many of his rural
calls, regardless of weather. On one of these occasions, in the winter, when
Dr. Kierland was to perform a surgical operation, a partial resection of the
maxilla, the horse ran away and the cutter tipped over, spilling passengers,
instruments and equipment in the snow. With neither his wife nor himself
hurt, Dr. Kierland gathered up the paraphernalia and in due time carried out
successfully the planned surgical procedure, which was followed by recovery
of the patient.
In the second year of his practice, Dr. Kierland, whose fine intellect and
scientific ability gave promise of great service to his community and to his
profession, was stricken with pulmonary tuberculosis. In the hope that the
journey and change of climate would prove beneficial, his father in 1870 took
him to Norway but not long after their return to Rushford the young physi-
cian died, on January 28. 1871. His death was announced in the Journal of
29?
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
the American Medical Association : “He will not miss the haven of hope, with
God at the helm.”
Dr. Kierland was survived by his wife ; their daughter and only child,
Ella; his brothers, Thomas and Louis; and his sisters, Isabel Kierland Eide
and Martha Kierland Hourn. Of that group, there were living in the early
nineteen-forties only his daughter, Ella Dahl Kierland Rich, retired at Santa
Monica, California, after a distinguished career as a concert pianist, and his
brother, Thomas Kierland, ninety-two years of age (1943), who had retired
some time previously after fifty-six years as a practicing pharmacist in Rush-
ford.
E. J. Kingsbury, who was to become a well-known medical practitioner of
southern Minnesota, was a native of New York State, born in Franklin
County on August 23, 1832. When he was four years old the family moved
to St. Lawrence County, where he grew up. He obtained his preliminary and
academic education at a district school in Potsdam, at a select school in Ray-
mondville and during six terms at the Raymondville Academy under Profes-
sor Montague. Thus prepared, at the age of eighteen years he began to study
medicine under preceptors, the first instructor Herman A. Boland, of Ray-
mondville, and the second, Dr. Goodrich, of Potsdam. He completed his
medical training by attending lectures at the American Medical Institute at
Cincinnati and he was graduated from that institution on March 14, 1854.
Beginning his medical practice immediately in Oswego County, New York,
he remained there until the autumn of 1855, when he traveled west to Min-
nesota Territory and settled in Mower County, pre-empting the southwest
quarter of section 20, town 102, range 14, in the present Bennington Town-
ship. In fact, he assisted in the organization of the township and served as
first chairman of the first board of supervisors. After a few years he moved, in
the autumn of 1860, to the village of Spring Valley, in Fillmore County, where
he remained in active medical practice for eight years. During this period there
was occasional mention in county records of his having received fees for medical
attendance on paupers.
In Spring Valley, if not immediately on his arrival, at least prior to 1865,
he had his offices on Broadway, opposite the tinshop. A professional card in
the Preston Republican of March 10, 1865, announced that E. J. Kingsbury
and Brother — the first and only mention found of the brother — were physi-
cians and surgeons, and a postscript set forth the following information :
E. J. Kingsbury, having been appointed Examining Pension Surgeon by the Commissioner
of Pensions, will attend to all applications for pensions with promptness and dispatch. They
will also attend to the collection of back pay and Bounty. g j Kingsbury
W. B. Kingsbury
Late in 1868 Dr. E. J. Kingsbury moved to Decorah, Iowa, where he re-
mained until 1870, when he again settled in Mower County, in the village of
LeRoy, which became his permanent home. The beginning of his practice
there was coincident with an outbreak of diphtheria during which he served
faithfully and with such success as to establish him in the confidence of the
community. During his first year in Le Roy, Dr. Kingsbury was one of
several reputable physicians of Iowa and Minnesota to endorse, in a notice
in Western Progress, the newspaper of Spring Valley, one Dr. H. J. Stalker,
mentioned earlier, apparently a dentist of merit who traveled about the
region.
March, 1947
293
HISTORY OF MEDICINE IN MINNESOTA
E. J. Kingsbury was married twice, the first time on July 3, 1853, to Lucia
A. Angell, who was born at Pomfret, Vermont, on April 8, 1829. Mrs.
Kingsbury died in Spring Valley, Minnesota, on September 28, 1867, leaving
one child, Flora A. Kingsbury; an infant son had died a year earlier. Dr.
Kingsbury’s second marriage took place on October 21, 1868, to Mary G.
Hard, who was born in Broome County, New York, on September 21, 1846.
Of this marriage there were three children, Mattie J., Mildred A. and Elmer
J. Kingsbury.
A strong advocate of temperance, E. J. Kingsbury from the age of seven-
teen years was a member of one temperance organization or another. That
he was a man of active intellect and professional versatility was evidenced
by the fact that he studied law and became a qualified member of the bar of
Minnesota, admitted on April 6, 1882, to practice law in all courts in the state.
In 1884 he had been serving for four years as police justice of Le Roy.
Dr. Kingsbury is said to have died in 1885, at the age of fifty-three years.
S. H. Knowles for a time in the early eighties was in Preston, Fillmore
County, and in this period, on July 25, 1883, aged twenty-five years, he be-
came a member of the Masonic Blue Lodge of the village: he did not with-
draw from membership until 1899, although it is believed that he long had
been gone from Preston.
In the local newspapers of 1883 there appeared items, always with ap-
probation, concerning Dr. Knowles’ professional services in cases of various
types. And in the Chat field Democrat of September 1, 1883, there appeared the
following note: “Dr. S. H. Knowles has resigned his position as County
Physician. Here is an opportunity for some enterprising doctor to travel over
the county, administer to the sick and furnish medicine, all for $300 a year.”
Finally, on November 29, 1883, the National Republican of Preston had this to
say :
S. H. Knowles left Preston yesterday for Omaha where he has entered into partnership
with Dr. J. C. Deinse, an old and successful practicing physician having an immense prac-
tice. Dr. Knowles will have charge of the general practice, for which he is well qualified.
The future of this young physician will be mainly successful. Few, if any, young men in his
profession have attained his experiences and knowledge of the literature of medicine and
surgery'. Preston has suffered a serious loss in his leaving. His friends gave him a reception
in Hamre Hall on Monday evening.
For what it may signify in this account, it should be stated that Dr. Seth
Knowles, a graduate of the College of Physicians and Surgeons, of Keokuk,
Iowa, in 1878 (if this was S. Id. Knowles, he was twenty years old), was
licensed to practice medicine in Minnesota on August 18, 1884, receiving
certificate No. 944 (R) under the “Diploma Law” of 1883. It should be noted
also that many physicians, although they promptly secured their licenses
under the new law, did not file them promptly. By 1890 Dr. Seth Knowles
was residing in Minneapolis, according to the 1883-1890 official register of
physicians of Minnesota; he died prior to 1909, presumably before 1907, since
his name does not appear in the first issue (1906) of the Directory of the
American Medical Association.
(To be continued, in the April issue.)
294
M innesota Medicine
President s flettel
MINNESOTA MEDICAL SERVICE, INC., TO BEGIN OPERATION SHORTLY
Minnesota Medical Service, Incorporated, a nonprofit corporation, has been born and is
now a living, vibrant organization. It was initiated by the Minnesota State Medical Associa-
tion, but there is no business connection between the two organizations. During the period
of nascency, which lasted almost two years, the committee on organization of medical service
worked diligently. It obtained information from many sources and it studied the plans
of organization and operation of similar corporations in other states. By this method^ it
hoped to utilize the features of value of other plans and sought to avoid the errors which
others have made. Finally the committee prepared the articles of incorporation, the proposed
contracts and the schedule of benefits. In addition to this, it prepared an agreement with the
Blue Cross and secured pledges from the physicians of Minnesota in order to finance the
enterprise. These pledges exceeded $100,000.
After this task was completed, the committee on organization made its report before a
special meeting of the House of Delegates of the Minnesota State Medical Association on
December 22, 1946. Immediately following the formal acceptance of the report by the
House of Delegates, the Council was instructed to proceed with the formation of the cor-
poration. Accordingly, the incorporators were selected by the Council and they were re-
quested to deal with the details incident to the creation of Minnesota Medical Service.
Within a few days the articles of incorporation were filed and accepted. The directors
of the corporation and its officers have been elected, and the pledges are being honored
in a most gratifying manner. It is predicted that the pledges already made will be re-
deemed, and probably many physicians who did not respond to the first call will seek an
opportunity to participate. In fact, many have already done so.
During the discussions which took place in the special meeting of the House of Delegates
just mentioned, it became apparent that some of the members believed that an indemnity
plan probably would be more acceptable than a service plan in some communities. There-
fore, a second resolution was proposed and adopted which provided that the Council should
appoint a committee of five members which should act as a liaison between the State Associa-
tion and the insurance companies in order to develop plans for the provision of low-cost
medical insurance on as broad a basis as possible. This committee was appointed without
delay, and a short time thereafter it met with representatives of insurance companies. A
similar liaison committee then was appointed by the insurance group and these two committees
have been proceeding with their work.
Within a short time, Minnesota Medical Service, Incorporated, will be ready to perform
its function. By this means, physicians of Minnesota are attempting to bring a high quality
of medical care and provisions for hospitalization to everyone. As physicians set themselves
to this task, they are aware that other schemes with similar purposes may present them-
selves. Their attitude toward such developments is one of complete co-operation as long
as such schemes fulfill the requirements of the principles of ethics of the practice of
medicine. They realize that probably no single plan will solve the entire problem, but they
hope that through the Minnesota Medical Service Plan, a useful purpose will be served in
bringing the proper kind of medical care to the infirm.
A great responsibility rests with physicians. Those who gave up so much to serve their
country in the recent conflict, as well as those who remained at home, have borne heavy
burdens during recent years. It is hoped that these new arrangements will lighten their
burden. The prospective importance of this plan, like that of all new ideas and new dis-
coveries, cannot be exaggerated but until it is accepted and used, it can exercise no influence
and therefore can work no good. Minnesota Medical Service, Incorporated, will need the
care and the interest of every practicing physician. No one can afford to adopt the attitude
of complacency or apathy. Of all evils, probably torpor is one of the most deadly. It
blunts the faculties of men, withers their powers and prevents effective progress. Since
progress depends on the energy of man, our alertness in support of this plan must not
slacken. We must maintain that vigor of character, that decisiveness and that audacity, both
of conception and execution which alone will pave the way to achievement.
President, Minnesota State Medical Association
March, 1947
295
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
CALORIE INTAKE AND INDUSTRIAL OUTPUT
Q cience* has published a simple understand-
^ able report out of war-ridden Germany that
teaches obvious nutritional lessons, especially the
need of adequate protein in order to maintain
weight when dietary fats have to be curtailed.
Dr. David B. Dill of Harvard University (In-
dustrial Physiology and J. M. Corps, U. S.
Army) brought this report back in late 1945.
There was an opportunity in Germany to appraise
the unit output of workers in quite standardized
employments, and to observe the effect of de-
creases or increases in terms of essential food re-
trenchments or supplements. Whereas it was
possible to add mineral and vitamin supplements,
these were of no avail in the absence of basic
foods and total calories consumed.
Thus, workers moving earth for an embank-
ment or mining coal (succumbing to German ex-
actitude and complaisance) furnished the scien-
tists with a chance to prove that “rationing of
food also means a rationing of industrial pro-
duction.” No doubt that is the source of much
trouble in Britain today, as well as in much of
the devastated world. “Reconstruction is a prob-
lem of calories,” according to this report.
Coal miners in training were alloted 1,200
calories daily, out of a total of 2,800, for “work.”
They handled seven tons of coal daily or used up
170 calories per ton. The researchers advised
adding 400 calories per day, and the output went
up to nine tons daily at a unit expenditure of 155
calories. But at this level the workers averaged
a weight loss of 1.2 kilograms in a period of six
weeks, and, of course, that could not be long
maintained. So they boosted the intake 800 cal-
ories, after which ten tons of coal were mined
daily and the weights of the workers returned to
normal.
It will immediately occur to many to ask about
morale, living conditions, individual degrees of
ambition or lethargy. For example we are in-
clined to think that people living in temperate
zones become tired and languid, like the natives,
*Kraut, H. A., and Muller (Dortmund, Germany); Calorie
intake and industrial output, Science, 104:495, (Nov. 29) 1946.
when they move to tropical climates. Against
this evidence is the experience of Stillwell’s en-
gineers using weak and tired Chinese coolies and
putting the famous road over the Hump. They
were not capable of heavy work until they were
fed more or less like football players, and then
their accomplishment was prodigious. Comment-
ing on what happened in Germany when food be-
came scarce, the authors add, “Under existing
conditions the job of one man often has to be
done by two or three with a resultant higher total
wage cost.”
The amount of American production in peace
and in war stems in great degree from well-fed
workers. We have a munificent soil, a virile
people, and to these have been added the power
of the machine. Despite the sending of vast sup-
plies of food ($300,000,000 worth to our portion
of occupied Germany alone, and a prospective
three-fourths of a billion demand to carry them
through 1948), we seem to have inspired envy
far more than a desire to emulate our capitalis-
tic motivated economy. The solemn facts of food
should be pounded into the heads of politicians
and peace planners. A world interchange of food
and goods is needed far in advance of a dissem-
ination of cockeyed ideas of rights, privileges, or
ideologies. E.L,T.
USE OF DIMERCAPROL (BAL)
"P VERY physician who administers any type
-*—J of arsenical should familarize himself with
a new potent detoxifying agent (BAL). This
was a result of war research and was developed
in England to combat the injurious effects of
lewisite gas, hence, the name British anti-lewisite,
which was abbreviated to BAL. This chemical
is 2, 3-dimercaptopropanol, a dithiol derivative.
It has been shown that arsenic interferes with
the pyruvate oxidation process of the tissues by
attaching itself to the -SH groups which are es-
sential for this reaction. BAL has a greater af-
finity for arsenic than these groups and, therefore,
releases them and forms stable non-toxic com-
pounds which are easily eliminated by the body.
296
Minnesota Medicine
EDITORIAL
BAL is able to prevent toxic reactions and to re-
verse the process if the tissue cells are not yet
dead.
BAL is indicated in all toxic arsenical reactions
such as neutralizing arsenical vesicant agents
which come in contact with the skin or mucous
membranes. Eagle* found marked relief and
rapid improvement in the majority of cases of
arsenical dermatitis in which BAL was used.
It was a life-saving measure in toxic encephalitis
and was beneficial in arsenical agranulocytosis,
aplastic anemia, hepatitis, and accidental ar-
senic overdosage.
BAL is usually administered intramuscularly
and, in the severe complications resulting from
arsenic administration, the dosage found to be
best suited is 3mg. per kg. This amount is given
every four hours for twelve injections, then four
injections are given on the third day, followed
by injections twice daily until ten days have
elapsed or complete recovery ensues. In less
severe reactions, the amount given is 2.5 mgs.
per kg. and, after the third day, only one to two
injections a day, as indicated.
The reactions to BAL include nausea, vomiting,
headache, burning of the mouth, throat and eyes,
pain in the jaws, lacrimation and salivation, a
constricted feeling of the throat and chest, and
burning and tingling of the arms and legs. These
occur about fifteen to twenty minutes after ad-
ministration of the drug. Barbiturates seem to
relieve these reactions and, if persistent, the dos-
age should be reduced.
Some investigators! have found BAL effective
in heavy metal poisonings occurring from mer-
cury, bismuth, gold, cadmium, zinc and lead. Its
usage in these instances requires further study,
and the exact methods of treatment are not yet
available.
F. T. Becker, M.D.
VAGOTOMY FOR PEPTIC ULCER
XT7HATEVER the cause of peptic ulcer, the
v * acid gastric secretion is generally accepted
as being the main factor which prevents healing.
The main purpose of medical treatment of
peptic ulcer is the constant neutralization of the
acid gastric juice by frequent feedings and al-
kalis. This can be accomplished comparatively
‘Eagle, H. : The Systemic Treatment of Arsenic Poisoning
with BAL. J. Ven. Dis. Inform., 27:114, 1946.
tj. Clin. Investigation, July, 1946.
easily during waking hours but is well nigh im-
possible during the night. This is a distinct dis-
advantage, for a characteristic of the stomach
in the presence of a peptic ulcer is that it secretes
an abnormally large amount of gastric juice and
possesses an increased motility during the fasting
period.
It has been known since Pavlov’s original ex-
periments that the vagus is concerned with gas-
tric secretion. A stomach isolated from the esoph-
agus and duodenum by transection of the low-
er esophagus and duodenum, but with the vagus
supply intact, will continue to secrete gastric
juices. Section of the vagus fibres supplying the
isolated stomach will result in a marked diminu-
tion in the quantity and acidity of the gastric
secretion.
Dragstedt, recognizing this fact, was the first
to propose and institute vagotomy in the treat-
ment of peptic ulcer. His reports have stimulated
others to follow his lead, and several hundred
vagotomies have now been performed.
In Dragstedt’s original operation, the trans-
thoracic approach was used, the seventh or eighth
left rib being resected. It was felt that only by
this approach could the operator be sure of iden-
tifying and severing all of the vagus fibres which
lie on the lower esophagus and are irregular in
their course. Later he found that, with the ab-
dominal approach, the terminal esophagus could
be freed and retracted several centimeters, to
make the right and left and communicating fibres
accessible. The advantage of the abdominal ap-
proach is that the site of the ulcer can be in-
spected, and additional operative procedures can
be undertaken at the same time if indicated. For,
vagotomy alone is frequently not the cure for
peptic ulcer. While it generally lowers stomach
secretion and acidity and lessens motility, it not
infrequently is followed by gastric stasis which
requires constant gastric suction for one or more
days following operation. If the ulcer has pro-
duced some narrowing of the pyloric outlet, a
gastroenterostomy may also be required.
It is too early to make a fair appraisal of
vagotomy in the treatment of peptic ulcer. Wheth-
er it is or is not the long-sought ideal operation
for the surgical treatment of the disease cannot
be stated. Certainly it is not indicated for every
peptic ulcer. So-called medical treatment is high-
ly satisfactory for most patients who are willing
to co-operate in the matter of dieting, taking al-
March, 1947
297
EDITORIAL
kalis, and abstaining from coffee, alcohol and
nicotine. Gastroenterostomy has relieved many a
patient with recurrent ulcer and/or pyloric ob-
struction, although the incidence of resulting
gastrojejunal ulcer is fairly high. Subtotal gas-
trectomy for recurrent and bleeding ulcer has
proved fairly successful in the hands of a few
surgeons but seems a rather formidable proce-
dure.
Vagotomy is apparently making a place for it-
self in the treatment of peptic ulcer. Perhaps it
is particularly indicated in young individuals who,
for one reason or another, do not respond to
medical treatment and in whom hypersecretion
of gastric juice is a prominent factor. Possibly it
has a place along with gastroenterostomy. Until,
however, indications for its use are more clear-
cut, and long-time results of the operation have
been observed, the members of the profession
should not become too overenthusiastic in recom-
mending it to their ulcer patients.
THE NURSING PROBLEM
THE great scarcity of registered nurses pre-
sents a problem dangerous and tragic to the
hospitals, physicians and the public, both in urban
and rural areas. The situation is truly alarming
because it is certain to become much worse before
it is better, as the supply of nurses is rapidly di-
minishing while the demand is increasing, chiefly
because of the civil hospital expansion program
and the vast construction for veterans.
The plain fact is that girls are, not entering the
nurses’ training course as offered in our city hos-
pitals. There are several elements entering into
this situation. The ease with which high school
graduates at present can secure satisfactory em-
ployment with little or no special training, and the
proportional poor pay for well-trained nurses are
two elements which are the result of war economy
and will adjust themselves.
We in the rural areas are convinced that the
chief element, which will not adjust itself, is the
unnecessary costs and other demands made upon
the girls in the courses offered in the cities today.
We feel we have good grounds for criticism, as
some years ago there were three-year nurses’ train-
ing courses in many rural hospitals, two years
spent at home and one year in a large city hos-
pital, an arrangement which prepared excellent
Read before the National Conference on Rural Health at
the PalmeT House, Chicago, February 8, 1947.
nurses in adequate supply. They proved them-
selves excellent because they were in great de-
mand, both in the affiliate city hospitals and the
country ; also, the State Board examinations
proved they were well grounded in the fundamen-
tals as their average standing was high — very
rarely did one fail. This desirable and successful
arrangement was abitrarily terminated by some
authority at the top. Some may say this was in
the past but cannot be a success today. Facts
prove the contrary.
In Minnesota we have three rural hospitals
which have been able to carry on under the affilia-
tion plan because of the consideration given them
by the Sisters at St. Mary’s Hospital in Duluth.
These hospitals have more applicants than they can
take, whereas most of the city hospitals have far
less than half their needs. I can speak with first-
hand knowledge concerning St. Francis Hospital,
Breckenridge, a neighboring town. Sister Eliza-
beth tells me she regrets exceedingly that she is
unable to take all her desirable applicants.
There are two chief reasons why the rural hos-
pital courses are successful :
1. They are out where the desirable girls grow.
2. The courses are so arranged that the girls
can earn their own way, aside from a few inci-
dentals. Here a poor girl has an equal chance
with those who have the means, resulting in bet-
ter nurses.
The present plan of giving a one-year course for
practical nurses and licensing them will help in
certain ways, but does not meet the great need
for more graduate nurses. We feel there is a
solution to the pressing problem, namely, the
establishment of nurses’ training courses in pro-
perly equipped rural hospitals, with one-year
affiliation in the large city hospital.
This is a plan that has succeeded and is now
succeeding where given a chance. Why not push
this plan through before the situation becomes
hopeless ?
W. L. Burnap, M.D.
Many a maternity patient has received obstetric care
in its most literal sense — that is, care which is focused
only on her reproductive organs — and died from tuber-
culosis or diabetes or cancer soon after delivery.—
Hazel Corbin, R.N., J. Nursing, (Aug.) 1946.
298
Minnesota Medicine
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
1947 NATIONAL HEALTH BILL
On February 10, the National Health Bill of
1947 was introduced to the Eightieth Congress as
S. 545. This bill, sponsored by Republican Sena-
tors Taft of Ohio, Smith of New Jersey, Ball of
Minnesota, and Donnell of Missouri, is a revised
version of last year’s Taft-Smith-Ball Bill, intro-
duced toward the close of the Seventy-ninth Con-
gress as an alternative to the Wagner-Murray-
Dingell measure.
The 1947 National Health Bill is a great im-
provement over the former measure. New provi-
sions have been added, and the basic philosophy
behind the measure has been clarified. Helpful
suggestions from members of the health, medical,
hospital and dental professions, both those inside
and outside of government circles, are responsible
for much of this improvement.
Representatives of the American Medical As-
sociation met with Senators Taft, Ball and Smith
on December 27 ; the following day, delegates
from the New York Academy of Medicine and
from the New Jersey State Medical Society met
with Taft, Ball, Smith and Donnell. Representa-
tives of the American Dental Association talked
with Taft on January 7.
Bill Clearly Indicates Revenue Source
One aspect of S. 545 which should please doc-
tors of medicine throughout the country is the
definite provision in Section 307 of the bill, for
an appropriation of funds from current revenues
to carry out the program which the bill sets up.
Section 307 was written into the bill largely at the
instigation of Senator Donnell, who. is a firm be-
liever in financing from current revenues, as op-
posed to bond issues. Many have felt with Sena-
tor Donnell that the government has too long au-
thorized appropriations without concern as to
where the money is to come from.
A brief look at S. 545 reveals the following
general provisions : ( 1 ) a grant of $200,000,000
a year to states on a population basis for medical
care, chiefly to low-income patients, (2) estab-
lishment of a new and independent national health
agency to handle all the federal government’s
health activities, (3) distribution of money for
dental care with 8 million proposed for the first
year and larger amounts each successive year up
to. 20 million the fourth year, (4) $10,000,000 for
cancer control through the financing of diagnostic
centers in the states, and (5) periodical medical
examinations of all children in public, non-public,
primary and secondary schools.
Measure to "Fill Gaps in Medical Service"
In a public statement made when he introduced
his bill, Senator Taft said : “The bill we are pro-
posing proceeds on the theory that the United
States already had a comprehensive medical serv-
ice as good as any in the world, but there are gaps
in the service, particularly in reaching the lower
income groups.”
The Taft-Smith-Ball-Donnell Bill has been re-
ferred to the Committee on Labor and Public
Welfare, of which Senator Taft is chairman, and
Senators Ball, Smith and Donnell are members.
An important feature of S. 545 is its proposal
to co-ordinate all health activities of the federal
government into one independent agency. There
is on foot in Washington a movement to put over
another bill, which would create a health agency,
but would place it in a subordinate position. This
bill would set up a Welfare Department, give its
head cabinet rank, and place under him three un-
dersecretaries, one to manage health activities, one
to take charge of welfare and social security and
one to concern himself primarily with education.
Welfare Department vs. Health Agency
A complete analysis of the question of a three-
cornered Welfare Department versus an Inde-
pendent Health Agency has been made by Dr.
Marjorie Shearon (Ph.D.), a non-partisan Wash-
ington research analyst.
The crux of the question, as Dr. Shearon sees
it, is this : Does American Medicine want a third
March, 1947
299
MEDICAL ECONOMICS
party between it and the President? If the top
civilian medical and health officer were an under-
secretary, she points out, that would mean he
must discuss health and medical programs, legis-
lation and policies with the President through an
intermediary — someone, perhaps, from the wel-
fare or social insurance fields.
In a recent issue of her regular Bulletin,
“American Medicine and the Political Scene,”
which she authors in connection with her work as
consultant on social legislation for Republican
members of the Senate, Dr. Shearon discusses the
question fully.
“An independent health agency has great mer-
it,” Dr. Shearon maintains. She explains that :
( 1 ) it would be founded on law, not created by
order of the President; (2) it would be headed by
a physician; (3) it would have its own funds
from Congress, so that its director would not have
to go “hat in hand” to a lay administrator an-
nually for approval of his budget; and (4) it
would be separated completely from the aggres-
sive, autocratic Federal Security Agency in which
the Social Security Administration is the domi-
nant unit.
Political considerations aside, and speaking only
for herself, on the basis of her observations, Dr.
Shearon predicts that an undersecretary of health
could easily become “only an also-ran,” even
though he might be an outstanding medical man.
Government "in Medical Picture to Stay"
“The Federal Government is in the medical
picture to stay,” Dr. Shearon declares. “It is up
to American Medicine to determine whether its
position in the family of federal agencies is to be
strong or weak.”
Dr. Shearon stresses the need for separation of
health and medical functions from the control of
the Federal Security Agency, calling this separa-
tion “the most important single objective to be
sought at this time.” The Taft-Smith-Ball-Don-
nell Bill calls for such a separation when it cre-
ates an independent health agency, responsible to
the President and headed by an outstanding phy-
sician-— thus it offers a way to protect highly tech-
nical health and medical functions of the Federal
Government from lay control.
According to Dr. Shearon, Labor regards the
Social Security Administration as its own agency
— and so long as health and medical functions are
a component part of a dominantly welfare-se-
curity agency, whether it be the Federal Security
Administration or a Department of Health, Edu-
cation and Security, Dr. Shearon warns that
“American Medicine will face the triple threat of
welfare workers, social insurance groups and or-
ganized Labor.”
Grant of $4,119,800 Proposed for Minnesota
Minnesota’s share of the $200,000,000 allotment
proposed by the National Health Bill of 1947
would be $4,119,800. This money, in accordance
with the underlying principles of the bill, repre-
sents aid to this and every other state to develop
their own health and medical, hospital and dental
services to low-income groups.
So that public money will be spent where most
needed, part of each state’s allocation is to be
spent for a survey of resources in the fields cov-
ered by the bill. Participating states will be ex-
pected to develop comprehensive programs during
a five-year period. Voluntary methods are en-
couraged through the provision for use of funds
for at least partial payment of premiums for per-
sons unable to pay in full for their own voluntary
insurance.
The re-introduction in the Eightieth Congress
of the storm-provoking Wagner-Murray-Dingell
Bill of last year by Senator Murray of Montana
promises a new fight between the proponents of
compulsory health insurance as recommended by
President Truman, and those who believe in the
use of voluntary means for distributing medical
services. A showdown is expected in the Senate
Labor and Public Welfare committee, to which
both the Taft-Smith-Ball-Donnell Bill and the re-
issued Wagner-Murray-Dingell Bill have been
referred.
MINNESOTA HEALTH LEGISLATION
Health in Minnesota is getting its share of at-
tention in the 1947 Legislature, and the hoppers
contain several measures aimed at correcting and
improving substandard conditions in certain areas,
some of which have existed a long time.
For one example — all Minnesota communities
that want full-time local health officers and other
health personnel shall have them, providing a bill
now under study by the legislators gets their ulti-
mate approval. This bill will enable local govern-
ments to set up their own health departments or
to pool their resources with those of adjacent
counties and municipalities to form joint health
departments.
300
Minnesota Medicine
MEDICAL ECONOMICS
Figures recently published in a State Depart-
ment of Health bulletin, point to a need for just
such a bill as this. Minnesota, the bulletin says,
has been spending around 42 cents a year for each
person for health services, an amount far from
adequate to fill the health needs of the people.
Considering that the majority of this sum is
spent in urban areas of the state, at least a million
people must do without their share of preventive
health services.
Minnesota’s 42-cent rate is one of the lowest
in the United States, the average for the forty-
eight states being about 61 cents per person an-
nually— -or 19 cents higher than the amount spent
in Minnesota. The Department of Health says
that about $1.00 per year per person is needed to
provide even minimum health services.
Minnesota Late in Establishing County
Health Departments
Minnesota is quite far down the line of states
to formulate permissive legislation for the es-
tablishment of local health services; if the meas-
ure passes, it will be the forty-second state to take
this step. A committee, known as the Minnesota
Committee on Local Health Services, formed in
1945 and including representatives of many or-
ganizations—the State Medical, Dental and Nurs-
ing Associations, labor and farm groups, co-oper-
atives, the PTA, the League of Women Voters,
the Federation of Women’s Clubs and others —
has been at work since December, 1946, formu-
lating basic principles to be embodied in a meas-
ure for submission to the 1947 Legislature.
That is the history behind Senate File No. 27,
introduced by Senators Wright, Wahlstrand and
Burdick, which provides for the appointment of
full-time health officers and sharing of expense
between participating counties on a population ba-
sis, and permits financing by federal, state and
county funds, and private gifts.
The Wright- Wahlstrand-Burdick Bill, after its
introduction, was referred to the Public Health
Committees of the House and Senate. Already
reported on favorably by the Senate Committee,
the bill is due to be reported on shortly by the
House Committee.
Seek Aid for Public Health Nurses
A measure to provide partial financial support
for every county which hires a public health nurse
is now before the Legislature and has been ap-
proved by the House of Representatives. It pro-
vides an annual grant to counties for public health
nursing services, payment of which is to be made
in quarterly installments.
A request for increased appropriations for state
mental institutions, aimed at making the “purely
custodial institution” a thing of the past in Minne-
sota is also being discussed by the lawmakers.
The bill would increase facilities of our present
institutions to provide more adequate treatment
for mental patients in addition to supervision and
care.
CANCER FIGHT INTENSIFIED
Minnesota’s proposed allotment in the 1947 ap-
propriation of $2,500,000 from the federal gov-
ernment for cancer control work is $52,665. With
these funds and those collected by the Minnesota
Cancer Society, the fight against cancer here in
Minnesota, where over 4,000 lives were claimed
by this disease last year, is growing ever more
intense.
An alert State Cancer Committee, consisting of
Dr. A. H. Wells of Duluth, chairman, and Drs.
D. P. Anderson, Jr., Herbert Boysen, E. C.
Hartley, J. A. Johnson, J. F. Karn, F. H. Mag-
ney, W. C. McCarty, Sr., Martin Nordland, W. A.
O’Brien and W. T. Peyton, is expanding its al-
ready active educational program. Several con-
ferences have been held for doctors, including
clinics and demonstrations of newer methods for
earlier diagnosis ; for public health nurses, em-
phasizing methods of case-finding and follow-up
care; and for lay leaders, presenting lectures on
the nature of cancer, its cure and prevention,
aimed at dispelling fear and spreading knowledge
of the disease.
At the physicians’ conference held on the
campus of the University of Minnesota January
2, 3, and 4, a total of 125 doctors from Minne-
sota, North Dakota and South Dakota attended.
Lay leaders attended a conference there January
23, 24, and 25.
Additional Conferences Scheduled
Conferences are scheduled for Duluth on
March 18 and 20 and for Worthington on March
25. At future dates, it is planned to hold confer-
ences in nine other sections of the state.
Through the Cancer Committee’s arrangements,
the Minnesota Cancer Society recently sent out
March, 1947
301
MEDICAL ECONOMICS
to state physicians a booklet containing thirteen
issues of the Cancer Bulletin, prepared by the
American Cancer Society and containing articles,
authored by specialists in the field, covering the
latest-discovered facts about cancer, as it attacks
various parts of the body, the lungs, the stomach,
the bladder, the genito-urinary tract, et cetera.
Starting about September, a series of monthly
supplementary bulletins containing later informa-
tion, which can be added to the booklet, will be
sent to the doctors.
In line with recent action taken by a joint com-
mittee of the American Medical Association and
the National Education Association to encourage
the inclusion of a study of cancer in the nation’s
high schools, “A Revised Study Outline on Can-
cer for Secondary Schools” was prepared by the
Minnesota Cancer Society and has been distrib-
uted to teachers in all public and private schools
in the state.
Pamphlet Contains Cancer Facts
At its last session, the House of Delegates of
the American Medical Association instructed the
Council on Medical Service to make a survey of
the ways in which funds for cancer control work
are being utilized by the various state and county
medical societies. Funds available are those pro-
vided by the federal government, distributed
through the state departments of health and those
coming from the American Cancer Society which
are utilized by State Committees on Cancer. The
American Medical Association wants to make
sure that these funds are administered wisely with
the co-operation of the practicing physician.
VETERANS MEDICAL SERVICE
With a little over half of the physicians in the
state having returned their enrollment cards,
making them participating physicians in the Min-
nesota Veterans Medical Service, this division of
the State Association officially began operations,
under Part I of the Uniform Fee Schedule, on
February 10.
Already, a total of 500 authorizations for medi-
cal service to veterans have been received by the
division from the Veterans Administration. Most
of these have been authorizations for treatment,
and some have been for physical examinations.
In a complex program of this kind, the begin-
nings are fraught with details and routines that
must be worked out until each cog of the machin-
ery is adjusted to work smoothly. Especially at
this beginning stage, the doctors who are strug-
gling through the rolls of red tape while trying to
give the best possible service to the veteran, are
turning in reports of services rendered, which in
a few cases are not quite up to the requirements
of the Veterans Administration. In these cases
the VMS must write and ask the doctor for addi-
tional information. As the program progresses,
of course, and doctors become accustomed to sub-
mitting these reports, there will be less and less of
this difficulty. And it is assured, with the co-op-
eration of the medical profession of this state,
the VMS will not only satisfy the needs of the
veteran but will also conform to government re-
quirements.
ACUTE INTUSSUSCEPTION
(Continued from Page 260)
Summary
1. Fifty-six patients upon whom fifty-eight
operations were done for acute intussusception
were studied.
2. The cardinal symptoms were found to be
intermittent colicky pain, vomiting and bloody
stool. These were present in 73 per cent of the
cases.
3. The best results were obtained where early
diagnosis was made and early treatment insti-
tuted.
4. Close co-operation between the pediatrician
and the surgeon is essential.
References
1. Gibbs, Edward W., and Sutton, Paul W. : Intussusception.
Ninety-two cases in infancy and childhood. Surgery, 14:
708-718, (Nov.) 1943.
2. Gordon, E. F. : Review of forty-two cases of intussuscep-
tion from the files of New Haven Hospital and two cases
seen in private practice. Arch. Pediat., 57:585-594, (Sept.)
1940.
3. Grigsby, G. P., and Kaplan, S. E. : Intussusception in in-
fancy and childhood. Kentucky M. J., 36:318-324, (Aug.)
1938.
4. Hipsley, P. L. : Intussusception and its treatment by hy-
drostatic pressure. M. J. Australia, 2:201, 1926,
5. Ladd, W. E., and Gross, R. E. : Intussusception in an-
fancy and childhood : a report of three hundred and seventy-
two cases. Arch. Surg., 29:365-384, (Sept.) 1934.
6. Mason, J. C., and Judd, E. S. : Acute intussusception;
fixation of cecum by exteriorization of appendix. Proc.
Staff Meet., Mayo Clin. 18:333-336, (Sept. 8) 1943.
7. Mayo, C. W., and Woodruff, R. : Acute intussusception.
Arch. Surg., 43:583-587. (Oct.) 1941.
8. Peterson, E. W., and Carter, R. F. : Acute intussusception
in infancy and childhood. Ann. Surg., 96:94-97, (July)
1932.
9. Robbins, F. R. : Acute intussusception. Ann. Surg., 95 :830-
839, (June) 1932.
10. Woodhall, B. : Modified double enterostomy (Mikulicz) in
radical surgical treatment of intussusception in children.
Arch. Surg., 36:989-997, (June) 1938.
302
Minnesota Medicine
Minnesota Academy of Medicine
Meeting of November 13, 1946
The regular monthly meeting of the Minnesota Acad-
emy of Medicine was held at the Town and Country
Club on Wednesday evening, November 13, 1946. Dinner
was served at 7 o’clock, and the meeting was called to
order at 8:15 by the president, Dr. S. E. Sweitzer.
There were fifty members and three visitors present.
Minutes of the October meeting were read and ap-
proved.
Upon ballot the following were elected as candidates
for membership in the Academy: University: Drs.
Donald Hastings and Leslie Spink; Saint Paul: Drs.
Edward Burch and Jerome Hilger; Minneapolis: Drs.
Ralph Creighton, Vernon Hart, Douglas Head, Stanley
Maxeiner, and William Rucker.
The scientific program followed.
PERIARTERITIS NODOSUM— TREATMENT
WITH PENICILLIN
S. MARX WHITE, M.D.
Minneapolis, Minnesota
Rich states that it has for some time been suspected
that there may be a basic factor common to rheumatic
fever, periarteritis nodosa, Henoch’s and Schonlein’s
purpura, rheumatoid arthritis, lupus erythematosus, and
quite probably some instances of glomerulonephritis.
He further indicates that there are now many reasons
for believing that all of these conditions may represent
the effects of vascular and collagen injury caused by
sensitization to a variety of different antigens. As a
result of experimental study, Rich and Gregory report
that typical diffuse periarteritis nodosa has been pro-
duced by establishing in rabbits a condition analogous
to serum sickness in man and that the condition is one
manifestation of the anaphylactic type of hypersensi-
tivity. In previous papers they had presented clinical and
pathological evidence that periarteritis nodosa has de-
veloped in patients as a result of hypersensitive reac-
tions following foreign serum and sulfonamide therapy.
As a result of their work, they state that the continued
administration of foreign serum or sulfonamides after
a hypersensitive reaction has occurred, or the injury of a
single large amount of foreign serum, increases the
danger of producing the vascular damage by prolonging
the contact of the sensitized body with the offending
antigen. As collateral evidence for the concept that vas-
cular damage can be produced through hypersensitivity,
they report that acute diffuse glomerulonephritis oc-
curred in a number of the animals that developed a
hypersensitive reaction to the foreign serum.
Much supportive information has been secured in re-
cent years, an example of which is furnished by Wilson
and Alexander. They report that in 300 consecutive cases
of periarteritis nodosa, bronchial asthma was identified
in fifty-four, or 18 per cent. Occasional apparent suc-
cess in the treatment of severe asthma with bronchitis
led to the suggestion that some effect might be produced
by penicillin in the treatment of the case of periarteritis
nodosa under discussion.
Case History
Mrs. M. P., aged seventy-three, was admitted to Eitel
Hospital May 31, 1945. She was a widow, mother of
three married children, one of them a surgeon in New
York City. Her medical history is rich in modernistic
medical and surgical procedures. The significant items
include :
1. In 1936 a diagnosis was made of hypopituitarism
and hypothyroidism with localized patches of a form of
scleroderma. Basal metabolic rates quite uniformly in
the neighborhood of minus 29 per cent; thyroid admin-
istration ; also amniotin was used over a period of
many months.
2. In November, 1936, uterine curettings secured be-
cause of post-menstrual bleeding showed senile endome-
trium with very thick-walled vessels but no evidence of
malignancy.
3. In 1939, there was a diagnosis of anxiety neurosis
with uterine prolapse.
4. The 1940 records show continued use of thyroid
substance with basal metabolic levels between minus 5
and minus 10 per cent. In October, 1940, the labia ma-
jora and minora were excised. Microscopic examination
showed marked atrophy of epithelium to the point of
ulceration, subcutaneous tissues showing hyaline degen-
eration and round cell infiltration. A diagnosis of krau-
rosis vulvae was made. Postmenstrual bleeding from
the uterus again indicated dilatation and curettage but
the curettings showed no malignant changes.
5. In 1943, there were mild arthritic manifestations in
the right knee and right index finger. The scleroderma
became reactivated in the perineal region and stilbes-
terol, which she had been taking in minimal doses, was
increased to 1 mgm. every three days.
She was admitted to Eitel Hospital on May 31, 1945,
with a history of sudden onset May 28 with malaise,
chills, vague body aches and pains. Following this, there
was recurring chilliness and headache with fatigue. The
day before admission she had difficulty in opening the
mouth, with tenderness over the temporomandibular
regions. There was no cough or dysuria. Examination
in brief : She appeared moderately ill. There was defi-
nite swelling and tenderness of the parotid region on
the left extending well below the angle of the mandible.
On the right there was some swelling but less than on the
left. The lungs were clear except for harsh breath
sounds at the angle of the left scapula. The heart was
negative except for frequent premature beats followed
by compensatory pause. Blood pressure was 114/55.
Electrocardiograms showed normal complexes with fre-
quent extrasystoles from a single ventricular focus.
No rash was noted on the skin. The patellar and
ankle reflexes were hyperactive but equal and normal.
There was no rigidity of the neck or extremities. The
impression was recorded that she had an epidemic paro-
titis and she was isolated.
However, with prompt subsidence of the local symp-
toms, daily temperatures rose to a maximum of 102.8° F.
March, 1947
303
MINNESOTA ACADEMY OF MEDICINE
at 4 to 8 p.m., with morning records of 99° to 100°. Oc-
casional chilliness was noted when temperatures rose.
With persistence of the fever, studies were instituted.
The urine was persistently negative. Leukocyte counts
of 12,300 to 15,500 were recorded up to June 11. Myelo-
cytes of all types constituted about 5 per cent of the
leukocytes, and occasional plasma cells and leukoblasts
were seen, but no myeloblasts. Heterophile antibody ag-
glutination was atypical at 1:10 dilution. Agglutination
with typhoid group and Brucella melitensis was nega-
tive.
Bone marrow biopsy, June 16, was reported by Dr.
R. H. Reiff as showing neutrophilic hyperplasia of the
marrow with inflammatory changes. The sedimenta-
tion rate of the red blood cells was 66 mm. in one hour.
X-ray studies showed no parenchymatous involvement
in the lungs except a typical calcified Ghon tubercle in
the lower left lung field. Minimal changes were noted
on the vertebrae with calcifications on the walls of the
aorta. There are minimal hypertrophic changes at the
intervertebral joints and of the fingers.
Qn June 7, pain in both temporal regions was noted
and there was very slight edema of the right temporal
region, but nothing more than moderate tortuosity and
diffuse thickening of the temporal arteries could be
made out. The pain in the left parotid region was defi-
nitely diminished.
Ophthalmoscopic examination showed only sclerosis
of retinal vessels consistent with her age.
On June 10, Dr. B. H. Morris noted complaint of pain
in the right wrist with no local signs. Also noted —
“Feels pain along the course of arm and leg veins,” but
there was no enlargement or tenderness over their
course.
By June 18 and 19, there had been a period of less-
ened temperature, beginning June 16 with maxima of
100° F., and she was eating better, sitting up more, and
seemed better in every way. There had been no specific
therapy to which this could be assigned. At this moment
she developed a throbbing pain in the right thumb with
an area of swelling and redness on the radial aspect
adjacent to the thumb nail and an area of redness and
induration appeared on the skin lateral to the left breast.
This area was about 1 cm. broad and 5 cm. long. It
followed a course downward and toward the median
line such as would be typical of a small superficial ar-
tery. The area was not particularly tender although the
breasts were very tender and there was a general hy-
persensitivity both of skin and muscles. By this time,
repeated blood cultures were still showing no growth
(and none appeared at any time later).
On June 27 biopsy material was secured from the skin
lesion and from the left deltoid muscle. Microscopic re-
port by Dr. R. W. Koucky : The deltoid region showed
no vascular lesions. The characteristic change was seen
only in the subcutaneous tissue. The process affected the
small arteries and an occasional arteriole. These small
arteries showed thrombosis and marked thickening of
the subintimal layer. All of the muscle and periarterial
zone was overgrown by young fibroblasts. There was
heavy, diffuse infiltration of polymorphonuclears. There
were syncitial masses like malformed giant cells. The
picture was typical throughout of periarteritis nodosum
with the exception that the heavy eosinophilia customar-
ily seen was absent in this case. Conclusion : Periarteri-
tis nodosum. (Slides shown)
On the day of admission, May 31, 1945, penicillin in-
tramuscularly had been started by a penicillin-conscious
assistant but was discontinued after thirty doses at
three-hour intervals and a total of 600,000 units. No
effect'on the fever or symptoms was noted at this time.
Following the diagnosis of periarteritis and despite the
indications apparently unfavorable to its use, penicillin
intramuscularly was again begun on June 28. Daily
amounts of 160,000 units was given over a period of
twenty-one days to July 19, with a total of 1,920,000 units.
During the first fourteen days of penicillin therapy
temperature rises to 103° F. continued. Then there fol-
lowed prompt abatement but only to 100° and 101° F.
maxima until discontinuance on July 19. During the
week of July 20-27, on two occasions only, records up
to 101.6° were noted, and after this time to August 19,
i.e., one month, temperatures up to 100° F. were occa-
sionally recorded. From then on to discharge on Sep-
tember 6 the temperature was normal, and she gradually
gained in strength and capacity.
During the period of penicillin administration, trans-
fusions from Rh negative donors were given on three
occasions in amounts of 300 c.c. each, with no reactions.
Hemoglobin values around 75 per cent remained essen-
tially unchanged. When seen after discharged, on Octo-
ber 2, 1945, the hemoglobin was 75 per cent, red cells
3,200,000, and leukocytes 11,400.
The winter of 1945-1946 was spent in California.
While there she had a relapse, the story being strongly
suggestive of her old trouble outlined above. In the
account of this illness, she reports that on her insistence
penicillin and five transfusions were again used with slow
recovery. A letter from Dr. William H. Leake, Beverly
Hills, California, may be quoted as follows: “Your pa-
tient, Mrs. M. P., was under treatment at Hollywood-
Presbyterian Hospital between May 4 and June 21, 1946.
She received five whole blood transfusions of 300-350
c.c. each on the following dates: May 13, 14, 16, 21, and
29. Over an eleven-day period, May 10 to May 21,
700,000 units of penicillin were administered. Shortly
after this treatment was instituted definite improvement
was noted in the patient’s condition.”
She was readmitted to Eitel Hospital on October 3,
1946. She complained of the same vague pains but had
no skin eruptions and no localizing symptoms. There
was much headache which she insisted was similar to
that she had had during her previous hospital stay.
There was extreme weakness, and she continually insisted
that her symptoms were identical with those of 1945 and
with those during her hospitalization in California in the
winter of 1945-46. She was insistent that penicillin and
transfusions be tried. During her stay no rise in tem-
perature was recorded. The blood pressure was 120/80,
weight 144 pounds ; general physical examination nega-
tive.
On October 4 her hemoglobin was 80 per cent ( 13.3
grams) with a leukocyte count of 6,000. On October 8,
hemoglobin 88 per cent (14.7 grams) with red count of
4,680,000; and October 10, hemoglobin 85 per cent, red
count 4,450,000, and leukocytes 6,850. Examination of
the urine gave negative findings.
Penicillin in doses of 25,000 units intramuscularly at
three-hour intervals up to and including October 15 was
given to a total of 2,500,000 units. Sbe was given trans-
fusions of 250 c.c. of blood on October 7 and October 12.
During the hospital stay her headaches disappeared,
vague pains no longer were troublesome, and she im-
proved in strength and well-being at a moderate rate so
that on the date of discharge, October 15, 1946, she was
feeling well, walking about and said that she had im-
proved very greatly. She has remained well and is
going about quite regularly.
It should be stated here that she has not been on thy-
roid or estrogen therapy for nearly two years. No iden-
tifiable allergen has been found in her case.
References
Rich, Arnold R. : The role of hypersensitivity in the pathogenesis
of rheumatic fever and periarteritis nodosa. Proc. Inst. Med.
Chicago, 15:270, (March) 1943.
Rich, Arnold R., and Gregory, John E. : Experimental demon-
stration that periarteritis nodosa is a manifestation of hyper-
sensitivity. Bull. Johns Hopkins Hosp., 72:65, 1943.
Wilson, Keith S., and Alexander, Harry L. : Periarteritis nodosa
— The relation of periarteritis nodosa to bronchial asthma
and other forms of human hypersensitiveness. J. Lab. &
Clin. Med., 30: 195-203, (March) 1945.
304
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
Discussion
Dr. A. R. Hall, Saint Paul : This is an interesting
contribution. Dr. White reports a case of periarteritis
nodosa which was benefited and possibly cured by
treatment with penicillin. Periarteritis nodosum has been
considered a condition in which the mortality is very
high. However, in most cases some of the lesions his-
tologically show evidence of regeneration.
I like the change of the name from periarteritis nodo-
sum to arteritis nodosum since it is more descriptive of
the pathological findings.
What is arteritis nodosum ? Is it a disease entity or is
it a tissue reaction which may be due to different causa-
tive agents? This woman was benefited by penicillin.
Penicillin is apparently of benefit in bacterial infections
only. If this is true, we are perhaps justified in thinking
that in this case the causative agent was bacterial infec-
tion. If we may add this case of possible bacterial in-
fection to the growing list of etiological factors which
have been reported as causing arteritis nodosum, we
have added to our understanding of these pathological
changes. Rich has reported finding arteritis nodosum in
patients who had been treated by the sulfonamides, by
iodine, etc., and has produced it experimentally by the
injection of foreign proteids. Selye had produced arteri-
tis nodosum in rats by the injection of adrenal cortex.
It seems that we should classify arteritis nodosum as a
tissue change which may be produced by many quite dif-
ferent agents.
Dr. J. A. Lepak, Saint Paul : I should like to ask Dr.
White whether any effort was made to isolate or culture
an organism from the removel tissue?
Dr. White, closing: There was no effort made to iso-
late any organism. I have been impressed, in trying to get
what information we have on this case, by the welter
of evidence coming forth at this time that periarteritis,
or better — arteritis nodosum, is a systemic reaction, al-
lergic in character, and by its relationship to asthma;
that the relationship that Alex Wilson showed to. asthma
is very suggestive. One interesting point is that in some
of the cases of periarteritis associated with asthma a
marked eosinophilia was found in the tissues. Some of
the cases reported with asthma do not show . these
changes in the tissues. Eosinophilia is not shown in the
tissues in the biopsy material in the present case.
THE TREATMENT OF HYSTERIA BY
NARCO-HYPNOSIS
HEWITT B. HANNAH, M.D.
Minneapolis, Minnesota
There is no branch of medicine which is attracting the
attention at the present time of both medical men and
lay people more than the neuroses and so-called psycho-
somatic medicine. It is estimated that one-third of all
patients who consult a physician do not have any definite
bodily disease to account for their complaints. There is
another one-third of the patients who have some bodily
disease but their symptoms are not explained by the
disease or they are out of proportion to any discoverable
pathological disease. We can, therefore, readily see what
an important role emotional factors must play in the
practice of medicine.
It was about a century ago that Virchow introduced
the structural conception of disease and this led to a
consideration of disease as a disturbance or change in
the structural cells and organs. This was the founda-
tion of gross and histological pathology. Diseases were
then divided into different components of ailments and
this caused the development of the various specialties
and specialists and the introduction of machines of
precision for diagnosis. In other words, we had the
machine age and the assembly line in medicine. Out of
this grew the clinic idea of the practice of medicine.
During this period of mechanical and laboratory de-
velopment, many essential discoveries were made which
have permitted us to better understand, diagnose and
treat the structural and biochemical disturbances of the
body. During this age of mechanical development the
emotional and psychological background of the patient
was lost and even the phase of his illness was many
times held in utter contempt by many doctors.
There has been a definite change in the attitude of
physicians during the past ten years and the pendulum is
swinging so that again there is marked interest being
shown everywhere in the so-called functional disturb-
ances. At this point, however, I want to emphasize the
importance of thoroughly studying the patient from the
organic standpoint to be sure he has no structural dis-
ease before he is branded as a neurasthenic, an anxiety
state, or a case of hysteria.
The treatment of the psychoneurotic often leads to
gratifying results but in such treatment the art of medi-
cine comes to the fore and the personality of the doctor
is still an important factor. There must be a never fail-
ing and kindly interest in the patient, and the doctor
should not complain of becoming tired of his patient.
The physician must take a very careful and thorough
history and develop all the conscious emotional compli-
cations that are present or have been present in the past.
This usually takes more than one interview and the phy-
sician should see the patient many times, get to know
him and gain his confidence.
Freud and his coworkers and followers have pointed
out that there are many emotional traumas which have
occurred in early life, as well as frustrations or repres-
sions which have been buried in the unconscious mind
and produce states of nervous tension and hysterical
symptoms. It was out of Freud’s concept that the sys-
tem of psychoanalysis was developed so that these re-
pressions, frustrations and emotional traumae could be
released and brought out into the open conscious state.
However, the psychoanalytic methods were long, tedious,
and expensive, and very few men were trained or had
experience to carry on the procedure.
It was during the present war that the procedure of
producing a trance state or a state of hypnosis by drugs
was used. This semi-sleep state has recently been re-
ferred to as narco-analysis. The drugs used have been
sodium amytal, sodium pentobarbital, and sodium pento-
thal. The patient is not given enough of the drug to pro-
duce deep sleep but he is in a dream state or a semisleep
state, or in a trance. The theory is that the drugs slow
down respiration and there is reduced consumption of
oxygen by the brain cells and a mild state of anoxemia
results.
I am going to report a series of selected cases which
have been treated by narco-analysis. The method used
Inaugural thesis.
March, 1947
305
MINNESOTA ACADEMY OF MEDICINE
is to dissolve 7.5 grains of one of the above-mentioned
drugs in 20 c.c. of distilled sterile water. A platinum
needle is used to prevent coagulation of blood aspirated
from the vein when the injection is stopped with-
out withdrawing the needle. The patient is placed
in a semi-darkened room on a comfortable bed. No one
else is present in the room except the patient and the
physician. The injection is made very slowly and as
soon as the patient complains of a numb feeling in the
roof of his mouth, a slightly dizzy feeling, and a slightly
drowsy feeling, the injection is stopped. The patient is
able to hear what is said to him, is able to talk clearly
and to answer questions distinctly.
While more barbiturate is being injected in order to
keep him in this semi-sleep state, a closer hypnotic re-
lationship is established between the patient and the
physician. There is a free association of ideas. There is
abnormal or extreme retentiveness of memory. Smallest
details of information are related, which may seem
trivial, and these become useful. Latent and repressed
conflicts come to the surface. The history of mental
suffering regains clarity and abnormal ideation becomes
amplified. The physician obtains a quantity of infor-
mation about the patient’s mental state which could not
be obtained during a much longer time with the usual
methods. The length of time involved in a treatment
may be as much as two or three hours. Every effort
should be made to make the patient accept consciously
the material which was obtained from his subconscious
mind. This will render him more capable of viewing the
past trauma in a sensible manner.
The following cases will explain more in detail the
method involved.
Case 1. — A man twenty-two years of age, unmarried,
was brought in six years ago by ambulance from an-
other city. He would not talk, open his mouth, or move
his arms or legs. He would only sit in a chair, with
his eyes closed. He defecated and urinated in the chair
or in lied. He had to be dressed, undressed, and carried
into the bathtub. He would not open his mouth to eat
and had to be tube fed. There was a history of acute
onset about two weeks previously, and also a history of
a somewhat bashful fellow who was a good student in
school and conscientious in his work. He was a college
graduate and his occupation was that of a pharmacist.
He was observed for several weeks, and there was no
improvement. He was tube fed during this time. Our
impression was one of an acute attack of schizophrenia
of the catatonic type.
Fifteen grains of sodium amytal were dissolved in
20 c.c. of sterile distilled water and injected slowly into
his vein at the elbow. After a few c.c. were injected,
the patient opened his eyes and looked around. He was
asked questions, was encouraged to talk, and slowly
unfolded the following story. About one year previously,
he was taken, one evening, by a bunch of fellows by
force as he was leaving the drug store to a house of
prostitution. He was undressed, placed in a room with
a group of nude girls, and the fellows were also present.
The girls coaxed him to have relations with them but
he refused, and then they attempted all sorts of per-
verted practices upon him. He said he was terribly
frightened, his heart beat rapidly, he perspired and could
not talk. They kept him there for several hours, then
dressed him and pushed him out the front door. He
found his way home, was in a very nervous state, and
was afraid his parents would find out what had hap-
pened. The same fellows continued to come around the
306
drug store, teasing him about the matter, and threaten-
ing to do it over again. He lived in constant anxiety and
fear until he said one day it seemed as if he was unable
to think, or to move or to talk. He related that he
wanted to talk, to obey instructions, to go to the bath-
room and to eat his meals, but he could not. In this
dream state he was assured that he would be all right,
and further sodium amytal was injected until he went
to sleep.
Upon awakening, he got up out of bed, went to the
bathroom, carried on a conversation with the nurses in a
normal manner. He remained in the hospital for sev-
eral weeks and I discussed the matter fully with him
but never referred to what he related to me with anyone
else. Six years have now elapsed. In the meantime he
has married and I have seen him on numerous occasions.
He has never had a recurrence.
Cme 2. — This patient is a twenty- four-year-old mar-
ried woman who has two children, six and four years of
age. She had a high school education. Her general
health had been good and she had had no operations.
Her present complaint was that of slapping her chest
with the right hand, over a period of six years. This
came on during the time she was pregnant with her
first child. The previous diagnosis had been one of post-
encephalitic syndrome. A neurological examination was
negative except for this constant slapping of the right
side of the chest with the right hand during her waking
hours. The spinal fluid examination was negative. She
had been treated with rabellon, stramonium, and seda-
tives.
I saw her on frequent occasions over a period of six
months and could not elicit from her anything of an
emotional character in her past history. It was my im-
pression that the constant slapping of the right hand
against the chest was not due to any organic disease of
the central nervous system. She was finally hospitalized
and given pentobarbital sodium intravenously. After a
few c.c. were injected, the slapping ceased and she be-
came very quiet. She complained of a numb feeling
in the roof of her mouth and she said she had a feeling
of well-being. She was then asked what had been both-
ering her or what had happened to upset her and
make her nervous. She said that when she was a senior
in high school she was going with two boys. She had
had sexual relations with both of these boys. One
month she did not menstruate and she knew she must
be pregnant but she did not know which boy was the
father. She was frightened about her condition and
was afraid to tell her mother who was a strict discipli-
narian and unduly religious. She did not know which
boy she wanted to marry or which one she should blame
for her pregnancy. Her nervousness increased and she
finally decided to choose one of the boys and get married.
She told the boy and they eloped and were married.
Each boy did not know about the other boy having had
relations with her. They came home after the marriage
and announced their marriage to their respective fami-
lies but did not tell of the pregnancy. About this time
she noticed some shaking of her right hand and this con-
tinued to get worse during her pregnancy. Up to this
time no one except her husband bad ever been informed
that pregnancy started before marriage. She had also
never informed her husband of the other fellow and
the possibility that the child did not belong to him. She
stated that she lived in constant fear during these years
that her husband might in some way find out about the
whole matter and also that her mother might find out
that she had been pregnant before her marriage. The
twilight state was continued for about two hours in
order to receive all of this history. She was told that the
slapping of her right hand had come about because of
all this emotional conflict and that when she awakened it
would all be gone. Enough pentobarbital was given to
her so that she went to sleep. Twelve hours later when
she awakened, she was nauseated and vomited, but there
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
was no subsequent tremor or slapping of the right arm
and hand. The whole matter has been discussed with
her subsequently. She has gained weight and is getting
along satisfactorily at home. Eighteen months have
now elapsed without any return of symptoms.
Case 3. — A married man, aged fifty-two, government
employe, lives in a small city. He was brought to my
office in a wheel chair. He had not walked for five
years. The history was that five years previously, on a
cold winter morning, he was on his way to the office
when he slipped and fell on the sidewalk. He had a
pain in his back and in one hip, but after a short while
he got up. He walked eight or ten blocks to his office,
attended to some work, and then went to a luncheon
meeting at a hotel. During the time he was at the
luncheon meeting he had a weak feeling, and perspired.
After lunch he walked into the lobby of the hotel and
sat down because his legs were getting weak. He was
taken home in a cab and by the time he reached home his
legs had become very rigid. He was taken to a hospital
where x-rays of his spine, pelvis, and hip joints showed
no abnormalities. A spinal fluid was negative. He was
told by one of the attending physicians that he had ex-
perienced damage to his spinal cord and that he would
probably never be able to walk again.
At the time I first saw him, the neurological examina-
tion showed no sensory disturbance, no difficulty in bowel
or bladder control, no great toe signs, no angle or patel-
lar clonus, and the deep reflexes were within normal
limits. The muscles of the legs were held flexed at the
knees and in a state of spasm but the degree of spasm
was not like an organic spasm but seemed to be to some
degree intermittent. Another spinal fluid was negative.
He was put in the hospital, given a small amount of
pentobarbital sodium and in a few moments his muscles
were completely relaxed and he then told me how fright-
ened he was when he fell down. He thought he could
not get up, that he would freeze to death before any one
would find him. On the way to the luncheon meeting
his heart pounded in his chest, he perspired profusely,
and a peculiar sensation came over him. In the trance
state, he moved his legs freely in bed, we got him out of
bed and he walked down the corridor of the hospital and
back to bed. As he walked down the corridor, the syr-
inge and needle were kept intact in his vein. He returned
to bed, we gave him some further barbiturate and he
went to sleep. Within two hours he wakened and his
legs still had fairly normal tone and he moved them
around in bed. However, within another couple of hours
his legs gradually became spastic again. We repeated
the treatment on at least a dozen occasions and several
times were able to get him to walk up and down stairs
and go onto another floor of the hospital. On at least
one occasion the spasm did not return until about four
hours after he wakened, and during this time he walked
around in the hospital without any help. During his
conscious state and before the spasm recurred, I dis-
cussed the whole matter with him but each time he
would tell me that eventually his legs would become
spastic again.
1 consider this case a failure, but a most interesting
experiment.
Case 4. — A married woman, fifty-five years of age,
without any children, suddenly lost her voice about eight-
een months before I saw her. Her husband accompanied
her to the office and could give no explanation for her
aphonia. The only way I could interview her was to
write the questions, and she gave me the answers in
writing. I could get no past history of instability from
her husband. He stated he had come home from a busi-
ness trip and found his wife speechless. They lived in
another state, and she had been treated with vitamins,
throat sprays, and by osteopaths and chiropractors.
The neurological examination was entirely negative.
There was nothing in the physical examination of any
consequence. I sent her to a very competent nose and
throat man, and he reported to me that he could find
no evidence of any disease of her larynx and that there
was no paralysis of the vocal cords.
Under narco-hypnosis she gradually began to talk ; at
first she only whispered and then gradually the volume
and quality improved. She stated that she lived alone
and that her husband was gone on business for pro-
tracted periods of time. They never had any children
and she was very much attached to her husband. Over
a period of years on four or five occasions her husband
had suffered attacks of hemorrhage from a duodenal
ulcer. While out on the road he would have to be hos-
pitalized and she would get a telephone call to go and
see him in some distant town. She said she lived in con-
stant fear that he would die in one of these attacks.
About two months before her aphonia occurred, he had
had another attack, was urged to have an operation, and
had refused. She was terribly frightened over the pros-
pective surgery and what might happen to him. She
was also afraid he would die as a result of one of the
hemorrhages. The day before he arrived home, the
telephone rang and she could not talk when she picked
up the receiver. She had not talked since. The whole
situation was one of fear and anxiety, and her own
worry her husband’s possible death from either operation
or recurring hemorrhage. Her loss of voice was a
conversion type of hysteria which arose out of this con-
flict. Upon awakening she talked in a mild, low tone of
voice, and during the next week her ordinary voice re-
turned to its normal state. The whole matter was dis-
cussed frankly with her after the narco-hypnotic treat-
ment was over.
Nine months have now gone by and she has had no
more difficulty. Her husband has not had any surgery
done and he has had no further hemorrhages.
Case 5. — A widow in her late fifties, who had been
employed for many years as a clerk for the Soo Line,
had not talked, for about a year when I saw her two
years agP. She had been treated for chronic laryngitis
without any benefit. I had her examined by Dr. Larry
Boies, and he found her vocal cords to be normal.
Her neurological and physical examinations were neg-
ative.
She was given pentothal sodium, and in the trance
state she told me about the death of her husband some
ten years ago. She was left with a daughter in her
teens. After the death of her husband she had to go to
work. She was very much attached to her daughter. The
daughter had finished high school and was working and
they were getting along very well. Two years before I
saw her the daughter developed acute appendicitis and
was operated upon. She got along very well in the hos-
pital and was taken home on the eighth day. As she was
taken from the automobile into the home, she slumped
over and was dead when she was finally brought into
the house. The mother was with her at the time. The
mother told me that some time later during the day she
had a queer feeling come over her and she could not
make a sound.
After she awakened from the sleep, she talked nor-
mally and continued to talk in a normal manner. I
heard from her frequently until April of 1946 when I
received word that she had died suddenly and that an
autopsy showed, a coronary thrombosis.
Case 6. — This is the case of another middle-aged wom-
an with an hysterical aphonia who was seen by Dr.
George Tangen, who is associated with Dr. Boies. He
was unable to find any disease of the larynx.
The physical and neurological examinations were neg-
ative, and the spinal fluid was negative. The underlying
problem of an emotional character was the drinking
and gambling of her husband and also her only child, a
daughter, who was married to a man whom she did not
like. She regained her voice and was all right for a
March, 1947
307
MINNESOTA ACADEMY OF MEDICINE
month and then lost her voice again. She returned for
further therapy. She regained the use of her voice for
another three months and now she cannot talk again.
The underlying problem with her husband and her
daughter still remains the same.
Case 7. — A married man, aged thirty-two was re-
ferred to me by an insurance company, because of in-
termittent jerkings of both arms and legs. These jerk-
ings occur every afternoon and evening.
This man fell down a church steeple in Duluth, a
distance of 80 feet, in 1940. He landed on a salamander.
He fractured his pelvis and one hip, and received some
third degree burns on his back. He was hospitalized a
long time and finally left the hospital after almost a
year’s stay. Sometime later in 1942, he had an occasional
muscle twitching in his body which occurred toward the
end of the day. He was married in 1942 and he has one
child. He has been able to work but toward the end of
each day, this intermittent jerking occurs. He stated
that doctors had told him it was the nervous shock from
the fall.
The neurological examination was again negative ex-
cept for the body jerking.
Under narco-hypnosis he told me the following story.
While in the hospital following the accident, he fell in
love with his special nurse and after he left the hospital
he saw her frequently and wanted to marry her. He
had sex relations with her quite frequently. However,
she did not want to marry him, and she went east to
get another position. While the nurse was gone he met
his wife and married her, although he was not in love
with her. His wife is frigid and rather quiet. Her fam-
ily visits them a great deal and he dislikes it. All in
all, he is unhappily married. His wife does not know
about the other girl. He stated that while at work he
does not have to think of the other girl but when he
comes home at night he sits down and dreams about her.
He also stated that when he thinks of the nurse he
almost always has the picture of himself falling down
the steeple. Then he seems to jerk his body.
While under narco-analysis, the whole thing was dis-
cussed with him from an emotional and intellectual
standpoint. He has had three treatments and was seen
several times between treatments. The whole matter
was discussed with him, and he now seldom has any
jerking.
Case 8. — This was an unmarried woman, forty-two
years of age, who was referred to me by an orthopedist.
She had an excellent position with one of the advertising
agencies in the Twin Cities. Her immediate complaint
was that when she walked, she turned her head toward
the left. This never occurred when she was sitting or
standing, but as soon as she started to walk her head
would turn to the left. If she put the tip of a finger
against her chin, then her head would not turn. If she
walked with a pencil or a cigarette in her mouth, then
her head did not turn to the left. Even if she had a
thread between her lips when she walked, her head did
not turn.
This woman had been examined and re-examined by
various competent people and no explanation had been
given her for this turning of the head except she was
told it was a habit.
Under pentothal sodium she related a long series of
emotional difficulties in her past life. When she was
fifteen years old her local neighborhood butcher at-
tempted to have sexual relations with her in the back
part of the butcher shop. She says she was terribly
frightened and never told anyone.
Later, she met a man in Iowa, was engaged to him,
had relations with him, but the engagement was broken
off. Subsequently this man went to Chicago and was
married. Some years later, our patient met him again in
Chicago and over a period of time they carried on illicit
relations. She told me that she had to be transferred to
another city in order to get away from him. When she
reached another city, she got along in a satisfactory man-
ner for a while until she met a group of men and wom-
en. At a party one night, the lights in the house all went
out and she realized that everyone there was having sex-
ual relations. The fellow she was with attempted to
have relations with her but she would not have anything
to do with him. When the lights finally came on the rest
of the members of the party made fun of her and she
was in a very embarrassing position. A few days after
this experience, she noted the phenomena of her head
turning to the left. It took some two to three hours for
her to relate all of her experiences in the past.
A week later she returned to the hospital and re-
mained another twenty-four hours and was given an-
other injection of pentothal sodium. She related many
of the details of her past experiences again and added
others to them. Subsequently I saw her several times in
my office and we went over all the experiences which
she had related to me under narco-hypnosis. Three
months have now elapsed and the last time I saw her she
told me there was no more turning of her head to the
left. She does not have to put a pencil in her mouth or
smoke a cigarette or put the tip of a finger to her chin
in order to keep her head from turning.
Case 9.— This is the case of a twenty-five-year-old
ex-service man who awakened every night between 1 :00
and 5 :00 A.M. with pain in his left lower abdomen. He
would get up and walk the floor or take a hot bath or
smoke cigarettes for a couple of hours. The pain was
intermittent in character. He had been examined by the
army and by several clinics, and a diagnosis of a func-
tional neurosis had been made. He was the son-in-law of
a physician, and the physician had gone to no end of
trouble in trying to find some organic basis for this pain.
Under narco-hypnosis the patient told of a very ex-
citing experience, when he was about twelve years old,
which occurred on the north shore of Lake Superior.
He was in a cabin with his parents when lightning
struck the cabin and it partially burned during a heavy
rain storm. He became very tense and nervous, could
not talk, and had to be carried into another bed. Fol-
lowing this experience, he stated that he had always been
very tense and unable to relax. When he was attending
the university, he would be very much upset at the time
of examinations. He finally went into the army and was
in the air corps. Every time he had to make a flight, and
especially if the flight was at night, he was very dis-
tressed and when the plane landed he would frequently
be unable to get out of the plane for a matter of five to
ten minutes. It was while he was in the Pacific that he
began to have the attacks of pain in his abdomen at
night.
This fellow has had three treatments, and the pain
has disappeared at night. He is still having attacks of
pain to a lesser degree in the daytime and still has a
feeling of nervousness and tenseness.
Case 10. — This woman, whom I have seen recently, is
about fifty years of age. She shrugs her shoulders. This
shrugging of her shoulders occurs during the daytime
but is gone during sleep.
Under drug hypnosis, she told about her husband’s
drinking, gambling, going out with other women, and
how her only daughter had become pregnant and had a
baby out of wedlock. She is still in the hospi al and
the shrugging of her shoulders has not entirely disap-
peared, but she is much better.
Conclusions
1. Drug hypnosis is very valuable in obtaining history
which otherwise could not be obtained.
2. It brings out of the unconscious many emotional
conflicts, repressions and frustrations. It gives one an
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MINNESOTA ACADEMY OF MEDICINE
opportunity to discuss these matters with the patient and
synthesize them in the conscious state.
3. It is not a cure-all for functional nervous cases
but it is certainly of great value in selected cases of con-
version hysteria where other methods have failed.
4. All cases of conversion hysteria do not respond to
this type of treatment but there is a sufficient number
of cases which do respond to make it a very valuable
therapeutic measure.
Discussion
Dr. Hannah : There is another feature in narco-
hypnosis that offers a very interesting future. A man,
recently referred to me by the United States Shipping
Corporation, complained of inability to hear when he was
tested on the audiogram. The audiogram showed an 80
per cent loss of hearing in each ear. However, this man
could hear ordinary conversation without much difficulty.
In conjunction with one of the otologists, we put this
man through the tests when he was in a state of narco-
hypnosis. In this state, he could hear very much better,
and the loss of hearing was only about 20 per cent. This
test was repeated under narco-hypnosis four times with
practically the same results. When the man awakened
four hours later, he had no memory of the tests.
This offers a very fruitful field for determining al-
leged loss of hearing or loss of sight in medicolegal
matters.
The meeting was adjourned.
A. E. Cardle, Secretary
POLIO COSTS IN MINNESOTA
Approximately $2,000,000 will have been expended in
Minnesota by the National Foundation for Infantile
Paralysis to combat the 1946 polio epidemic before the
last case can be considered closed, according to Charles
B. Rogers, state campaign chairman for the annual
“March of Dimes.” This total represents half of the
epidemic emergency fund for the National Foundation
and more than two times the contributions of Minnesota
residents to the “March of Dimes” since it was launched
* in 1938.
This sum represents costs of medical, nursing and
physical therapy care, hospital bills, salaries and main-
tenance of nurses, and equipment. More than 900 nurses,
40 physical therapists, two epidemiologists, 43 respira-
tors, 60 hot pack machines, 18 suction machines, and
some 2,400 pounds of wool for hot packs were sent
into Minnesota during the epidemic. Personnel and
equipment were rushed in by planes, trucks and trains.
“Next to the Minneapolis General Hospital,” Mr.
Rogers reports, “the Kenny Institute received the largest
contributions of any of the six Minneapolis hospitals used
for the care of polio patients — more than $46,000. In
addition, more than $24,000 of doctor and hospital bills
were paid for patients who received the Kenny treatment
in the Kenny Institute.”
The University of Minnesota, since 1938, has been
granted $699,243 by the National Foundation for investi-
gation, research, and short courses for physicians, nurses
and physical therapists. - — Bulletin, Hennepin County
Medical Society, January, 1947.
M\rch, 1947
GETTING THE MOST FROM
A PATHOLOGIST
(Continued from Page 279)
Most of the autopsies in the country today are
being done by relatively untrained and inex-
perienced men. Attention to detail is of first im-
portance. The cause of death will be found in
the great majority of cases without microscopic
study, but sections will add greatly to confidence
in gross conclusions. A few blocks of tissue in
10 per cent formalin can be submitted to the
pathologist, along with a copy of the clinical his-
tory and gross findings. With knowledge of the
diagnostic problem at hand, he will prepare a tis-
sue report with relevant information. The doctor
should always request these slides and study them.
If the autopsy problem is one of possible pois-
oning, the tissue must not be formalized. Gen-
erous specimens of blood, urine, heart, liver,
spleen, brain, stomach, and gastric contents, are
packed in ice and sent either to the coroner of
Hennepin or Ramsey county or to a toxicologic
laboratory recommended by him. There are very
few good laboratories of this type in the state.
The University of Minnesota has no facilities
for toxicologic diagnosis.
It has been the intention of this paper to
present some of the advantages and shortcomings
of pathologic examination and to suggest that
too little information is forwarded with speci-
mens. The pathologist can profitably use clin-
ical findings when studying tissue but usually is
forced to do without them. The clinician who
wants the ultimate in diagnostic accuracy will
properly prepare his tissues for examination and
will write a history. The preparation of such a
report to accompany each specimen consolidates
the ideas of the doctor and stimulates the interest
of the pathologist.
The single flaw in the remarkable progress in the
control of tuberculosis in the United States is the fact
that the disease is still a major cause of death, killing
more Americans than all other infectious and parasitic
diseases combined. In spite of a constant search for
drugs to effect a lasting cure, no substance has been
found that is completely satisfactory. Various sulfona-
mides, although capable of modifying the disease in
experimental animals, have proved too toxic for contin-
uous_ use in human patients, and streptomycin, which
provides considerable protection, has not effected per-
manent cure. Since no specific remedy has been dis-
covered, the accepted methods of treatment which have
obtained excellent results in a great many cases, must
be relied on. Editorial, New England J. Med., (Dec.
5) 1946.
309
Minneapolis Surgical Society
Stated Meeting Held December 5, 194G
The President, Thomas J. Kinsella. M.D., in the chair
SURGICAL MANAGEMENT OF CHRONIC
FISTULAS OF THE RECTUM FOLLOWING
PENETRATING WOUNDS
ROBERT J. TENNER, M.D., F.A.C.S.
Minneapolis, Minnesota
This paper presents a discussion of sequelae of a
type of injury which fortunately is rare in civilian
practice, but which was a not infrequent occurrence
during this past war. It deals with injuries to the
infraperitoneal portion of the colon which were caused
by missiles entering the dorsum of the body, penetrating
the rectum, and resulting in persistent chronic fistulas
in this region.
Much has been written recently regarding wounds
of the rectum and infraperitoneal portion of the large
bowel. The initial surgical treatment and the definitive
treatment have been discussed in detail. Nevertheless,
I wish to describe my experienc in the surgical man-
agement of seven cases of this type of fistula. By
chronic fistulas is meant such as have persisted for
three to five months since injury despite diversion of
the fecal stream by colostomy. Such fistulas communi-
cated in all instances with the posterior or postero-
lateral portion of the extraperitoneal rectum, and the
external openings were found in the sacrococcygeal and
right and left buttocks regions at the location of wounds
of entry of the missiles.
When first seen, such patients all had good functioning
colostomies and their chronic fistulas were apparent on
the dorsum of the body. In some cases there was a
healed, depressed, firm, fixed scar on the right or left
buttocks, in the center of which the external orfice of
the fistulous tract could be seen ; in others there was a
clean granulating wound, in which the fistulous tract
opening could be identified. On evaluating the direction,
depth and extensiveness of the fistulous tract, several
diagnostic measures were used including barium enema
(to check patency of the distal loop also), lipiodol in-
jection, methylene blue injection, digital examination
of the rectum, proctoscopic examination and probing
of the wound. In all cases the extent of the fistula
was ascertained readily and in most of the cases a
probe could be inserted through the external opening
and could be felt in the lumen of the bowel by the
examining finger. Barium enema alone was not very
helpful as it was difficult to introduce barium into
the small sinus tract in some instances. However, in
the lateral view, the barium enema usually showed a
Inaugural thesis as a member of the Minneapolis Surgical
Society.
From the Surgical Service, Billings General Hospital, Fort
Benjamin Harrison, Indiana.
posterior tenting of the rectum, and this deformity
caused by adherent scar would demonstrate the location
of the internal opening. There were three defects which
were quite large and would admit the tip of the exam-
ining finger in the internal opening.
History
A typical history given by the seven patients up to
the time they entered our hospital was that of a young
soldier from twenty to thirty years old who was wound-
ed in the buttocks or sacrococcygeal area by gun shot
or shrapnel. He was admitted to an aid station, then
a surgical evacuation hospital, where treatment was
instituted.
Three patients received minimal debridement and
abdominal exploration at the surgical or evacuation
hospitals. Retroperitoneal hemorrhage was found, in-
jury to the rectum suspected and colostomy performed.
All three patients later displayed fecal fistulas through
the entrance wounds. Two of the seven patients were
treated ideally. The wound of entrance was debrided,
and it was apparent that the recuin had been perforated.
In such cases the rectal wound was closed, the wound
packed open loosely and sigmoid colostomy performed.
In one soldier the wound was debrided and packed
loosely, and in this instance abdominal pain resulted
together with signs of abdominal injury. A celiotomy
was performed but nothing except retroperitoneal or
infraperitoneal hemorrhage was apparent, and the ab-
domen was closed. A fecal fistula developed within two
days in this soldier and it was necessary to make a loope
colostomy. Immediate treatment of one soldier who
had a large posterior bowel perforation consisted of
debridement only and, due to other wounds, shock was
present and was treated. On the fourth day after
injury he improved and it became evident then that a
fecal fistula was present. Colostomy was performed.
All seven soldiers were given careful and adequate sup-
portive treatment and were evacuated to the zone of
the interior.
On arrival at our hospital all seven patients presented
the chronic fistulas described above. Their general
condition was good. The abdominal wo nds were
healed and all colostomies were functiong adequately.
All seven soldiers had had early surgery following the
injury and one important principle was carried out in
all, i.e., the perirectal space was drained by incision
and debridement. In two patients the ideal treatment
was instituted initially; that of incising and draining
the perirectal space by debridement, then locating the
perforation, and closing this opening into the rectum,
followed by colostomy. Unfortunately, in both soldiers
310
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MINNEAPOLIS SURGICAL SOCIETY
chronic fistulas resulted, but I am certain that a great
many similar wounds to the rectum were healed in
this manner. Croce1 cited two instances of spontaneous
closure of rectal fistula following colostomy alone.
There were many other similar instances, no doubt.
It is difficult to determine why such fistulas persist.
In all of the soldiers I operated on, the mucosa was
everted and markedly adherent to the dense scar tissue
which resulted from the healing by secondary intention.
In three patients the coccyx had been removed in the
original debridement. In two, the badly comminuted
coccyx was still present and fixed in the surrounding area
by scar tissue, and in the remaining instances the coccyx
was undisturbed.
Surgery
Operation was performed in all seven soldiers. The
fistulous tracts were excised, the perforations closed
and the wounds packed open to permit healing by sec-
ondary intention.
Preoperative preparation consisted of irrigating the
distal loop, following which all fluid was aspirated.
Usual preoperative medications were given, and low
spinal anesthesia was used in all instances. A suspension
of sulfasuccidine was instilled into the distal loop daily
for three or four days preoperatively to decrease the
bacterial flora.
At operation almost all of the scar was excised by
elliptical excision. The incision was carried toward the
midline when the external opening was in the lateral
buttocks and the coccyx or fragments of coccyx were
removed if present. Very good exposure resulted.
The fascia propria was incised transversely in the mid-
line for additional exposure, and by means of blunt
dissection through the areolar tissue the proximal rectum
was identified as described by Murray.2 In two patients
the perforation was identified at the tip of the fifth
sacral vertebra, and in both the everted mucosa was
attached firmly to the anterior aspect of the sacrum by
osteoperiosteal scar tissue. Removal of the fifth sacral
segment by rongeur and stripping of the bowel from
the periosteum were necessary in order to mobilize the
rectum. In all instances the perforation was identified
and the scarified margins excised. The rectal segment
was mobilized sufficiently in large perforations to make
transverse closure possible, thus preventing undue nar-
rowing of the lumen. With an opening less than one
centimeter in diameter, the scarred margin was cleaned
and closure made in the direction of least tension, some-
times by purse-string suture. Two rows of inverting in-
terrupted chromic catgut 000 were used in all seven
cases. The finger was inserted in the rectum to ascertain
a complete closure. Sulfathiazole powder was dusted into
the wound and a boric ointment-laden gauze was packed
lightly into the defect. A few deep interrupted silk
sutures were placed in the lateral extremes of the incis-
ion in order to close some of the dead space, but such
merely diminished the size and extent of the wound
which was to heal by secondary intention.
Postoperative Care
The packs were removed within twenty-four hours
and a light cradle was applied to keep the wound dry.
Sulfathiazole again was dusted into the depth of the
wound and the cavity packed lightly with dry gauze.
The wound was dressed daily until healed in three to
five weeks. Two or three days after operation all pa-
tients were permitted to be up and about the ward.
All wounds healed solidly except one which broke down
on the seventh day. In this patient the spur of the
colostomy was below the skin surface and feces entered
the distal loop. I believe this was the main factor in
the recurrence, because, after reconstruction of the
colostomy and adequately diverting the fecal stream, the
fecal fistula was again operated on in the above described
manner and healed completely.
In all these soldiers the colostomies were closed while
I was still in the army, and there were no recurrences.
The most recent colostomy closure was followed for
only three weeks. At that time the patient was having
normal bowel movements, and the posterior wound was
well healed.
Discussion
Perforation of the rectum must be suspected in in-
stances of penetrating injury to the perineal, sacro-
coccygeal region, or buttocks. Usually a perforation
can be seen by proctoscopy or identified on digital
examination. If much blood is seen in the rectum,
bowel damage usually is present. With bleeding from
the rectum and lower abdominal pain present, explora-
tory operation is indicated if condition of the patient
permits. Any injury to the colon above the peritoneal
reflection can be repaired and, if retroperitoneal injury
is suspected by evidence of hemorrhage in the retro-
peritoneal space, exclusion colostomy may be performed.
Following this procedure, it is important to debride the
wound of entrance and adequately drain the perirectal
space. If a perforation is seen it should be sutured. If
no perforation is seen, the space should be drained,
nevertheless, to guard against possible later perforation
which may occur because of infarction or contusion of
the bowel wall. The colostomy will control the sepsis
by eliminating gross contamination and reducing the
intraluminal pressure. In addition the incidence of
secondary hemorrhage and even perforation of the
bowel may be reduced by colostomy. A few cases re-
ported in the literature with perforation of the rectum
have had the above ideal treatment, yet fecal fistula has
resulted. This may be accounted for by (1) inadequate
closure of the perforation, (2) not inverting the mucous
membrane and approximating the serosal surfaces of the
bowel, (3) the presence of too much infection, (4) a
colostomy which dees not completely divert the fecal
stream or (5) inadequate blood supply as a result of
the injury. When the bowel wall is everted and ad-
herent to surrounding structures by scar, there is little
chance of the fistulas closing. Many fistulas will heal by
conservative means, and ■ some will heal intermittently,
only to break down later.
In patients who develop chronic fistulas in spite of the
above program, another operation should be performed.
After exposing the area adequately the bowel seg-
ment is mobilized sufficiently to close the perforation
without tension and the wound allowed to heal by
secondary intention.
March, 1947
311
MINNEAPOLIS SURGICAL SOCIETY
It is fairly well established that the majority of fecal
fistulas of the abdominal colon will close and heal
spontaneously, providing the lumen of the bowel is ade-
quate to permit the passage of feces in this area. Fur-
ther, fistulas from the infraperitoneal colon secondary
to operation for low-lying carcinoma with low resec-
tion of the rectum usually will heal spontaneously.
But with chronic fistulas herein discussed there is little
or no chance of spontaneous healing because of trauma,
scar tissue, poor blood supply and absence of peritoneum,
and surgical repair is certainly indicated.
Summary
Seven soldiers were operated upon for chronic posterior
fecal fistula which communicated with the infraperito-
eneal portion of the rectum following injury by shrapnel
and gun shot.
All patients had been operated upon in overseas in-
stallations. The wounds of entrance had been debrided
and colostomies performed.
There was no evidence of osteomyelitis of the coccyx
or sacrum present in any of these cases, in spite of the
persistence of mucopurulent and fecal drainage from
the fistulas.
The seven patients were treated in a standard man-
ner. The fistulous tract including the surrounding scar
tissue down to the bowel wall was excised. The rectum
was mobilized adequately, margins of the perforations
freshened, and the perforation closed by two rows of
fine chromic catgut suture inverting the bowel wall. The
wounds were packed lightly with gauze and allowed
to granulate in.
Wounds healed readily without complications in six
instances and the colostomy was closed later without
recurrence of the fistulas.
One patient failed to heal. An inadequate colostomy
was reconstructed so that the fecal stream was diverted
completely. A further operation was successful and
the colostomy was closed later.
References
1. Croce, Edmund J., Johnson, Vansel L., and Wiper, Thomas
B.: Ann. Surg., 122:408-431, 1945.
2. Murray, Gordon: Surg. Gynec. & Obst., 82:283-289, 1946.
Discussion
Dr. Wallace I. Nelson : Allow me to insert a few
words about prophylaxis. Now that the war is over it
is a little late to prevent these complications in battle
casualties, but the principles hold for injuries in civilian
life. In studying a large number of these patients with
colostomies returning from overseas, I found that a
number were not properly defunctioning the distal loop.
There were also a large number of patients with
wounds of the rectum who merely had a colostomy
established but did not have the pararectal space drained
until an abscess had formed. As a matter of prophy-
laxis, I think that the establishment of a truly defunc-
tioning colostomy and the early drainage of the pararec-
tal space would prevent some of the chronic fistulas.
Dr. John R. Paine: I would like to point out one
other thing. Doctor Tenner’s selection of these cases
represents a group of patients which presented as many
difficulties as any type of wound which medical officers
saw. I think that type of wound, if one excludes the
thoraco-abdominal wounds, had about as high a mor-
tality as any in the major categories of wounds. In
such cases it was found best by experience to operate
on the pelvis first and the abdomen last. This was
largely due to the matter of shock occurring with
shifting the position of the patient. Frequently, he had
to be turned over on the abdomen in the Kraske posi-
tion to have pelvic surgery done and withstood the shock
much more poorly than if the pelvic surgery had been
done first.
PULMONARY DECORTICATION FOR
INFECTED ORGANIZED
HEMOTHORAX
Report of a Case
By H. P. HARPER, M.D.f (By Invitation)
Minneapolis, Minnesota
Pulmonary decortication was described originally in
1893 by Fowler,4 who advocated the procedure in the
treatment of chronic empyema. For various reasons
the operation was not widely accepted until World
War II. Decortication carried out early in the course
of an empyema usually resulted in recurrent or spread-
ing infection. Postponement of the procedure until the
empyema cavity became relatively sterile resulted in
overmaturity of the fibrin wall which made stripping
impractical or impossible. In the treatment of organized
hemothoraces in the war wounded, the advent of ef-
fective chemotherapeutic agents and antibiotics was very
timely. By their use, septic complications were reduced
to a minimum and the time of surgical intervention be-
came elective. In these cases, pulmonary decortication
attained such notable success that the procedure pos-
sibly should be re-evaluated as to its place in the treat-
ment of empyema.
It appears that even in experienced hands at least
5 per cent of all significant acute hemothoraces result
in either empyema or a chronic organizing phase in spite
of various methods of therapeutic management.2-6 The
chronic phase is characterized by the development of an
intrapleural, space-occupying, fibrous envelope usually
filled with a viscous, plasma-like liquid, containing fibrin
shreds and the debris of degenerated red blood cells.
The exact pathogenesis and mechanism of this change
are not entirely clear but, at least under certain circum-
stances, whole blood in the pleural cavity apparently
lays down its fibrin content on all pleural surfaces
bounding it. The constant thrashing movements of the
diaphragm, mediastinal wall, and thoracic wall possibly
stimulate this fibrin deposit on the moving parts in much
the same manner as occurs when whole blood is stirred
with a spatula.3 Simultaneously, red cell degeneration
begins at the center of the hematoma in the defibrinated
blood, which is much diluted by effusion from the
easily irritated pleura. Early in the course of events,
while fibrin is still being laid down about the periphery
of the hematoma, active fibroplasia and angioplasia be-
gin in the fixed fibrin nearest the pleura.1 This pro-
liferative process proceeds from the pleura towards
the center of the hematoma and, in about three weeks,
Published with permission of the Chief Medical Director, De-
partment of Medicine and Surgery, Veterans Administration,
who assumes no responsibility for the opinions expressed or
conclusions drawn by the author.
tSurgical resident, Minneapolis Veterans Hospital.
312
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
results in the formation of adult fibrous tissue in those
portions nearest the pleura. This organizing fibrous
wall has been given the name of “peel.” If undis-
turbed surgically or otherwise, the peel and the under-
lying pleura are said to attain cellular intimacy in
about eight weeks. 1>,s
A markedly decreased vital capacity produced by the
persistent space-occupying lesion is the most pronounced
physiological disturbance of an uncomplicated organizing
hemothorax. The immobilization of the diphragm and
mediastinum further disturb normal physiology and may
give rise to symptoms. The collapsed and partially
atelectatic lung is very prone to abscess formation,
bronchiectasis, or pneumonitis. The nutrient-rich fluid
contained within the peel is also particularly subject to
infection and to the development of complicating empy-
ema.
Organized hemothorax does not produce any partic-
ularly diagnostic symptom complex. Its development in
carefully followed chest injuries is usually obvious, but
many cases are asymptomatic until supervening infection
precipitates signs. As has been pointed out frequently,
the history of significant chest trauma may be mislead-
ing or difficult to elicit. Nonspecific symptoms such
as chest pain, dry cough, dyspnea, malaise, anemia or
weight loss may direct attention to the chest. Hemop-
tysis, foul sputum, chills, and fever usually are the
results of complications, but often provide a lead. The
history of even insignificant chest trauma ; the clinical
and roentgenological demonstration of an immobile, per-
sistent, space-occupying, intrapleural mass ; and the as-
piration of blood or degenerated products of blood from
the mass usually suggest the diagnosis.
Since atelectatic lung and the degenerated center of
an organizing hemothorax are both very prone to
develop infection, the primary aim of surgery must be
the complete re-expansion of the lung with obliteration
of all dead space. In cases where more than SO per
cent of a pleural cavity is involved, this can be accom-
plished best by evacuation of the liquid contents of
the mass and removal of that portion of the peel
actually constricting the lung. Normal respiratory physi-
ology may be re-established further by removing the con-
stricting peel from the diaphragm. Since the peel de-
velops adult fibrous tissue in its deep layers after
three weeks and does not attain cellular intimacy with
the underlying pleura until eight weeks, this is the
ideal period for decortication. If decortication is at-
tempted too early, the peel will not have attained suf-
ficient intrinsic strength to allow easy surgical manipu-
lation. If allowed to mature too long, the peel can
be separated from the underlying pleura only with
difficulty,, and much capillary bleeding results. In this
over-mature stage decortication may result in such ex-
tensive tearing of pleura and lung tissue that Ranso-
hoff’s discission operation5 may be the procedure of
choice.
By proper use of effective chemotherapeutic agents
and antibiotics, pulmonary decortication may be carried
out successfully even in the presence of infection with-
in the hematoma. Burford, et al.1 report nineteen cures
out of twenty-five cases of infected organized hemo-
thorax treated by decortication. The remaining six de-
veloped small basal empyemas requiring further minor
surgery. From this and other reports of comparable
success in the treatment of this special type of empy-
ema, it is interesting to speculate that, with the develop-
ment of further improved bacteriostatic and bacterio-
cidal agents, pulmonary decortication may become the
treatment of choice in the management of most empy-
emas.
Recently at the Minneapolis Veterans Hospital a
pulmonary decortication was performed successfully for
massive infected organized hemothorax. As a re-
minder that this condition occurs in civilan life and as
evidence of the effectiveness of the procedure in spite
of existing infection, the case is reported in some
detail.
Case Report
A railroad lunch concession clerk, aged fifty-five, was
admitted to the Minneapolis Veterans hospital, August
6, 1946, with a history of having sustained minor lacera-
tions of the right elbow, the right knee, the frontal
scalp and the right anterior chest the night of June
24, 1946, when he tripped over a railroad tie while
returning home from work. The lacerations were
sutured and dressed by his family physician who was
consulted the same night. There were no significant
symptoms, and the patient continued his usual work
for about two weeks thereafter.
On the night of July 8, 1946, the patient experienced
a sudden, rather oppressive dyspnea when he arose from
bed to urinate. Severe sharp pains in the right lower
chest began at the same time. The pain was most
marked posteriorly and was made worse by deep res-
pirations. There was no cough, sputum, or hemoptysis.
Weakness, malaise and anorexia were progressive, and
the patient was unable to work. The dyspnea persisted
and was aggravated by any type of exertion. The
right chest pain gradually decreased in severity and
disappeared completely by the end of the month.
A dull aching pain and sensation of numbness in the
right shoulder appeared,- August 3, 1946. This pain
seemed to radiate down the right arm to the ulnar side
of the hand. The patient finally decided to seek fur-
ther medical advice because of this new symptom and
because of his pjpor general health, including a weight
loss of 20 to 25 pounds.
The past history, family history, and history by sys-
tems were noncontributory.
The physical examination on admission revealed a
fairly well developed but rather emaciated white man
displaying moderate but obvious dyspnea. His temper-
ature was 101 degree Fahrenheit. The pulse was 120
per minute. Respirations were counted at 24 per minute.
The blood pressure, 110 systolic and 70 diastolic in mil-
limeters of mercury. The general physical examination
was essentially negative except for the chest which
showed almost complete lack of respiratory excursion on
the right; There was percussion dullness with total ab-
sence of fremitus and breath sounds on the right side
below the level of the third rib anteriorly. The heart
was normal in size to percussion, and no murmurs or
irregularities of rhythm were detected.
Admission laboratory tests showed a hemoglobin of
8.6 Gm. and erythrocyte count of 3,260,000 for each
cubic millimeter of blood with hyperchromasia, anisocy-
tosis, and poikilocytosis on smear. The leukocyte count
was 8,400 with 76 per cent polymorphonuclears, 23 per
cent lymphocytes, and 1 per cent monocytes. The sedi-
mentation rate was 115 millimeters in one hour. Urin-
alysis, blood serology, and sputum studies for acid-fast
March, 1947
313
MINNEAPOLIS SURGICAL SOCIETY
Fig. 1. Chest x-ray examination on
admission shows massive right hemo-
thorax.
Fig. 2. Chest x-ray examination im-
mediately postoperative shows 75 per
cent re-expansion of the right lung.
Fig. 3. Chest x-ray examination at
the time of postoperative follow-up
shows some residual thickened pleura
in the right lower thoracic cavity.
bacilli were negative. Blood chemistry studies were
all normal.
X-ray examination on admission (Fig. 1) demon-
strated fluid obscuring the entire right half of the
thorax except for a narrow triangular strip of air-
containing lung ascending from the right hilum to the
apex.
The diagnosis on admission was “pleural effusion,
right thorax, etiology undetermined,” and the patient
was accepted on the medical service for detailed study
and treatment.
A thoracentesis of the right chest was performed
August 8, 1946, and 500 cubic centimeters of syrupy
dark red fluid were aspirated. X-ray examination im-
mediately thereafter showed no significant change other
than the appearance of bubbles of air overlying multiple
fluid levels. The roentgenologist’s diagnosis was multi-
locular, encapsulated empyema. Laboratory examina-
tion of the aspirated fluid showed a protein of 3.7 grams
for each 100 cubic centimeters, a leukocyte count of
18,000 for each cubic millimeter of fluid, and an eryth-
rocyte count of 500,000 for each cubic millimeter.
No tumor cells or acid-fast bacilli were found. Culture
of the fluid was positive for hemolytic staphylococcus
aureus.
General supportive medical management was carried
out, and the patient was given two blood transfusions
of 500 cubic centimeters each. He improved somewhat
clinically but continued to follow a febrile course with a
daily fever of 100° to 101° F. in spite of the administra-
tion of 40,000 units of penicillin parenterally every four
hours. On August 13, 1946, a second thoracentesis was
performed and 350 cubic centimeters of fluid identical
with that of the first aspiration were removed. Re-ex-
amination of the blood on August 14 showed that the
hemoglobin had risen to 14.6 Gm. and the erythrocyte
count to 4,250,000.
August 15, 1946, the patient was seen by the surgical
service in consultation. The diagnosis of an infected
organized hemothorax seemed likely but a primary
malignancy of the pleura could not be excluded because
of the patient’s age, the insignificant history of trauma,
and the lag between apparent trauma and the onset
of symptoms. It was felt that in either case an explora-
tion of the right chest was indicated.
Operative Procedure. — On August 16, 1946, the right
thorax was opened after wide subperiosteal costectomy
of the seventh rib under intratracheal cyclopropane anes-
thesia. About 2,000 cubic centimeters of syrupy brown
fluid containing many large soft fragments of fibrin were
removed and the typical firm, smooth peel of an or-
ganized hemothorax was revealed. Superiorly slight
transmission of the respiratory movements from the
constricted atelectatic lung could be felt. Palpation
interiorly showed a diaphragm completely immobilized
by the fibrous peel. No evidence of neoplasm was de-
tected.
That portion of the peel in contact with the lung
superiorly was then removed by careful blunt dissection.
A similar removal of the peel from the diaphragm re-
sulted in immediate resumption of normal respiratory
excursions. The lung was freed from minor adhesions
of the upper mediastinum and then was expanded to
normal size by positive pressure applied through the
intratracheal tube. Fenestrated catheters were placed
in the lower portions of the thoracic cavity anteriorly
and posteriorly through trocar punctures and the oper-
ative incision was closed tightly in layers without drain-
age using fine interrupted silk sutures. 100,000 units of
penicillin in 400 cubic centimeters of saline were instilled
through the posterior catheter and, after maximum ex-
pansion of the lung had been assured, both catheters
were clamped. The tracheo-bronchial tree was aspi-
rated per bronchoscope and the patient was returned to
his room where a constant negative pressure of 12 to 14
centimeters of water was applied immediately to the
anterior catheter by means of a Stedman pump setup.
The patient remained in the Trendelenburg position
until his blood pressure was stable and he had fully
recovered from anesthesia. He' was then placed in
semi-Fowler’s position. After a period of six hours,
in which to allow residual penicillin to be effective, the
posterior catheter was unclamped and likewise attached
to the suction apparatus. Chest radiograph taken di-
rectly after surgery showed that the right lung had
been re-expanded to about 75 per cent of normal (Fig.
2).
Postoperatively, particular attention was directed to-
ward the maintenance of uninterrupted negative pressure
within the affected side of the thorax. Twenty cu-
bic centimeters of 250 units for each cubic centimeter
of penicillin were injected by needle through the wall
of each catheter every four hours to keep them clear.
Fluid balance was maintained carefully and protein intake
augmented by 45 grams of amino acids intravenously for
each day. Forty thousand units of penicillin were ad-
ministered parenterally every three hours, and pain was
controlled by the administration of 50 to 75 milligram
doses of demerol.
314
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
Examination of the fragments of peel removed at op-
eration showed them to be firm and fibrous with an
average thickness of 5 mm. Microscopically (Fig. 4),
the surface toward the center of the hematoma was
made up of many young fibroblasts and newly develop-
Fig. 4. Microphotograph of the peel removed at operation.
On the right is the mature fibrotic peripheral portion. On the
left is the immature organizing central portion showing active
fibroplasia and abundant newly developing capillaries.
ing capillaries. The surface toward the pleura was
densely fibrous and resembled scar tissue. The inter-
mediate area showed gradual transition between these
extremes.
On the third postoperative day the anterior catheter
was removed, and the patient was allowed to sit on the
side of his bed the following morning. On the fifth day
the posterior catheter was removed, and the patient was
allowed up in a wheel chair. Convalescence was steady,
and by the ninth postoperative day he was fully ambu-
latory and afebrile.
On August 27, 1946, the eleventh postoperative day,
a fever of 100.6° developed, and examination revealed
a phlebothrombosis of the lower extremities extending
up to the popliteal spaces bilaterally. Anticoagulant
therapy consisting of oral dicumerol and continuous
intravenous heparin was started at once. The blood
prothrombin concentration decreased enough in forty-
eight hours to permit discontinuance of heparin. Admin-
istration of oral dicumerol was continued for a total of
10 days. The remaining convalescence was uneventful
and the patient was discharged from the hospital, Sep-
tember 10, 1946.
On November 1, 1946, the patient returned to the
surgical outpatient section for postoperative checkup.
Physical examination at that time revealed nothing
abnormal except minimal tenderness in the operative
scar. The patient had gained about 14 pounds in
weight and felt very well. X-ray examination of the
chest revealed some residual thickened pleura at the
right base but was otherwise normal (Fig. 3).
Summary
The pathogenesis of organized hemothorax is dis-
cussed briefly. The case of a patient with an infected
organized hemothorax who became symptomatic two
weeks after apparent insignificant chest trauma is re-
ported. The technique of the decortication operation
and the postoperative management of the reported case
are presented in some detail.
References
1. Burford, T. H., Parker, E. F., and Samson, P. C. : Early
pulmonary decortication in the treatment of posttraumatic
empyema. Ann. Surg., 112:163, (Aug.) 1945.
2. Elkin, D. C., and Harris, M. H.: Injuries to the chest.
Ann. Surg., 113:688, 1 94 f .
3. Elliott, T. R. : Gunshot wounds of the chest. Brit. M. J.,
1:442, 1919.
4. Fowler, George R. : A case of thoracoplasty for removal
of a large cicatricial fibrous growth from the interior of
the chest — the result of an old empyema. M. Record,
44:839, (Dec.) 1893.
5. Ronsohoff, Joseph: Discission of the pleura in the treat-
ment of chronic empyema. Ann. Surg., 43:502, 1906.
6. Smithy, H. G. : Traumatic hemothorax with special refer-
0 ence to chronic persistent' types. J. Thor. Surg., 12:338.
(Apr.) 1943.
Discussion
Dr. John R. Paine : Doctor Harper’s case is the
first one of the kind which has come to my attention
in civil practice. It is still difficult for me to believe
that the trauma this man says he suffered caused the
hemorrhage in his chest, but we have been able to find
no other cause. Those who have had no experience in
decortication of the lung have missed some of the
pleasures of surgery. There are certain things that give
us pleasure. A surgeon derives real satisfaction, after
going into the chest, scooping out cups of blood and not
being able to find the lung, in taking the peel off and
seeing the lung expand under his hand so that when
he has finished the lung fills the chest cavity completely.
We had a striking experience during the war treating
organized hemothorax. The American way of treatment
in most of these cases was as Doctor Harper has in-
dicated. The British never did become convinced of the
merits of this operation. They stuck, to the conserva-
tive idea of repeated aspirations. That isn’t entirely
true but the general British plan was not to do so radical
an operation. They preferred to aspirate a few ounces
of fluid this week and then next week take a few more
ounces. In the majority of cases treated this way, the
patient regained a large percentage of his vital capacity,
but I do not believe the recovery was as complete as
when the patient is operated on and the peel removed.
I am sure the time of recovery is much shorter when
the patient is treated by the method described by Doctor
Harper.
CRITERIA FOR CHOLEDOCHOSTOMY TUBE
REMOVAL
R. W. UTENDORFER, M.D.f
Minneapolis, Minnesota
The general policy of surgeons in this area has been
to insert some type of choledochostomy tube when-
ever the common bile duct has been opened during a
surgical procedure. It is important, therefore, to es-
tablish definite critieria for determination of the optimal
time for removal of such a tube.
At the Minneapolis Veterans hospital we employ the
three criteria which have been suggested previously
by Bergh.3
(1) cholangiographic evidence that the biliary
tree is structurally normal, that no filling de-
fects suggestive of stone are present, and that
the contrast medium empties readily into the
duodenum ; (2) direct evidence that the sphinc-
fSurgical resident, Minneapolis Veterans Hospital.
Published with permission of the Chief Medical Director, De-
partment of Medicine and Surgery, Veterans Administration, who
assumes no responsibility for the opinions expressed or conclu-
sions drawn by the author.
March, 1947
315
MINNEAPOLIS SURGICAL SOCIETY
ter resistance is normal and that the sphinc-
ter is not irritable; (3) subjective comfort
of the patient, and lack of drainage around the
tube when the catheter is clamped.
Before a choledochostomy tube may be removed it
is essential that the patient be comfortable during peri-
ods when the tube is clamped. However, this simple
clinical test in itself is not sufficient, for it is well
known that stones may be present in the duct without
obstructing bile flow and without producing symptoms.^
Likewise, we have demonstrated that the patient with
an irritable sphincter of Oddi may, at times, tolerate
closure of the choledochostomy tube without discom-
fort.
Cholangiograms are made in all cases in which a
patient has a tube draining the common bile duct. A
satisfactory cholangiogram is best obtained by the use
of a nontoxic contrast medium having a watery con-
sistency, miscible with bile. The hepatic ducts and the
common duct should be filled, and the ease with which
the contrast medium enters the duodenum should be
observed. Cholangiograms are most important in the
recognition of calculi or other duct obstructions, but
also may reveal the presence of hepatic abscesses, and
possibly spasm of the sphincter of Oddi, or stricture
of the duct due to inflammatory reaction. In this con-
nection, Royer15 states that he is able to distinguish
spasm from stricture on the basis that spasm gives ec-
centric narrowing of the duct shadow, while concentric
narrowing is a finding in true stricture. Important as
cholangiography is, it still leaves information to be de-
sired concerning the condition of the sphincter of Oddi,
whether it is in spasm, whether it is irritable and may
be stimulated to contract in abnormal spasm, or whether
it has normal tone. In order to evaluate this with any
degree of accuracy it is necessary to conduct direct
tests of the resistance of the sphincter of Oddi.
Although the technique of this test is simple, it is
not yet in general use, and may therefore be described
briefly. The apparatus required consists of an infusion
flask connected to the open end of the choledochostomy
tube by rubber tubing, incorporating a Murphy drip bulb
in the system so that flow may be observed. The ap-
paratus is sterilized, filled with saline solution, and air
is evacuated from the system, save for the small air
gap in the Murphy drip bulb. The flask is suspended
from a standard, and arranged so that it may be
elevated and lowered at will, thereby varying the pres-
sure of the column of fluid in the system. Readings
are taken directly on a centimeter scale suspended from
the standard, and adjusted so that the zero point is
placed at the estimated level of the common bile duct.
In carrying out the test, the infusion flask is elevated,
then lowered to the point at which saline solution fails
to run through the tubing. When this point is reached,
the column of solution is supported without any flow in
either direction, and the drop suspended in the Murphy
bulb moves with the respiration of the patient. Eleva-
tion of the flask above this point allows saline solution
to flow into the biliary tract, as evidenced by dripping
solution through the Murphy drip bulb, and lowering
the flask beyond this point causes reflux of fluid back
into the infusion system. The level at which the column
of saline solution is suspended without flow in either di-
rection is taken as a measurement of the sphincter re-
sistance. That this test is fairly delicate, in spite of the
simplicity of the apparatus, is demonstrated by the
marked changes produced by induced spasm, as when
morphine is administered, or the flask suddenly elevated.
Whenever practicable, the test is performed in the morn-
ing, after withholding breakfast, or at other times of the
day, after a fasting period of four to eight hours, since
it has been shown that ingestion of food lowers sphincter
resistance — fatty foods having a marked effect, with
less response to protein, and no effect after ingestion of
carbohydrate.4 The patient should not have received
opiates prior to the test, since morphine, codein and re-
lated drugs produced spasm of the sphincter.3
By this technique, the resistance offered by the sphinc-
ter of Oddi has a normal range of 9 to 23 centimeters
of water, with the ideal normal being 13 to 15 centi-
meters. Spasm of the sphincter may produce readings
indicating a resistance of 30 to 40 centimeters of water,
or more, and in these patients the resistance readings
are usually more fluctuant than in normals. Irritability
of the sphincter thus demonstrated is probably more
commonly associated with organic pathologic condition
such as an inflammatory process, or irritation caused by
stone; but purely functional derangement (biliary dy-
skinesia or biliary dyssenergia) may also produce spasm.
From this, it is seen that by sphincter resistance tests
we are able to tell, with a fair degree of accuracy, the
condition of the sphincter of Oddi, in so far as tone and
spasm are concerned, but this test gives no information
as to the presence of stone or growth not causing ob-
struction, unless there be an associated irritability of
the sphincter, as is often the case.
It has been the practice at the Minneapolis Veterans
Hospital to judge the time for removal of the cho-
ledochostomy tube on the basis of these three criteria.
If the patient tolerates clamping of the tube for twelve
hours without discomfort, if the cholangiogram is nor-
mal, and if the sphincter is not irritable and the re-
sistance is normal, the tube may be removed. In the
usual uncomplicated case the cholangiogram may be
done on the seventh to ninth day postoperatively, and
the sphincter resistance test may be done the following
day. The choledochostomy tube may, thefefore, be
removed in eight to ten days in the event of a normal
response.
In the presence of an irritable sphincter, however, the
choledochostomy tube should be left in place for longer
periods of time. Prolonged decompression of the ducts
by means of external drainage permits the sphincter to
return gradually to normal. We have seen a number of
cases in which this has occurred. The time required for
the return of the sphincter to normal may be from
several weeks to several months. However, if the
still irritable, the patient is very likely to suffer re-
currence of pain which may resemble biliary colic, or
we have seen no patient in whom the criteria for re-
may be a vague epigastric distress. In contrast to this,
choledochostomy tube is removed While the sphincter is
moval of choledochostomy tubes have been satisfied,
who has had postcholecystectomy pain.
We may conclude, therefore, that we have available
316
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
three valuable criteria for judging the time when a
choledochostomy tube may be removed, each of these
having its own particular advantages and limitations.
In recapitulation, clamping the tube is a clinical test
of limited value, which gives little information as to
the structural or physiological status of the duct sys-
tem. Cholangiograms give a picture ‘of the anatomical
condition of the biliary ducts, but give little informa-
tion concerning the condition of the sphincter. Since this
condition of the sphincter is such an important consider-
ation, direct measurement of the resistance of the
sphincter of Oddi should be carried out. No single test
furnishes sufficient information concerning the post-
operative morphology and physiology of the biliary duct
system, but by employing all three criteria we are able
to gain valuable knowledge as to the condition of the
ducts, the presence or absence of stones, the condition
of the sphincter, and the tolerance of the patient to
the existing conditions. The optimal time for removal
of a choledochostomy tube may, therefore, be deter-
mined accurately by the use of these criteria.
References
1. Bergh, G. S. and Layne, J. A. : Proc. Soc. Exper. Biol.
& Med., 38:44-45, 1938.
2. Bergh, G. S. and Layne, J. A.: Am. J. Physiol., 128:4:
690-694, 1940.
3. Bergh, G. S. : Surgery, 11: 2:299-330, 1942.
4. Bergh, G. S. : Am. J. Digest. Dis., 9 : 1 :40-43, 1942.
5. Best, C. H. and Taylor, N. B. : The Physiological Basis
of Medical Practice. 4th Ed. Baltimore: Williams & Wil-
kins Co.,
6. Boyden, E. A. : Surgery, 1 :25-37, 1937.
7. Carter, R. F. : Surg. Gynec. & Obst., 63:163-169, 1936.
8. DeLor, C. J., Means, J. W. and Shinowara, G.Y. : Rev.
Gastroenterol., 9: 3:239-246, 1942.
9. Ivy, A. C., Voegtlin, W. L. and Greengard, PI. : J.A.M.A.,
100: 17:1319-1320, 1933.
10. Ivy, A. C. : Physiol, Rev., 14:1-102, 1934.
11. Ivy, A. C., and' Bergh, G. S. : J.A.M.A., 103:20:1500-1504,
1934.
12. Ivy, A. C., and Sandblom, P: Ann. Int. Med., 8:115-122,
1934.
13. Eayne, J. A. and Bergh, G. S. : Surg. Gynec. & Obst.,
70:18-24, 1940.
14. Lueth, H. C. : Am. J. Physiol., 99:237, 1931-1932.
15. Mixer, H. W. and Rigler, L. G. : Staff. Meet. Bull. U.
Minn. Hosp., 17: 23:343-354, 1946.
16. Nash, Joseph: Surgical Physiology, 1st Ed. Springfield,
Illinois : C. C. Thomas.
17. Schwegler, R. J., Jr., and Boyden, E. A.: Anat. Rec.,
67:441-467, 1937.
18. Schwegler, R. J., Jr. and Boyden, E. A. : Anat. Rec.,
68:17-41, 1937.
19. Schwegler, R. J., Jr. and Boyden, E. A. : Anat. Rec.,
68:193-219, 1937.
Discussion
Dr. George Bergh : There is little to add to what
Doctor Utendorfer has said. He has covered the sub-
ject very well from our point of view. The criteria
have been of real value to us, and we employ them
routinely.
Dr. J. M. Hayes : I am wondering whether there are
any statistics as to what was the average time for
removing the tube.
Dr. R. W. Utendorfer : In the normal case, from
eight to ten days.
Dr. Carl Rice : I would like to ask Doctor Uten-
dorfer and Doctor Bergh whether there are medica-
tions which will relieve the spasm of the sphincter? I
notice morphine did not.
Dr. R. W. Utendorfer : The only drugs that have been
found to be very effective on the sphincter are amyl
nitrite and,' to a lesser extent, nitroglycerine. There
are some cases in which spasm of the sphincter is not
relieved by amyl nitrite. Atropine and some of the
usual spasmolytic agents have no effect. We are testing
some of the newer ones at present, but cannot tell
about them' yet.
March, 1947
MASSIVE GASTRIC HEMORRHAGE DUE TO
HEMORRHAGIC GASTRITIS NECESSITATING
GASTRIC RESECTION
Case Report
G. H. HALL, M.D.f
Minneapolis, Minnesota
Surgical arrest of massive gastrointestinal hemor-
rhage continues to offer problems of major importance.
This is particularly true when the vomiting of blood or
the passage of large, bloody, loose and frequent stools
occurs in a patient who presents practically no other
symptoms or findings. Consideration of possible causes
of the bleeding then becomes a matter of considerable
concern.
Reports from most of the larger clinics indicate that
ulcers of the stomach or duodenum are responsible for
90 per cent of upper gastrointestinal tract hemorrhages.
The next most common cause, bleeding from esophageal
varices, secondary to cirrhosis of the liver, has a re-
ported incidence of from 2 to 5 per cent. Other less
frequent causes of hematemesis and melena include
carcinoma of the stomach or duodenum, benign tumors
of the stomach, injuries to the stomach, blood dyscrasi-
as, and ulceration in a Meckel’s diverticulum.
Another possible source of massive bleeding from the
upper gastro-intestinal tract, and one which has received
little emphasis, is hemorrhagic gastritis. Bockus reports
that in about one-fourth of the cases of massive
hemorrhage into the upper gastrointestinal tract, roent-
gen study performed after the emergency is over fails
to reveal an ulcer or other gastroduodenal lesion.
Meyer and Steigmann2 state that negative x-ray findings
are reported in from 30 to 50 per cent of patients who
have had gastric hemorrhage. Pathologists not infre-
quently have been unable to demonstrate at autopsy the
source of bleeding in patients who have seemingly
died of massive upper gastrointestinal hemorrhage. It
should be recalled that post-mortem antolysis of the
mucous membrane of the stomach occurs soon after
death.
Examination of the stomach with the gastroscope has
enabled visualization of areas of gastritis from which
oozing of blood occurs and actual superficial ulcera-
tions have been noted. It is not at all unlikely that a
high percentage of the 25 to 50 per cent of patients
who have negative x-ray findings after hemorrhage has
subsided bleed from such lesions. As yet, the fre-
quency of gastritis as a cause of massive upper gastro-
intestinal hemorrhage has not been determined. That
it can occur and that it can cause massive bleeding hds
been- emphasized to the staff at the Minneapolis Vet-
erans hospital by experience with the following case.
Case History
The patient, a thirty-two-year-old veteran of World
War II, was admitted to the medical service of the
hospital on September 15, 1946. His presenting com-
Published with permission of the Chief Medical Director,
Department of Medicine and Surgery, Veterans Administration,
who assumes no responsibility for the opinions expressed or
conclusions drawn by the author.
-{•Surgical resident, Minneapolis Veterans Hospital. -
317
MINNEAPOLIS SURGICAL SOCIETY
plaints were severe weakness and dizziness following the
passage of large black liquid stools beginning three days
prior to admission.
The patient’s army career began in March, 1944, when
he was assigned to the infantry. He had had no com-
Fig. X. Section taken through the linear lesion in the mu-
cosa.
plaints referable to the gastrointestinal system until
January, 1945, when he noticed a bloody stool. There
were no other symptoms at that time. He was hos-
pitalized in an army general hospital, where he ap-
parently was studied thoroughly. A barium x-ray exam-
ination of the stomach was made, stools were ex-
amined, and he was put on various diets. After having
been hospitalized for about a month, he was discharged
to duty, but transferred from the infantry to the air
corps, where he assumed the duties of a truck me-
chanic. He was told only that he had a “nervous
stomach.” He experienced no further appreciable diffi-
culty during his remaining army service. The patient
stated that he drank only very moderately and smoked
about one package of cigarettes a day.
About one month prior to admission, he began to
experience a dull aching distress, which he described
as “bloating.” This would begin in both flanks and
gradually extend into the epigastrium, where it would
remain. This distress usually occurred about one-half
hour after meals and would be relieved somewhat by
belching or by the ingestion of alkalis.
On the evening of September 12, three days prior to
admission, he had a large bowel movement, consisting
entirely of black liquid. Following this, he experienced
severe cramping pains in the lower abdomen, which
were relieved by two additional passages of black
liquid. He became weak and experienced dizziness on
walking or standing. On the following day, he con-
tinued to feel weak and dizzy. No nausea nor vomiting
was experienced, however, and he was able to eat
normally. The next day, defecation again produced
a black liquid stool, and on September 15, another black
liquid stool was passed. His family physician then
was called and that same day he was sent to the hos-
pital, where he was admitted with a tentative diagnosis
of bleeding peptic ulcer.
Examination on admission revealed an unusually tall,
slender, red-haired male. Although he was 6 feet 6
inches tall, the patient weighed only 140 pounds. There
was noted a generalized, moderately severe pallor of the
skin and mucous membranes. He appeared to be nerv-
ous and apprehensive. The temperature on admission
was 99.2 Fahrenheit, the pulse rate 120 per minute and
the blood pressure was 112 systolic and 60 diastolic in
Fig. 2. Section through one of the smaller hemorrhagic
areas. Note the large number of erythrocytes in the region of
the muscularis mucosae, with break-through into the mucous
membrane.
millimeters of mercury. The heart and lungs were
normal to percussion and auscultation. The abdomen
was flat and soft. No masses were palpated and no
tenderness found. The liver and spleen were not en-
larged. No other physical abnormalities were noted.
The hemoglobin on admission was 4.9 grams (31 per
cent) and the red blood cell count was 1.6 million. The
white blood cell count ranged from 6,000 to 11,000 and
differential counts were within normal limits. The
bleeding time was two and one-half minutes, the clot-
ting time was six minutes, and the prothrombin time
was thirteen seconds as compared with a normal con-
trol of thirteen seconds. Study of the blood morphology
revealed findings consistent with a secondary anemia.
Urinalyses showed no albumin, sugar, nor abnormal
sediment, and specific gravities ranged from 1.009 to
1.024. Stool examinations consistently showed a four
plus guaiac test for occult blood.
On admission to the medical service, the patient was
placed on a regimen of strict bed rest and was given
morphine. A nasal tube was introduced into the stomach
and he was given a continuous drip of high caloric,
high protein liquid diet night and day. Amphogel,
ascorbic acid and vitamin K were added. Atropine sul-
phate, grains 1/100, was given every six hours. Daily
transfusions of 500 cubic centimeters whole citrated
blood were administrated by slow intravenous drip.
After three days of this treatment, the patient felt
much improved, the hemoglobin had risen to 9.7 grams
(62 per cent) and the red blood cell count to 3.1 million.
Nasal tube feedings were discontinued and hourly feed-
ings of milk and cream alternating with amphogel were
substituted. The first bowel movement during hospitali-
318
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
zation occurred two days after admission, however,
and was definitely tarry.
Five days after admission, the patient suddenly be-
came faint and vomited 900 cubic centimeters of bright
red blood. 1,000 cubic centimeters of whole blood were
Fig. 3. Another section through a small hemorrhagic area.
Erythrocytes have not broken through to any great extent.
given during the night, and the hemoglobin and red
blood cell count the following morning remained at
about the previous level. The hematocrit was 29 per
cent. The blood pressure, which was checked hourly,
remained at around 110 systolic and 70 diastolic, and
the pulse at about 100 per minute. Surgical consulta-
tion was requested the following morning. Because the
patient had not been in true shock and because the
source of bleeding had not been determined, the decision
was made to continue medical management in the hope
that bleeding would subside so that a barium study
of the upper gastrointestinal tract might enable localiza-
tion of the bleeding area. Gastroscopy was considered,
but deemed unwise. It was thought, however, that if
further massive hemorrhage should occur, immediate
surgical intervention should be undertaken.
The previously outlined medical management was con-
tinued. One definitely tarry stool was obtained by ene-
ma, but additional stools were reported to be lighter in
color. Ten days following the episode of hematemesis,
the medical resident was called at 3 :30 a.m. because the
blood pressure had dropped to 86 systolic and 55 di-
astolic. One unit of plasma followed by 500 cubic
centimeters of whole blood restored the pressure to
normal. It was found, however, that the hemoglobin
had dropped to 6.7 grams (43 per cent) and the red
blood cell count to 2 million for each cubic millimeter
of blood in spite of the transfusion. Since hemorrhage
appeared to be continuing despite eighteen days of active
medical management, preparation for surgery was
deemed advisable. Because it was feared that barium
x-ray study or gastroscopy might cause further bleed-
ing and because probabilities were in favor of a bleed-
ing gastric, or duodenal ulcer, these diagnostic aids
seemed contraindicated. The patient was given sufficient
blood to raise the hemoglobin to 15.4 grams (98 per
cent) and the red blood cell count to 4.5 million by
continuous slow drip and laparotomy was performed
nineteen days after admission. He had received a total
of 7,500 c.c. of whole blood prior to operation.
Under intratracheal cyclopropane plus curare anes-
thesia, a left subcostal incision was made and the
abdomen explored. The stomach was unusually large
March, 1947
and elongated, and the stomach wall was edematous,
but the serosal surfaces presented no evidence of scar-
ring. The first portion of the duodenum was distended,
but there was no deformity or scarring anteriorly and
no adherence to the pancreas posteriorly. The small
bowel was examined from the ligament of Treitz down
to the terminal ileum. No abnormalities were noted
except that black liquid, presumed to be blood, could
be seen through the serosa beginning high in the je-
junum. The colon also contained a large quantity of
soft black material. Since no other cause for the hema-
temesis and melena could be established, it was decided
that a small peptic ulcer was the most likely cause and
that gastric resection should be done. The pyloric por-
tion of the stomach and about four centimeters of the
duodenum distal to the pylorus were first devascularized
and the duodenum opened. The mucous membrane ap-
peared to be normal and careful inspection failed to
reveal the prescence of a bleeding point. The duodenum
then was inverted with a running layer of chromic cat-
gut re-inforced by a second layer of interrupted 0000
silk sutures. The inverted duodenal stump was buried
into the capsule of the pancreas.
The greater curvature was devascularized up to and
including the lower two vasa brevia and the lesser
curvature to the left gastric artery. About 75 per cent
of the stomach was removed and a Hofmeister type
of short-loop, retrocolic gastro-jej unostomy performed,
using the Wangensteen aseptic technique.
Upon opening the resected stomach, the pathologist
found no ulcer present. The mucosa of the stomach was
thrown into normal appearing rugae except in the
pyloric antrum, where it was smoother. On the pos-
terior wall of the fundal portion of the stomach, there
was noted a linear defect in the mucosa measuring 2
centimeters in length and up to 3 millimeters in diame-
ter. The defect was shallow, dark red, and presented
irregular borders. In addition, other sections showed
occasional tiny hemorrhagic foci within or just beneath
the mucosa.
Some doubt remained as to the source of the hemor-
rhage, however, until miscroscopic studies were made.
Sections through the linear lesion in the mucosa showed
complete dissolution in continuity of the mucous mem-
brane extending into the muscularis mucosa and possi-
bly into the deeper muscle layers. There was a dense
infiltration of extravasated blood. Sections through the
smaller hemorrhagic areas revealed massive aggregations
of erythrocytes, most densely collected in the muscularis
mucosa. In some instances, there seemed to be actual
necrosis of this muscular layer. There was definite
edema between the muscular layers and in the connective
tissues. Furthermore, inflammatory cellular exudate,
and mild scatterings of eosinophiles, polymorphonuclear
cells and lymphocytes, was noted in the vicinity of the
lesions. The diagnosis of the pathologist was subacute
diffuse gastritis with focal mucosal and submucosal
hemorrhages.
The postoperative course was without complication.
No further melena or hematemesis occurred, and no
more blood transfusions were necessary. Gastric analysis
postoperatively proved the patient to be achlorhydric
to histamine. Barium radiographic examination re-
vealed no abnormality of the esophagus or residual
pouch, and barium passed readily into the small bowel.
The patient was seen subsequently one month after
surgery. There had been no recurrence of his pre-
vious symptoms. He stated at that time that he had
been feeling fine, had been eating well, and had gained
about 10 pounds in weight.
Bibliography
1. Bockus, H. L. : Gastro-enterology. Philadelphia: W. B.
Saunders Co., 1944.
2. Meyer, K. A. and Steigmann, F. : Gastric hemorrhage :
Implications as to treatment. S. Clin. N. A., 24:30, (Feb.)
1944.
(Continued on Page 339)
319
♦ Reports and Announcements ♦
MEDICAL BROADCAST FOR MARCH
The following radio schedule of talks on medical
and dental subjects by William O’Brien, M.D., Di-
rector of Postgraduate Medical Education, University
of Minnesota, is sponsored by the Minnesota State
Medical Association, the Minnesota State Dental Asso-
ciation, the Minnesota Hospital Service Association in
co-operation with the Minnesota Hospital Association
and the Minnesota Nurses Association, and the Uni-
versity of
Minnesota School of the Air.
1
11:30
A.M.
KUOM-
KROC-
KFAM-
Medicine in the News
4
9:00
A.M.
WCCO
The Code of Medical Ethics
5
11:00
A.M.
KUOM
We Inherit Some Traits But
We Acquire Others
7
9:00
A.M.
WCCO
Pneumonia
8
11:30
A.M.
KUOM-
KROC-
KFAM-
Medicine in the News
11
9:00
A.M.
wcco
Industrial Nursing
12
11:00
A.M.
KUOM
Stimulants and Narcotics Can
Be Very Harmful
13
9:00
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WCCO
Influenza
IS
11:30
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KUOM-
KROC-
KFAM-
Medicine in the News
18
9:00
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wcco
Rural Health and Nursing
19
11:00
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KUOM
Self-Prescribed Medicine Can
Be Most Injurious
20
9:00
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WCCO
Speech Disorders in Childhood
22
11:30
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KUOM-
KROC-
KFAM-
Medicine in the News
25
9:00
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WCCO
Conservation of Vision
26
11:00
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KUOM
Your Mental Outlook Can Help
or Hinder
27
9:00
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WCCO
Mouth Infections
29
11:30
A.M.
KUOM-
KROC-
KFAM-
Medicine in the News
PRIZE CONTEST ANNOUNCED
The American Association of Obstetricians, Gynecolo-
gists and Abdominal Surgeons announces a Foundation
prize contest.
Further information may be obtained from Dr. James
R. Bloss, secretary, 418 Eleventh Street, Huntington 1,
West Virginia.
E. STARR JUDD LECTURE
The fourteenth E. Starr Judd lecture will be given by
Dr. I. S. Ravdin, John Rhea Barton Professor of Sur-
gery at the University of Pennsylvania, Tuesday evening,
April IS, 1947, at 8:15 in the Auditorium of the Museum
of Natural History. Doctor Ravdin’s subject is “Chang-
ing Concepts in Surgical Care.”
The late E. Starr Judd, an alumnus of the Medical
School of the University of Minnesota, established this
annual lectureship in surgery a few years before his
death.
AMERICAN COLLEGE OF CHEST PHYSICIANS
The thirteenth annual meeting of the American College
of Chest Physicians is scheduled to be held at the Am-
bassador Hotel, Atlantic City, New Jersey, June S to 8.
An interesting scientific program has been planned for
this meeting. Prominent speakers from other countries
will present papers.
520
The oral and written examinations for Fellowship
will be held on the first day of the meeting, June 5.
Applicants for Fellowship in the College who plan to
take these examinations should communicate at once
with the Executive Secretary, American College of
Chest Physicians, 500 North Dearborn Street, Chicago
10, Illinois.
The convocation for new Fellows and Life Members
of the College will be held on Sunday, June 8. At
this time certificates will be awarded to Fellows and
Life Members admitted since June, 1946.
AMERICAN SOCIETY FOR THE STUDY OF STERILITY
The third annual convention of the American Society
for the Study of Sterility will be held at the Hotel
Strand, Atlantic City, New Jersey, on June 7 and 8,
1947, preceding the annual AMA Convention. The gen-
eral theme of the meetings will be that of attempting
to disseminate to the physician treating marital infer-
tility an over-all picture of the latest advances in repro-
duction. The convention will include original papers,
round table discussion, scientific exhibits, and personal
demonstrations. Registration for the sessions is open
to members of the medical and allied professions.
Additional information may be obtained from the
secretary, Dr. John O. Haman, 490 Post Street, San
Francisco 2, California.
INDUSTRIAL HEALTH MEETINGS
A conclave of combined professional personnel in
industrial health work over the entire nation will take
place at the Hotel Statler, Buffalo, N. Y., April 26
through May 4, 1947.
These meetings will represent the 32nd annual gather-
ing of the American Association of Industrial Physicians
and Surgeons ; the ninth annual conference of the Amer-
ican Conference of Governmental Industrial Hygienists;
the eighth annual meeting of the American Industrial
Hygiene Association; the fifth annual conference of the
American Association of Industrial Nurses, and the
fourth annual meeting of the American Association of
Industrial Dentists.
The sessions will be replete with many new subjects
of interest, including among others, round table discus-
sions for chemists, engineers, physicians and nurses; a
symposium on new problems in the developments of
industrial hygiene ; a discussion of state codes and indus-
trial hygiene administration ; conferences on environmen-
tal control, on particle size, and analytical procedures ;
clinics on fractures and traumatic surgery, including a
symposium on back problems; hazards incident to the
use of the atomic bomb ; reports on the Bikini experi-
ments with motion pictures; tracer chemistry in toxico-
logical research and experience with range finding tests ;
progress in the teaching of industrial medicine in Amer-
( Continued on Page 322)
Minnesota Medicine
indications for "smootkage”
SEARLE
RESEARCH
"smootkage” — the gentle, non-
irritating action of Metamucil — is indicated in any type
of constipation or other gastrointestinal dysfunction
requiring a mild, soothing but effective stimulant
to bowel evacuation.
metamucil provides a soft, bland, plastic
bulk which exerts a stimulating effect on the bowel
reflexes and facilitates elimination of the fecal content
in a completely normal and natural manner.
metamucil is the highly refined mucilloid
of Plantago ovata (50%), a seed of the psyllium
group, combined with dextrose (50%), as a
dispersing agent.
IN THE SERVICE OF MEDICINE
March, 1947
Metamucil is the registered trademark of
G. D. Searle & Co., Chicago 80, Illinois
321
REPORTS AND ANNOUNCEMENTS
INDUSTRIAL HEALTH MEETINGS
(Continued from Page 320)
ican medical schools ; the development and administra-
tion of industrial dental clinics in various industrial
groups; a panel discussion on new preventive measures
in industry ; a panel discussion on in-service education
of the nurse in industry, and many other subjects which
can be found by consulting the preliminary program.
Further details and copy of the preliminary program
may be secured by writing to Dr. Edward C. Holm-
blad, Managing Director of the American Association
of Industrial Physicians and Surgeons, 28 East Jackson
Blvd., Chicago 4, Illinois.
All hotel reservations are made by the Housing Bu-
reau, Buffalo Convention and Tourist Bureau, Inc., 602
Genesee Bldg., Buffalo, N. Y.
DAKOTA COUNTY SOCIETY
All officers of the Dakota County Medical Society
were re-elected for 1947 at the annual meeting on Jan-
uary 28 at the Gardner Hotel in Hastings. Dr. Albert
J. Emond, Farmington, was retained as president ; Dr
J. A. Sanford, Farmington, vice president, and Dr. L.
R. Peck, Hastings, secretary-treasurer.
The society elected a cancer committee to co-operate
with the state and national cancer organizations, naming
Dr. A. J. Emond as chairman, and Drs. Leo Burns,
South Saint Paul, and L. R. Peck as committee mem-
bers.
HENNEPIN COUNTY SOCIETY
At a meeting on February 3, it was announced that
Dr. Ralph H. Creighton, Minneapolis, had been elected
president of the Hennepin County Medical Society.
He will take office in October.
Dr. Robert L. Wilder and Dr. William P. Sadler were
named vice presidents; Dr. Charles A. Aling, secre-
tary-treasurer, and Dr. Thomas Lowry, librarian. Mem-
bers elected to various boards are : Drs. Willard D.
White and John H. Moe, board of directors ; Drs. Ed-
win G. Benjamin and Otto W. Yoerg, board of censors;
Drs. S. Marx White and Vernon L. Hart, board of
ethics; and Drs. Henry L. Ulrich and James K. Ander-
son, board of trustees, Drs. Kenneth Bulkley, O. J.
Campbell, Richard H. Crammer and Donald McCarthy
were elected delegates to the State Medical Associa-
tion.
The program for the meeting featured a talk by Dr.
Donald W. Hastings, head of the University of Minne-
sota psychiatry and neurology department, who spoke
on “Psychotherapy in General Practice.”
McLEOD COUNTY SOCIETY
At the annual meeting of the McLeod County Medi-
cal Society, held January 9 at Glencoe, Dr. C. W. Trues-
dale, Glencoe, was elected president, and Dr. John W.
Gridley, Glencoe, secretary. A resolution was passed
endorsing the national drive for the infantile paralysis
fund.
MINNESOTA SURGICAL SOCIETY
Dr. C. W. Mayo, Rochester, was elected president
of the Minnesota Surgical Society at the organization’s
first postwar meeting, held in Rochester on January 31.
The society last met in 1941, when it was decided to
discontinue meetings for the duration of the war.
Also elected to office at the January meeting were
Dr. O. J. Campbell, Minneapolis, vice president, and
Dr. Malcolm G. Gillespie, Duluth, secretary-treasurer.
During the morning session of the one-day meeting,
the group was addressed by Drs. M. B. Dockerty and
B. T. Horton, Rochester. At the afternoon session,
papers were presented by Drs. F. R. Keating, J. H.
Grindlay, J. C. Cain, Hiram E. Essex, H. Waltman
Walters, S. W. Harrington and F. Z. Havens, all of
Rochester.
A dinner was given at the Mayo Foundation House
for the society in the evening.
STEARNS-BENTON COUNTY SOCIETY
Dr. Gilman H. Goehrs, St. Cloud, was elected presi-
dent of the Stearns-Benton County Medical Society at
a meeting held in St. Cloud on January 23. Dr. A. H.
Zachman, Melrose, was named president-elect for 1948
and also a delegate for 1947.
Others elected to office were Dr. F. H. Baumgartner,
Albany, vice president; Dr. John N. Libert, St. Cloud,
secretary-treasurer; Dr. R. N. Jones, St. Cloud, alter-
nate delegate, and Dr. S. T. Raetz, St. Cloud, advisory
committee chairman.
Dr. Rodney Sturley, Saint Paul, was principal speaker
at the meeting, discussing the use of hormones.
The society voted to sponsor the annual essay contest
for junior and senior high school students on the sub-
ject, “Why Private Practice of Medicine Furnishes This
Country with the Finest in Medical Care.”
WASECA COUNTY SOCIETY
Re-elected as president, Dr. George H. Olds, New
Richland, was chosen to head the Waseca County Medi-
cal Society for another term, at the annual meeting held
at Hotel Waseca on January 7. Dr. H. M. Mclntire,
Waseca, was elected vice president, and Dr. S. C. G.
Oeljen, Waseca, secretary-treasurer.
The society and the ladies auxiliary, which held its
annual meeting at the same time, were entertained at a
dinner at the hotel by Dr. and Mrs. Clifford T. Wadd,
Janesville.
WASHINGTON COUNTY SOCIETY
The Washington County Medical Society held its
regular monthly meeting on February 11. Following
a business discussion, a colored motion picture entitled
“Intocostrin” was shown through the courtesy of E. R.
Squibb and Sons.
322
Minnesota Medicine
NOW - - - THE
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WRITE OR WIRE FOR INFORMATION
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One of our greatest heritages is fine
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voices and orchestras. Capehart has long
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discriminate music patrons an instrument
to recreate these masterpieces with infi-
nite fidelity, regardless of theme, voice
or instrumentation. The new Capehart,
with its "Personal Appearance" tone and
True-Timbre pick-up keeps faith with this
honored tradition.
The Capehart Early Georgian in Walnut or Mahogany.... $1,1 45
March, 1947
323
WOMAN’S AUXILIARY
You can write it
with certainty . . .
Chances are most physicians have never
visited the pharmaceutical laboratories
where the medications they use routinely
are manufactured. You yourself, perhaps
could not name the scientific staff or de-
scribe the methods followed in your favorite
drug house.
One factor you depend upon — "THE
NAME OF THE MANUFACTURER." All
other factors — laboratory facilities, per-
sonnel, procedure — are wrapped up in
THE NAME.
Physicians have relied on the name DORSEY
(until recently Smith-Dorsey ) for over 38
years because the factors behind the name
ere right. Dorsey laboratories are fully
equipped, capably staffed, follow rigidly
standardized testing procedures throughout.
When you write the name, do it with cer-
tainty . . . "Dorsey."
THE SMITH-DORSEY COMPANY
Lincoln, Nebraska • Dallas • Los Angeles
MANUFACTURERS OF FINE PHARMACEUTICALS SINCE 1908
Blue Earth, Redwood-Brown and
Nicollet-Le Sueur Counties
A joint dinner meeting of the medical societies and
auxiliaries of Blue Earth, Redwood-Brown and Nicollet-
Le Sueur Counties was held on January 20, 1947 with
the Nicollet-Le Sueur group as hosts. There was a
very large attendance.
Dr. Robert L. Wilder of Minneapolis addressed the
group and Dr. Robert N. Barr of the Minnesota State
Health Department spoke on the cancer problem and
its control.
After the program the various societies and auxiliaries
had their individual meetings.
Auxiliary members discussed Hygeia, pending legis-
lation and the cancer essay and poster contests.
Hennepin County
The February meeting of the Hennepin County Medi-
cal Auxiliary was held February 7, 1947 at the Medical
Arts Lounge, Minneapolis.
Dr. Donald W. Hastings of the department of psy-
chiatry at the University of Minnesota talked on “Cer-
tain Types of Emotional Illness.”
Mrs. John H. Moe was tea chairman for the day,
and Mrs. Jalmer H. Simons served as hospitality chair-
man.
Ramsey County
The January Meeting of Ramsey County Medical
Auxiliary was held at the home of Mrs. A. A. Kugler,
1368 Edgcumbe Road, Saint Paul.
Mr. Douglas K. Baldwin of the American Red Cross
had as his topic, “Let Us Not Take It for Granted”
and Richard Enquist of Saint Paul played a group of
violin selections.
Tea followed the program with Mrs. Charles Waas
and Mrs. E. C. Bohland pouring.
Awards were presented to two winners of essays on
tuberculosis in a contest conducted as part of the Christ-
mas Seal Program — Delores Carley of White Bear
High School and Irma Artell of Mechanic Arts High
School, Saint Paul.
Upper Mississippi
At a dinner meeting of the Upper Mississippi Medi-
cal Auxiliary held January 25, 1947, the following of-
ficers were elected : Mrs. A. J. Lenarz, Browerville,
president; Mrs. I. L. Mitby, Aitkin, president-elect;
Mrs, Virgil Quanstrom, Brainerd, vice president ; Mrs.
A. M. Mulligan, Brainerd, secretary, and Mrs. A. N.
Borgerson, Long Prairie, treasurer.
The state cancer society and county nursing projects
were discussed at this meeting. Mrs. J. A. Thabes,
Sr., State president-elect, reported on the national auxil-
iary board meeting held recently in Chicago.
The tuberculosis essay contest, sponsored by the
auxiliary was very successful. A number of state win-
ners were residents of the Upper Mississippi territory.
The auxiliary voted contributions to the Red Cross,
Christmas Seals and the State Cancer Society.
324
Minnesota Medicine
The advice is always "SEE YOUR DOCTOR"
For over 18 years, Parke, Davis & Company has conducted an educational
advertising campaign in behalf of the medical profession — teaching the
importance of prompt and proper medical care. Now appearing in color in LIFE and
other leading magazines, these "See your doctor" messages reach
an audience of more than 23 million people.
* rn a i
ftr>p>orfc
* fro"> Park,
ar«t proper
:e' Davjs
medical
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amo ue ™at heart a •
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“ffcance m the body ^ correctab/e,Cd°"
Wp°rao, condi d- often merely „ j
* £ changes the heartt'^’ " Wcfl ac- L
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Ifhe finds yourh
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finding the n
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March, 1947
325
IN MEMORIAM
In Memoriam
CLARENCE MARTIN JACKSON
Dr. Clarence Martin Jackson, professor emeritus of
anatomy and former head of the department at the
University of Minnesota, died January 17, 1947, of
Parkinson’s disease after a long disabling illness. He
retired from the University in 1941 before the comple-
tion of his term of service because of his disability.
Dr. Jackson was born in WhatCheer, Iowa, April 12,
1875 and was seventy-one years old at the time of his
death. He received the B.S., M.S., and M.D. degrees
from the University of Missouri, and in 1923 he was
awarded the LL.D. degree by the University of Mis-
souri in recognition of his services to education.
Shortly after receiving his M.D. degree, Dr. Jackson
was made professor of anatomy and head of the de-
partment at the University of Missouri, and later he
was appointed dean of the medical school. In 1913
he accepted the appointment as head of the Department
of Anatomy at the University of Minnesota, which
position he held until his retirement in 1941.
Dr. Jackson was long recognized as a leader in medi-
cal research. He was acting dean of the graduate
school at Minnesota for several years while Dean Ford
was on leave of absence; and in 1923-24 he was chair-
man of the Medical Division of the National Research
Council. He was a fearless champion of research dur-
ing the trying period when the Minnesota Medical
School was being transformed from an ordinary medi-
cal college to the brilliant teaching and research posi-
tion which it has now attained. Only those of the
faculty who were here during that period realize the
courage and tact which he constantly displayed in
bringing about each small advance to a higher level of
scholarship.
During a large part of his active life Dr. Jackson was
interested in the effects of nutrition upon growth, and
his earlier extensive investigations were summarized in
1925 in his book entitled “The Effects of Inanition and
Malnutrition upon Growth and Structure.”
During the next five years he extended these interests
to a study of body build and physique in university
students, and much of this work was incorporated in a
book in 1930, jointly published by J. A. Harris, C. M.
Jackson, D. G. Patterson and R. E. Scammon, entitled
“The Measurement of Man.”
In the next decade he returned to his earlier interests,
analyzing especially the effect of protein and fat-defi-
cient diets on growth. Also, these years were increas-
ingly occupied by his contribution to the teaching of
anatomy. In 1933, the ninth edition of Morris Human
Anatomy was published under his editorship and he was
working on the tenth edition when obliged to turn it
over to another because of ill health. Finally, just
as he retired, his monumental Report (to the American
Association of Anatomists) of the Committee on Ana-
tomical Nomenclature, of which he was chairman, was
published. In 1922-24 he had been president of the As-
sociation.
The local chapter of Phi Beta Pi medical fraternity,
of which Dr. Jackson was a member, has for several
years sponsored an annual lecture called the “Jackson
Lecture,” in which many distinguished scientists have
participated.
In the death of Dr. Jackson the Medical School has
lost one of its most distinguished professors, and one
who will long be remembered lovingly by the hundreds
of students who came under the influence of his teach-
ing.
E. T. Bell
CHEST X-RAY SURVEY
A program unique in the history of health service is
being planned for this spring and summer in Minneap-
olis. Every resident over fifteen will be given the op-
portunity for a free chest x-ray.
Three mobile x-ray units and seven portable units will
be in operation at the same time in various locations in
the city beginning May 5. No one will walk more than
four blocks for a chest x-ray. Employes in industries
which have not already taken advantage of this service
will be able to have an x-ray at the plant.
The purpose of this health program is to locate un-
suspected cases of tuberculosis, cancer of the lung and
heart diseases, according to Dr. Frank J. Hill, city
Commissioner of Health.
The program is being sponsored by the Hennepin
County Medical Society and the Hennepin County Tuber-
culosis Association. It is being directed by the Minneap-
olis Health Department with the co-operation of the
U. S. Public Health Service.
The Mary E. Pogue School
Complete facilities for training Retarded and
Epileptic children educationally and socially.
Pupils per teacher strictly limited. Excellent
educational, physical and occupational therapy
programs.
Recreational facilities include riding, group
games, selected movies under competent super-
vision of skilled personnel.
Catalogue on request.
G. H. Marquardt, M.D. Barclay J. MacGregor
Medical Director Registrar
2G Geneva Road, Wheaton, Illinois
(Near Chicago)
326
Minnesota Medicine
IN PROPYLENE GLYCOL
MILK DIFFUSIBLE VITAMIN D PREPARATION
ODORLESS - TASTELESS • ECONOMICAL
Growing children require vitamin D
mainly to prevent rickets. They also
need vitamin D, though to a lesser degree ,
to insure optimal development of muscles
and other soft tissues containing
considerable amounts of phosphorus . . .
Milk is the logical menstruum for
administering vitamin D to growing children,
as well as to infants, pregnant women
and lactating mothers. This suggests
the use of Drisdol in Propylene Glycol,
which diffuses uniformly in milk,
fruit juices and other fluids.
Average daily dose for infants 2 drops,
for children and adults 4 to 6 drops,
in milk. Available in bottles of 5, 70 and
50 cc. with special dropper delivering
250 U.S.P. units per drop.
m
Ipigjp
;
DRISDOL, trademark Reg. U. S. Pat. Off.
& Canada, Brand of Crystalline Vitamin D2
(calciferol) from ergosterol
CHEMICAL COMPANY , INC.
Pharmaceuticals of merit for the physician • New York 13, N. Y. • Windsor, Onf.
March, 1947
327
Of General Interest
Dr. H. P. Van Cleve, formerly of Minneapolis, is
now located at Dodge Center.
* * *
Drs. A. E. Henslin and Merrill Henslin have moved
into a newly furnished suite of offices in Le Roy.
* * *
Dr. C. F. Medlin, Truman, recently moved into his
newly constructed office building and is conducting his
practice there.
* * *
Dr. F. J. Kucera, Hopkins, attended the twentieth
annual convention of the National Conference on Medi-
cal Service held in Chicago in February.
* * *
Dr. Paul R. Lipscomb, Rochester, attended the Wat-
son-Jones Fracture Clinic held recently in Chicago under
the auspices of the University of Kansas.
* * *
Dr. Frederick Gunlaugson, Moorhead, formerly with
the Fargo Clinic, has joined the staff of the state hos-
pital in Fergus Falls. Mrs. Gunlaugson, the former Dr.
Eleanor Iverson, was once a member of the same staff.
Dr. Albert V. Stoesser is now located in a new office
at 1409 Willow Street, Loring Park, Minneapolis, where
he is continuing his practice in allergy and pediatrics.
* * *
Dr. Thomas L. Pool, Rochester, discussed “Some of
the Common Errors in Urology” at a meeting of the
Ramsey County Medical Society in Saint Paul.
* * *
Dr. E. V. Allen, Rochester, spoke on the clinical use
of anticoagulants at a meeting of the Cincinnati Academy
of Medicine.
* * *
Dr. Harold N. Rygh, who practiced for a short time
in Cokato following his discharge' from military service,
recently moved to Atwater and opened offices there.
* * *
Opening of a new office in downtown Jackson has
been announced by Drs. W. H. Halloran and W. B.
Wells of that city.
* * *
Dr. Joseph F. Schaefer, Owatonna, was unanimously
elected president of the Steele County Mass X-Ray
Committee at the organization meeting held in Owatonna.
(Continued on Page 330)
7jke Stethetron
'/(/fiico
REMARKABLE development which
assures accuracy in auscultatory diagnosis.
An electronic stethoscope which ampli-
fies the faint heart and chest sounds you
wish to hear while subduing the other
sounds toconvenient levels forcom-
parison.
Easily detects faint murmurs and dis-
ease sounds which cannot be heard
through the old-fashioned acoustic stetho-
scope.
A demonstration will convince you.
MAICO of Minneapolis, 74 So. 9th Street
Adams Bros. Distributors Tel. Atlantic 4329
MAICO of St. Paul, 1108 Commerce Bldg.
Louis J. Kelly, Mgr. Tel. Garfield 6144
328
Minnesota Medicine
Smith, Kline & French Laboratories, Philadelphia, Pa.
Benzedrine Inhaler
A c*tAaAz/& C4
^ <e*cy /h^zAoJ ^<n/
7^e tl*</cl£ Mtoc&fcu. . .
Each Benzedrine Inhaler is packed with racemic amphetamine, S. K. F.f
250 mg - menthol, 12.5 mg.; and aromatics.
Shambaugh, G. E., Jr.: J. Iowa M. Soc. 31:373.
Wide margin of safety Benzedrine
Inhaler, N.N.R., is strikingly effective in reducing
the congestion accompanying head colds, allergic
rhinitis and sinusitis, but it does not give rise
to any significant degree of secondary turgescence,
atony, or bogginess, when used as directed.
March, 1947
329
OF GENERAL INTEREST
In Cholangitis . .
Decbolin produces hydrocholeresis,
flushing the bile ducts, removing
accumulated mucus and inspissat-
ed bile.
In Cholecystitis . .
Decbolin relieves stasis, discourages
ascending infection, promotes
drainage.
In Biliary Surgery. .
Decbolin fits well into the post-
operative routine by materially
helping to keep the bile passages
free from offending debris.
HOW SUPPLIED: Decbolin in VA gr. tab-
lets. Boxes of 25, 100, 500 and 1000.
foecfiaCin
Reg. U. S. Pat. Off.
(dehydrocholic acid)
AMES COMPANY, Inc.
Successors to Riedel - de Haen, Inc.
ELKHART, INDIANA
(Continued from Page 328)
Dr. Henry Van Meier, Stillwater, was reappointed
county physician at a meeting of the Washington County
commissioners in January.
* * *
Dr. O. V. Johnson, Fergus Falls, has accepted a posi-
tion as medical consultant in the legal department of
the Veterans Administration in Minneapolis.
* * *
Dr. W. W. Brown, who has been with the Veterans
Bureau in Minneapolis for the past fourteen years, has
moved to Isle where he has opened his practice.
* * *
F)r. L. G. Smith, Montevideo, was one of the twenty-
one Minnesota physicians who recently incorporated the
Minnesota Medical Service, a nonprofit organization for
voluntary prepaid medical care.
* * *
Dr. Chester A. Anderson, formerly of Buffalo, who
was recently discharged from the armed forces, has
moved to Winsted where he has opened an office for
the practice of medicine.
* * *
Dr. T. H. Leitschuh, formerly of Sleepy Eye, has
become an associate of Dr. J. A. Cosgriff in Olivia.
Since his discharge from the navy after three years
of service, Dr. Leitschuh has lived in Minneapolis.
* * *
Two lectures were delivered by O. T. Clagett, Ro-
chester, at a postgraduate course at the George Wash-
ington LIniversity School of Medicine in Washington,
D. C. Dr. Clagett spoke on “Surgery of the Pancreas”
and “Recent Advances in Surgery of the Biliary Tract.”
* * *
On February 8 in Chicago Dr. John D. Camp, Ro-
chester, presided at the fourteenth annual conference of
the Teachers of Clinical Radiology, sponsored by the
Commission on Education of the American College of
Radiology, of which Dr. Camp is chairman.
* * *
Dr. John M. Waugh, Rochester, presented two papers
at a meeting of the Sioux Valley Medical Association,
in Sioux City, Iowa. His subjects were “The Acute
Conditions of the Abdomen” and “Management of Pel-
vic Tumors.”
* * *
Drs. W. M. Balfour and W. L. Benedict, Rochester,
have been named members of the Board of Governors
of the American College of Surgeons. Dr. G. B. New,
also of Rochester, has been named second vice president
of the organization.
* * *
Both Dr. Richard Magraw and Dr. R. F. Mueller,
Two Harbors, have discontinued their practice in Lake
County. Dr. Magraw has moved to Saint Paul. Dr.
Mueller has been enjoying a two-month vacation and has
not yet announced his future plans.
(Continued on Page 332)
330
Minnesota Medicine
two traumas
1. J.A.M.A. (April 22) 1944
Upjohn
The sick or injured patient is almost simultaneously
subjected to two traumas— the basic pathologic process
and tissue malnutrition— for malnutrition almost al-
ways begins "as soon as injury or disease occurs.”1
Recognition of the vitamin depleting role of dietary
restrictions, increased metabolism, glucose infusions,
and impairment of absorption, has brought with it
the realization that vitamins must be administered in
therapeutic— not maintenance— dosages when multiple
deficiencies complicate disease. Upjohn provides a full
range of maintenance and therapeutic vitamin prepa-
rations for oral and parenteral administration.
FINE PHARMACEUTICALS SINCE 1886
UPJOHN VITAM IN S
March, 1947
331
OF GENERAL INTEREST
INI
ig
p sy r
il
N1
LkJ
[r
i
.jiM
l
JJ
Jvl
'Hto-nmuqiiwuw-*”'
ALCUJftH. M *
v f UroW '°5>C<t' ft
*-.C? <*» Oftl N*, &> 1 $ \\
MERCUROCHROME
(H. W. & D. brand of merbromin,
dibromoxymercurifluorescein-sodium)
Extensive use of the Surgical
Solution of Mercurochrome
has demonstrated its value in
preoperative skin disinfec-
tion. Among the many advan-
tages of this solution are:
Solvents which permit the
antiseptic to reach bacteria
protected by fatty secretions
or epithelial debris.
Clear definition of treated
areas. Rapid drying.
Ease and economy of pre-
paring stock solutions.
Solutions keep indefinitely.
The Surgical Solution may
be prepared in the hospital or
purchased ready to use.
Mercurochrome is also sup-
plied in Aqueous Solution,
Powder and Tablets.
HYNSON, WESTCOTT
& DUNNING, INC.
Baltimore l, Maryland
(Continued from Page 330)
Formation of the Montevideo Clinic took place in
January through the association of Dr. L. R. Lima, Jr.,
and Dr. W. A. Owens, Montevideo. Their now-com-
bined offices have been remodeled and a considerable
amount of new equipment has been installed.
* * *
Dr. F. M. McCarten, Stillwater, was appointed coroner
by the Washington County commissioners on February 4.
A deputy coroner for several years, Dr. McCarten suc-
ceeded Dr. J. H. Haines, who had resigned from the
office.
* * *
Principal speaker at a meeting of the Arrowhead
Society of Medical Technologists, Duluth, was Dr. W.
V. Knoll, pathologist at St. Mary’s Hospital. Dr.
Knoll discussed a color film, “Animated Hematology,”
which dealt primarily with the blood and bone find-
ings in macrocytic anemias.
* * *
Dr. J. S. Blumenthal, Minneapolis, has been elected
chief of staff of St. Andrew’s Hospital. Dr. Blumen-
thal, a practicing physician and surgeon in the Columbia
Heights district of Minneapolis for over twenty years,
is also an assistant clinical professor of medicine at the
LTniversity of Minnesota.
* * *
Dr. J. L. Mills, Winnebago, was a member of a dele-
gation which visited Saint Paul in January to get in-
formation from the State Board of Health in regard
to state recommendations as to hospital building. A
hospital drive is planned by Winnebago citizens for
this spring.
* * *
Dr. W. R. Lovelace II, Rochester, has announced his
resignation from the staffs of the Mayo Clinic and
Mayo Foundation to continue the practice of his uncle
in Albuquerque, New Mexico. While at the Mayo Clinic,
Dr. Lovelace did experimental work with the BLB mask
in high altitude flying.
* * *
Dr. C. Anderson Aldrich, Rochester, pediatrician at
the Mayo Clinic, spoke on the Rochester child health
project at a meeting of the Minneapolis Community
Health Service, February 10. Dr. Aldrich also recently
addressed the American Orthopsychiatric Association ifi
Cincinnati on “The Pediatrician Looks at Personality.”
* * *
Announcement has been made by the Doms-Pierson
Clinic, Slayton, of the recent entry of Dr. Richard M.
Johnson into the partnership.
Dr. Johnson, a graduate of the University of Nebras-
ka School of Medicine in 1942, was formerly at Mann-
ing, Iowa, after completing a tour of service in the
navy.
* * *
Dr. Myron O. Henry, Minneapolis, was named presi-
dent-elect of the American Academy of Orthopedic
Surgeons at a recent meeting in Chicago. Dr. Henry,
(Continued on Page 334)
Minnesota Medicine
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
BROWN & DAY, INC.
St. Paul 1, Minnesota
say "BENSON
n
• • •
: Prescription Analysis Lens Grinding
: Lens Tempering Ophthalmic Dispensing
| Orkon Lenses (Corrected Curve)
■ Cosmet Lenses (Distinctive style and' beauty)
: Hardrx Lenses (Toughened to resist breakage)
: Soft-Lite Lenses (Neutral light absorption the 4th :
: Prescription component) :
! N. P. BENSON OPTICAL COMPANY j
: Established 1913 jj
| Main Office: Minneapolis, Minnesota :
■ Aberdeen Albert Lea Beloit Bismarck Brainerd \
: Duluth Eau Claire Huron LaCrosse Rapid City ■
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i.mn. mm.
/[arch, 1947
333
mrnimrmmrrrmm
OF GENERAL INTEREST
HEARING AID
World's Smallest Hearing Aid
Sizes 23/4 -27/8 Weight— 5 'A Ounces
The smaller the hearing aid
the greater your comfort.
Only One Unit to Wear
Personalized Fitting
For Home or Office Appointment
Call MAin 2787
or write
CLEARTONE HEARING AID
608 Nicollet Room 416 MA. 2787
Minneapolis 2. Minnesota
We co-operate with the medical profession
Human Convalescent Serums
are available lor prevention or treatment
HYPER-IMMUNE PERTUSSIS
MUMPS SCARLET FEVER
POLIOMYELITIS MEASLES
POOLED NORMAL SERUM
Address or telegraph communications or
requests to
Human Serum Lafauratury
West-108, University Hospital
Minneapolis 14, Minn.
Main 8551, Ext. 276 24-hour Service
(Continued from P\age 332)
who is president of the Clinical Orthopedic Society and
present secretary-treasurer of the Academy, will assume
his new office in January, 1948, succeeding Dr. Rex L.
Diveley, New York.
* * *
Dr. Walter C. Alvarez, professor of medicine at the
Mayo Foundation, Rochester, spoke at the thirty-seventh
annual meeting of the Jewish Family and Children’s
Service of Minneapolis, held February 19 at the Radis-
son Hotel in Minneapolis. An internationally recognized
authority on psychosomatic medicine, Dr. Alvarez dis-
cussed “What Makes People Sick.”
* * *
Dr. W. E. Macklin, Jr., Litchfield, joined the staff
of the Mankato Clinic on March 1 as radiologist. A
physician in Litchfield for twelve years, Dr. Macklin
served in the navy in World War II. Since his dis-
charge, he has been taking graduate work in the De-
partment of Radiology at the University of Minnesota.
He recently passed the examination of the American
Board of Radiology.
* * *
Dr. Waltman Waters, Rochester, and Dr. Shields War-
ren, assistant professor of pathology, Harvard Medical
School, have been appointed to serve on the National
Advisory Cancer Council by Dr. Thomas P'arran, Sur-
geon General of the U. S. Public Health Service. Dr.
Walters was first appointed to the Council in 1941, but
service in the navy interrupted his connection with the
Council.
* * *
On January 20, 1947, Drs. Robert E. Priest, Lawrence
R. Boies and Neill F. Goltz presented a paper at the
Middle Section meeting of the American Laryngological,
Rhinological and Otological Society in Chicago. The
paper summarized the experiences at the University of
Minnesota Hospitals and the Minneapolis General Hos-
pital with tracheotomy in bulbar poliomyelitis during the
epidemic of 1946.
* * *
Dr. Alfred S. Nelson, Thief River Falls, has become
affiliated with the Bratrud Clinic of that city, specializing
in internal medicine. A graduate of the University of
Minnesota Medical School in 1943, Dr. Nelson interned
at Ancker Hospital, Saint Paul, and then served for
twenty-six months in the army medical corps. His major
assignment was at a general hospital in Manila, Philip-
pine Islands.
* * *
Dr. Robert M. Watson, formerly of Royalton, is now
affiliated with the Bratrud Clinic in Thief River Falls,
in the capacity of obstetrician and gynecologist. Follow-
ing graduation from the University of Minnesota Medi-
cal School and internship at Miller Hospital, Saint Paul,
Dr. Watson served for eighteen months in the army
medical corps. While stationed at Lovell General Hos-
pital, Fort Devens, Massachusetts, he was assistant chief
of surgery in charge of obstetrics and gynecology.
334
Minnesota Medicine
OF GENERAL INTEREST
Under the subsidization of the Hennepin County
Tuberculosis Association, a broad new health program
is being launched in Minneapolis public schools, with
Helen Starr, associate professor of physical education
at the University of Minnesota, as director.
In addition to handling accident and emergency cases,
the health program includes careful control of commu-
nicable diseases, emphasis on physical education for every
child in school, and intensified health instruction.
* * *
“Cicatricial Stenosis of the Nasopharynx: Correc-
tion by Means of a Skin Graft” was the subject of a talk
by Dr. F. A. Figi, Rochester, before the Southern Sec-
tion of the American Laryngological, Rhinological and
Otological Society, at a meeting in Miami Beach, Florida.
While in Florida, Dr. Figi also presented two papers
at the midwinter postgraduate course in otolaryngology
and ophthalmology held by the Graduate School of Med-
icine of the University of Florida.
* * *
Offices have been opened at the Two Harbors Hospital
by Dr. Ralph Papermaster and Dr. Harry N. Simmonds.
Dr. Papermaster, who is specializing in surgery, was a
surgical resident at Minneapolis General Hospital for
three years, and served as head of an army surgical team
in the European theatre for two years. Dr. Simmonds,
who will do general practice, interned at Columbus Hos-
pital in New York City and then served for two and
one-half years in the army medical corps.
Dr. Ward Norton Van Potter and Dr. Viola Ellen
Sheridan, both of whom hold Fellowships at the Mayo
Clinic, were married on December 28, 1946, in Rochester.
Dr. Sheridan, a graduate of the Medical College of
Creighton University, Omaha, Nebraska, interned at the
Women’s and Children’s Hospital in San Francisco. Dr.
P'otter, a graduate of the Medical College of the Uni-
versity of Toronto, Ontario, interned at the General
Hospital in Montreal, Quebec, Canada.
* * *
Dr. Francis E. Harrington, former superintendent of
Minneapolis General Hospital and former commissioner
of Minneapolis, was praised in an article in a recent is-
sue of the J ournal-Lancet for building an outstanding
anti-tuberculosis program for Minneapolis. The article,
written by Dr. J. A. Myers, professor of public health at
the University of Minnesota, states : “Under Dr. Har-
ington’s leadership, tuberculosis has reached such a low
ebb in Minneapolis that workers are beginning to talk
about eradication, rather than control of the disease.”
* * *
“CORRECTION— In the announcement of the opening
of the offices of Dr. Frank W. Quattlebaum and Dr.
Jane E. Hodgson, which appeared in the January issue
of Minnesota Medicine, it was incorrectly stated that
Dr. Quattlebaum had served a fellowship in obstetrics
and gynecology at the Mayo Clinic. Dr. Quattlebaum
took his training in surgery at the University of Minne-
AFTER HOURS
A laugh for the Doctor
"JACK ... WRENCH. .. SPARE."
Over two thousand grocers in the Northwest carry
HOME BRAND STRAINED BABY FOODS.
HOME BRAND ON THE LABEL MEANS GOOD FOOD ON BABY’S TABLE
GRIGGS, COOPER & CO. • TWIN CITIES, TWIN PORTS, FARGO
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March, 1947
335
OF GENERAL INTEREST
sota and at the Mayo Clinic. His associate, Dr. Jane
Hodgson, completed her fellowship in obstetrics and
gynecology at the Mayo Clinic in 1944 and is limiting her
practice to this specialty.
* * *
Believed to be Minnesota's oldest practicing physi-
cian, Dr. George D. Haggard, Minneapolis, celebrated
his ninetieth birthday on January 18.
Born in 1857 in Fairpoint, near Rochester, while
Minnesota was still a territory, Dr. Haggard has served
three generations of many of the state’s oldest families.
He graduated from the University of Minnesota Medi-
cal School in 1893 and interned at Minneapolis General
Hospital. For four years he was health officer of Min-
neapolis. At present he is on the staff of Northwestern
and Asbury hospitals. He still answers many calls,
though a heart attack six months ago forced him to
curtail his activities.
* * *
Dr. and Mrs. Moses Barron, Minneapolis, were guests
of honor at the annual Jewish National Fund dinner,
held January 26 at the Radisson Hotel. In recognition of
Dr. and Mrs. Barron’s twenty-five years of leadership
in Minneapolis Jewish affairs, nearly 100 organizations
gathered to present the couple with a book bearing the
names of contributors to the development of a forest in
Palestine that will be named for the Barrons.
Dr. Barron, a professor of medicine at the University
of Minnesota, is a past president of the Hennepin
County Medical Society, the Minnesota Society of Inter-
nal Medicine, the Minnesota Pathological Society, and
the Minneapolis Academy of Medicine.
* * *
Dr. Victor Johnson, Chicago, dean of students in
biology and medicine and professor of physiology at
the University of Chicago, will become director of the
Mayo Foundation for Medical Education and Research
next fall. He will succeed Dr. Donald C. Balfour,
present director, who is scheduled to retire in October,
1947.
Dr. Johnson, author of several articles and books, is
a member of numerous scientific and educational organ-
izations and is on the advisory committee of the Surgeon
General, Llnited States Public Health Service, in ad-
ministration of the Federal Hospital Survey and Con-
struction Act. To accept the Mayo appointment, he
resigned as secretary of the AMA Council on Medical
Education and Hospitals.
Following retirement, Dr. Balfour, who has been di-
rector of the Mayo Foundation since 1937, will serve
as director emeritus and as professor of surgery emeri-
tus in the University of Minnesota graduate school.
* * *
Five physicians comprised the medical staff of the
Bemidji Clinic when it opened the doors of its new
building in January. Drs. D. F. McCann, T. P. Gros-
chupf, and D. D. Whittmore, Bemidji, were joined by
Drs. W. J. Deweese and S. F. Becker to form the
TTOMEWOOD HOSPITAL is one of the
Northwest's outstanding hospitals for the
treatment of Nervous Disorders — equipped
with all the essentials for rendering high-grade
service to patient and physician.
Operated in Connection with
Glenwood Hills Hospitals
HOMEWOOD HOSPITAL
Corner Penn and Plymouth Avenues North
Minneapolis Minnesota
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Borcherdt Malt Soup Extract is a
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336
Minnesota Medicine
OF GENERAL INTEREST
clinic group which will practice in the recently com-
pleted office building.
Dr. Deweese, a graduate of the University of Nebras-
ka Medical School and a veteran of World War II,
has completed a residency in surgery at the Kings Coun-
ty Hospital in New York. Dr. Becker, who graduated
from the University of Minnesota Medical School be-
fore serving in the navy, was formerly a member of
the Bratrud Clinic in Thief River Falls. More recently
he has been doing graduate work at the University of
Minnesota.
Negotiations are in progress to add other members to
the clinic staff, and the founders hope to have the group
completed by early summer.
HOSPITAL NEWS
Harry Rice, Afton township, was made a member
of the Lakeview Hospital board at the meeting of the
Washington County commissioners in January. He
succeeded Lou Orr, who had previously resigned.
* * *
Named president of the St. Cloud Hospital medical
staff at the annual meeting in January was Dr. F. J.
Schatz. He succeeded Dr. J. N. Libert. The staff
elected Dr. S. J. Raetz as vice president, and Dr. F. H.
Baumgartner, secretary.
* * *
Dr. Charles A. Aling was named medical staff chair-
man of St. Barnabas Hospital, Minneapolis, at the annual
staff meeting February 5. Dr. Elmer J. Lillehei was
elected vice chairman, and Dr. William E. Proffitt be-
came secretary-treasurer.
* * *
At the annual staff meeting of Eitel Hospital, Minne-
apolis, Dr. Frank R. Hirschfield was elected chief of
staff to succeed Dr. William R. Jones. Dr. Ray Coch-
rane was chosen assistant chief of staff, and Dr. Gordon
G. Bowers was elected secretary.
* * *
In Brainerd, Dr. J. A. Thabes, Sr., has been elected
chief of staff of St. Joseph’s Hospital, succeeding Dr.
V. E. Quanstrom, Dr. R. A. Beise has been selected to
place Dr. W. E. Fitzsimons as vice chief of staff, and
Dr. Fitzsimons has succeeded Dr. J. A. Thabes, Jr., as
secretary-treasurer.
^
With his re-election as president, Dr. J. E. O’Donnell
heads the staff of St. Mary’s Hospital, Minneapolis, for
a second term. Dr. F. B. Mach is serving as vice
president, and Dr. L. J. Happe is secretary-treasurer.
These three men, together with Dr. Leo C. Culligan,
Dr. B. A. Dvorak and Dr. L. A. Lang, form the ad-
visory board of the hospital.
%
On January 10, Dr. A. J. Spang was elected chief of
staff of Miller Memorial Hospital, Duluth, at the medi-
cal staff’s annual meeting. Other officers named were
Dr. K. R. Fawcett, vice chief of staff, and Dr. Karl
Johnson, secretary-treasurer. Dr. A. L. Abraham and
Dr. Miriam Fredericks were elected as new members
Kalman & Company, Inc.
Investment Securities
Members:
Chicago Stock Exchange
Minneapolis-St. Paul Stock Exchange
ST. PAUL MINNEAPOLIS
ACCIDENT • HOSPITAL •
SICKNESS
INSURANCE
FOR PHYSICIANS, SURGEONS, DENTISTS EXCLUSIVELY
/ PHYSICIANS \
All ( \
Alt
> PREMIUMS iX wa&iONS ^ CLAIMS C
COME FROM V DENTISTS /
GO TO
$5,000.00 accidental death
$25.00 weekly indemnity, accident
and sickness
$10,000.00 accidental death
!j $50.00 weekly indemnity, accident
and sickness
$15,000.00 accidental death
; $75.00 weekly indemnity, accident
and sickness
$20,000.00 accidental death ......
$100.00 weekly indemnity , accident
and sickness
$8.00
Quarterly >
$16.00
Quarterly
$24.00
Quarterly
$32.00
Quarterly
ALSO HOSPITAL EXPENSE FOR MEMBERS
WIVES AND CHILDREN £
86c out of each $1.00 gross income used for
members’ benefits
$3,000,000.00 $14,000,000.00
INVESTED ASSETS PAID FOR CLAIMS
$200,000.00 deposited with State ot Nebraska for protection of our members.
Disability need not be incurred in line of duty — benefits from
the beginning day of disability
PHYSICIANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION
45 years under the the same management
400 FIRST NATIONAL BANK BUILDING • OMAHA 2, NEBRASKA
337
March, 1947
riiiiiiiiiiiiiiiiiiiiiiiiiiiiiniMiiiiiiiiiiiiiiiiiiiiniiiiiiiiiiiiiiimiiiiiiiiiniiiiiiiiiiii
OF GENERAL INTEREST
of the executive committee, while Dr. Mario Fischer
was named an ex-officio member.
* * *
Two New Ulm hospitals elected officers at annual
staff meetings on January 9.
Heading the Loretto Hospital staff are Dr. Carl J.
Fritsche, president; Dr. O. B. Fesenmaier, vice presi-
dent, and Dr. O. J. Seifert, secretary.
Union Hospital officers are Dr. H. A. Vogel, presi-
dent; Dr. O. J. Seifert, vice president, and Dr. Carl
J. Fritsche, secretary.
* * *
Organization of a community hospital board in Blue
Earth was completed in early January. John Frundt
was elected president of the board, Martin Madison, vice
president, and Frances Schneider, secretary-treasurer.
President at a later meeting of the board were the
local doctors of Blue Earth, as well as Dr. C. D. Snyder,
Kiester; Dr. A. W. Sommer, Elmore, and Dr. Lewis
Hanson, Frost. The board selected Minnie Fenskc
as superintendent of the hospital. A medical staff was
organized, with Dr. C. E. Wilson as head.
* * *
Hibbing General Hospital has selected Dr. T. A. Es-
trem as chief of staff, Dr. C. N. Harris as vice presi-
dent, and Dr. T. R. Schweiger as secretary.
Department heads named at a staff meeting in Jan-
uary are Dr. L. W. Johnsrud, surgery; Dr. L. S. Nel-
son, internal medicine; Dr. L. W. Morsman, ophthal-
mology; Dr. Andrew Sinimark, otolaryngology; Dr.
C. N. Harris, pediatrics; Dr. Frank Bachnik, obstetrics;
Dr. A. C. Tingdale, communicable diseases and con-
tagion; Dr. C. S. Raadquist, x-ray; and Dr. Randall
Derifield, laboratory.
* * *
The position of executive administrator of North-
western Hospital, Minneapolis, was assumed on March
1 by Russell Nye, former administrator of the Dallas,
Texas, city-county hospital system.
Mr. Nye, who before his new appointment was presi-
dent-elect of the Texas Hospital Association has held
administrative positions at Michael Reese Hospital in
Chicago, Crawford-Long Memorial Hospital in Atlanta,
and the LIniversity of Iowa Hospitals. He succeeds
Colonel Harry Brown, who has been on military leave
and who will return to active army duty.
* * *
Chief of staff of St. Luke’s Hospital, Duluth, for 1947
is Dr. A. O. Swenson, who was recently elected to suc-
ceed Dr. Anderson C. Hilding.
Also named by the hospital staff were Dr. Gordon C.
MacRae, vice chief of staff; Dr. J. R. Manley, chief of
obstetrics ; Dr. Peter S. Rudie, chief of surgery ; Dr.
R. E. Nutting, chief of pediatrics; Dr. M. F. Fellows,
chief of eye, ear, nose and throat ; and Dr. A. H. Wells,
chief of pathological laboratories. Dr. F. J. Hirsch-
boeck, Dr. A. L. Abraham, and Dr. C. M. Bagley,
secretary, were named to the executive committee.
* * *
Earl C. Wolf, purchasing agent of St. Mary’s Hospi-
tal in Rochester, was named president of the Minnesota
REST HOSPITAL
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reputable physicians who may supervise the treat-
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Dr. Hewitt B. Hannah
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always in demand. |
EXCELLENT CARE TO CONVALESCENT AND
CHRONIC PATIENTS
Rates Reasonable. Patients under the care of their own physicians, i
who direct the treatment. |
5511 Lyndale Ave. So. LO. 0773 Minneapolis, Minn. |
Ill
338
Minnesota Medicine
OF GENERAL INTEREST
Hospital Association at a meeting of the board of direc-
tors in Minneapolis on January 18.
Former first vice president of the Association, Mr.
Wolf was appointed to serve out the unexpired term
if the late W. W. Sherman, who was superintendent of
:he Naeve Hospital in Albert Lea. His tenure will ex-
pire May 15, when the Association holds its annual meet-
.ng in Minneapolis.
Emil Hanson, superintendent of Winona General Hos-
pital, was elected to Mr. Wolf’s former office.
* * *
Election of Dr. L. R. Gowan as chief of staff of St.
Mary’s Hospital, Duluth, was announced on February
7. He replaces Dr. J. E. Power in the position.
Other staff officers of the hospital, elected at the
same time, are Dr. C. O. Kohlbry, president-elect; Dr.
F. T. Becker, secretary of the staff; Dr. R. P. Buckley,
:hief of pediatrics, and Dr. A. J. Bianco, chief of sur-
gery.
Officers continuing from 1946 are Dr. Frank Cole,
:hief of anesthesiology; Dr. J. A. Winter, chief of eye,
ear, nose and throat; Dr. C. W. Taylor, chief of con-
tagion; Dr. E. L. Tuohy, chief of laboratories; Dr. Rich-
ard Bardon, chief of medicine ; Dr. L. E. Schneider,
chief of neurology ; Dr. J. R. Moe, chief of obstetrics ;
Dr. M. H. Tibbetts, chief of orthopedics, and Dr. M. A.
Nicholson, chief of urology.
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MASSIVE GASTRIC HEMORRHAGE
(Continued from Page 319)
Discussion
Dr. Hamlin Mattson : In the first section you
showed, isn’t that sufficient to give a diagnosis of ulcer
in the mucous membrane?
Dr. G. H. Hall : Yes. The pathologist called it a
small acute ulcer.
Dr. Hamlin Mattson : From what part of the stom-
ach was that taken?
Dr. G. H. Hall : The posterior upper portion of the
resection.
Dr. John R. Paine: I should like to ask some of
the experienced surgeons what a surgeon is supposed
to do if he operates for an ulcer and does not find
an ulcer. Do you leave the stomach in or take it out?
Dr. Willard White: I don’t pretend to be able to
answer the question, but if you have a patient into
whom you are pouring blood and he is pouring it back
as fast as you pour it in, you have to do something,
and I think that resection is exactly the thing to do.
I have had to make this same decision, myself.
Dr. John R. Paine: It is a pure and simple gamble.
The only bad thing is that you have to take out the
stomach. The ulcer may be somewhere else.
Dr. J. M. Hayes : In speaking of gastric hemorrhage,
we must refer back to a previous discussion before
this society on the use of Koagmin. Dr. Arnold Jack-
son of Madison popularized this drug in this vicinity.
Those who have given it a trial are usually enthusiastic
about the results. I have used it several times in case
of severe gastric hemorrhage and agree with Jackson
that it will often check the hemorrhage sufficiently to
defer an emergency operation.
Cook County
Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY — Two-week intensive course in Surgical
Technique, starting March 17, April 14, May 12,
June 9.
Four-week course in General Surgery, starting March
31, April 28, May 26.
Two-week course in Surgical Anatomy and Clinical
Surgery, starting March 17, April 14, May 12, June 9.
One-week course in Surgery of Colon and Rectum, start-
ing April 7, May 5, June 2.
Two-week course in Surgical Pathology, every two
weeks.
GYNECOLOGY — Two-week intensive course, starting
April 14, May 12, June 16.
One-week course in Vaginal Approach to Pelvic Surg-
ery, starting April 7, May 5, June 9.
OBSTETRICS — Two-week intensive course, starting
April 28, June 2.
MEDICINE — Two-week intensive course, starting April
7, June 2.
Two-week Gastroenterology, starting April 21, June 16.
One-month course in Electrocardiography and Heart,
starting June 16, September 15.
DERMATOLOGY and SYPHILOLOGY — Two-week
course, starting April 14, June 16.
General, Intensive and Special Courses in all Branches
of Medicine, Surgery and the Specialties
TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address;
Registrar, 427 S. Honore St., Chicago 12, 111.
March, 1947
339
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
Practical Physiological Chemistry. Twelfth Edition.
Philip B. Hawk, Ph.D., President and Bernard L.
Oser, Ph.D., Director, Food Research Laboratories,
Inc., New York; and William H. Summerson, Ph.D.,
Associate Professor of Biochemistry, Cornell Univer-
sity Medical College, New York. 1323 pages. Ulus.
Price, $10.00, cloth. Philadelphia: The Blakiston Co.,
1947.
Radiology for Medical Students. Fred Tenner Hodges,
M.D., Professor and Chairman, Department of Roent-
genology, University of Michigan; Isadore Lampe,
M.D., Associate Professor, Department of Roentgen-
ology, University of Michigan, and John Floyd Holt,
M.D., Assistant Professor, Department of Roentgen-
ology, University of Michigan. 424 pages. Illus.
Price, $6.75, cloth. Chicago: Year Book Publishers,
1947.
The Com pleat Pediatrician. Practical, Diagnostic,
Therapeutic and Preventive Pediatrics. Fifth Edition.
Wilbur C. Davison, M.A., D.Sc., M.D., Professor of
Pediatrics, Duke University School of Medicine and
Pediatrician Duke Hospital ; formerly Acting Head of
Department of Pediatrics, Johns Hopkins University
School of Medicine, etc. Price, $3.75 check with
order, or $4.00 on credit, cloth. Durham, N. C. :
Duke University Press, 1946.
Fundamentals of Clinical Neurology. H. Houston
Merritt, M.D., Professor of Clinical Neurology, Col-
lege of Physicians and Surgeons, Columbia Univer-
sity; Chief of Division of Neuropsychiatry, The
Montefiore Hospital ; Fred A. Mettler, M.D., Ph.D.,
Associate Professor of Anatomy, College of Physi-
cians and Surgeons, Columbia University, and Tracy
Jackson Putnam, M.D., Professor of Neurology and
Neurological Surgery, College of Physicians and Sur-
geons, Columbia University, New York. 289 pages.
Illus. Price, cloth, $6.00. Philadelphia: The Blakis-
ton Co., 1947.
Health Examinations. A Manual for the General
Practitioner. Prepared for Medical Society of the
County of New York, by the Special Committee on
Preventive Medicine. 144 pages, paper cover. Pre-
sented with the compliments of Mead Johnson &
Company, Evansville, Indiana, 1947.
SHOCK TREATMENTS AND OTHER SOMATIC PROCE-
DURES IN PSYCHIATRY. L. I!. Kalinowsky, M.D., Re-
search Associate in Psychiatry, College of Physicians and Sur-
geons Columbia University, and New York State Psychiatric
Institute and Hospital, Assistant Neurologist, Neurological In-
stitute of New York; and Paul H. Hoch, M.D., Assistant
Clinical Psychiatrist, New York State Psychiatric Institute and
Hospital; Instructor in Psychiatry, College of Physicians and
Surgeons, Columbia University. 320 pages. Price $4.50. New
York: Grune & Stratton, Inc., 1946.
This is a very well-organized, authoritative, easy-to-
read treatise on, primarily, shock treatment but it deals
also with other somatic non-surgical treatment, pre-
frontal lobotomy, and theoretical considerations in re-
lation to this phase of psychiatric therapy.
A brief review of historical development is given, and
comprehensive and detailed practical instruction in the
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INSTRUMENTS • TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494
340
Minnesota Medicine
BOOK REVIEWS
use of insulin shock treatment and the convulsive ther-
apy is carefully outlined.
The authors have been identified for several years in
practical work in research on new procedures in the
treatment of mental illness and are highly qualified to
present their findings and opinion in an authoritative
fashion.
This book is highly recommended to the psychiatrist
and neurologist. Every important problem is carefully
considered. Specific references and an excellent bibli-
ography of several hundred important papers and books
will aid the specialist to find further details on any point
that is of particular interest to him.
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INDEX TO ADVERTISERS
Abbott Laboratories 230
American Meat Institute 232
American National Bank 343
Ames Co., Inc ...330
Anderson, C. F., Co., Inc 239
Ayerst, McKenna & Harrison, Ltd 255
Benson, N. P., Optical Co 333
Birches Sanitarium, Inc 342
Borden’s Prescription Products Division 243
Borcherdt Malt Extract Co 336
Bristol Laboratories, Inc 245
Brown, & Day, Inc 333
Burroughs Wellcome & Co 233, 254
Camel Cigarettes 247
Camp, S. H., & Co .236
Ciba Pharmaceutical Products, Inc Facing page 240
Classified Advertising 342
Cleartone Hearing Aid 334
Cook County Graduate School of Medicine 339
Dahl, Joseph E., Co 343
Danielson Medical Arts Pharmacy 340
Druggists Mutual Insurance Co 343
Ewald Bros Inside Back Cover
Franklin Hospital 342
General Electric X-Ray Corporation 235
Glenwood Hills Hospitals 249
Glenwood-Inglewood Co 341
Griggs, Cooper & Co 335
Hall & Anderson 343
Holland-Rantos Co., Inc 240
Homewood Hospital 336
Human Serum Laboratory 334
Hynson, Westcott & Dunning 332
Kalman & Co., Inc 337
Kinney, H. W., &. Sons, Inc 241
Kroll, August F 343
Laboratory Ramsey County Medical Society 246
Lilly, Eli, & Co Facing page 256
McGowans 323
Maico Co 328
Massachusetts Indemnity Insurance Co 226
Mead Johnson & Co 344
Medical Placement Registry 342
Medical Protective Co 234
Merck & Co., Inc 250
Milwaukee Sanitarium Back Cover
Mithun X-Ray Co 339
Mounds Park Sanitarium Back Cover
Murphy Laboratories 343
Nestle’s Milk Products ! 253
North Shore Health Resort 333
Palm Orthopedic Appliance Co 340
Parke, Davis & Co Inside Front Cover, 225, 325
Philip Morris & Co. Ltd. Inc ,.244
Physicians Casualty Association 337
Physicians & Hospitals Supply Co. Inc 231, 340, 343
Pogue, Mary E., School 326
Rest Hospital 338
Rexall Drug Co 238
Roddy-Kuhl-Ackerman 340
St. Croixdale Sanitarium 228
Schenley Laboratories, Inc 248
Schering Corporation 237
Schmid, Julius, Inc 252
Schusler, J. X., Co 342
Searle, G. D., & Co 321
Seelert Orthopedic Appliance Co 341
Smith-Dorsey Co 324
Smith, Kline & French Laboratories 251, 329
Squibb, E. R., & Sons 229
Upjohn Co ,.331
Vocational Hospital 338
Walker Vitamin Products, Inc 256
Williams, Arthur F 343
Winthrop Chemical Co. Inc 327
Wyeth, Inc 242
Zemmer Co 342
March, 1947
341
The Birches Sanitarium, Inc.
2391 Woodland Avenue
Duluth 3, Minnesota
A hospital for the care and treatment of
Nervous and Mental disorders. Quiet, cheer-
ful environment. Specially trained personnel.
Recreational and occupational therapy.
Psychiatrists in Charge
L. R. Gowan, M.D. L. E. Schneider, M.D.
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PART TIME— TEMPORARY— PERMANENT
When in need of a PHYSICIAN, DENTIST, OFFICE NURSE, TECHNICIAN, MEDICAL SECRETARY, or
OTHER PERSONNEL for medical and dental offices, clinics, and hospitals contact —
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OLIVE H. KOHNER, Director
TAILORS TO MEN
SINCE 1886
The finest imported and
domestic woolens such as
SCHUSLER'S have in stock
are not too fine to match
the hand tailoring we al-
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379 Robert St. St. Paul
George Dejmek
Classified Advertising
WANTED — Well qualified young physician interested in
general practice and obstetrics for association with
well-established general surgeon in suburbs. , Good
salary. Address E-9, care Minnesota Medicine.
LOCUM TENENS WANTED — For period from April
20 to June 10. A. I. Arneson, M.D., Morris, Minne-
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Practical Nursing Course
Nine months' course open to high school
graduates or women with equivalent
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For further information
write
Mrs. Lydia Zielke, Supt. of Nurses
FRANKLIN HOSPITAL
501 Franklin Avenue Minneapolis 5, Minnesota
PHYSICIAN WANTED — To join group in Northern
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group if congenial. Prefer recent graduate. Address
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FOR RENT — New doctor’s offices in Long Lake, Min-
nesota. New building; thriving community. Excel-
lent opportunity for lucrative practice. Apply Lyman
Lumber and Coal Company, Excelsior, Minnesota.
FOR SALE — Pavex machine, like new. Sacrifice, $85.00.
Address E-5, care Minnesota Medicine.
t'C' * , * mm >'■
i ' V/ : ||p:5 . «♦'
A complete line of laboratory
controlled ethical pharmaceuticals.
Chemists to the Medical Profession for 44 years.
Min. 3-47 ZJhe Zemmer Company
Oakland Station • PITTSBURGH 13, PA.
342
Minnesota Medicine
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414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
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Orthopedic Braces and
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Physicians' specifications
followed precisely.
Scientific manufacture
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AUGUST F. KROLL
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230 WEST KELLOGG BLVD.
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Radiological and Clinical j
| Assistance to Physicians !
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MURPHY LABORATORIES
Minneapolis: 612 Wesley Temple Bldg. - - At. 478*
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March, 1947
343
The rooster’s legs
are straight.
The boy’s are not.
The rooster got plenty of vitamin D.
Fortunately, extreme cases of rickets such as the one above illustrated
are comparatively rare nowadays, due to the widespread prophy-
lactic use of vitamin D recommended by the medical profession.
One of the surest and easiest means of routinely administering vitamin D (and vitamin A)
to children is MEAD’S OLEUM PERCOMORPHUM WITH OTHER FISH-LIVER
OILS AND VIOSTEROL. Supplied in 10-c.c. and 50-c.c. bottles. Also supplied in bottles
of 50 and 250 capsules. Council Accepted. All Mead Products Are Council Accepted. Mead
Johnson & Company, Evansville 21, Ind., U.S.A.
344
Minnesota Medicine
For estrogenic therapy THEELIN is offered in
ampoule form. Protection of potency and steril-
ity of the original pure crystalline hormone are
afforded by this individualized packaging.
THEELIN for Therapy
Climacteric symptoms in varying degrees of
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women as they enter and pass through phases
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decreases typical manifestations associated with
this condition.
THEELIN
Now available in all sizes:
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MASSACHUSETTS INDEMNITY INSURANCE COMPANY
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MINNEAPOLIS 2, MINNESOTA
346
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 April, 1947 No. 4
Contents
Medical Service Program in the Veterans Ad-
ministration Hospitals.
General Paul R. Hawley, Washington, D. C 377
Voluntary Prepayment Medical Care and Its
Rural Aspects.
Louis A. Buie, M.D., Rochester, Minnesota 382
The Treatment of Persons Who Have Bron-
chial Asthma.
Arthur T. Laird, M.D., Duluth, Minnesota 386
Nitrogen Balance and Its Clinical Application.
Robert E. Hansen, B.S., M.D., and Edward L.
Tuohy, M.D., F.A.C.P., Duluth, Minnesota 394
Observations on the Management of Vasomotor
Rhinitis.
James B. McBean, M.D., Rochester, Minnesota.. 399
Orchiectomy and Hormones in Prostatic Car-
cinoma.
Philip F. Donohue, M.D., Saint Paul, Minnesota. . 403
Mycetoma or Madura Foot.
Henry W. M eyerding , M.D., and J. A. Evert, Jr., M.D.,
Rochester, Minnesota 407
Case Report:
Intestinal Ascaris Diagnosed Roentgenographically
in Minnesota.
R. S. Leighton, M.D., and R. J. Weisberg, M.D.,
Minneapolis, Minnesota 410
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. (Continued from March
issue.)
Nora H. Guthrey, Rochester, Minnesota 412
President's Letter :
Medical Benevolence 419
Editorial :
Minnesota Cancer Society 420
Fading Ink 420
Tuberculosis Surveys in Minnesota 421
Intravenous Ether — An Aid to Collateral Circu-
lation 422
Report of the House of Delegates — American
Medical Association, December 9-11, 1946 423
Medical Economics :
County Officers Hear Progress Reports on
MSMA Programs 424
Minnesota Academy of Medicine:
Meeting of December 11, 1946 427
Meniere’s Disease : Endolymphatic Hydrops.
Lazvrence R. Boies, M.D., Minneapolis,
Minnesota 427
Peripheral Arterial Embolism.
Joseph F. Borg, M.D., Saint Paul, Minnesota. .432
Reports and Announcements 442
Woman's Auxiliary 444
In Memoriam 446
Of General Interest 448
Book Reviews 454
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in flection 1103, Act of October 3, 1917, authorized July 13, 1918.
April. 1947
347
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
G. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — $3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions — $3.50.
The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
ST. CROIXD ALE ON LAKE ST. CROIX
PRESCOTT, WISCONSIN
MAIN BUILDING— ONE OF THE 8 UNITS IN “COTTAGE PLAN”
A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous and Mental Disorders
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Illustrated folder on request.
NEUROPSYCHIATRISTS
PRESCOTT OFFICE
Prescott, Wis.
Howard J. Laney, M.D.
Tel. 39 and Res. 76
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Sll Medical Arts Building
Minneapolis. Minnesota
Tel. MAin 1357
SUPERINTENDENT
Dorothy M. Most, R.N.
Prescott, Wisconsin
T'el. 69
348
Minnesota Medicine
• . . even on self-rectified current
Forced oil circulation within the sealed -off tube housing, coupled with large
volume air-blast, so increases its heat dissipation rate that the "Airflow” tube
can be operated continuously, even on self-rectified current... the only tube so rated.
This unique design principle" is another example of the trail-blazing engineering
which has made the Picker hallmark on x-ray equipment a symbol of consistently
high performance over an exceptionally long life.
*U. S. Pat. No. 2.259.037
Brown & Day# Inc.
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ST. PAUL, MINN.
sets the pace in X-ray
April, 1947
349
dub!
Eminent et
dieturq
At meal time his renowned judgment deserts him.
Eating only the food he likes, a choice of notably
limited range, he thrice daily produces a burlesque
on proper nutrition. Inevitably, this perennial first-
nighter makes his entrance into some physician’s recep-
tion room — the victim of a self-made, borderline vita-
min deficiency. In the same cast, you will find other
familiar types. Included in it are the ignorant and in-
different, people "too busy” to eat properly, those on
self-imposed and badly balanced reducing diets, exces-
sive smokers, food faddists and alcoholics, to name a
few. hirst thought in such cases is dietary reform, of
350
course. Along with that, a dependable vitamin supple-
ment may well be in order. When you prescribe an
Abbott vitamin product, you are assured that the
patient will receive the full vitamin potencies intended.
Your pharmacy carries a complete line of Abbott vita-
min products in a variety of dosage forms and pack-
age sizes, and will be pleased to fill your prescriptions.
Abbott Laboratories, North Chicago, Illinois.
SPECIFY
Abbott Vitamin Products
Minnesota Medicine
T HIS excellent Paper Towel is not
■ only sanitary and absorbent, but it
is entirely free of lint. Because like oth-
er SOLAREUM products, it was pro-
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For wiping the hands after washing;
for a cover on the headrest of your ex-
amining table; as a paper napkin for
the food tray; or, as a temporary floor
mat for the barefoot patient, and num-
erous other expedients, this Paper Tow-
el serves the purpose well. There is
nothing else like it.
In each roll you get 450 running feet
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Ask our salesman about this generous We also supply SOLAREUM Paper Table
size Paper Towel, with Holder for your Sheeting, continuous rolls and individual sheets,
wall, or write direct to us. to cover every need for examining tables.
ALL-STEEL. ENAMELED
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A Practical. Sanitary
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Built of heavy sheet steel and carefully
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SOLAREUM Towel. Finish in durable baked
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with screws furnished. Dustproof, and secure.
No*hing to get out of order.
Towel pulls out over steel ledge which
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Choice of white enamel or walnut color.
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■ ■ V.'X
'A8LtTS
m
|*|>jS£.ac*d norn» far tripe*' 1 »,
^ *®'OiHiri* mocioHyd ■- *
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«l (**} MM»A«imeU • C'lX‘^d
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Pyribenzamine
Pyribenzamine. (brand of tripelennaminc) Trade Mark Reg. IT. S Pat. Off.
ALL PYRIBENZAMINE PRESCRIPTIONS CAN NOW
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352
Minnesota Medicine
BIBLIOGRAPHY
Pyribenzamine hydrochloride— Ciba’s anti-his-
taminic— has won prompt recognition since its recent introduction.
It has proved successful in a high percentage of cases of urticaria, hay
fever, asthma; and today is widely prescribed.
Hoekstra, Jr. and Steggerda, F. R. Fed. Proc.
5:48-9. Feb.. 1946.
Koepf, G. C.. Arbesman. C. E. and Lenzner, A.
Fed. Proc. 5:56-7, Feb., 1946.
Craver, B. N.. Seip, P., Cameron, A. and Yonkman,
F. F. Fed. Proc. 5:172, Feb., 1946.
Mathieson, D., Hays, H. W., Chess. D., Cameron,
A. and Yonkman, F. F. Fed. Proc. 5:192-3. Feb., 1946.
Sherrod, T. R., Schloemer, H. F. and Loew, E. R.
Fed. Proc. 5:2C2, Feb., 1946.
Yonkman, F. F., Chess, D., Hays, H. W., Rennick,
B. and Mayer, R. L. Fed. Proc. 5:216, Feb.. 1946.
Epstein, S. Wise. Med. J. 45:489-96. May. 1946.
Mayer, R. L. J. Allergy 17:153-65, May, 1946.
Sangster, W., Grossman, M. I. and Ivy, A. C.
Gastro. 6:436-8, May, 1946.
Friedlaender, S., Feinberg, S. M. and Ffinberg,
A. R. Proc. Soc. Exp. Biol. & Med. 62:65-7, May,
1946.
Friedlaender, S. and Feinberg, S. N. J. Allergy
17:129-41, May, 1946.
Baer, R. L. and Sulzberger, M. B. J. Invcs. Derm.
7:147-8, June, 1946.
Horton, B. T. and Macy, D., Jr. Med. Clin. N. A.
811-31, July, 1946.
Mayer, R. L., Hays, H. W., Brousseau, D.. Mathie-
son, D., Rennick, B. and Yonkman, F. F. J. Lab. &
Clin. Med. 31:749-51, July. 1946.
Friedlaender, S. Am. J. Med. 1:174-9, Aug., 1946.
Yonkman, F. F., Chess. D., Mathieson, D. and
Hansen, N. J. Pharm. & Exp. Thera. 87:256-64.
July, 1946.
Arbesman, C. E., Koepf, G. F. and Miller, G. E.
J. Allergy 17:203-9, July, 1946.
Feinberg, S. M. J. Allergy 17:217-30, July, 1946.
Unger. L. Ann. Allergy 4:299-334, July-Aug., 1946.
Baer, R. L. and Sulzberger, M. B. J. Inves. Derm.
7:201-6, Aug., 1946.
Lesser. M. A. Drug & Cosmetic Ind. 59:334-6 and
422-6, Sept., 1946.
Koepf, G. F., Arbesman, C. E. and Munafo, C.
J. Allergy 17:271-4, Sept., 1946.
Arbesman, C. E., Koepf, G. F. and Lenzner, A. R.
J. Allergy 17:275-83, Sept., 1946.
Chobot, R. J. Allergy 17:325-6, Sept., 1946.
Epstein, S. Geriatrics 1:369-83, Sept. -Oct.. 1946.
Curry, J. J. Med. Clin. N. A., 1138-48, Sept., 1946.
Mayer, R. L.. Eisman, P. C. and Aronson, K.
J. Bact. 52:257-8, Aug., 1946.
Editorial: Ann, Allergy 4:399-400, Nov., 1946.
Queries and Minor Notes: J.A.M.A. 132-183. Sept.
21, 1946.
Feinberg, S. M. J.A.M.A. 132:702-13. Nov. 23, 1946.
Mayer, R. L. and Brousseau, D. Proc. Soc. Exp.
Biol. & Med. 63:187-91, Oct., 1946.
Barach, A. L. J. Allergy 17:352-7, Nov., 1946.
Editorial: J. Allergy 17:399-400, Nov., 1946.
Morginson, W. J. J.A.M.A. 132:915-9, Dec. 14, 1946.
Goodhill, V. Laryngoscope 56:687-92. Nov., 1946.
Allen, F. N. Lahey Clin. Bull. 5:52-7, Oct., 1946.
Huttrer, C. P., Djerassi, C., Beears, W. L.,
Mayer, R. L. and Scholz, C. R.: J.A.C.S. 68:1999-
2002, Oct., 1946.
Friedlaender, A. S. and Friedlaender, S. North
End Clin. Quart. 7:14-18, Oct., 1946.
Selle, W. A. Texas Rep. Biol. & Med. 4:435-45.
Winter, 1946.
Friedlaender, A. S. and Friedlaender, S. J. Lab. &
Clin. Med. 31:1350, Dec., 1946.
Tatum, A. L. Wise. Med. J. 45:1147, Dec., 1946.
Glaser, J. Am. Pract. 1:185-90, Dec., 1946.
Pyribenzamine— (PBZ). Heb. Med. J. 2:151-150, 1946.
COUNCIL ACCEPTANCE
mine now has been formally accepted
by the A.M.A. Council on Pharmacy and Chemistry. A report to the
Council on anti-histaminic agents was written by S. M. Feinberg, M.D.,
in the November 23, 1946 issue of the J.A.M.A. Pyribenzamine was
found to be highly effective, and produces relatively few side effects.
FOR YOUR CONVENIENCE— in obtaining sample and literature, we suggest you fill out and mail us the coupon.
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April, 1947
353
The doctor hit it right on the button !
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ical Protective kind), he bought protection against any malpractice charge, how-
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MINNEAPOLIS Office: Robert L. McFerran and Stanley Joseph Werner, Representatives
816 Medical Arts Building, Telephone Atlantic 5724
Minnesota Medicine
Solomon Grundy
There are still too many Solomon Grundys — "born on Monday. .. died
on Saturday"— for despice the gratifying decline in infant mortality,
there is still only slight reduction in the number of deaths of infants under one
month. To better an infant’s chance of survival, the first feedings— and
the right formula — can do much to minimize the early hazards to life.
'Dexin’ has proved an excellent "first carbohydrate" because of its
high dextrin content. It (1) resists fermentation by the usual intestinal
organisms; (2) tends to hold gas formation, distention and diarrhea
to a minimum, and (3) promotes the formation of soft, flocculent,
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Simply prepared in hot or cold milk/Dexin' brand High Dextrin Carbo-
hydrate is well taken and well retained. 'Dexin' does make a difference.
HIGH DEXTRIN CARBOHYDRATE
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Composition — Dextrins 75% • Maltose 24% • Mineral Ash 0.25% • Moisture
0.75% • Available carbohydrate 99% • 115 calories per ounce - 6 level packed1
tablespoonfuls equal 1 ounce • Containers of twelve ounces and three pounds «
Accepted by the Council on Foods and Nutrition, American Medical Association.
'Dexin5 Reg. Trademark
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M ust
INCREASED IRRITATION
follow
INCREASED SMOKING?
PEOPLE are smoking heavily . . . far more than ever before.
To minimize nose and throat irritation due to smoking,
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ably less irritating . . . Philip Morris.
This proof of Philip Morris superiority is dependent not
only upon laboratory evidence, but on clinical observation as
well. Research was conducted not by anonymous investigators ,
but by recognized authorities . . . and published in leading
medical journals.
The fact is Philip Morris advantages result directly from
a distinctive method of manufacture described in published
reports.
Philip Morris
TO THE PHYSICIAN WHO SMOKES A PIPE: We suggest an unusually fine new blend — COUNTRY
Doctor Pipe Mixture. Made by the same process as used in the manufacture of Philip Morris Cigarettes.
Philip Morris & Co., ltd., Inc.
119 Fifth Avenue, N. Y.
356
Minnesota Medicine
PLANNING ' NOT LUCK
) rt '/
Planning— not luck— is responsible for
the pure, crystal-clear solution of
NEO-IOPAX for urography. Every pre-
caution known for obtaining a sterile fluid,
completely free from foreign particles, is
taken with this contrast medium during its pro-
duction. And when NEO-IOPAX is ampuled it must
pass before a corps of specially trained inspectors whose
sole task is to detect and reject any solution containing the least
visible trace of extraneous matter.
A final inspection by the physician himself before intravenous or
retrograde injection is invited by the water-clear glass ampule in
which NEO-IOPAX is dispensed.
NEO-IOPAX, disodium N-methyl-3,5-diiodo-chelidamate, is supplied as a
stable, crystal-clear solution in 50 and 75 per cent concentrations.
Trade-Mark NEO-IOPAX— Keg. U. S. Pat. Off.
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1 Evidence obtained by direct
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Jelly forms an occlusive film
over the cervical os which
remains for as long as ten
hours postcoitus.
3 Clinical tests conducted by
a prominent research organ-
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ness; also that it may be
used continuously without
untoward effect.
I An independent accredited
i laboratory, after comprehen-
sive testing, reports that it is
rapidly spermatocidal and
totally free of toxic or irritat-
ing properties.
"RAMSES" Vaginal Jelly is
offered for use under the
guidance of physicians. It is
supplied to patients through
prescription pharmacies in
packages containing a large
tube of jelly with applicator
at $1.25. Refills without ap-
plicator $1.00.
Physicians interested in obtaining complete information on concep-
tion control are invited to write for our revised Physicians' Manual.
'6?7C
JULIUS SCHIUID, int. 423 West SSlhSt., New York 19, N. Y.
'The word "RAMSES” is a registered trademark of Julius Schmid, Inc.
1
!
1
r
f
358
Minnesota Medicine
An Appeal to You.. Doctor
SCHOOL OF
PSYCHIATRIC
nUBSIHG
•
MID-YEAR CLASS
will start in
June
Candidates for the
June class should
make reservations at
once. School and
health record must be
reviewed and corres-
pondence completed
prior to acceptance.
An acute shortage exists in the nursing field. The problem of
supplying an adequate number of well-trained nurses to the
medical profession has become a difficult one. Your help in
recruiting candidates for training schools is greatly needed.
In your wide acquaintance, you possibly know of many girls
who could be interested in becoming a nurse. As a leading
citizen of your community you are in a position to assist them
in their vocational choice. A trained nurse is a benefit to both
your patient and yourself. We are prepared to refer the student
nurse back to you on completion of her training.
A Career in Nursing Offers:
. Training in a highly paid profession
• A secure position unaffected by economic depression
. Work with skilled professional men and women
. The best preparation for marriage
Glenwood Hills Hospitals, beautifully located on the outskirts of
Minneapolis, are currently offering to qualified applicants a one year
course in the School of Psychiatric Nursing. All phases of the sub-
ject are skillfully presented by a capable and experienced faculty. Class-
room and laboratory study is combined with an interesting program
of actual work on the ward. Regular classes begin in January, June,
and September.
Here is an opportunity to attain a useful higher education and
still enjoy the beauty of summer to its fullest. Swimming,
boating, hiking, and golf are a few of the recreational pastimes
available to the student nurse. Tuition is free. We will be
happy to send full information on request. A postcard is suf-
ficient. Address Miss Margaret Chase, R.N., B.S., Director,
School of Nursing, Glenwood Hills Hospitals.
• Our hospitals must be staffed
. Our sick must be cared for
• Our doctors must have nurses
Enuuooc
i
s
os
a
s
3 501 Golden Valley Road : Route Seven : Minneapolis, Minn
April, 1947
359
WHEN CHRONIC ILLNESS INCREASES
THE NUTRITIONAL NEEDS
Chronic disease, whether febrile or neoplastic,
imposes many additional metabolic demands
upon the organism. Paradoxically, appetite is
apt to wane at this time, making satisfaction of
these requirements difficult. In consequence,
weakness becomes excessive and the ability to
resist secondary infection is impaired.
Because it contains all of the nutrients
known to be essential, the dietary supplement
made by mixing Ovaltine with milk can play
an important role in augmenting the intake of
the very nutrients needed. This nutritious food
drink provides biologically adequate protein,
readily utilized carbohydrate, highly emulsi-
fied fat, B complex and other vitamins in-
cluding ascorbic acid, and the essential min-
erals iron, calcium, phosphorus. Its delicious
taste assures patient cooperation, since it is
taken with relish, even when most other foods
are refused.
THE WANDER COMPANY, 360 N. MICHIGAN AVE., CHICAGO 1, ILL.
Three servings
daily of Ovaltine, each ma
de of
Vi oz. of Ovaltin
e and 8
oz. of whole milk,*
provide:
CALORIES
669
VITAMIN A
3000 I.U.
PROTEIN
32.1 Gm.
VITAMIN Bi
1.16 mg.
FAT
31.5 Gm
RIBOFLAVIN
CARBOHYDRATE
64.8 Gm.
NIACIN
6.8 mg.
CALCIUM
1.12 Gm
VITAMIN C
30.0 mg.
PHOSPHORUS
0.94 Gm.
VITAMIN 0
417 I.U.
IRON
12.0 mg.
COPPER
0.50 mg.
*Based on average reported values for milk.
360
Minnesota Medicine
Yes, and experience is the best teacher in smoking too!
According to a recent Nationwide survey :
More Doctors
smoke Camels
'// — HE wartime cigarette shortage was a real experience to smokers. Whether
') they intended to or not, people found themselves smoking many different
brands, learning by actual experience the differences in cigarette quality.
The result of all these comparisons was the biggest demand for Camels
in history. And today more people are smoking Camels than ever before.
But, no matter how great the demand:
We don’t tamper with Camel quality. Only choice tobaccos, properly aged,
and blended in the time-honored Camel way, are used in Camels.
R. J. Reynolds Tobacco Co.
Winston-Salem, N. C.
t/ian any ot/ier cigarette
April, 1947
361
PYORTANIN SURGICAL GUT
Plain and Jcrtnalijed
Manufactured Since 1899 by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia
• • •
Price XiJt
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE G NONBOILABLE
Sizes 000 — 00 — 0—1 — 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
• • 9
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FOR SALE BY SURGICAL DEALERS AND DRUGGISTS
362
Minnesota Medicine
O o
who use Dorsey
pharmaceuticals -and con-
tinue to use them-are
granting us the highest
possible award: their con-
fidence.
Confidence— the Medallion
of Merit awarded by our
friends-binds us more
closely than ever to high
manufacturing standards.
For continued confidence
must be earned every day,
by redoubled vigilance in
our laboratories, plant and
packaging departments.
The products we offer you
are doubly reliable-be-
cause our friends are de-
pending upon us to keep
them so.
MANUFACTURERS OF
PURIFIED SOLUTION OF LIVER • DORSEY
SOLUTION OF ESTROGENIC SUBSTANCES • DORSEY
April, 19-! 7
363
CARTOSE
u,d Corbohydrat* lor
b A rv ■
f°R INFANT FEEDING
^^Directed 3G®2 by, rt'Y*kian.,.
pur« starch P’^jS^.
«rmet,c of hjgf1 vacuum
W° ,tonSpcPn,iJ,s ®au«a! 1 * °*
*20 calories per fl- or.
WELL TOLERATED by the NEWBORN
Clinical experience establishes that
CARTOSE* is especially well toler-
ated by newborn infants.
CARTOSE supplies carefully bal-
anced amounts of non-fermentable
dextrins, with maltose and dextrose.
These offer the advantages of: spaced
absorption because of the time re-
quired for hydrolysis of the higher
sugars : less likelihood of distress due
to the presence of excessive amounts
of fermentable sugars in the intesti-
nal tract at one time.
CARTOSE is liquid; formula
preparation is simple, rapid, and ac-
curate. It is compatible with any for-
mula base: fluid, evaporated, or dried
milk.
*The word CARTOSE is a registered trademark of H. W.
Kinney and Sons, Inc.
CARTOSE
Mixed Carbohydrates
H. W. KINNEY & SONS, INC.
COLUMBUS, INDIANA
364
Minnesota Medicine
is vitamin-fortified
Developed by E. V. McCollum, Formulac Infant Food is
fortified with all the vitamins known to be necessary for adequate
infant nutrition. The McCollum procedure of incorporating the
vitamins into the milk itself reduces the risk of human error or
oversight in supplementary administration.
Formulac is a concentrated milk in liquid form. It contains
sufficient vitamins of the B complex, Vitamin C in stabilized form,
Vitamin D (800 U.S.P. units), copper, manganese and easily
assimilated ferric lactate— rendering it an adequate formula basis
both for normal and difficult feeding cases. No carbohydrate has
been added to Formulac. It contains only the natural lactose
found in cow’s milk.
Formulac is promoted ethically, to the medical profession
alone. It has been tested clinically, and proved satisfactory in
promoting normal development and growth. Priced within range
even of low-income budgets, Formulac is available in drug and
grocery stores from coast to coast.
DISTRIBUTED BY KRAFT FOODS COMPANY
NATIONAL DAIRY PRODUCTS COMPANY, INC.
NEW YORK, N. Y.
•For further information about
FORMULAC, and for profes-
sional samples, drop a card to
National Dairy Products Com-
pany, Inc., 230 Park Avenue,
New York 17, N. Y.
April, 1947
365
H Y
Brand
DEMEROL,
366
Mm*
' V, - -J ' \
Write for
detailed literature
Demerol, the potent, synthetic analgesic, spasmolytic
and sedative, relieves labor pains promptly and effectively
without danger to mother and child. There i$ no weakening
of uterine contractions, lengthening of labor, or postpartum
complication due to the drug. Bad effects on the newborn are
practically nil: no respiratory depression or asphyxia from ~
analgesia of the mother. Simplicity of administration is another commend-
able feature. Warning: May be habit fc
Ampuls (2 cc., 100 mg.); vials (30 cc., 50 mg./cc.). Narcotic blank rec
DROCHLORIDE
of meperidine hydrochloride (isonipecaine)
trademark Reg. U. S. Pat. Off. & Canada
COMPANY,
I N C.
New York 13, N. Y. • Windsor, Ont.
Minnesota Medicine
Today’s newly diagnosed diabetic can live a
near-normal life. Most mild or moderately
severe cases can be controlled with one daily
injection of ‘Wellcome’ Globin Insulin with Zinc,
which also allows a higher carbohydrate intake
more nearly normal. The intermediate action
of Globin Insulin closely parallels physiologic
needs; maximum activity occurs when the
patient is awake and eating, but wanes to mini-
mize nocturnal hypoglycemia.
INITIAL DOSAGE AND DIET: One-half hour before
breakfast administer 2/3 units of Globin Insulin
for every gram of sugar spilled in a 24-hour
urine specimen. Or start with 15 units of Globin
Insulin and increase dosage every few days.
Divide the total carbohydrate allowance (140
to 240 gms.) as 1/5 breakfast, 2/5 lunch and
2/5 supper. (The total 4/5 lunch-supper allow-
ance may be apportioned to fit the patient’s re-
quirements.) Midafternoon hypoglycemia may
usually be offset by 10 to 20 gms. of carbo-
hydrate between 3 and 4 p.m.
BURROUGHS WELLCOME & CO. (U.S.A.)
FINAL ADJUSTMENT: Both diet and dosage must
be adjusted subsequently to meet the individual
needs. Final carbohydrate distribution may be
based on fractional urinalyses. Globin Insulin
dosage is adjusted to provide 24-hour control as
evidenced by a fasting blood sugar level of less
than 150 mgm., or sugar-free urine in fasting
sample.
‘Wellcome’ Globin Insulin -with Zinc is a clear solu-
tion, comparable to regular insulin in its freedom
from allergenic properties. Available in 40 and 80
units per cc., vials of 10 cc. Accepted by the Council
on Pharmacy and Chemistry, American Medical
Association. Developed in The Wellcome Research
Laboratories, Tuckahoe, New York. U.S. Patent No
2,161,198. LITERATURE ON REQUEST.
' Wellcome ‘ Trademark Registered
INC., 9 & II EAST 4IST STREET, NEW YORK 17, N.Y
April, 1947
367
'Tftodentt ELECTRO-CA RDIOGRAPHY
Portable , rugged , electrically oper-
ated without batteries. Cardiotron is
available with or without stand.
The first successful
*D ciect- ^ec<ncU*ty
Electrocardiograph..,
With more than 1 200 now in use throughout the
world, the Cardiotron has established the principle
of instantaneous recording in general clinical elec-
tro-cardiography.
The Cardiotron is fast, accurate and sensitive. It
makes an immediate black and white cardiogram-
on permanent chart paper. It is free from skin re-
sistance eirors. It reveals more information than any
other electrocardiograph instrument.
IMPORTANT: Factory-supervised installation and service
are available in most parts of the world. Good deliveries
are scheduled. Cardiotron is sensibly priced.
Send for 12-page descriptive booklet
GaJidicbien
ELECTRO-PHYSICAL LABORATORIES, INC., 29$ Dyckman St., New York 34, N. Y.
ELECTROCARDIOGRAPHS, ELECTROENCEPHALOGRAPHS, SHOCK
THERAPY APPARATUS, AND SPECIAL ELECTRONIC EQUIPMENT
Distributed by
C. F. ANDERSON CO.. INC
901 MARQUETTE AVENUE
MINNEAPOLIS 2. MINN.
368
Minnesota Medicine
Addressed to
your women patients
In its current "See Your Doctor" advertise-
ment Parke, Davis & Company emphasizes
the importance of seeking medical counsel
at the time of menopause. This educa-
tional campaign, in behalf of the medical
profession, appears regularly in color in
LIFE and other leading magazines.
menopause
J m a series of
importance of
n,os‘ "omen tod
"r Harige of life.
•tension.
established fact th:
1 mental strain
t0 the changing f,
It is an e~*- - ’
eornfort and
traceable t : ;
other glands.
During thepast fei
ma"y things
the V Produce,
command :
the symptoms of this
1701 fishes, headaches
Passion, sudden gain in’,
doctor can usually ggj,,
Symptoms.
But there
consult
Physical dis-
are directly
■ ovaries and
'toy cars, n
about thc gl
• -As a result,
?tew and.
™-ca Iscienecha., lcancd
“* ■ and horm„acs
type of glandular imbalance
w%hT:„drn’ mrntai *■'
gnr, and insomma . . . vo..r
«e common me„0Da„„i
are other r
J our doctor as s
the menopause.
f* t/ns 'w. your l„
. t,u‘ ""‘e when y
rtre m blood pressure
intestinal disturbance.
,Vs important to he
periods actually indicate
ralW th» pregnancy „
some other disease.
Sek VOW! DOCTOJt. IIC
Enf» •and mcntal Probit
qually ‘mportant, his s„„,
c^nscl a, this tlnic. ;s vo "
sot"' health in the
• too, wliy
you notice
°AVIS & co.
April. 1947
369
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
370
Minnesota Medicine
IN INTRANASAL THERAPY
Neo-Synephrine
BRAND 0/ f R H £ N rli £ R H R / N £
HYDROCH LORI D E
^ f£ai>/c
ejUfaleectb
If the quality of action of a nasal decongestant be the summation of
its deeds and misdeeds, then the clinical response to Neo-Synephrine
affirms its choice for the symptomatic treatment of the nasal congestion
accompanying upper respiratory infections...
IT ACTS QUICKLY
IT ACTS ADEQUATELY
IT ACTS LASTINGLY
Even upon repeated administration
Neo-Synephrine generally does not cause:
• Compensatory recongestion, bogginess, atony
• Cardiac or central nervous system stimulation
• Inhibition of ciliary activity
• Blanching of the nasal mucosa
For Nasal Decongestion
Neo-Synephrine shrinks swollen nasal mucous membranes . . . relieves the hyper-
secretion associated with colds and sinusitis ... is ideally suited for use by dropper,
spray or tampon; for displacement; or as a jelly.
For Prescription and Office Use . . . supplied as !4% and 1% solutions (isotonic) in
bottles of 1, 4 and 16 f). oz.; also as Vi% jelly in applicator tubes of Ve oz.
Literature and samples
will be gladly sent
upon request.
m
v^Stearn s
“^Dvedlon
DETROIT 31, MICHIGAN
New York Kansas City San Francisco Atlanta Windsor, Ontario Sydney, Australia Auckland, New Zealand
Trade-Mark Neo-Synephrine Reg. U. S. Pat. Off.
April, 1947
371
EMPHASIS ON
FLOW —
IXecfufiCiri
334 gr- tablets. Boxes of 25, 100, 500 and 1000;
powder 25 Gm.
Fluidity of the bile is the factor which
determines success in removal of
thickened and purulent material from
the bile passages. Decholin (chemi-
cally pure dehydrocholic acid) stimu-
lates the liver cells to produce a thin,
easily flowing bile, which flushes the
ducts, and promotes drainage.
AMES COMPANY, Inc.
Successors to Riedel - de Haen, Inc.
ELKHART, INDIANA
■OiiiiiiiiiiiinnfmffnimiiiiimhmiiiiimiiiiiimiiiiiiimmmiiiTw.
I IDENTICAL TWINS !
SERVICE"
Prescription Analysis Lens Grinding :
Lens Tempering Ophthalmic Dispensing j
Orkon Lenses (Corrected Curve) :
Cosmet Lenses (Distinctive style and beauty) :
Hardrx Lenses (Toughened to resist breakage) :
Soft-Lite Lenses (Neutral light absorption the 4th •
Prescription component) :
N. P. BENSON OPTICAL COMPANY !
Established 1913
Main Office: Minneapolis, Minnesota E
Aberdeen Albert Lea Beloit Bismarck Brainerd E
Duluth Eau Claire Huron LaCrosse Rapid City :
Rochester Stevens Point Wausau Winona ■
iyuiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiimimiiiiimiiiiiiiiiiiiiiiiiimir
Cook County
Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY — Two-week intensive course in Surgical
Technique starting April 14, May 12, June 9, July 21.
Four-week course in General Surgery starting April
28, May 26, July 7.
One-week Surgery of Colon and Rectum starting
April 7, May S, June 2.
Two-week Surgical Anatomy and Clinical Surgery
starting April 14, May 12, June 9.
Two-week Surgical Pathology every two weeks.
GYNECOLOGY — Two-week intensive course starting
April 14, May 12, June 16.
One-week course in Vaginal Approach to Pelvic Sur-
gery starting April 7, May S, June 9.
OBSTETRICS — Two-week intensive course starting
April 28, June 2.
MEDICINE Two-week intensive course starting April
7, June 2.
Two-week Gastroenterology starting April 21, June 16.
One-month course Electrocardiography and Heart Dis-
ease starting June 16, September IS.
DERMATOLOGY AND SYPHILOLOGY— Two-week
course starting April 14, June 16.
General, Intensive and Special Courses in all Branches
of Medicine, Surgery and the Specialties
TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar, 427 S. Honore St., Chicago 12, 111.
372
Minnesota Medicine
1 “ Premnrin ” . . . Effective when given by mouth
2“Prcmarm” . . . Rarely produces unpleasant side reactions
3uPrentarin” ... Highly potent
"Premarin" provides an effective medium for the management of the menopausal patient.
Prompt alleviation of distressing symptoms with comparative freedom from untoward effects
may usually be anticipated with this conveniently-administered natural estrogen. To these
advantages may be added the emotional uplift which is frequently reported following Therapy
and is invariably described by the patient as a feeling of well-being... therapy with a "plus."
The- average suggested" dosage is 1.25 mg. to 3.75 mg. daily. Once symptoms have subsided,
dosage may be gradually reduced.to a . ...
"Premarin" is available as followsr
Tablets of 1 .25 mg. in bottles of 20, 100 and 1000.
Tablets of 0.625 mg. in bottles of 100 and 1000.
Liquid containing 0.625 mg. per 4 cc. (one teaspoonful) in bottles of 120 CC.
CONJUGATED ESTROGENS
(equine)
AY ERST, McKENNA & HARRISON Limited
22 EAST 40TH STREET, NEW YORK 16, N.Y.
April, 1947
373
COUNCIL ACCEPTED
relief is obtained, continue with smaller doses to keep
the patient comfortable. Theocalcin strengthens heart
Brand of theobromine-calcium salicylate, . •...•■ , , .
Trade Mark reg. u. s. pat. o<f. action, diminishes dyspnea and reduces edema.
r
Human Convalescent Serums
are available for prevention or treatment
HYPER-IMMUNE PERTUSSIS
MUMPS SCARLET FEVER
POLIOMYELITIS MEASLES
POOLED NORMAL SERUM
Address or telegraph communications or
requests to
Human Serum Laboratory
West-108, University Hospital
Minneapolis 14, Minn.
Main 8551, Ext. 276 24-hour Service
Kalman & Company, Inc.
Investment Securities
Members:
Chicago Stock Exchange
Minneapolis-St. Paul Stock Exchange
ST. PAUL MINNEAPOLIS
374
Minnesota Medicine
FREE: HUMAN INTEREST
GOOD POSTURE CHART in
full color 18"x24" designed
for physicians’ offices, clin-
ics and health centers. One
in a standard series widely
distributed in schools, col-
leges, industrial plants,
"Y’s” and similar outlets.
Write for your office copy
of this educational chart on
your professional letterhead
to SAMUEL HIGBY CAMP
INSTITUTE FOR BETTER
POSTURE, EMPIRE STATE
BLDG., NEW YORK 1, N. Y.
MAY 5—10
In its ninth year, National Posture Week
continues its sound ethical program of focus-
ing the attention of the country on the sig-
nificance of Good Posture as an important
element in good health and physical fitness.
Distribution of authentic literature through
schools, colleges, medical and government
bodies; and industrial, professional and civic
public health groups is an important part of
the program. Physicians, educators and lay
groups in the field of public health have
shown in practical cooperation and volumi-
nous correspondence that they approve the
methods of National Posture Week and its
year-round program.
It is our hope that our current campaign will
again merit the approval and cooperation of
the medical profession.
S. H. CAMP & COMPANY, Jackson, Michigan
World’s Largest Manufacturers of Scientific Supports
Offices in New York • Chicago
Windsor, Ontario . London, England
These two heavily illustrated 16 page booklets on
r/\tt • Posture prepared especially for distribution by
physicians to their patients. Their titles are: "The
Human Back ... its relationship to Posture and Health" and
"Blue Prints for Body Balance." Ask for the quantity you
need on your professional letterhead. THE SAMUEL HIGBY
CAMP INSTITUTE FOR BETTER POSTURE, Empire State
Bldg., New York 1, N. Y. Founded by S. H. Camp & Com-
pany, Jackson, Mich.
April, 1947
375
1. Notional Research Council Bull
No. 109 (Nov.) 1943, p. 36.
2. Southern M. J 3:172 (Feb.) 1946.
3. Statistical Bull. Metropolitan
Life Ins. Co. 27:6 (Dec ) 1946
When the diet of SO generations of rats was improved,
it was found that they gained a longer average life span
and longer "prime of life”1 with "increased growth and
efficiency, decreased death rate and increased vitality at
all ages." Without waiting 50 generations, "the size and
health of our young adolescents”2 and increased longevity3
amply confirm the fact "that the science of nutrition has
made vast strides.”2 For the present generations and
those to come, Upjohn provides, and will continue to pro-
vide, the finest in vitamins, in forms and dosages to fill
the needs of medical and surgical practice.
Upjohn
FINE PHARMACEUTICALS SINCE 1888
UPJOHN
VITAMINS
376
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30
April, 1947
No. 4
MEDICAL SERVICE PROGRAM IN THE VETERANS ADMINISTRATION
HOSPITALS
GENERAL PAUL R. HAWLEY
Washington, D. C.
TN RECENT months the demands of my work
have forced me to limit my speaking en-
gagements to a minimum. I have made an excep-
tion in the case of your invitation solely because
I wanted very much to come here and tell you
personally how much I appreciate the support of
this department of the American Legion in our
effort to improve the quality of medical care given
the veteran. You have been tolerant of our mis-
takes and patient with the slowness of our im-
provements. I feel, however, that you have real-
ized that we have only one objective and that is
to give the veteran the very best of medical care.
On my part, I have come to regard this de-
partment of the American Legion as an unselfish
organization devoted to the true welfare of the
veteran. I have never received any recommen-
dation from the officers of your department which
was in any way biased by political considerations.
I congratulate you upon such leadership.
In coming here to thank you for your help and
co-operation, I do not mean to imply that I resent
criticism, or that I regard all criticism as an un-
friendly gesture. I expect criticism — in fact, I
would say that I welcome criticism. But I do
hope that criticism will be well-informed, that it
will be based upon fact, and that it will not be
prompted by selfish or self-seeking motives.
One of the situations for which we are criti-
cized frequently is that we do not have enough
hospital beds to care promptly for every veteran
who seeks admission to a hospital. This is quite
true. There are several reasons for this, but the
Address delivered at a meeting of the Department of Minne-
sota, the American Legion, St. Cloud, Minnesota, August 13,
1946.
only cogent reason is that we are unable at this
time to obtain a sufficient number of physicians
of proper quality to operate any more beds than
we are now operating. I want to emphasize this
qualification of “proper quality” when I speak
of physicians.
I am constantly amazed at the number of peo-
ple in this country — at least, at the number who
come into my office — who seem to think that a
doctor is a doctor, that all doctors are equally
trained and equally competent. These people de-
scend upon me in delegations, insisting that I
take over and operate a surplus army or navy
hospital in their home towns. When I point out
that I must have a great deal of help from local
physicians, since we do not have enough full-
time specialists in the Veterans Administration,
they assume an injured expression and say, “Why,
we have the finest doctors in the country in our
town, and they would alk be glad to help.”
Then, when I investigate the training and the
qualifications of the doctors in their town, I find
perhaps one or two specialists of real training
and the rest general practitioners. Now, mind
you, I have no doubt but that these general prac-
titioners are excellent as general practitioners,
and I could not have any but the highest regard
for general practitioners of medicine. My grand-
father was a general practitioner ; my father was
a general practitioner ; and I started my career in
medicine as a general practitioner. In our home-
town plan for outpatient treatment of veterans
with service-connected disabilities, we shall use
the services of thousands of general practitioners
throughout the United States, and they will give
April, 1947
377
MEDICAL SERVICE PROGRAM— HAWLEY
the veterans the finest of care. Furthermore,
when we general practitioners have a patient who
requires the care of a specialist, we refer that
patient to a specialist.
So, when a veteran needs a specialist, he must
have a specialist. The great majority of hospital
cases are of a severity that requires the attention
of a specialist; and we would be short-changing
the veteran in a shameful fashion if we offered
him one kind of a doctor when he needed another
kind of a doctor.
Now, here is my position. It may be wrong,
but it is the position of a doctor who is con-
cerned only with the welfare of his patients. I
do not want to operate any more hospital beds
than I can operate at a standard that the veteran
deserves. I do not want to offer the veteran any
medical service of poor quality. I much prefer to
offer him none at all than to offer him some that
may cost him his life or his future health. I
want the veteran to feel that, when he comes to
the Veterans Administration, sick or disabled,
he will get only first-quality medical care. It
would be an empty gesture — nay, it would be
criminal — to offer the veteran poor medical care
in order to offer him more medical care. We want
quantity — yes — but we shall not sacrifice quality
merely to produce quantity.
Rut a much more vicious form of crit-
icism is beginning to arise. Our motives have
been questioned in certain quarters. The pro-
gram has been attacked by certain organizations.
Some of these critics may be sincere, but if so,
they are misinformed. However, I think the time
has come to speak frankly — some of them un-
questionably are motivated by selfish, personal
greed.
A year ago the Medical Service of the Vet-
erans Administration was made up of a few out-
standing men in medicine, of a number of what
might be called average medical men, and of some
distinctly inferior medical men. As is always
the case, one poor man can do more harm than
ten good men can do good. So the medical serv-
ice of the Veterans Administration suffered se-
verely from the reputation given it by the poor
element.
The veterans’ organizations and the public were
demanding improvement of this medical service.
They were demanding the weeding out of in-
competents. Well, we have tried to weed out the
incompetents. Some of them we have dismissed.
Others we have moved to positions of lesser re-
sponsibility. A doctor may be incompetent to do
major surgery but reasonably competent to make
routine physical examinations. As rapidly as
possible, we have replaced incompetents with well-
trained and able physicians, either on a full-time
or a part-time basis.
Here is one curious result of our efforts to give
the veteran better doctors. Some — not all, of
course — of the same people, some of the same
organizations, who one year ago were damning
the medical service of the Veterans Administra-
tion, have now taken up cudgels in behalf of
the incompetent doctors who have been replaced.
They are attacking our program solely upon this
ground. But — remember this — they are fighting
for privileges for the doctor, not for better medi-
cal care of the veteran. I am not running this
medical service for doctors — I am running it for
patients — and I know no other way of raising the
standard of medical care of the veteran than to
replace poor doctors with excellent doctors. You
can’t make an omelette without breaking some
eggs.
I am fully aware that, in our haste to improve
conditions, we have made mistakes. We may
have displaced in the service, but not removed
from the service, some doctors who were better
than their records indicated. We are now cor-
recting, and we shall continue to correct, such
mistakes as rapidly as we discover them. But
the hard fact is that we have made more mistakes
in the other direction, by not removing some
doctors who should be removed. And, let there
be no mistake about this, if I must commit an
injustice, I would much rather commit it against
a doctor than against a patient.
The fact is that no physician in the Veterans
Administration of even average qualifications has
suffered from this reorganization. The great
majority of them were advanced one grade when
they were taken into the new Department of
Medicine and Surgery. None was demoted. Many
of the excellent men were advanced two grades.
All these actions, however, were taken with only
one thought in mind, the good of the veteran
patient. Again I say, we are not operating this
medical service for doctors, we are operating it
for the patients. No doctor has a vested right in
his position in the Veterans Administration. If
the doctor’s services are good for the veteran pa-
tient, there is nothing too good for the doctor.
378
Minnesota Medicine
MEDICAL SERVICE PROGRAM— HAWLEY
If the doctor’s services are not good for the vet-
eran patient, there is no place in the Department
of Medicine and Surgery for that doctor.
Some of the criticisms leveled at this pro-
gram smack of the witch-hunting of the seven-
teenth century. These critics say that we are
using veterans as guinea pigs, that we are experi-
menting on them in veterans’ hospitals. Nothing
could be farther from the truth. But the worst
aspect of this criticism is that these misinformed
critics are being furnished their information by
certain disgruntled doctors of the old regime of
the Veterans Administration. These doctors know
that they lie. And the fact that they know they
lie, and use these lies in an effort to destroy a
program which offers more to the sick veteran
than has ever been offered to him before, is a
measure of the character of these men. If you
want men of this character to take care of the
veteran, I and a great number of other doctors
will step down gladly and turn the program over
to them.
I want to make it very plain that I am not
indicting any great proportion of the older men
in the Veterans Administration medical service.
Many of these men have hoped and prayed for
years for a program of this kind. Many of them
are supporting it unselfishly. Some of the older
men know that they can never qualify for the
additional pay of specialists ; but they realize, as I
do, that new standards have grown up in medi-
cine and that, if we are to improve this service,
we must accept these standards and abide by
them. The fact that they have passed the age
where they themselves can enjoy this extra com-
pensation has not soured them, and they are
loyally supporting our efforts. We shall even-
tually identify the small group of malcontents
who are trying to sabotage this program. There
is no place in the Department of Medicine and
Surgery for a doctor who places his own interests
above the interests of the veteran patient.
The most absurd aspect of this ignorant criti-
cism is that our program is exactly like that in
the most famous hospitals and clinics in the
United States. These are all teaching institu-
tions. Here in your own state stands the first,
the largest, and the most famous of all the great
clinics of the world. It is a teaching institution.
It trains resident physicians and surgeons, ex-
actly as we are training them in veterans’ hospi-
tals. Its clientele is drawn from all economic and
social classes, millionaires to paupers. And its
millionaire patients are used in its teaching pro-
gram just as are its pauper patients. While I
know nothing of the policies of the Mayo Clinic,
and certainly shall not presume to speak for it,
I would venture the opinion that it would not
consider staying in business without its teach-
ing program.
The training program in veterans’ hospitals is
established for the same reason that the training
program was established in the Mayo Clinic, that
it was established in the Massachusetts General
Hospital, that it was established in Johns Hop-
kins Hospital, and that it was established in every
outstanding hospital in the United States. The
reason is that the patient gets better care in a
teaching hospital than he gets in a non-teaching
hospital — his case is studied more thorough-
ly, and the staff members are constantly stim-
ulated to higher standards. We have this pro-
gram today in thirty-two of our 107 veterans’
hospitals. The standard of patient care in these
thirty-two hospitals is not to be compared to the
standard of patient care in the other seventy-
five. Here in the State of Minnesota is a vet-
erans’ hospital that compares favorably with any
hospital in the world. Here is a hospital in which
the veteran is assured of receiving absolutely
first-class medical care, a hospital which he can
enter with confidence. I ask you only one ques-
tion: has this always been true of the Minne-
apolis Veterans Hospital? If and when I get
sick, if and when I need a surgical operation, I
shall go into one of our teaching hospitals. I
would enter the Minneapolis Veterans Hospital as
a patient without the slightest question in my
mind but that I would get absolutely first-class
care. I want no veteran to have to accept a
lower standard of medical care than I would
accept for myself ; and I shall not be satisfied
with any veterans’ hospital until I am willing to
enter that hospital as a patient myself.
I have spoken of new standards which have
been introduced into medicine within the past fif-
teen years. These are the standards set up by the
American Specialty Boards. I shall not bore you
with a detailed technical description of the func-
tions of these Boards, but a simple explanation
will help you to understand the next point I
wish to make.
Any licensed physican can call himself a spe-
cialist and practice any specialty in medicine,
April, 1947
379
MEDICAL SERVICE PROGRAM— HAWLEY
regardless of whether he knows anything about
the specialty or not. I can go back to the State
of Indiana tomorrow, where I am licensed to
practice medicine, and set myself up as a special-
ist in diseases of the eye, although I have had no
training whatsoever in diseases of the eye other
than the little that was given to me thirty years
ago in medical school, and that, I assure you, was
not very much. However, if unsuspecting patients
came to my office — and they would come in great-
er or lesser numbers — I could treat any of their
eye diseases, I could operate upon them for cat-
aract (which is a very delicate operation), I
could operate upon children for crossed eyes. If
my patients were blinded as a result of the treat-
ment I gave them, it would just be their hard
luck. My license to practice medicine permits me
to undertake anything in the field of medicine
and surgery.
Realizing this situation, a few well-trained
specialists set about doing something to protect
the public from incompetent and unscrupulous
physicians who were practicing specialties with-
out adequate skill. So now, each specialty of med-
icine has its own examining board to test the
qualifications of physicians desiring to practice
that specialty. These boards require from three
to five years of intensive postgraduate training
in the specialty before they will even admit a
candidate for examination. Then they subject
the candidate to a searching examination in that
specialty. 1 f he passes, the board issues a di-
ploma to the physician, which testifies that he has
had adequate training in his specialty. While
this diploma has no standing in law, the patient
is protected against quackery if he employs only
specialists who are diplomates of their respective
specialty boards. I must make it perfectly clear,
however, that not all well-qualified specialists are
diplomates of their specialty board. Some of the
older men, who had been practicing a specialty
for years before the boards came into being,
never bothered to obtain certification. However,
almost all of the younger men who are entering
specialties make a serious effort to obtain their
board diplomas.
You can understand how difficult it is to ob-
tain such a diploma, and how much better trained,
on the whole, these diplomates are. In the old
regime of the Veterans Administration, there
were only approximately sixty diplomates of
American Specialty Boards in the medical serv-
280
ice, and these were largely x-ray men and labor-
atory men. There were only a very few in the
fields of internal medicine and surgery.
Since, January 3, 1946, on which date the
President signed Public Law 293, we have em-
ployed full-time and placed on duty in the medi-
cal service of the Veterans Administration, 150
additional diplomates of American Specialty
Boards — the cream of the profession, the corps
d’ elite of medicine. Never before could this
service boast of such a large group of experts.
We have more than doubled our number of ex-
pert specialists.
But this is not all. Among these men are many
who have held positions of distinction in the world
of medical education. I shall quote from only a
few of their applications for appointment in the
Department of Medicine and Surgery : professor
of surgery, University of Illinois ; assistant pro-
essor of medicine, Johns Hopkins University;
professor of clinical surgery, Women’s Medical
College of Philadelphia ; assistant professor of
medicine, University of Pennsylvania ; assistant
professor of surgery, University of Maryland;
associate professor of medicine, Wayne Univer-
sity, and many more. I want to emphasize that
these men are now full-time doctors in the Veter-
ans Administration. In addition, we have several
hundred diplomates of American Specialty Boards
who are daily giving part-time service to the
veteran.
How many men of this professional stature do
you think would have come with us under the
old regime? What is it that now attracts such
able physicians to the Veterans Administration?
It is just two things. First, they believe that
this service is now free from politics and that
they can practice real, honest medicine. And
second, they desire the opportunities we have
made for them to teach medicine. Most of the
outstanding men in medicine love to teach, and 95
per cent of these outstanding men would never
have considered the Veterans Administration as
a career without the opportunity to teach and to
train younger men.
Now, just what is the teaching program in vet-
erans’ hospitals? From the criticism leveled at
us from certain sources, one would think that
we were undertaking the training of first-year
medical students. The fact is that our residents
in training are all graduates of Class A schools
of medicine, that they have completed their in-
Minnesota Medicine
MEDICAL SERVICE PROGRAM— HAWLEY
ternships and that they are fully licensed to prac-
tice medicine. They are a standard of physicians
that the Veterans Administration would have been
extremely happy to employ in years past.
There are only two ways by which a doctor
can perfect himself in a specialty of medicine.
One is for the doctor to train himself — by trial
and error. This may result in good training after
some years of what amounts to experimentation
on patients, but it is rather tough on patients
until the doctor acquires some degree of compe-
tence. Many of the older doctors in the Veterans
Administration trained themselves in this way,
because there was no other way for them to get
training.
The other way is for a doctor to work under
the guidance and direction of an expert in the
specialty — an expert who teaches him, who pre-
vents him from making mistakes, and who does
not permit him to touch a patient until it is evi-
dent that he is competent to undertake some small
part of an operation. For three years he works
under the direct supervision of the expert, and
there is no experimentation upon patients with
this method.
Which method do you prefer? Do you want
to be cared for by the doctor who is teaching
himself, or do you prefer the doctor whose every
step is being supervised by an expert?
Thus, these resident physicians in training in
veterans’ hospitals are exactly the kind of doctors
that the Veterans Administration would have been
happy to have employed in times past. But what
would have happened if they had been employed
AT LEAST,
We think it was de la Rouchefoucauld who said,
“There is always something in the misfortunes of our
friends that does not quite displease us.”
This morning, after we had brought ourself abreast
of the latest developments in the labor situation; after
we had mastered our nausea over the statistics of low-
ered production, decreased exports, et cetera, that would
result, we turned to foreign news in the hope of finding
something cheerful;
In no time at all we came upon this gem :
London, November 30. (UP) — Sixty-four doctors
and nurses — the entire medical staffs of two London
hospitals — have received dismissal notices for refusing
to obey an order of the Willesden Borough Council to
join a trade union, it was disclosed today. The Coun-
in years past? The majority of them would have
been placed in full charge of the treatment of
patients, with little or no supervision, and with
little or no instruction. Many of them would
have groped their way into the specialties of
medicine. Today, these same young men work
under the close supervision of highly qualified
specialists. They are guided and trained. They
are not permitted to make mistakes. Which of
these systems do you think results in the better
•care of patients ?
I am making no apologies for the new medical
program of the Veterans Administration. No
apologies are necessary. It has been given the
enthusiastic approval of the leaders of American
medicine. The only question is whether you want
to believe medical men of national reputation or
a few disgruntled doctors who have a purely
selfish interest in jobs with the Veterans Ad-
ministration.
Whether I remain in my position is of no im-
portance. I accepted this position, and have re-
mained thus far, at a very considerable financial
sacrifice. The best thing that could happen to
me personally would be that I am driven out of
this position. I cannot, in conscience, resign so
long as there is hope to give the veteran the best
in American medicine, but I can always be fired.
I do hope, for the sake of the veteran, that
there is never any return to the medical service
of the past. Who operates this service is of no
importance whatsoever. But how it is operated
is of the most vital importance to the veteran.
NOT YET
cil’s action leaves only one doctor, the medical super-
intendent, to care for 100 patients at Willesden Maternity
Hospital.
Socialized Medicine ! The closed shop applied to doc-
tors. We are a little vague as to what the Borough
Council of Willesden is, but somehow we feel a
little safer with our mothers and babies in the hands
of medical men selected by Boards of Trustees. We
are glad we don’t have to join a union if we don’t
want to.
Oh, and by the way, what happens to the mothers and
the babies? The Council bent on asserting its authority
seems as indifferent to their fate as Mr. Lewis was to
the general suffering he was causing. — New York J.
Med., Feb. 15, 1947.
April, 1947
381
VOLUNTARY PREPAYMENT MEDICAL CARE AND ITS RURAL ASPECTS
LOUIS A. BUIE. M.D.
President, Minnesota State Medical Association
Rochester, Minnesota
TN this presentation I shall use the expression
“medical care” to mean those services which
usually are represented in the doctor’s bill. Med-
ical care, then, is distinct from hospital care.
Voluntary prepayment medical care dates back
to 1882 but its expansion is relatively recent.
This expansion began in Washington and Ore-
gon shortly after World War I as an effort de-
signed to overcome some of the undesirable
features which existed in contract practice. Little
was done elsewhere during the next ten years.
With the depression came interest in ways and
means of assisting people in what we then called
the “low-income” or “borderline” groups of the
population. In order to assist people of these
groups, experiments were carried on with many
plans. State medical associations, county medical
societies, the Farm Security Administration (now
the Fanners Home Admistration) and others
studied and experimented with prepayment and
postpayment ideas.
Prepayment plans today can be divided into
three groups : service plans, indemnity plans and
a combination of the two. In the service plans
the fee or rate paid by the organization to the
physician constitutes the entire amount which
either the organization or the patient will be re-
quired to pay for the service. This was the gen-
eral pattern of the early plans and of those
born of the depression.
In the indemnity plans, the patient is paid a
prearranged amount for specified medical services
or care. The patient is responsible for paying
the physician. The physician charges the patient
according to his own fee schedule. The charged
fee may be more or less than the amount paid by
the organization to the patient and is generally
determined by the physician on the basis of the
patient’s ability to pay. Up to the present time,
the indemnity plan usually has not been the pat-
tern preferred by physicians but sometimes is the
only avenue open in forming an organization.
In the third type of plan, the patient whose
income is below a certain level receives service
Read at the annual Delegate Meeting of the Minnesota Farm
Bureau Federation at the I.owry Hotel, Saint Paul, January 13,
1947.
benefits and the patient whose income is above
this level receives indemnity benefits. Usually
these levels are set at $1,000 to $2,000 a year
for single persons and at $2,000 to $3,000 for
families. This is probably the most popular plan
today.
The movement toward prepayment plans ac-
tually received its first real impetus as a result
of the achievement of the Blue Cross Hospital
Service Plans. With both hospitals and patients
in dire need of some sort of program to ease the
burden of costs of expensive hospitalization, these
plans spread quickly.
With the prepayment plans for hospital charges
as guides, a number of state medical associations
undertook to develop plans for medical care. The
first state-wide plan to be put into operation
was California Physicians’ Service. This was
followed within a year by Michigan Medical
Service. These two plans, together with the coun-
ty medical society bureaus of Washington and
Oregon, gave the medical profession the neces-
sary basis on which to build what has now be-
come a nation-wide movement.
Growth
Counting Oregon and Washington plans as two
state-wide plans, the growth of prepayment plans
for medical care since 1939 has almost paralleled
that of the hospital plans. It took Blue Cross
between five and six years to place thirty-eight
plans in operation. This compares favorably with
the six years it took to develop thirty-seven plans
for medical care. The same comparison also can
be made with reference to enrollment. In medi-
cal plans, 2,845,000 subscribers were enrolled
from 1929 to 1946. In Blue Cross plans,
2,870,000 subscribers were enrolled from 1932
to 1939.
In some ways, the achievements of the medical
profession in developing its own prepayment pro-
gram are remarkable. The problems involved in
the payment and handling of claims for medical
services are far more difficult than those for hos-
pitalization. It took years of experimenting and
compromising to work out solutions, but the
progress made to date offers its own proof that
advancement has been made.
382
Minnesota Medicine
PREPAYMENT MEDICAL CARE— BUIE
An organization to pay for hospital care deals
with relatively few institutions. A plan designed
to pay for medical care deals with hundreds, or
even thousands, of physicians. Physicians are
anything but institutions. They are individuals
and, as a practical administrative matter, a plan
for medical care must not depend on a relatively
uniform institutional point of view but on a host
of individual attitudes, if the principles of the
private practice of medicine and high quality of
medical care are to be retained.
The latest figures show that eighty-four pre-
payment plans for medical care have been ap-
proved or sponsored by medical societies and the
Blue Cross. Organizations are now in operation
in thirty-three states, and, in addition, are being
formed in thirteen states and the District of Co-
lumbia. In only two states is no plan for pre-
payment for medical care in process of develop-
ment.
From some sources you may hear that the prin-
ciple of voluntary prepayment has failed, that
prepayment plans have not measured up to the
demand of the public. These are unwarranted
claims. The fact that not one of the prepayment
plans developed by medical societies has failed
since 1939, plus the fact that only two states re-
main in status quo, attests to the fact that efforts
sponsored by organized medicine thus far have
not failed. However, there is still much to be
done.
Method of Expansion
Here are two avenues for expansion in the pro-
gram for prepayment for medical care. The first
refers to benefits (in the form of services, indem-
nities or both) that can be offered in view of fees
paid and premiums charged. The second refers
to subscribers and to enrollment.
Let us consider each of these avenues separately
for a few moments. The expansion of benefits is
limited partly by insurance principles ; that is, by
the amount of the premium, dues, or whatever the
income is called, that can be collected. In other
words, the benefits cannot exceed what the public
will or can pay for.
In the early plans in use in Washington and
Oregon, these benefits included practically all
medical services : surgery, home and office calls,
and even limited nursing and dental care. Through
the years since these plans were inaugurated, this
broad coverage has been continued. The plans or-
ganized in 1939 and 1940 followed this lead and
also provided for reasonably complete medical
care. In contrast, in later plans full coverage has
been demonstrated to be unsatisfactory. It was
found that the public would not or could not pay
the premiums necessary to carry such a broad
contract. Wherever a contract for surgical care
and a contract for general medical care were of-
fered, the ratio of enrollment was more than 100
to 1 in favor of the surgical program. As a result,
the plans generally have preferred to begin by
offering fairly restricted coverage, including such
items as surgical care, obstetrical care, x-ray
charges, and fees for anesthesia, all applying only
if the patient is hospitalized. Then, as experience
was obtained, benefits were added. The latest de-
velopment has been the addition of medical serv-
ice in the hospital. Now most of the services nec-
essary in cases so severe as to require hospitali-
zation are covered.
The tendency to limit services to those accorded
in the hospital is a natural one. In the first place,
most of the costly illnesses are those that require
hospitalization for the patient. Second, there is
likely to be little abuse of such services. Third,
actuarial experience with relation to hospitalized
patients is sufficient to provide more certain bases
for determining adequate premiums or rates than
are available with respect to patients seen in their
homes or at offices of physicians. A recent study
of fifty-one plans for medical service shows that
thirty-four offer surgical, obstetrical and specified
medical services in the hospital. This same study
shows that under some plans benefits are contin-
uing to expand. In twelve of the plans, provision
is made for general medical care such as home and
office calls and, in five, almost complete coverage
is provided.
The average monthly premium for a single sub-
scriber is approximately $1.25 and ranges from as
little as 60 cents to $4.85. Family coverage ranges
from $1.35 to $10 a month, with an average of
about $3.
Organizations are still experimenting with
benefits and with premium rates. As in one or-
ganization success is attained with some new idea,
it is made available to other organizations. The
same, of course, is true of failures. In this man-
ner, expansion or retrenchment will continue as
actual experience and public demand dictate.
Here in Minnesota it is expected to offer, at the
outset, something about midway on the scale just
April, 1947
383
PREPAYMENT MEDICAL CARE— BUIE
described. By this I mean that it is intended to
offer more to the subscribers than just surgical
care or medical care while in hospital but less than
full coverage. The contract as finally agreed upon
probably will provide for limited general medical
care (home and office calls) and certain special
medical services.
This is the intention because it is believed that
our need in Minnesota is somewhat different from
that in the highly urban areas where most plans
have started. In our state, about 50 per cent of
the people live on farms or in small towns and
villages. It is necessary to offer these people a
contract under which they will be provided with
reasonably adequate medical services. Experi-
ments in rural areas have, of course, shown that
the rate of utilization is higher than in. cities. The
financial risk is greater. Where workers are not
covered by workmen’s compensation insurance,
all injuries and illnesses automatically come with-
in the scope of a prepayment plan.
The success of a plan under which general
medical coverage is offered depends on two things,
namely, control of abuses and adequacy of pre-
miums. Abuses may be perpetrated by the physi-
cian or the subscriber. It is the duty of the medi-
cal profession to keep its own members in line.
So, too, it is the duty of enrolling groups, whether
they are drawn from factories, farms, or towns
and cities, to keep tab on their members. The
same sort of fifty-fifty responsibility plays a part
in determining premiums. What can the sub-
scribers pay; what must be charged if the organi-
zation is to remain financially sound? I have
mentioned that before, and have given some fig-
ures. I mention it here again because it has an
obvious bearing on what I propose to take up
next, namely, the second of the two avenues for
expansion and what its limitations are.
Expansion of the program of prepayment for
medical care is limited then partly by the ability
and willingness of the public to enroll as subscrib-
ers. Most of the plans have been applied in urban
areas where large enrollment was possible. This
was a sound method because the sooner an organi-
zation obtains adequate spread of its risks, the
sooner it can expand its program of benefits and
enrollment. Large enrollment provides this spread
much more easily and quickly than small enroll-
ment. Not only this, but the cost per subscriber is
lower if enrollment is large than if it is small.
The pattern is now changing. Nearly every or-
ganization which has reached reasonable enroll-
ment and a sound financial level is turning to ways
and means of reaching all groups of the popula-
tion, particularly rural groups.
In general, the pattern has been to deal with the
farm group not as a separate entity but to include
it in what is called “community” enrollment. In
community enrollment, the farmer is included
with the residents of a city, town or village near
which he lives. Usually the town is a center for
banking, a source of supplies and so forth. The
whole community then composes the group, and
premiums are payable at a central place.
A successful Blue Cross enrollment campaign
in rural areas was carried out by the Weld Coun-
ty, Colorado, Agricultural Health Association.
Enrollment was on a community basis, reaching
all elements of the community as a civic service.
Weld County, the largest county in Colorado, is
about three times the size of Rhode Island and
boasts a population of 63,700. Greeley, with 15,
900 residents, is the largest city in the county.
There are several smaller towns, the largest of
which has a population of 1,800. Prominent busi-
nessmen, leaders of farm organizations and va-
rious club leaders met with Blue Cross represent-
atives and decided to form a health association
under the Colorado law governing co-operatives.
Twelve directors, each representing a definite dis-
trict in Weld County, govern the health associa-
tion. This division provided units that were
workable as to area and population for an enroll-
ment and administrative program. Enrollment
was not limited to Blue Cross but each district
was allowed to enroll separately in the Colorado
Medical Service plan whenever 50 per cent or
more of the families in the district had subscribed
to the health association and to Blue Cross. Ex-
perience demonstrated the value of a paid secre-
tary, to work full-time with the voluntary commit-
tees ; also to keep the records and to handle the
billing. The secretary’s salary and other necessary
expenses were financed by an annual charge of
$1.00 per year assessed against each member who
was more than eighteen years of age. To date,
Weld County has 8,000 enrolled. In Colorado,
ten similar county health associations have been
organized, and one of every six persons in rural
areas and one of every two urban residents have
been enrolled.
In Iowa, fiftv-five similar county health im-
provement associations have been organized. In
384
Minnesota Medicine
PREPAYMENT MEDICAL CARE — BUIE
other states enrollment on a similar community
basis is taking place although organization is less
formal.
Although the foregoing does not apply solely
to medical plans, voluntary prepayment medical
plans are making rapid progress in rural areas.
The problem cannot be solved on a national level.
It must be worked out in the community where
the need exists. Everyone in the community must
lend support if any effort is to succeed.
Continuing improvements in transportation will
accelerate the growing tendency of rural people to
bring the patient to the physician. Thus, physi-
cian’s care and other health facilities can be ex-
tended over an area that will include a sufficient
number of people to meet the costs of the services
provided.
The fees for medical sendees rendered by rural
practitioners are not excessive. However, there
are times when illness strikes and the severity of
the case cannot be predetermined. For this rea-
son, many farm families faced with severe illness
find it difficult to meet the full costs when illness
does strike. This problem is basically the same as
it is with people living in towns.
Medical Care for All
The medical profession has felt that it has done
well to charge for its services on the basis of the
patient’s ability to pay, charging nothing at all in
many instances and thus excluding nobody from
medical care. But this method is not agreeable
to everybody concerned nor is it certain that it will
prove sound in a future of unknown stresses.
The only sound method so far devised to provide
medical care for everybody in a free society is
through use of the insurance principle. Prepay-
ment plans for medical care available to all people
of a community, townspeople and farmers alike,
tend to spread the risk and distribute the costs.
Thus, having the cost known in advance, proper
planning and budgeting for the otherwise unpre-
dictable costs of illness are possible.
Physicians, because of their special training,
will bear the responsibility for the professional
aspects of the program. They also will see to it
that fees are not higher than they should be. The
recipients of medical service cannot escape the
responsibility of paying the cost of the services.
Both parties to the contract should do their full
share in providing the needed facilities.
For ten years or more physicians have operated
organizations under pilot plans for insurance
against the costs of medical care. From this ex-
perience they now feel that they should recom-
mend prepayment plans. Thus, the American
Medical Association enters the picture. This as-
sociation is not a superior authority which issues
orders to its state and county units. It is the re-
cipient of, and gives expression to, decisions
reached in the county and state units. These units
have caused to be formed a Council on Medical
Service of the American Medical Association and
one of its chief functions is to help in the devel-
opment of prepayment plans in various communi-
ties. The state medical associations and the
American Medical Association have rural health
committees devoting their attention to the rural
problem.
As has been said, physicians are co-operating in
local efforts and also are making available pre-
payment plans of medical societies so that every-
one interested may have an opportunity to insure
himself against medical expense. Local repre-
sentatives of farm organizations, business groups
and local medical societies working in full co-op-
eration and understanding are now in a position
to work out the difficult economic problem of de-
livering medical care to all the people.
A Qualification
In closing, may I say that the assignment to
discuss this subject was accepted with full reali-
zation of the vastness of' the problem.
At the height of ancient Greek culture, there
were said to be only seven philosophers who knew
the truth ; everyone else was ignorant. Today
many of us believe that we alone know the truth.
How many are there who, like Socrates, will ad-
mit that all they know is that they know nothing ?
Aristotle remarked that everybody contributes
something to the truth but no one person can ap-
prehend it by himself. No mortal is ever entirely
right.
April. 1947
385
THE TREATMENT OF PERSONS WHO HAVE BRONCHIAL ASTHMA
ARTHUR T. LAIRD. M.D.
Duluth, Minnesota
A STHMA is a Greek word which means
^ ^ shortness of breath, or panting. In Eng-
lish it has come to mean severe dyspnea, which
may occur in a variety of conditions. We speak
of bronchial asthma and of cardiac asthma, but
used in this way it is merely the name of a
symptom.
The word is quite generally used to denote-
bronchial asthma alone, that is to represent the
definite clinical complex exhibited by certain pa-
tients who between periodic attacks of wheezy
dyspnea are to a large degree subjectively and
objectively well. Even used in this sense it is not
really the name of a disease. While ordinarily
the symptom complex can be recognized without
too much difficulty, the diagnosis of its exciting
cause and the underlying constitutional basis
should also be made.
A patient suffering from an attack of bronchial
asthma is having a form of shock, somewhat
similar to the anaphylactic shock which occurs in
experimentally sensitized animals. Admitting the
occurrence of such paroxysms on a nonallergic
basis and of their development without previous
protein sensitization or exposure to allergens oth-
er than bacteria within the patient’s own body,
it is still generally agreed that bronchial asthma
in most cases is a clinical manifestation of an
allergic diathesis which the patient has had since
birth and which he has inherited.
Adequate diagnosis requires not only that the
character of the paroxysm be recognized, and if
possible the exact nature of its exciting cause,
but for successful treatment it must be constant-
ly kept in mind that there is also present an un-
derlying constitutional state.
In no condition is it more necessary that the
physician who hopes to benefit his patient per-
manently become thoroughly acquainted with him
as an individual, know his antecedents and con-
tinue in close touch with him throughout his en-
tire life.
Persons who have bronchial asthma are thus
different from other people. They nearly all be-
long to a definitely allergic group which is said
to comprise from 10 to 15 per cent of our popu-
Read before the medical staff of St. Mary’s Hospital, Du-
luth, Minnesota, October 3, 1946.
lation, and for the most part they are born with
a predisposition to develop asthma or some form
of allergy.
That the tendency to become sensitized is trans-
mitted according to the Mendelian law as a
dominant characteristic was shown by Cooke and
Vanderveer in 1916.
Asthma may be more or less of a handicap
in accordance with the frequency and sever-
ity of the paroxysms as they occur at inter-
vals during a longer or shorter life. The
patient’s titre or measure of sensitiveness to
this particular allergen or bete noir varies in
different individuals and is not always at the
same level in the same individual. There are
many predisposing causes which may lower it,
and it is well worth the patient’s and physician’s
time to seek them out and avoid them. It is
the tendency, not the specific sensitivity, that is
inherited. Persons inheriting such a tendency
are handicapped as truly as those who have lost
an eye or a limb. The main underlying cause of
asthmatic seizures is this bad family history.
It is peculiarily unfortunate if both father and
mother are asthmatic or even allergic to the extent
of being sufferers from hay fever or other de-
finite manifestations of allergy. A child born in
such a family needs special watchfulness on the
part of his parents and his doctor. The acquire-
ment of an inferiority complex is an incidental
handicap which awaits many such children, even
if they do not develop allergic symptoms.
Many superficial observers will feel that most
asthmatics are neurotics and will look for a psy-
choneurosis to explain their sufferings, but scien-
tific analysis has never been able to prove that
asthma is a neurotic or hysterical reaction.
A mental element was suspected in the case of one
of our patients who had been driven by her distress
to long journeys and strange behavior. Meanwhile,
her children had to travel with her, and their sur-
roundings and experiences were not those included in
a child’s bill of rights.
This young woman, in 1936 before her marriage,
when twenty-two years of age, was doing housework
in Minneapolis and contracted a severe cold. Since then
she has had asthma more or less continuously. Meanwhile
she married and she has had three children. She was in
several states and various hospitals while her husband
386
Minnesota Medicine
BRONCHIAL ASTHMA— LAIRD
was in the army. Though a resident of Stearns county,
Minnesota, she came to Duluth in 1944 and expected to
remain here indefinitely on account of the climate. She has
had skin tests and was found to be allergic to feathers,
dander and certain foods, and was given various treat-
ments, including sinus surgery and removal of nasal
polyps, but when she arrived here she was thoroughly
convinced that climate and intravenous injections of
aminophyllin were the only things that could help her.
In fact, she was addicted to the intravenous use of
aminophyllin. Admitted to St. Mary’s Hospital on
July 22, 1944, she received intravenous injections of
aminophyllin at frequent intervals, sometimes several
times a day. She remained in the hospital nearly two
months, getting various other medicines and treatments
as well. Among them was potassium iodide.
On November 19, 1944, when she consulted the Duluth
Clinic, she was the picture of distress. This appearance
was accentuated by an extensive acne of her face, and
she again received temporary relief through an intra-
venous injection of aminophyllin. Later the same night
she appeared at the emergency room at St. Mary’s
Hospital and asked for another intravenous injection.
This sort of thing continued for several days and. nights
and kept the interns busy, until four days later she was
admitted following an early morning emergency injec-
tion of aminophyllin. She had received fifty-nine such
injections in the previous six weeks. In the hospital
she received more aminophyllin injections. The pa-
roxysms of dyspnea, for which she sought relief were
likely to occur at most inconvenient times, often when
the nurses were busy with meals and interns were
difficult to secure. She seemed such a difficult and un-
reasonable patient that she was transferred to the psy-
chopathic ward, but the psychiatrist who was consulted
reported that her actions and deportment were typical
of one suffering from a chronic medical condition and
were due to introspection, anxiety about herself and
her problems, rather than any psychosis.
She was then removed to another ward and the situ-
ation was explained to her as well as could be. There
she received intelligent and tactful care from the in-
terns and nurses and was asked to co-operate as far as
possible. Gradually she became less apprehensive, and
acquired some faith in intramuscular and. rectal injec-
tions of aminophyllin, and before discharge was re-
lieved by adrenalin. Later when she was admitted to
St. Luke’s Hospital in a temporary panic, the same
program was followed. After a two-weeks stay she was
transferred with her children to St. Cloud in an auto-
mobile, attended by a nurse. During the trip she was
entirely free from symptoms. A year later the Steams
County Welfare Board reported that she and her chil-
dren had left some time previously for the Southwest,
either to join her husband or to search for a better
climate. That there was an anxious mental state which
added to her difficulties seems apparent. If she had
been endowed with a different temperament her treatment
would perhaps have been simpler. A great deal of her
distress was certainly from apprehension.
We had another patient whose dominant idea was
that he could not exist without oxygen. After hun-
dreds of dollars had been spent for its constant and
continuous use in St. Luke’s and Miller Hospitals,
since he evidently was a very sick man, the intern
and the medical and nursing staff finally succeeded in
weaning him from his dependence on it without doing
him harm.
The other members of the family of one of our
patients were thoroughly convinced that their mother’s
asthmatic attacks were largely nervous in origin and
that she could avoid them by using her will power.
This attitude on their part made her lot especially dif-
ficult and unhappy. She was undoubtedly neurotic.
However, her neurosis did not cause her asthma, but
on the contrary, was to a large extent caused by it.
Worries about financial and family affairs may
also seriously depress the patient’s threshold to
allergic reaction. Marital difficulties have been
complicating and unsolved problems in several of
our cases. While the avoidance of mental dis-
turbance is necessary in the treatment of the asth-
matic, the maintenance of the best possible condi-
tions for general bodily health is equally as im-
portant.
This has recently been emphasized by Dr.
Francis M. Rackeman. Depletion of vitaliy can
only lower the patient’s threshold to reaction and
make it possible for his latent or subclinical al-
lergy to express itself. There is a group of pa-
tients consisting mostly of children and young
adults who have asthma in isolated attacks, each
attack following a new cold. Such attacks may
sometimes be brought on by simple fatigue. In
such cases, besides the avoidance of known aller-
gens, improvement of the general health of the
patient is most important. Better hygiene regula-
tion of his daily life, the time and quality of
meals and daily activities, the institution of ade-fc
quate periods of rest, fresh air and exercise, the
use of extra vitamins and vaccines, are all helpful
measures.
Some allergic persons living a well-regulated
life are not much handicapped by asthmatic at-
tacks. One of our patients was a boy of seven-
teen who had asthma for several years. He de-
veloped a severe attack on October 12, 1944, and
was admitted to St. Mary’s Hospital where he
secured relief from adrenalin. He was ;quite
thoroughly studied and found to have sinusitis
and to be quite sensitive to various dusts, but not
to foods. No surgery or change of climate was
advised nor was his school work interrupted. He
was simply asked to secure nine hours sleep if
possible and to follow a slightly limited regime.
He also took an oral cold vaccine. Careful hy-
April. 1947
387
BRONCHIAL ASTHMA— LAIRD
giene, rather than the vaccine, was probably re-
sponsible for the fact that he had no colds dur-
ing the following winter. Early in the summer
of 1945, although he was frank in telling of his
asthmatic history, he was accepted by the navy.
In June of 1946 his mother reported that he had
been in the navy a year, part of the time being
spent at the Great Lakes Training Center in Illi-
nois and part of the year in New Orleans, but
that he had had no recurrence of asthma.
It will often be found that an asthmatic pa-
roxysm has been preceded by a period of poor
general health during which the patient has been
below par. He may have had pneumonia, or an
operation or just an upper respiratory infection.
Often enough he has gone through a serious emo-
tional experience and as a result has lost appetite
and sleep. He needs an “ordered life” without
“strain or stress” to keep the threshold of his sen-
sitivity low enough to prevent the occurence of
explosive reactions. “Debility” and “depletion,”
to use Dr. Rackman’s terms, often cause them.
Getting acquainted with an asthmatic patient
involves very careful history-taking to bring out
underlying accessory causes which precipitate dis-
tressing episodes. Experience has shown, accord-
ing to Unger, that in almost every severe case of
asthma someone has been neglectful. The phy-
sician is not consulted often or retained to be a
life counselor or guide to his patient, who mud-
dles along or is neglected by his parents and
friends until a violent reaction occurs, at which
time they cry vociferously for help.
Hospitalization for a short time is often a wise
measure since it changes the patient’s environ-
ment, aids in the more exact determination of his
susceptibilities, and raises his reactive threshold
to offending allergens. Unless fundamental study
and care is given, the patient is readmitted again
and again, or else remains at the hospital for an
indefinite period. One Duluth patient remained
hospitalized for more than a year ; another has
been admitted nine times in the past two years
to the same hospital.
Whatever the offending allergen may be that
precipitates the asthmatic attack, the explosive re-
action that occurs is substantially of the same
nature in each case.
There is practical agreement that asthma pa-
tients have, in the mucous membrane lining the
bronchial tubes, sensitized cells containing anti-
bodies that are specific for certain allergens.
When the specific allergen comes in contact with
these antibodies in the sensitized cells in the
bronchial mucosa, whether it reaches them through
the inhalation of air containing it or by way of
the blood stream, the reaction occurs. The se-
verity of the reaction depends on the degree of
sensitivity of the cells and the amount and charac-
ter of the allergen. The bronchi containing the
sensitized cells are the trigger area, and their
degree of sensitivity may be so great that the most
trifling circumstances, given any exposure to the
antigen, may cause the explosion, even in some
cases the passage from a sun-warmed area into
the shadow.
As in anaphylactic shock there is narrowing
of the lumen of the bronchial tubes by the out-
pouring of mucous which partially fills them, and
probably also by muscle spasm in the smaller
bronchi. The patient becomes more or less short
of breath, begins to wheeze, and has a moderate
amount of cough and expectoration. In more
severe attacks the dyspnea becomes extreme and
all the accessory muscles of respiration are
brought into play. Tachycardia and sweating
occur. The individual is utterly miserable, just
as he has been before and is in many cases des-
tine to be again and again.
As in surgical shock, a toxic histamine-like
substance is believed to be set free which initiates
the profound local and systemic reaction. The
distribution of the blood is altered and its control
changed. Internal secretions, especially adrenalin,
are called into the circulation and various bio-
chemical changes promptly occur, including in-
crease in the hydrogen ion concentration, all of
which have their effect on the control centers in
the medulla. Fear and emotional shock are ac-
companied by somewhat similar phenomena.
The purpose of the emergency treatment of
asthma is to interfere with the mechanisms pro-
ducing shock and to lessen its severity.
The diagnosis is usually not difficult and in
most cases has already been made. The wheezy
dyspnea is characteristic, the long history of re-
curring paroxysm with no evidence of disease
between the attacks makes confusion with the
dyspnea of heart disease or pneumonia unlikely.
However, as has been said, “All is not asthma
that wheezes,” and laryngeal affections, extrinsic
and intrinsic lesions of the trachea and bronchi,
foreign bodies, diseases of the heart and lungs,
388
Minnesota Medicine
BRONCHIAL ASTHMA— LAIRD
Loeffler’s syndrome and functional air hunger all
have to be considered.
The following summary has been prepared for
me by Sister Loretta and the record librarians at
St. Mary’s Hospital in Duluth. It is concerned
with admissions to that hospital in 1944 and 1945.
Nearly every general practitioner and internist on
the staff was represented among the thirty-eight
physicians in charge of the patients.
As a rule, the procedures used to control the
patient’s paroxysms and relieve his distress were
the usual well-recognized or recently publicized
methods, which it may be worth while to review
here.
Treatment Used:
Adrenalin 58.7
Ephedrine 32.5
Phenobarbital 32.6
Morphine sulphate -. 11.9
Various sedatives 39.6
Aminophyllin 46.0
Oxygen 19.0
X-ray therapy 24.6
Hot packs 11.9
Steam 27.7
Radiant heat 3.9
Sulfa drugs 26.9
Penicillin 8.7
Histamine 8.7
Sat. Sol. K I 8.7
Cough mixture 34.1
Results:
Improved 99.2
Died 79
ASTHMA GROUP STUDY, ST. MARY’S HOSPITAL
DULUTH, MINNESOTA
1944-1945
Total Cases
1944 70
1945 56
Age:
Under 10
10-20
20-30
30-40
40-50
50-60
60-70
70 plus
Sex:
Male
Female
Duration:
First attack
More than one attack....
Not mentioned
Exciting Cause:
Pollen
Seasons
Feathers/
Dander
Food
House dust
Excitement
Cough
Cold air
History of Other Allergies:
Eczema
Hives
Hay Fever
Dermatitis
No allergy
Not mentioned
Eosinophilia:
3% plus
4% plus
5% plus
6% plus
Per Cent
. . 31.7
. . 9.5
.. 3.2
.. 13.5
.. 7.1
.. 11.9
.. 15.8
.. 15.8
57.1
42.9
23.0
69.0
7.9
6.3
18.2
3.2
3.2
10.3
3.9
3.2
50.7
5.5
12.7
3.2
8.7
2.3
5.5
61.1
10.3
5.5
2.3
19.0
No eosinophilia 26.1
Not mentioned 34.9
The purpose of the emergency hospital treat-
ment of asthma is, as has been stated, to inter-
fere with the mechanism producing the shock and
to lessen its severity. A number of medicines
and measures have been proved to be helpful for
this purpose in Duluth as elsewhere.
Adrenalin. — The most commonly used and
most effective medical treatment of the paroxysm
is the subcutaneous or intramusclar injection of
adrenalin. A dose of .35 c.c. of a 1 : 1000 solu-
tion in normal saline may control the attack for
a time varying from minutes to hours and often
is as effective as a larger dose. The smaller dose
can be repeated at half hour intervals if necessary.
Adrenalin is of no value given orally and is rare-
ly used intravenously. It must be used with some
caution in those with hypertension and heart dis-
ease. If the usual saline solution is not effective,
adrenalin may be given as a 1 :500 suspension in
peanut oil by intramuscular injection, in which
case its action is somewhat slower and more pro-
longed. The inhalation of a still stronger watery
solution, 1 TOO, from a special nebulizer, helps
many patients. Some chronic asthmatics require
or demand as many as ten or more injections of
adrenalin in one day. The relief obtained by a
single injection may in other cases last for weeks
or months.
If the usual saline solution is not effective, ad-
renalin may be given as a 1 :500 suspension in
peanut oil by intramuscular injection, in which
case its action is somewhat slower and more pro-
longed. The inhalation of a still stronger watery
solution, 1 TOO, from a special nebulizer, helps
many patients. Some chronic asthmatics require
or demand as many as ten or more injections of
April, 1947
389
BRONCHIAL ASTHMA— LAIRD
adrenalin in one day. The relief obtained by a
single injection may in other cases last for weeks
or months.
After a time, especially in the severe and pro-
tracted cases, the patient may become adrenalin-
fast, a condition which however is usually not
permanent.
When the patient’s sensitivity to his allergen re-
mains low and his attacks are mild, they may be
relieved by the use of ephedrine, a drug whose
effect is similar to that of adrenalin. It has the
advantage that it may be given by mouth. There
are a dozen or more preparations, each highly
recommended by the manufacturer as effective in
asthma, which consist of ephedrine combined with
phenobarbital aminophylin or other substance.
The patient may take such tablets three times a
day or when needed to control an attack. If his
attacks come in the night, he may take an enteric-
coated tablet in the evening which becomes effec-
tive some hours after it is taken. Several of our
patients have found the occasional or continued
use of such tablets, together with hygienic meas-
ures, all that was required to keep them fairly
comfortable for long periods.
Adrenalin was used in the treatment of nearly
every asthmatic patient admitted to St. Mary’s
Hospital in Duluth in 1944-1945. Ephedrine,
usually in combination with phenobarbital, was a
supplementary medication routinely prescribed.
Amino phyllin. — When patients cease to be re-
lieved by simple medication or by the use of
adrenalin, it becomes necessary to employ other
means to lessen or banish their distress. Theo-
phyllin ethylenediamine, or aminophyllin, as it
is commonly termed, is a valuable synthetic xan-
thine derivative. Used intravenously it promotes
prompt relief in most cases. It must be given
slowly to avoid causing syncope. In order that it
may be injected slowly it is nearly always given
in a considerable amount of saline solution. The
usual dose is 0.48 gm. ( 7)4 gr.) in 20 c.c. of nor-
mal saline solution. Sometimes 0.24 gm. (3%
gr.) in 10 c.c. of norma) saline solution is suf-
ficient to give relief. Aminophyllin is said to act
by inhibiting bronchospasm through direct action
on the bronchial musculature, while adrenalin
stimulates the sympathetic nerve fibres in the
bronchi causing shrinking of the bronchial mucosa
through vasoconstriction of the arterioles, at the
same time producing bronchial dilatation through
relaxation of the bronchial muscles.
Aminophyllin given orally has not proved very
effective in relieving asthmatic attacks. It has
sometimes been given intramuscularly with satis-
factory results in 0.48 gm. (7)4 gr.) doses which
are furnished in 2 c.c. ampules.
It is sometimes effective in rectal injections,
0.48 gm. (7)4 gr.) being administered in 20 c.c.
of distilled water as a retention enema, or it may
be given in a suppository containing 0.36 gm.
(5)4 gr.).
Since intravenous injections cannot be admin-
istered by the patient himself or very frequently
at home by his physician, the patient requiring
aminophyllin should ordinarily be hospitalized.
Aminophyllin finds its greatest field of useful-
ness in patients who temporarily are not relieved
by adrenalin, and according to the Council of
Pharmacy and Chemistry the American Medical
Association3 it is probably a safer drug than
adrenalin in the occasional cases where there may
be indecision regarding the “bronchial” or “car-
diac” nature of the attacks. Intramuscular and
rectal administration should be used more fre-
quently than they have been.
Oxygen. — Oxygen, or oxygen with helium, is
frequently administered to relieve distress from
asthmatic seizures. In some cases immediate
relief is secured.
Forty per cent oxygen at the rate of 4 to 6
litres a minute is the usual prescription. Con-
tinous oxygen is occasionally required, or seems
to be, for considerable periods, as already men-
tioned. A mixture of helium and oxygen in the
proportion of 80 per cent helium and 20 per cent
oxygen offers the advantage that, inasmuch as
the mixture has only about one-third of the
weight of air, it is breathed more easily. Fol-
lowing the use of oxygen, patients who have
become re factory to adrenalin may again be
able to get relief from it.
Two ounces of ether with four ounces of olive
oil per rectum is effective in securing relaxation
for some patients. Occasionally general anes-
thesia has been employed with benefit.
X-Ray Therapy. — Schilling10 in 1906 noticed
that an asthmatic patient felt better after fluoro-
scopy, and various observers have since recorded
improvement after x-ray treatment. Desjardins5
has explained the benefit as due to the action of
the x-rays in producing a decrease in the secre-
tory power of mucous glands, a liberation of an-
390
Minnesota Medicine
BRONCHIAL ASTHMA— LAIRD
tibodies by the destruction of leukocytes and a
stimulation in the production of eosinophiles.
However, although forty years have passed
since Schilling’s report, x-ray treatments have
not yet been proven of extraordinary value for
relieving or preventing asthmatic attacks. What-
ever beneficial effect they may have does not seem
to be lasting.
Enough has been said to indicate that the hos-
pital treatment of bronchial asthma has usually
meant rather desperate attempts on the part of
the attending physician to meet an emergency to
relieve a patient in dire distress, to treat a symp-
tom without getting rid of its cause.
Morphine. — The administration of morphine
is mentioned only to be condemned. Although
the patient gets relief, sudden death is not un-
common following its administration. It is es-
pecially dangerous when used as a last resort.
It probably causes death by depressing the cough
reflex and the respiratory center. When it does
not cause death directly, its use is likely to be
followed by nausea and vomiting which definitely
increase the mortality. Some allergic individuals,
moreover, are hypersensitive to morphine itself,
and frequently it causes pruritis, if no more
serious result. It is not denied that in some cases
morphine relieves when other measures have
failed, but too often it quiets the patient perma-
nently. Unger11 reports five fatalities following
the use of morphine to control asthmatic seiz-
ures, in 1926, 1928 and 1929.
Since abandoning its employment, only two
deaths from asthma have occurred in his practice.
As a matter of fact, except when morphine is
used, deaths rarely occur during asthmatic seiz-
ures or in status asthmaticus. Often the patient
wishes he could die but doesn’t.
More than 10 per cent of the asthmatic pa-
tients at St. Mary’s Hospital in 1944 and 1945
received morphine. Fortunately there was only
one death in this series and that was not follow-
ing its use.
Demerol, an opium derivative, in spite of Paul
de Kruif’s recent panegyric in the Reader’s Di-
gest4 over its use in asthma, as God’s own medi-
cine, has not been found very useful or very safe.
Various other sedatives and hynotics are often
helpful. Phenobarbital, seconal, amytal, or nem-
butal may be tried, but they may do harm if
pushed to the point where the patient’s ability to
expectorate is lessened. One must be on guard
for idiosyncrasies.
Most asthmatics endure necessary surgical op-
erations fairly well. It is easier and safer to op-
erate between the attacks, but when delay would
be dangerous, it has often been found that the
anesthesia brings on relaxation and long-contin-
ued relief. Morphine should not be given in the
preparation of the patient. Substitutes such as
the barbiturates (nembutal, amytal, and pheno-
barbital) should be employed instead. Aspirin
should not be given, unless it has been ascertained
that the patient is not hypersensitive. One of
our patients had a nearly fatal shock after being
given 5 grains. Still it was not infrequently
ordered in the series.
Febrile diseases are not especially influenced
by the presence of asthma, and during their
course the patient may have temporary relief from
his attacks. This was true in one of our cases,
an old lady, who, while having frequent asthmatic
seizures, developed bronchopneumonia for which
she was hospitalized. During its course she was
free from asthma, but it recurred following her
convalescence. Did her fever act as a form of
therapy ? On the other hand, head colds and sore
throats often precipitate asthmatic attacks.
Specific Treatment. — Separation of the patient
from exposure to the allergen for which he has
acquired a greater or less degree of sensitivity is
a form of specific treatment. Sometimes the of-
fending substance is already known to the patient ;
hence, the value of careful history taking. Re-
moval of the patient from his home to the hospi-
tal may shed light on the subject. If the attacks
cease, the allergen may be absent in the new en-
vironment.
If not known or discoverable in this way, val-
uable leads may be given by careful skin testing,
though often enough some of the substances to
which the patient responds by positive reactions
are not the one which produce his symptoms. He
may react positively to substances with which he
rarely comes in contact, or of which he encoun-
ters such small amounts that this threshold of
sufficient susceptibility to permit an attack is not
reached. His sensitivity to some other substance
may be the one that really causes the trouble.
Satisfactory skin testing requires skill and ex-
perience and judgment. The tests may be on the
patient’s skin, or if for any reason, such as the
Apkil, 1947
391
BRONCHIAL ASTHMA— LAIRD
presence of skin eruptions or a general condition
of debility or depletion, this is not practicable,
they may be done on the skin or another person
who, however, must not be an allergic individual
himself. This indirect form of testing is based
on the Prausnitz-Kustner10 phenomenon, in ac-
cordance with which the patient’s sensitivities can
be transferred to a limited area of the skin of
another individual by preliminary injections into
it of the patient’s serum.
Whether the direct or indirect methods of test-
ing are chosen, care must be used to avoid over-
dosage, as severe constitutional reactions and even
fatalities have resulted in some cases. The pa-
tient who is being tested should remain in the
physician’s office long enough for untoward symp-
toms to develop, and restoratives should always be
at hand in case syncope occurs.
The tests are performed in various ways — on
the skin by simple contact or patch methods, and
in the skin by the scratch or by intracutaneous
procedures. They are time consuming and should
be directed and observed by one thoroughly famil-
iar with them, preferably a trained allergist.
When the substance or substances to which the
patient is sensitive and which appear to be re-
sponsible for his asthmatic attacks are identified,
breaking of contact with them is sometimes quite
simple. Food allergens may be omitted from the
diet. The face powder may be changed if it is
responsible. Contact with animal dander may
cease when the dog or cat is banished. Offending
pollens may be avoided by moving to a place
where they do not exist, or are not sufficiently
abundant to overcome the patient’s modicum of
resistance, as in the hay fever havens of America
where the breezes blow them away. If one must
stay where there are pollens to which he is super-
sensitive, air filters and air conditioning may help
to keep them out of a room.
If considerable contact is unavoidable, desensi-
tization may be tried. Perhaps hyposensitization
is a better term since complete and permanent
desensitization is rarely possible. The best that
can usually be hoped for is a reduction of the
patient’s sensitivity.
This form of treatment may be given orally
in case the allergens which distress the patient
are foods. If they are pollens or bacteria, a series
of hypodermic injections of extracts or suspen-
sions is used.
Dosages, solutions and time intervals differ
somewhat in various hands. The principle is the
same that underlies immunization to tuberculin
by Dr. Trudeau’s method. Very minute doses
are given at first. The dose is gradually in-
creased. Every effort is made to avoid general
reactions. It is remarkable with what high dilu-
tions they may occur even after the use of what
seems like homeopathic attenuations of the dos-
age.
Fatal shock has occurred more than once during
specific treatment, and, though infrequent, the
possibility of its developing should be kept in
mind and guarded against.
The exact technique, the dosage and spacing
of injections, the best and latest methods of pre-
paring and administering extracts are described
in current literature on allergy and should be
followed to avoid disaster.
Very satisfactory results have been obtained
from hyposensitization treatment by experts.
Unger11 secured freedom from symptoms for
at least a year in this way in 33.6 per cent of 122
patients whose asthma was due to pollen.
The best results come from perennial rather
than merely seasonal or preseasonal treatments.
Asthma has been classified by some authorities
as extrinsic, due to substances from without the
patient’s body to which he has become sensitized
and which reach his trigger cells in the bronchial
mucous membrane by inhalation or the blood
stream, and intrinsic, due to substances already
present within the body. Upper respiratory in-
fections frequently initiate asthmatic attacks, and
at times no extraneous allergens can be found
that are responsible. A patient may originally
have become asthmatic as a result of sensitization
to external antigens and may have been desensi-
tized, but in the meantime have developed bac-
terial sensitivity which continues his asthma. In
some such cases desensitization with bacterial
vaccines has been helpful. Autogenous vaccines
are to be preferred, but stock vaccine may be
used.
Since a histamine-like substance is believed to
have an important part in producing the allergic
paroxysms, as well as in other forms of shock,
efforts have been made to desensitize the patient
to histamine. Histamine and histaminase have
been used in Duluth as elswehere for this pur-
pose. Recently, Horton and his co-workers7 in
392
Minnesota Medicine
BONCHIAL ASTHMA— LAIRD
the Mayo Clinic have been experimenting along
this line with a new preparation known as bena-
dryl, which has been given some publicity. It
has been tried with encouraging results in other
allergic conditions such as hay fever and eczema,
but no remarkable success has yet been noted with
asthmatic cases. Histamine is so intimately con-
cerned in various bodily functions that the ques-
tion may be raised whether complete desensitiza-
tion to it would be desirable. Insulin and fever
therapy have also been used in the treatment of
asthma.
It is not to be expected that any form of treat-
ment that merely relieves an attack of asthma is
going to prevent recurrences. Lowering the pa-
tient’s threshold of sensitivity by specific treat-
ment is of more value, but even this will not
suffice to keep the patient comfortable without
avoidance of conditions which cause depletion
and debility.
Nothing can be done to remove entirely the
congenital handicap, the inherited constitution.
With such an inheritance, the development of
some degree of hypersensitivity to various aller-
gins is inevitable. The physician’s problem is
the prevention of the more serious degrees of
allergic response. If the child is already devel-
oping eczema, every effort should be made to
forestall hay fever and especially asthma. Al-
lergic children are a special responsibility. Al-
lergic families must be recognized and their fu-
ture health guarded. If the reactions can be
kept minimal, they may not cause too great a
handicap, but if these cases are neglected the
results may be dire indeed.
The distress suffered by patients who have
severe bronchial asthma is pitiable and is probably
as hard to bear as the pains caused by cancer
or heart disease, with the added foreboding of
many future attacks. More appreciation of the
courage and heroism of those who endure them
should be shown. The sequels of repeated at-
tacks may be definite pathological conditions of
various kinds. Emphysema commonly results from
them and eventually heart strain. Various condi-
tions, migraine, gastrointestinal crises, Meniere’s
disease and the dreaded periarteritis nodosa have
all been suspected of allergic affiliations.
The child born with an allergic tendency, a
capacity for becoming hypersenitive to all sorts of
allergens, should be guarded from exposure to
excessive amounts of the more common and
notorious ones. If a certain amount of contact
with them is unavoidable, his general health and
resistance must be kept at a high level through-
out his whole life. This is a large contract. The men
who have suceeded best in fulfilling it have not
merely been skilled allergists, but they have ap-
proached the problem with the broad view of
experienced internists, and in addition to specific
measures have used a considerable amount of
psychosomatic therapy. The patient’s morale must
be kept up. His apprehensions must be relieved
and freedom from fear secured if possible. He
must have a strong arm to lean on. His handi-
cap may, to a large extent, often be overcome.
There are a number of men in the larger cities
who in this way have made life worth' living for
a large number of patients during a series of
years. Such help is needed everywhere.
So far we have not considered bronchial asthma
as a social problem. The actual number of asth-
ma cases is unknown. The condition is not re-
portable. Five-tenths of one per cent of selectees
for military service in a group of 45,000 were
rejected because of severe allergic states, chiefly
asthma,6 and it may be assumed that that percen-
tage approximately represents its prevalence.
There are probably several hundred thousand as-
thmatic persons in the United States, of whom a
considerable proportion are wage earners. As
already stated, perhaps 10 per cent of the popula-
tion show some evidence of allergic predisposi-
tion. The avoidable economic loss from impaired
working capacity is certainly worth salvaging.
The expense to welfare agencies from asthmatics
seeking hospital relief and change of climate is
very considerable.
A national crusade for the prevention and
control of asthma has been advocated and doubt-
less will materialize. It should follow the lines
already laid down in other successful health pro-
motion efforts. They represent the combined ef-
forts of the medical profession and the lay public.
Research should be a necessary part of the pro-
gram. The facts about the condition should be
widely publicized.
The services of experts in treatment should be
made available to all patients. As regards asthma,
physicians should recognize the occurrence of al-
lergic families and discourage intermarriage. The
children of allergic patients should be treated as
(Continued on Page 422)
April, 1947
393
NITROGEN BALANCE AND ITS CLINICAL APPLICATION
ROBERT E. HANSEN. B.S.. M.D., and EDWARD L. TUOHY, M.D., F.A.C.P.
Duluth, Minnesota
npHE term nitrogen balance connotes the degree
■*- of equilibrium of the body in terms of nitro-
gen taken into the organism and the amount lost.
The main routes of nitrogen loss are through the
urine, feces and exudates. In cases where the or-
ganism sustains an illness or injury, some of the
body tissues are catabolized, the nitrogen excre-
tion exceeds the ingestion of nitrogen, and the
body is said to be in negative nitrogen balance.
As recovery progresses the body retains more ni-
trogen than it excretes, thereby acquiring a posi-
tive nitrogen balance.
Since nitrogen is one of the important sub-
stances in protein, and because it is the element
with which we can deal objectively in studies to
determine the protein status of our patients, we
will frequently use these terms, nitrogen and pro-
tein, interchangeably in this discussion. An im-
portant decisive fact to remember is that quanti-
tatively 1 gm. of nitrogen is equivalent to 6.25
gm. of protein, or protein contains 16 per cent
nitrogen.
During the past several years, the interest in pro-
tein metabolism has increased considerably. Un-
doubtedly the past war has exerted a great influ-
ence in this direction. One of the authors ( R. E.
H.) has observed the mark of protein deficiency
in many European people. It was dramatic, it was
pitiful, and it was deadly. We must diligently re-
member that protein deficiency is not a rare phe-
nomena which is confined to the unfortunate, mal-
nourished and starving peoples. Even those who
have been blessed with health, wealth and an
abundance of excellent food may feel the sting of
protein deficiency should they suffer from a frac-
ture or convalesce from an operation or illness.
And let us not forget the women in gestation who
require careful protein consideration, because the
human embryo will most certainly demand its
“pound of flesh.”
Hemostasis names the physiologic process of
normal balance and adaptation. We propose to
emphasize the protein factor therein.
Nutritionally, the proteins are assuming the
principal role for which they got their name from
From the Department of Medicine, St. Mary’s Hospital, Du-
luth, Minnesota.
the Greek — first in body rebuilding. One might
say that we as humans are essentially suspensions
of proteins in water.
Students of protein metabolism have advanced
several theories in an attempt to explain this body
function. More recently Borsook and Keighly3
have emphasized the factor of dynamic equilibri-
um in which breakdown and resynthesis proceed
hand in hand — dietary nitrogen replacing tissue
nitrogen, and the nitrogen of various organs un-
dergoing continuous interchange. Even in a starv-
ing animal, tissue protein does not undergo catab-
olism alone, but is being continuously resynthe-
sized, new protein being formed in one tissue
from nitrogen derived from another.
Chemically, proteins are organic molecules
composed of linked amino acids. Nutritionally,
proteins are considered to be of two types, the su-
perior and inferior — the superior being the pro-
tein with a high biological value and adequate
digestibility. Animal proteins are classed here.
They have a high biological value because they
contain the essential amino acids (ten in all) in
the proportions which closely resemble human
protein. They have a 95 to 100 per cent digesti-
bility. The inferior protein is one which is lack-
ing in one or more of the essential amino acids or
which is less digestible and absorbable. The vege-
table proteins tend to fall into this group. The
ingestion of inferior proteins alone necessitates
wastage of its end products. The amino acids of
the protein are broken down and excreted instead
of entering into tissue protein, and, as a result of
this, body tissues have to be broken down to fur-
nish essential amino acids for protein metabolism.
In such a situation the body enters into a negative
nitrogen balance. Now how does all of this fit
into a person’s average daily existence? It is defi-
nitely true that a person on a well-balanced mixed
diet will get all the essential nutrients. It is only
when the protein intake is restricted or unutilized
that one must give exact consideration and choose
proteins of high biological value.
The process of protein digestion is relatively
simple — the molecules are acted upon by enzymes
in the stomach and small intestine, breaking them
into proteoses, polypeptides and amino acids. The
394
Minnesota Medicine
NITROGEN BALANCE— HANSEN AND TUOHY
amino acids and polypeptides are absorbed and
enter the portal circulation and lymph, and then
the general circulation. We can readily see that
any disturbance in the normal digestion of pro-
tein will definitely affect the ultimate protein me-
tabolism, chiefly by reducing the amount of amino
acids absorbed. The stool nitrogen in such cases
will increase, and this is the basis of the generally
utilized methods of studying nitrogen balance.
When the amino acids attain the circulation,
they are either used for the restoration of tissue,
for the building of hemoglobin or plasma pro-
teins, for the manufacture of hormones or intes-
tinal enzymes, or they are sent to the liver and
deaminized, releasing carbohydrate for energy and
diverting nitrogenous elements for urinary excre-
tion.
Let us consider the production and maintenance
of tissue protein, plasma protein and hemoglobin.
The body gives first consideration to the produc-
tion of hemoglobin, which takes preference over
other body protein needs. It may draw from the
tissue and plasma proteins, but does not in turn
contribute to the protein pool. Perhaps this is the
explanation for the rare occurrence of a true pro-
tein deficient hypochromic anemia in this coun-
try. Usually we see the iron deficiency type.
Considering now the tissue protein, we know that
every tissue must retain a minimum level of pro-
tein if it is to live. Under normal circumstances,
cells contain more than the absolute minimum,
and some of these proteins are in a labile form,
readily available to the body if needed. This pro-
tein has been termed the “deposit protein.” In a
well-nourished, average-sized man this measures
about 2 kg., which actually is a small amount. In
addition to the hemoglobin and tissue protein
there are the plasma proteins, which have three
constituents: (1) fibrinogen, formed chieflv in
the liver and used in the clotting mechanism, be-
ing converted by thrombin into insoluble fibrin ;
(2) globulins (alpha, beta and gamma) which are
intimately concerned with certain pathological
functions, such as antibody formation, and are
formed in the liver and lymph nodes, and (3) al-
bumin which is formed in the liver and is respon-
sible for the maintenance of the osmotic pressure
of the blood. It is this serum albumin which is
lost in the urine in nephrosis ; it is the predomi-
nant protein lost in exudates; it is the protein
primarily affected in hypoproteinemia.
Because a dynamic equilibrium exists between
the plasma and tissue proteins, a lowering of the
serum albumin occurs only after the body pro-
teins have been severely depleted. Elman8 has
shown that a loss of 1 gm. in the total circulating
serum albumin entails the destruction of 30 gm.
of body protein. For example, an average-sized
man (70 kg.) has a circulating volume of 3 liters.
If he loses 1 gm. of albumin per 100 c.c., it corre-
sponds to the loss of 10 pounds of flesh. Return
of the plasma albumin concentration to normal
may occur before, and often long before, the body
deficit is made up, but is probably only temporary
and a prompt fall would result unless the protein
intake is maintained. Thus the return to a normal
plasma albumin indicates that the treatment is ef-
fective but not necessarily complete, and that the
high protein food intake must be maintained until
normal weight and strength are regained. At Hal-
loran General Hospital, Sprintz15 observed that a
group of soldiers with chronic infections who lost
one-third to one-half their original body weight
following injury showed no hypoproteinemia or
abnormal albumin-globulin ratio. In the presence
of normal plasma proteins there may be a marked
depletion of body tissue. Only if there is a low
plasma protein can one attempt to make an accu-
rate statement regarding the state of the tissue
protein.
The diagnosis of protein deficiency depends
upon the clinical symptoms and signs, corrobo-
rated by laboratory studies. The clinical picture
is familiar to us, manifested by anorexia, weak-
ness, mental depression, failing memory, weight
loss and edema. The edema level is recognized as
about 5 gm. per cent. The laboratory procedures
which objectively assist in the diagnosis are: the
hemoglobin determination, the plasma protein
analysis and the nitrogen balance studies. The
Kjeldahl procedure or one of its modifications
may be used for the study of nitrogen elimination.
In addition, measurements of strength and endur-
ance by a physical fitness test or an ergograph4
have proved to be valuable assets. The study of
weight curves has been a convenient method to aid
in the evaluation of a patient’s protein status.
Wangensteen and Varco18 advocate the feeding of
a high-protein, high-caloric diet to surgical patients
who have lost body weight. They recommend at
least a week of nutritional preparation for every
10 per cent of the original body weight lost. Per-
haps the disadvantage of weight studies is the
April, 1947
395
NITROGEN BALANCE— HANSEN AND TUOHY
possibility of large fluid shifts which may mask
the loss or gain of flesh.
Let us consider here two factors which affect
protein metabolism — the energy requirements of
the body and the special demands made during
injury or illness.
The energy requirements are of paramount im-
portance to the body and are supplied first. The
three necessary nutrients are carbohydrate, fat
and protein, which furnish energy at the rate of
4, 9, and 4 calories per gram, respectively. The
body uses about 1,800 calories, and if this energy
is not supplied in the diet, the body burns its own
stores. If the body cannot obtain sufficient calo-
ries from the fat and carbohydrate, the protein
catabolism is greatly increased and one can ob-
serve the “terminal rise” of nitrogen excretion, so
named because the organism would die shortly
after its appearance. This process is known as
auto-cannibalism. Carbohydrate exerts a specific
protein sparing effect apart from the fact that it
furnishes energy as does fat, because the sparing
effect exhibited by a given amount of carbohy-
drate cannot be brought about by the same amount
of fat possessing double the caloric value.2 Carbo-
hydrate alone has a marked sparing effect, where-
as fat alone does not, a positive nitrogen balance
cannot be maintained on a diet of protein and fat.
A probable explanation for the great sparing ef-
fect of carbohydrate is that its intermediary prod-
ucts of metabolism make it possible for the nitro-
gen resulting from tissue breakdown, in a pre-
dominantly protein and fat diet, to be used in re-
synthesizing amino acids for body protein.
The demands upon protein metabolism during
injury or illness have added new interest and
stimulus to a consideration of what happens there-
to after injuries, operations or physiological up-
sets which occur in infectious processes, chronic
wasting, malignant disease and metabolic disturb-
ances. A review of some of the recent reports
features certain dramatic and unsuspected breaks
in nitrogen metabolism.
Following extensive burns, a hypoproteinemia is
known to occur, due to several factors such as
tissue destruction, loss of serum protein in exu-
dates, failure of hepatic function in protein syn-
thesis and loss of ingested food because of diar-
rhea or vomiting. The extent of protein loss in
exudates has been shown by Co Tui5 to vary from
1.2 gm. to 9.5 gm. per day. The extent of uri-
nary nitrogen loss after severe burns was demon-
strated by Taylor,16 who found, in a series of
twenty-two cases, a nitrogen loss of up to 45 gm.
in one day, which is equivalent to about 280 gm.
of protein.
The resutls of a study conducted by Hirshfield
and associates11 on twenty-three cases of thermal
burns, revealed that patients excreted rather large
amounts of nitrogen, and unless they were receiv-
ing a high-caloric, high-nitrogen intake, they
showed a negative nitrogen balance and weight
loss. Attempts were made to force large amounts
of food in the early acute stage but proved un-
successful because of intolerance. However, after
three or four days the patients were able to take
abundant food, and the body response showed a
definite swing to a positive nitrogen balance. Dur-
ing the initial acute phase when the patients were
unable to tolerate large diets, they were given in-
travenous protein hydrolysates. At present most
authors agree that the use of parenteral hydroly-
sates should only be used during emergencies, and
replacement by oral therapy at the earliest moment
is greatly advantageous.
Protein deficiency develops frequently and in-
sidiously in patients anticipating operation for
peptic ulcer or gastrointestinal malignancy. In
contrast, Thorton17 did not find this commonly in
patients requiring thoracic surgery. Hartzell10 re-
ported it in general surgical patients and Bartels1
noted its significance in patients needing thyroid-
ectomy. Postoperatively, the average surgical pa-
tient lapses into negative nitrogen balance unless
attention is paid to the adequate intake of protein.
Co Tui6 and his associates studied nitrogen metab-
olism in eight patients following gastrectomy.
Four patients received the usual postoperative
standard ward diet of weak tea followed by fre-
quent small feedings, slowly increased ; the other
four patients received large amounts of protein
in the form of casein hydrolysates, which were
given by a gastric tube. The results were remark-
able. Those fed on the usual ward routine were
in negative nitrogen balance, lost weight, regained
their strength slowly and had a protracted con-
valescence. Tn contrast, the patients receiving
protein hydrolysates were in positive nitrogen
balance, gained weight, regained strength rapidly
and had a shortened convalescence.
Others have studied the same problem in vari-
ous surgical procedures such as herniorrhaphy,
appendectomy and cholecystectomy. They have
found that patients who are fed a high-caloric
396
Minnesota Medicine
NITROGEN BALANCE— HANSEN AND TUOHY
diet and are given high-protein materials paren-
terally and orally remain in a positive nitrogen
balance and gain weight and strength in about
one-half the time of those in negative nitrogen
balance because of inadequate protein intake.
Some interesting work has been done at the
Johns Hopkins Hospital12’13 on nitrogen studies
in patients with fractures and in those who had
osteotomies. A series of six cases of fractures of
the large bones of the lower extremities in other-
wise healthy males revealed that these patients
reached their maximum negative nitrogen excre-
tion on the sixth postfracture day; their total ni-
trogen loss amounted to about 200 gm. This ex-
pressed in terms of protein would be 1,400 gm. ;
in terms of body tissue it equals 15 pounds. The
duration of the negative nitrogen phase lasted
thirty-six days. Some of these patients were
studied for an additional three weeks, and it was
found that they replenished their lost nitrogen at
a slow rate — only 15 per cent replacement over a
three-week period on a diet of 120 gm. of protein
in 2,600 calories. In the cases of osteotomies
these patients reached their maximum negative
nitrogen excretion on the fourth day ; their total
nitrogen imbalance lasted nine days. Their nitro-
gen was restored rapidly by comparison — 75 to 90
per cent in three weeks.
In the field of radiology some studies have been
made at Harvard9 which have described the nitro-
gen metabolism changes after use of deep x-ray
therapy. In general, it was found that a shift to-
ward a negative nitrogen balance occurred during
irradiation, followed by a return to a positive bal-
ance after treatments. The negative balance tend-
ed to be delayed about forty-eight hours after
beginning treatment. There was a correlation
found between the degree of nitrogen loss and the
sensitivity of the patient’s lesion to x-ray. The
patients with the most sensitive lesions would ex-
crete the greatest amount of nitrogen, and there
did not appear to be any correlation between the
nitrogen loss and the dosage of x-ray. The basis
for the negative nitrogen balance was the amount
of tissue destroyed.
The problem of nitrogen balance occupies a
prominent phase in the medical field. Of the met-
abolic diseases, thyrotoxicosis, Addison’s disease,
and diabetes mellitus present a special problem
in protein metabolism. Patients who exhibit thy-
rotoxicosis have a greater protein need because of
the increased metabolism. Weight loss may be
extreme and the muscle and liver protein may be
greatly reduced. A high-caloric, high-protein diet
is indicated in conjunction with specific measures
of treatment. It is well established in untreated
or poorly controlled diabetes, that large quantities
of nitrogen are excreted in the urine as the result
of increased conversion of protein to carbohy-
drates. As a consequence of this, a large protein
deficit may occur. Insulin will correct this, but an
ample amount of protein is needed to correct any
existing deficiencies. Great weight loss occurs in
Addison’s disease. Regardless of the complexities
involved, it is evident that “protein sparing” by
carbohydrate and fat is defeated.
In liver disease a positive nitrogen balance is a
must. Cirrhosis produces liver impairment and
interference with gastrointestinal function. The
liver impairment is the cause of plasma protein
imbalance because the liver is unable to synthesize
the albumin properly. The mechanism is un-
known, but clinically we know the difficulty in
maintaining the serum albumin in patients with
advanced cirrhoses. A study of five cases of cir-
rhosis by Post and Patek14 revealed that though
the patients were given high-protein diets, the se-
rum albumin showed no correlated rise with the
protein feedings. This is in direct contrast to the
results obtained in cases of protein starvation
without primary liver disease where the serum al-
bumin does reflect the protein intake. This study
on patients with liver cirrhosis showed that the
absorption of protein was adequate (the fecal ni-
trogen was normal) and that the retention of ni-
trogen was definite as shown by the positive uri-
nary nitrogen balance. The possible explanation
for the failure of the serum albumin to increase
is the faulty synthesis of the albumin by the dam-
aged liver. In cases of infectious hepatitis the
early prescribed treatment was that of a high-
carbohydrate, high-caloric diet, the purpose being
to restore liver glycogen and limit hepatic damage.
All recent studies emphasize the greater value of
protein in protecting the liver cells, especially the
amino acids, cystine and methionine, which con-
tain sulfur.
Such illnesses as chronic peptic ulcer, chronic
pancreatitis, regional enteritis, ulcerative colitis,
chronic gastritis and gastrointestinal malignancy
have a marked effect upon protein balance and
they do so because of anorexia, restricted diets,
vomiting, intestinal hypermotility with diarrhea,
draining fistulas and excessive putrefaction. The
April, 1947
397
NITROGEN BALANCE— HANSEN AND TUOHY
resultant negative nitrogen balance with hypoal-
buminemia and edema of the bowel aggravate the
already present gastrointestinal dysfunction, pro-
ducing a vicious cycle. Because these diseases are
likely to be chronic and exhibit some permanent
structural or functional change, the vital factor is
the proper maintenance or a satisfactory daily diet
over a long period of time. However, such meas-
ures as repeated feedings of small quantities of
highly nutritious food, supplemented by oral or
parenteral amino acids and the use of blood trans-
fusions, may be needed at times to correct acute
deficiencies.
The role of protein in infection is still under-
going much investigation. As concerns the infec-
tion itself, perhaps there occurs a failure of anti-
body response in hypoproteinemic patients, be-
cause we know many of the circulating antibodies
are found in globulin fractions. With regard to
convalescence it has been shown that patients who
have survived the acute infection will recover
more rapidly and completely if they have an ade-
quate protein and caloric diet.
We have stressed the close relationship of ni-
trogen balance or protein metabolism to various
surgical and medical conditions, and we have
shown that it is necessary in the proper treatment
of many illnesses of man. Now, how can we
supply the necessary proteins and keep a positive
nitrogen balance in our patients? The most effec-
tive and satisfying way is good, properly chosen
food by mouth. Unfortunately there is a limit
to the amount of food a sick person can take, or
will eat, and the problem of hyperalimentation can
onlv be solved by the use of supplementary feed-
ings. However, the use of parenteral feeding
should be dictated by necessity and not by con-
venience.7 In the acute cases, where hypopro-
teinemia is caused by surgical shock, burns or
hemorrhage, the best protein replacement is plas-
ma and whole blood ; however, in chronic cases
this is not too effective and is very expensive.
For example, to give 100 gm. of protein by plasma
or blood one would have to give the equivalent of
six pints of whole blood; the hemoglobin is
worthless as far as aiding tissue construction even
though there is a good quantity present. For the
chronic cases needing protein, there are the pro-
tein hydrolysates which are mixtures of amino
acids prepared by either acid hydrolysis (split-
ting) or enzymatic hydrolysis. These prepara-
tions are not as expensive as whole blood or plas-
ma and may be used in large quantities either par-
enterally or orally. Complete parenteral feeding
can be accomplished with the amino acids, glucose/
minerals and vitamins, and can be continued for
one or two weeks. However, this will rarely be
necessary and the early use of oral administration
is strongly advised. A disadvantage of the oral
route is that most hydrolysates have an unpleas-
ant taste, and one must search for a suitable dis-
guising vehicle. When hydrolysates are used, one
must not forget that it is necessary to add vita-
mins, minerals, glucose and fatty acids to the diet
so that the nutritional support is complete.
In conclusion, there is in the current medical
literature much on experimental and clinical inves-
tigation upholding the present-day concept of pro-
tein as the most important dietary constituent in
health and disease. It justly deserves to be called
the “magic of life.” The problem of nitrogen
balance touches everyone who is confined to bed
for some injury, operation, or illness. It even has
become a problem for study in perfectly healthy
individuals who were put to bed for a period of
five days, because they, too, showed a negative
nitrogen balance.
For routine medical practice, checking of ni-
trogenous equilibrium by complicated estimates of
nitrogenous loss (urine and feces) is impractical.
As we have implied, however, a knowledge of the
situations where nitrogenous wastage is known
to occur puts the clinician on his guard. It is easy
to get laboratory estimates of blood and other tis-
sue fluids, yet gross estimates are more informa-
tive. We may easily chart the weight curve and
know that the period required for protein resto-
ration takes more and more time dependent upon
the degree of nitrogen deprivation ; and the law
of receding returns is dictated by the circum-
stance that the bodily machine (like a factory)
must first build its component parts before it
functions as a whole. Streamline mass produc-
tion (no effort lost) is demonstrated only with
the factory clicking in full co-operation — supply
and disposal — a healthy unit. So it is with human
economy.
References
1. Bartels, E. C. : Serum protein studies in hyperthyroidism.
New England J. Med., 218:289-294, (Feb.) 1938.
2. Best and Taylor; Physiological Basis of Medical Practice.
Ed. 4, p. 554. Baltimore: Williams and Wilkins, 1945.
3. Borsook, H., and Keighly, J. L. : Proc. Roy Soc. London,
s.B., 118:488, 1935.
(Continued on Page 426)
398
Minnesota Medicine
OBSERVATIONS ON THE MANAGEMENT OF VASOMOTOR RHINITIS
JAMES B. McBEAN, M.D.
Rochester, Minnesota
/I" OST rhinilogists would agree that vaso-
motor rhinitis is one of the unsolved
problems in the specialty. Many excellent articles
on the subject have appeared in the literature of
recent years, but the multiplicity of treatments
suggested and the variation in results obtained
from them lead to the conclusion that the etiology,
pathology and physiology of this condition are
not well understood.
In order to limit this discussion, seasonal hay
fever or pollen allergy will not be included in the
term “vasomotor rhinitis.”
Allergy and Anaphylaxis
It is commonly recognized that scratch tests or
intracutaneous tests do not always produce posi-
tive results among patients who have perennial
vasomotor rhinitis. Hansel10 said that results of
skin tests are reliable in the presence of pollen
allergy, but that when other types of allergy to
inhalants or food occur, skin tests may not be of
value. We are all familiar with the patient who
has vasomotor rhinitis but whose particular aller-
gen cannot be detected even after a history has
been carefully taken and skin tests and an elimi-
nation diet have been employed. Urbach suggested
that in cases in which an allergen can be identi-
fied the condition should be termed “allergic
rhinopathy,” and that when no extrinsic allergen
can be demonstrated the condition should be
called “pathergic rhinopathy.” He used the word
“rhinopathy” rather than “rhinitis” because, path-
ologically, the condition in question is not charac-
terized by inflammation. Williams26 distinguished
between the antigen-antibody type of allergy and
the intrinsic or physical form of allergy. Hay
fever is an example of ihe former, and nonspecific
vasomotor rhinitis is an instance of the latter.
Williams devised the term “syndrome of intrinsic
allergy,” which includes vasomotor rhinitis,
Meniere’s syndrome, myalgia and the vasodilating
pain syndrome. He gave numerous references to
support the theory that the allergic reaction,
whether antigen-antibody or intrinsic, is accom-
panied by damage to cells as histamine is released
Read at the meeting of the Milwaukee Oto-Ophthalmic So-
ciety at Milwaukee, Wisconsin, January 28, 1947.
From the Section on Otolaryngology and Rhinology, Mayo
Chnic, Rochester, Minnesota.
April, 1947
into the tissue spaces. This reaction may be pro-
duced by a specific allergen or antibody or by
various other factors which are nonallergic in
nature. The latter include cold, heat, changes in
atmospheric pressure, emotional disturbances and
endocrine dysfunctions. Other authors have sup-
ported the view that in many cases vasomotor
rhinitis is nonallergic in origin ; among such au-
thorities are Paterson, who wrote that vasomotor
rhinitis is a localized manifestation, in the nasal
mucous membrane, of generalized nervous im-
balance, and Laub, who believed that vasomotor
rhinitis is caused by imbalance in endocrine secre-
tion.
Although anaphylactic shock in the experimen-
tal laboratory and allergy in the human being are
not identical, there is a close similarity between
the two reactions. Code1 has said that the forma-
tion of a toxic chemical substance during anaphy-
lactic shock was one of the first mechanisms sug-
gested for the production of the symptoms of
that reaction. He quoted Dale and Laidlaw
(1910), who pointed out the similarity between
the phenomenon of anaphylactic shock and the
physiologic action of histamine. Code raised the
question of whether histamine is present in the
blood plasma or is held within the cells. In some
very interesting experiments he found that in the
blood of dogs and rabbits 74 to 89 per cent of
the total histamine content of the blood was pres-
ent in the leukocyte layer of centrifuged blood.
In the same paper he reported that during anaphy-
lactic shock in guinea pigs the total content of his-
tamine in the blood was three to nine times the
normal value. He also found that the usual ratio
of histamine-to-plasma and histamine-to-leuko-
cytes is reversed, meaning that during anaphy-
lactic shock the major, portion of the histamine is
in the plasma, whereas the histamine content of
the leukocyte almost disappears. Code empha-
sized, however, that the release of histamine into
the blood plasma does not account for the whole
picture of anaphylactic shock, for example, the
incoagulability of the blood and the fact that dogs
sometimes die some hours after anaphylaxis has
been induced and after the histamine content of
the blood has returned to normal. He suggested
399
VASOMOTOR RHINITIS— McBEAN
that histamine is released as a consequence of
damage occurring within the sensitized cells, and
that it is the damage to such cells that is the fun-
damental etiologic factor in the allergic or ana-
phylactic reaction. Dragstedt has raised the ques-
tion of whether this substance is histamine or a
“histamine-like substance.”
Troescher-Elam, Ancona and Kerr reported
finding a histamine-like substance in the nasal se-
cretions of both patients who had allergic rhinitis
and patients who had the common cold. They
found that the amount of this substance varied
widely in the two conditions, and also found no
correlation between the amount of the histamine-
like substance and the number of eosinophils in
the secretion.
Clinical Observations
The diagnosis of vasomotor rhinitis can be
made on the basis of paroxysmal attacks of sneez-
ing, with nasal congestion and watery or mucoid
discharge. The mucosa of the nose usually ap-
pears pale and waterlogged, and a mucoid dis-
charge is present. If the disease has not pro-
gressed too far, and is in a period of remission,
the nose may appear normal on examination. The
presence of polyps indicates long-standing dis-
ease. If a purulent discharge also is present, it
indicates the presence of secondary hyperplastic
sinusitis.
Hansel,9 in his comprehensive monograph, re-
ferred to numerous sources regarding the signifi-
cance of eosinophils in the nasal secretions of pa-
tients who have nasal allergy. More recently,
Hald, D. Miller, and A. R. Miller reported on
the significance of cytologic examination of nasal
smears. It seems to be a well-substantiated fact
that eosinophilia of the nasal secretion indicates
the presence of allergy. At the Mayo Qinic, cy-
tologic examination of nasal smears is not carried
out routinely, because it is believed that a diagno-
sis can be made, in most cases, without it.
It is worthwhile for the physician to spend
some time in questioning the patient about the
relationship of his nasal symptoms to environ-
mental factors, such as animals, house dust, oc-
cupational dusts and fumes, foods and drugs, as
well as such nonallergic factors as cold, heat,
changes in weather, fatigue and nervous tension.
Because results of cutaneous tests are not always
reliable in vasomotor rhinitis, the type of history
mentioned in the preceding sentence frequently
will be of more help than such tests. This is in
contradistinction to the situation in seasonal hay
fever, in which results of skin tests are much
more reliable.
When the history indicates that the patient has
extrinsic allergy, cutaneous tests should be carried
out. At this point 1 should like to urge that the
rhinologist himself perform cutaneous tests for
patients whose allergic symptoms are confined to
the nose. The great majority of these patients will
consult a rhinologist first ; he may save the pa-
tient much time and expense if he himself will do
the relatively few tests needed.
Treatment
In our experience at the clinic, desensitization
of a patient to the usual specific allergens which
cause perennial vasomotor rhinitis has not been
very successful. It is rather a question of avoid-
ance of the offending substance. Elimination of
animal pets in the home, avoidance of certain
foods or drugs, and possible change of occupation
all should be considered.
Hansel9'11 and Shambaugh wrote that house
dust is a major factor in most cases of vasomotor
rhinitis. Shambaugh said that underlying nasal
allergy is responsible for chronicity in at least
70 per cent of all cases of chronic sinusitis and
90 per cent of all cases of chronic rhinitis. He
also wrote that if pollinosis is excluded, house
dust is a major factor in at least 90 per cent of
all cases of chronic nasal allergy. As a corollary
to this theory, Shambaugh and Hansel recom-
mended desensitization with house dust in cases
in which results of cutaneous tests are negative.
They stressed the use of very small initial doses
and of gradual increase in such doses, until the
optimal symptomatic relief is obtained. At such a
time an adequate maintenance dose is to be em-
ployed. No definite rules for dosage can be giv-
en, because the condition of every patient is an
individual problem. Hansel believed that many
therapeutic failures, when desensitization with
house dust is employed, are caused by the fact
that treatment was begun with too large a dose, or
that the dose used was increased beyond the opti-
mal point.
There are several nonspecific measures that
should be carried out, and these will give relief
to many patients. Houser, in a recent article, dis-
cussed these empiric measures ; they include the
use of dustproof covers on pillows and mattresses,
hypo-allergic cosmetics, elimination of household
400
Minnesota Medicine
VASOMOTOR RHINITIS— McBEAN
pets and cessation of the use of nose drops and
inhalers.
Williams28 has said that the overuse of nose
drops is responsible for many instances of chronic
nasal congestion. Lake applied the term “rhinitis
medicamentosa” to such instances. At the Mayo
Clinic many of our patients who have vasomotor
rhinitis derive at least some improvement from
cessation of all intranasal medication. Feinberg
and Friedlaender have reported on chronic nasal
congestion which is said to arise from the fre-
quent use of a naphazoline nasal vasoconstrictor
(privine hydrochloride).
Schall held that vasoconstrictors give only tem-
porary relief ; he advised against their use. He
said that the basic pathologic feature is edema and
dilation of the cavernous spaces. He recommend-
ed subepithelial electrocoagulation or destruction
of the dilated spaces by means of the careful in-
jection of sclerosing fluid. The agents recom-
mended are a 5 per cent solution of sodium mor-
rhuate or of a proprietary sclerosing agent (syl-
nasol) .
Histamine and nicotinic acid. — The physiologic
effects of histamine are known to be : (1) con-
traction of smooth muscle, (2) constriction of ar-
terioles, (3) dilatation and increased permeability
of the capillaries, with localized edema and (4)
increased secretion by the secretory glands. This
subject was discussed by McLaurin, as well as by
Williams and Code, previously referred to herein.
Because of the similarity between the action of
histamine and the symptoms of allergy, these au-
thors have treated vasomotor rhinitis by small
doses of histamine in an attempt to desensitize the
patient. McLaurin used histamine azoprotein,
and reported eventual good results in the treat-
ment of all but two of 102 patients. The two pa-
tients experienced recurrence. Farmer and Kauf-
man administered histamine subcutaneously to
forty-one patients who had nasal allergy. The ini-
tial dose they used varied from 0.01 gamma
(1/1,000 mg.) to 0.1 gamma. The highest dose
they used was 100 gammas. They reported good
results in twenty-five cases, fair results in ten,
and poor results in six. Gant, Savignac and
Hochwald administered dilute solutions of hista-
mine by mouth, and attempted to provide imme-
diate relief during attacks of vasomotor rhinitis.
They reported on thirty-three patients, three of
whom were un-co-operative. Of the remaining
thirty, all but two were relieved by this treatment.
April, 1947
The dose varied from 1 drop of a 1 : 1,000 solu-
tion to 25 drops of a 1 : 1 00 solution. The average
dose was 5 to 7 drops of a 1 : 1,000 solution of
histamine in a glass of' water. Williams26 treated
his series of patients with twice-daily subcuta-
neous injections of histamine. In most of his
cases he started with 0.1 c.c. of a 1 :50,000 solu-
tion of histamine base and increased this by 0.1
c.c. each time, until symptoms disappeared or an
objective return to normal was noted in the nose.
The maintenance dose varied between 0.1 c.c. of a
1 :50,000 dilution and 0.1 c.c. of 1 : 1,000 dilution
of histamine base. He found, however, that in
most cases in which relief was obtained, the symp-
toms recurred on cessation of treatment. He ob-
tained good results for thirty-three patients and
fair results for seven. For eighteen patients the
treatment was a failure.
Harris and Moore first suggested the use of
nicotinic acid in the treatment of Meniere’s dis-
ease. They felt that the association of perceptive
deafness with vertigo suggested the presence of a
degenerative disease, and they further noted that
a high percentage of pellagrose patients had ver-
tigo. They administered thiamine chloride with-
out benefit, but when 250 mg. of nicotinic acid was
added daily, seventeen of twenty patients were re-
lieved of vertigo. As stated previously, Williams
said that vasomotor rhinitis and Meniere’s disease
are part of the intrinsic allergy syndrome. Conse-
quently, he treated a series of patients with nico-
tinic acid with about the same results he had ob-
tained from histamine.
At the Mayo Clinic nicotinic acid now is being
administered to many patients who have vaso-
motor rhinitis. The dose must vary to some de-
gree to fit the requirements of each patient, but
the average patient receives subcutaneously an ini-
tial dose of 25 mg. of nicotinic acid (niacin), and
this amount is increased by 25 mg. twice a day
until 100 mg. is being administered twice daily.
After a few days the patient is sent home to take
100 mg. once a day subcutaneously for one to
three months. If symptomatic relief is obtained
and if it continues, the patient may change to the
oral form of administration and take 100 mg. of
nicotinic acid twice a day. So far as is known
now, this medication can be continued indefinite-
ly, although in many cases it is possible to reduce
the dose to 100 mg. taken two or three times a
week.
It is too early for me to make any statement as
. 401
VASOMOTOR RHINITIS— McBEAN
to the long-range results of nicotinic acid therapy
among my patients. I am able to say, however,
that many of my patients who have vasomotor
rhinitis are relieved of their symptoms over a pe-
riod of several months.
Benadryl. — Beta dimethylaminoethyl benzhy-
dryl ether hydrochloride (benadryl) is a synthetic
substance which has the property of counteracting
many of the physiologic effects of histamine. If
the theory that the type of allergy under consid-
eration is due to the release of histamine is true,
benadryl should produce symptomatic relief in
vasomotor rhinitis. The subject was discussed
from several points of view in a symposium on
the drug by McElin and Horton, Koelsche,
Prickman and Carryer, Williams27 and Code.2
Williams said that the effect of benadryl on per-
ennial vasomotor rhinitis appeared to be superior
to that of nicotinic acid.
Benadryl certainly gives marked relief to many
patients, but all rhinologists are familiar with the
many instances in which the drug appears to be of
no value. Sometimes the side effects — drowsiness
or nervousness — are most annoying. This again
raises the question as to whether the release of
histamine is or is not the cause of the symptoms
of allergy. In this respect I can do no better than
to quote Code1 : “In allergic reactions, histamine
may produce a dramatic veil of symptoms, behind
which lies the damaged cell.”
A newer drug, pyribenzamine, appears to ex-
ert about the same effects as benadryl. Perhaps
the side reactions of pyribenzamine are not so no-
ticeable among some patients as are the side ef-
fects of benadryl.
Comment
I have not included a discussion of the treat-
ment of nasal polyps and secondary hyperplastic
sinusitis. It is sufficient to say that surgical cor-
rection of these conditions is indicated before sat-
isfactory results can be expected from the forms
of therapy described herein.
Summary and Conclusions
The relationship of anaphylaxis and allergy has
been discussed, together with the theory of the
release of histamine during the reactions. The
tvpes of therapy based on this theory have been
described, and their results in various investiga-
tors’ hands have been noted.
The syndrome of intrinsic allergy and the en-
couraging results of nicotinic acid therapy offer a
field for further investigation. Many patients
who have perennial vasomotor rhinitis can be re-
lieved to varying degrees by nonspecific therapy,
including elimination of dust, hyposensitization to
house dust, electrocoagulation of the submucosa
of the turbinates, elimination of household pets,
and cessation of the use of nose drops.
The newer antihistamine drugs, benadryl and
pyribenzamine, offer relief to many patients.
Further investigation is needed to determine
what lies behind the damage to cells and the re-
lease of histamine in the allergic reaction.
References
1. Code, C. F. : The mechanism of anaphylactic and allergic
reactions; an evalution of the role of histamine in their pro-
duction. Ann. Allergy, 2:457-471, (Nov. -Dec.) 1944.
2. Code, C. F. : A discussion of benadryl as an antihistamine
substance. Proc. Staff Meet., Mayo Clin., 20:439-445, (Nov.
14) 1945.
3. Dale, H. H., and Laidlaw, P. P. : Quoted by Code, C. F.l
4. Dragstedt, C. A.: The significance of histamine in anaphy-
laxis. J. Allergy, 16:69-77, (Jan.) 1945.
5. Farmer, Laurence, and Kaufman, R. E. : Histamine in the
treatment of nasal allergy (perennial and seasonal allergic
rhinitis). Laryngoscope, 52:255-266, (Apr.) 1942.
6. Feinberg, S. M., and Friedlaender, Sidney: Nasal conges-
tion from rrequent use of privine hydrochloride. J.A.M.A.,
128:1095-1096, (Aug. 11) 1945.
7. Gant, J. C. ; Savignac, R. J., and Hochwald, Adolph : His-
tamine by mouth in the treatment of vasomotor rhinitis.
New England J. Med., 229:579-58 2, (Oct. 7) 1943.
8. Hald', Erling: Two hundred cases of allergic nasal affec-
tions. Acta oto-laryng., 31:23-31, 1943.
9. Hansel, F. K. : Allergy of the Nose and Paranasal Sinuses.
A monograph on the subject of allergy as related to oto-
laryngology. St. Louis: C. V. Mosby Company, 1936.
10. Hansel, F. K. : Principles of diagnosis and treatment of
allergy as related to otolaryngology. Laryngoscope, 53:260-
275, (Apr.) 1943.
11. Hansel, F. K. : Some experience with small dosage dust and
pollen therapy. South. M. J., 38:608-613, (Sept.) 1945.
12. Harris, H. E., and Moore, P. M., Jr.: The use of nicotinic
acid and thiamin chloride in the treatment of Meniere’s
syndrome. M. Clin. North America, 24:533-542, (Mar.) 1940.
13. Houser, K. M. : The allergic nose. Arch. Otolaryng., 44:-
565-567, (Nov.) 1946.
14. Koelsche, G. A. ; Prickman, L. E., and Carryer, H. M. :
The symptomatic treatment of bronchial asthma and hay
fever with benadryl. Proc. Staff Meet., Mayo Clin., 20:432-
433, (Nov. 14) 1945.
15. Lake, C. F. : Rhinitis medicamentosa. Proc. Staff Meet.,
Mayo Clin., 21:367-371, (Sept. 18) 1946.
16. Laub, G. R. : Rhinitis vasomotoria due to imbalance of en-
docrine glands. Laryngoscope, 55:179-186, (Apr.) 1945.
17. McElin, T. W., and Horton, B. T. : Clinical observations on
the use of benadryl: a new antihistamine substance. Proc.
Staff Meet., Mayo Clin., 20:417-429, (Nov. 14) 1945.
18. McLaurin, J. W. : Desensitization by histamine (histamine
azoprotein) in vertigo, periodic headaches and vasomotor (al-
lergic) rhinitis. Review of the literature and report of 102
personal cases. Laryngoscope, 56:253-281, (June) 1946.
19. Miller, A. R.: Cytologic examination of nasal smears; an
aid in diagnosis of chronic nasal sinus disease. Northwest
Med., 44:242-249. (Aug.) 1945.
20. Miller, Daniel: The significance of eosinophilia in rhinology.
Ann. Otol., Rhin. & Laryng., 53:74-80, (Mar.) 1944.
21. Paterson, W. P. E. : Vasomotor rhinitis. Canad. M. A. J.,
52:400-405, (Apr.) 1945.
22. Schall, L. A.: Pathology of nasal mucous membrane and
suggestions as to treatment. Ann. Otol., Rhin. & Laryng.,
53:391-396. (Sept.) 1944.
23. Shambaugh, G. E.. Jr.: Nasal allergy for the practicing
rhinologist. Ann. Otol., Rhin. & Laryng., 54:43-60, (Mar.)
1945.
24. Troescher-Elam, Elizabeth; Ancona, G. R., and Kerr, W. J. :
Histamine-like substance present in nasal secretions of com-
mon cold and allergic rhinitis. Am. T. Physiol., 144:711-716,
(Oct.) 1945.
25. Urbach, Erich: Vasomotor rhinitis; a proposed classification
based on an allergic analysis of seventy-four cases. Arch.
Otolaryng., 33:982-992, (June) 1941.
26. Williams, H. I.. : Physiologic phenomena which are misin-
terpreted as nasal disease. Journal-Lancet, 60:216-220, (May)
1940.
27. Williams, H. L. : Intrinsic allergy as it affects the ear, nose
and throat: the intrinsic allergy syndrome. Ann. Otol., Rhin.
& Laryng., 53:397-443, (Sept.) 1944.
28. Williams, H. L. : Use of benadryl in the syndrome of physi-
cal allergy of the head: a preliminary report. Proc. Staff
Meet., Mayo Clin., 20:434-436, (Nov. 14) 1945.
402
Minnesota Medicine
ORCHIECTOMY AND HORMONES IN PROSTATIC CARCINOMA
PHILIP F. DONOHUE, M.D.
Saint Paul, Minnesota
CARCINOMA of the prostate has long been
regarded as one of the most deadly, if not the
most hopeless, diseases affecting the aging male.
According to statistical studies, the condition oc-
curs in 17 per cent of men over fifty years of age
and in 25 per cent of men over sixty years of
age. Unfortunately, the disease is present for a
considerable length of time without the knowl-
edge of its victim and may advance to an incur-
able stage before symptoms develop which lead to
examination and discovery. As a result of this
insidious character, less than 2 per cent of all
the individuals with carcinoma of the prostate
consult a physician while the condition is still
amenable to a cure. The remaining 98 per cent
or more, when first seen by the physician, present
various stages of extension of carcinoma. Before
the introduction of treatment by castration and
the administration of estrogen, the disease ad-
vanced until great suffering and disability were
experienced, and management of this stage of the
disease was entirely a matter of relief of pain,
with frequent resort to deep x-ray and opiates.
With our present methods of androgen control
treatment available, the progress of the disease
now may be checked for periods of several
months or years and patients with pain and phys-
ical disability may return to states of comfort
and physical well-being. Such startling results
may continue for varying periods. A small num-
ber of patients have remained well and without
signs of the disease for more than five years, and
there is just a possibility of complete eradication
of the disease. However, relapse is the rule, as
shown by follow-up studies which show the tem-
porary nature of the good results and the recur-
rence of pain, loss of weight and weakness, end-
ing in death from prostatic cancer. Since its in-
troduction five years ago, this form of therapy
has been fully tested clinically and is now firmly
established as a simple and effective method of
suppressing the painful and disabling effects of
metastatic carcinoma of the prostate. Although
beneficial results are temporary and the disease
is eventually reactivated, many months or even
years may be added to life.
Read at the annual meeting of the Minnesota State Medical
Association, Saint Paul, May, 1946.
April, 1947
Androgen control treatment is a method of
completely disposing of the male hormone by
castration or by neutralization through the admin-
istration of estrogen. The method is based upon
the investigations of Huggins who showed that
the epithelial cells of metastatic lesions of pro-
static carcinoma are directly influenced by andro-
gen. Androgen is a stimulant to the growth of
these cells, and consequently, to the spread of the
disease. Regression of the metastatic lesions will
result when androgen is removed by castration or
neutralized by the administration of stilbestrol.
Application by Huggins of either of these meth-
ods to patients with demonstrable metastasis was
followed by immediate subjective and objective
improvement.
Before any method of treatment is adopted,
every patient with carcinoma of the prostate
should be thoroughly examined to determine the
extent of the malignancy. The examination
should include x-ray survey of the bones of the
pelvis, vertebrae, ribs, femurs, x-ray examination
of the lungs, and determination of acid phospha-
tase in the blood. Of particular importance is
the examination of the prostate by rectal palpa-
tion. Even in early cases the findings are suffi-
ciently characteristic to be strongly suggestive.
As the condition advances in the prostate, the
changes become more striking and typical and
the diagnosis correspondingly easier to make. It
is estimated that in 60 or 75 per cent of cases,
prostatic carcinoma begins in the posterior lobe,
and since this part of the prostate is immediately
adjacent to the anterior wall of the rectum, it
would seem that a high percentage of early in-
volvement can be discovered by careful rectal
palpation frequently carried out in all men over
fifty years of age. On examination, the absence
of the normal elasticity of the gland and the
presence of one or more areas of induration
strongly suggest the possibility of carcinoma, and
when the induration is marked, there should be
little doubt. When the indurated area is limited
to the gland substance, and the adjacent structures
at the periphery of the prostate are free, the
condition may be considered localized and suit-
able for cure by operation. In some cases moder-
403
PROSTATIC CARCINOMA— DONOHUE
ate degrees of induration are difficult to evaluate.
These doubtful cases should be examined periodi-
cally, and other possible causes such as prostatic
calculi and prostatic inflammation excluded by
x-ray studies and examination of prostatic secre-
tion. The nature of the localized induration may
remain in doubt until a specimen is obtained for
biopsy. This procedure is to be recommended in
doubtful cases. Perineal exposure of the poster-
ior surface of the prostate is required, and this
permits immediate radical removal of the entire
gland and seminal vesicles in the event the exami-
nation shows carcinoma.
Eventually the malignant process spreads and
involves the entire gland substance and capsule.
From the prostate the growth extends upward to
invade the seminal vesicles and the base of the
bladder. The process may penetrate the capsule,
spreading laterally to the pelvis and downward
to the membranous urethra. Rectal examination
at this stage shows the prostate transformed into
a stony hard, irregular, immovable mass at-
tached to the bony pelvis laterally and extending
upward beyond the reach of the finger. Spread
of the disease beyond the prostatic area occurs
by way of the perineural lymphatics to the re-
gional lymphatic glands. Later the bones are in-
volved. The pelvis, sacrum and vertebra are
the most frequent sites of the metastasis, but the
process may also be found in the ribs, femurs
or humeri. Lesions may appear in the lungs and
in the lymphatic glands of the neck and the
groin. Metastatic extension to the spinal cord
may occur with motor and sensory paralysis of
the lower extremities.
The purpose of treatment in carcinoma of the
prostate differs with the stage of the disease. In
cases in which the growth is well localized within
the prostatic capsule, complete eradication of the
disease is possible, and this should be the aim of
treatment. At present, such cases are encountered
infrequently but can be expected to be recognized
in increasing number when more people are aware
of the possibility that carcinoma of the prostate
may exist in any man past fifty regardless of the
absence of suggestive symptoms. With routine
rectal examination in all men past fifty, more
cases will be found suitable for radical perineal
prostatectomy, which is the only way cancer of
the prostate can be cured.
When the malignant process has spread beyond
the prostate, cure of the disease is impossible,
404
and in this event the purpose of treatment is to
relieve or diminish suffering and to prolong life.
Great suffering and physical disability occur
sooner or later in almost every case and require
androgen control treatment. The optimum mo-
ment to begin treatment and the choice between
estrogen and castration will depend upon the
clinical picture and the findings on examination
of the patient. From the experiences of others and
that of the writer with hormonal treatment in
advanced incurable prostatic cancer, several facts
have emerged which are helpful in obtaining the
greatest relief for the longest period of time.
These observations indicate that responses to the
oral use of estrogen (stilbestrol) and to castra-
tion are similar and equal, although somewhat
more rapid with castration. Relief of pain, re-
gression of metastatic lesions, return of vigor and
physical capacity follow either method. These
benefits are temporary and ultimately disappear.
Patients relapsing following good results from
estrogens will often recover following castration.
Relapses following castration may or may not
improve when given estrogens. Since neither
estrogens nor castration prevent the develop-
ment of metastasis, both should be withheld dur-
ing early stages of the disease. The full benefit
of both forms of treatment for the longest periods
possible are then available in the metastatic stage.
Stated in another way, androgen control treat-
ment achieves the longest possible life survival
for the patient when used only for the relief of
symptoms of metastatic carcinoma of the prostate
and to check or eradicate demonstrable metastatic
lesions. The effect of the treatment may be fol-
lowed by frequent determination of the serum
acid phosphatase. High readings are suggestive
of metastatic activity, but low or normal readings
may be of no value.
Clinically, incurable carcinoma of the prostate
is encountered in either one of two stages of the
disease. In the first are the patients seeking relief
because of urinary obstruction. They show in-
volvement of the prostatic capsule and varying
degrees of local extension of the malignancy but
have no symptoms of metastasis or evidence of
metastatic lesions on examination. These patients
require no androgen control treatment at that
stage but are examined at frequent intervals to
discover the spread of the disease. This includes
blood acid phosphatase and x-ray examinations
of the bones.
Minnesota Medicine
PROSTATIC CARCINOMA— DONOHUE
In the second group are individuals with defi-
nite symptoms of metastasis or with demonstrable
metastatic lesions. These patients require imme-
diate androgen control treatment. Treatment is
begun with stilbestrol in doses up to 10 mg. daily,
which may be reduced to 2 or 3 mg. when relief
is established. The effect of stilbestrol is evaluated
by periodic examination, with particular reliance
on the x-ray findings in the bones. The return
of pain or the increase in size or number of
metastatic lesions is evidence of definite relapse
from the benefits of stilbestrol, and castration is
then indicated. Transurethral resection may be
required to relieve obstruction developing in
either group.
The reports of three cases will illustrate some
of the problems encountered in treatment.
Case Reports
Case 1. — M. T., aged sixty-three, had no general or
urinary symptoms when seen on January 14, 1943. An
indurated area on the posterior lobe of his prostate was
a chance finding during a search for a focus of infec-
tion to explain his keratitis. The periphery of the gland
and the seminal vesicles were normal. The acid phos-
phatase was normal, and an x-ray showed no evidence
of bone metastasis. The diagnosis was probable car-
cinoma of the prostate. A biopsy was indicated.
On January 20 biopsy findings showed carcinoma,
and a radical perineal removal of the prostate and the
seminal vesicles was done. The specimen weighed 43
gm. and had a fairly large indurated area surrounded
by a smooth intact capsule. The pathological report
was adenocarcinoma of the prostate with normal semi-
nal vesicles.
When seen on April 22, the patient was feeling fine,
and his acid phosphatase was normal. X-ray revealed a
questionable metastasis in the pelvis. On September 22
x-ray examination showed diffuse metastases throughout
the pelvis. The patient had no symptoms, and his urinary
control was improving. The acid phosphatase was still
normal. Castration was performed on October 4, 1943.
X-ray examination on January 6, 1944, showed that
the metastases in the pelvis were unchanged. Over a
year later, on March 7, 1945, the patient presented no
complaints. His urinary control was satisfactory, al-
though occasionally he had an escape of a small amount
of urine in the late afternoon. The osteoblastic metastases
in the pelvis were shown by x-ray to be definitely dis-
appearing.
An x-ray examination the following year, on March
13, 1946, demonstrated that complete clearing of the
osteoblastic metastases in the pelvis had occurred. No
signs of them were visible. Chest x-ray findings were
also normal. On May 15, 1946, forty months after the
diagnosis and radical perineal prostatectomy, the patient
felt healthy and vigorous.
This case emphasizes the importance of pe-
riodic rectal examination of the prostate in all
men after the age of fifty. This sixty-three-year-
old man had had no complaints referrable to the
prostate and discovery of the malignancy was
something of an accident. Unfortunately spread
of the disease had occurred although not demon-
strated until nine months after prostatectomy. It
may be assumed that the condition could have
been discovered while in a curable stage if pe-
riodic rectal examination had been made. Castra-
tion was performed when metastatic lesions were
demonstrable and the disappearance of these le-
sions after two and a half years is striking. Even-
tual relapse is expected.
Case 2. — K. D., aged sixty- four, complained of sciatica
and pain in the sacrum when seen on November 29,
1941. He had a slight amount of urinary difficulty.
Residual urine was found to be 75 c.c. His prostate was
moderately enlarged and had two hard areas extending
to the periprostatic tissue, with induration of the base
of the bladder and the right seminal vesicle. X-ray
examination revealed a normal pelvis. The diagnosis was
carcinoma^ of the prostate extending beyond the gland.
On April 9, 1942, the sacral and sciatic pain had in-
creased. Stilbestrol was administered and gave relief.
On May 15 the acid phosphatase was measured at 20.7
units, and x-ray examination showed metastases in the
pelvis and femurs. A month later, on June 15, the pain
had increased severely, and the patient was unable to
walk or move his legs. On neurologic consultation a
metastatic involvement of the lumbrosacral area of the
spinal cord was diagnosed. X-ray examination further
revealed metastases in the ribs and in the thoracic spine.
Castration was performed.
By July 29 the patient felt comfortable and was
able to walk alone fairly well. His clinical improvement
was amazing, and by November 23 he had no pain
and was able to walk satisfactorily with a cane. His
appetite was good, and he had returned to work. Rectal
examination showed that the prostatic hardness had dis-
appeared.
On January 12, 1943, six months after the castration,
the patient complained that the pain in his right hip
had returned two weeks earlier. It seemed to be aggra-
vated by standing. He was confined to bed and given
4 mg. of stilbestrol daily. He had had a moderate weight
loss, and the lymph glands in his neck were enlarged.
On March 30' an x-ray showed that he had developed
a pathologic fracture of the right femur. By November
29, 1943, he was quite cachectic and was receiving fre-
quent opiates for pain. X-rays revealed extensive metas-
tases to the ribs and the left shoulder. On January 13,
1944, twenty-six months after diagnosis, and eighteen
months after castration, the patient died.
In this case the disease was rapidly destruc-
tive, and the response to androgen control treat-
ment short or incomplete. Stilbestrol was ad-
ministered for symptoms suggestive of metastasis
April, 1947
405
PROSTATIC CARCINOMA— DONOHUE
at a time when acid phosphatase and x-ray studies
were normal. Stilbestrol failed to check the de-
velopment of metastases and paralysis due to
involvement of the spinal cord. Almost com-
plete symptomatic recovery followed castration
but lasted only six months and did not prevent a
pathologic fracture.
Androgens are found in the urine in cases
relapsing after castration, indicating extragona-
dal source of the male hormone. These sources
are quiescent for variable periods, but eventually
become activated, releasing androgens which stim-
ulate the metastatic process. The nature of the
activating agent is unknown.
Case 3. — W. S., aged seventy-one, was seen on July
12, 1942, complaining of urinary difficulty, passage of
blood from the rectum, and lumbosacral pain. He had
a large mass in the right groin. Rectal examination
disclosed a large irregular mass involving the anterior
rectal wall and the upper rectum. X-ray studies demon-
strated a deformity of the rectum, as well as extensive
metastases in the pelvis and vertebrae. The diagnosis
was metastatic carcinoma of the prostate with urinary
obstruction. A transurethral resection and castration
were performed.
On August 30 the mass in the groin was diminishing,
the pain was less severe, and he was no longer passing
blood from the rectum. X-ray examination on September
14 showed that there had been an increase in the meta-
static carcinoma in the pelvis and in the lumbar verta-
brae. The mass in the groin had disappeared.
On January 24, 1944, one and one-half years after
diagnosis and castration, improvement was noted in the
bony changes in the pelvis and vertebrae. The patient
was seen again on May 16, when he complained of
pain in the rectum and stated that he was having fre-
quent bloody stools. A colostomy was performed,
followed by a posterior resection of the rectum. The
pathological diagnosis was adenocarcinoma of the rec-
tum. The patient made a good recovery and returned to
business.
He was in good health when seen on May 15, 1946,
almost four years after castration had been performed.
He had no pain, and his colostomy was functioning well.
Here a large metastatic mass in a lymphatic
gland disappeared soon after castration. Bony
metastases at first increased but later a definite
regression occurred. He has recovered from re-
moval of the rectum for carcinoma, attends to
business and lives comfortably four years after
castration.
Summary
1. Androgen control treatment is not a cure
for carcinoma of the prostate.
2. It is, however, an effective method of sup-
pressing the metastatic stage of the disease.
3. Stilbestrol and castration are equally effec-
tive.
4. Neither stilbestrol nor castration prevents
metastasis and should be withheld until metastasis
has occurred.
5. Pain, x-ray changes in the bones, and ele-
vated serum acid phosphatase are indications for
androgen control treatment.
6. Return of comfort for the longest possible
period of time is obtained when stilbestrol is used
first and castration is withheld until the effective-
ness of stilbestrol has diminished.
7. A gain in life survival of eighteen months
to two years is the average, but the period may
be considerably longer in some cases.
8. All men over fifty years of age should have
rectal palpation of the prostate at least once a
year.
9. Suspicious areas of induration may call
for biopsy.
10. Radical perineal prostatectomy is indicated
when carcinoma is found, and this is the only
wav carcinoma of the prostate can be cured.
PENICILLIN
The topical use of penicillin ointment is becoming a
standard form of therapy in industrial clinics. All
clinical therapeutic trials of the past several years have
demonstrated the effectiveness of this new antibiotic
agent when incorporated in a suitable ointment base and
used locally in the treatment of impetigo contagiosa,
sycosis barbae, infectious eczematoid dermatitis, ecthy-
ma, furunculosis, carbuncles, chronic ulcers of the ex-
tremities, and other susceptible infections of the skin.
flndustrial Medicine, 15:576. (Oct.) 1946.
The treatment of staphylococcic and streptococcic local
infections of the skin has produced the most dramatic
results. It has proved to be of value in the treatment of
secondarily infected lesions, which are superimposed
on dermatophytosis, acne vulgaris, and contact derma-
titis.
Penicillin is not a cure-all for skin infections. It will
not replace accurate diagnosis and other specific therapy,
nor will it replace surgery and debridement. But, when
used locally, penicillin is an ideal antiseptic.! — New
York J. Med., Feb. 15, 1947.
406
Minnesota Medicine
MYCETOMA OR MADURA FOOT
Report of Cases Including One Case of Maduromycosis of the Hand
HENRY W. MEYERDING, M.D., and J. A. EVERT, JR., M.D.
Rochester, Minnesota
A MYCETOMA is a chronic granulomatous
lesion caused by a fungus infection and
characterized by indolent inflammatory swellings
containing multiple sinuses which may penetrate
into the bone and discharge a substance containing
tiny granules. The lesion is most commonly found
in the feet, where it has been called Madura foot.
The disease is rare in the United States, although
it is fairly common in certain parts of the tropics.
In a recent review of the subject, Burns, Moss
and Brueck collected reports of thirty-five cases
observed in the United States and Canada and re-
ported three additional cases. More recent case
reports have been presented by several others, in-
cluding Wood, Clough, Gottlieb, Hatch and
Wells, Peters, and Symmers and Sporer. It is the
purpose of this article to present data on three
cases of mycetoma of the foot and one case of
mycetoma of the hand which have been observed
at the Mayo Clinic.
The disease is endemic among out-of-door
workers in such hot dry tropical regions as south-
ern India, where it was first described, Mexico
and the southwestern part of the United States.
The majority of the cases seen in North America
have been found in the latter region. Among 100
successive patients observed in India, ninety-one
were agricultural workers. Among the thirty-
eight patients in the United States, twenty-one
were laborers or farmers. Physicians who have
seen much of the disease comment on its frequen-
cy among people who go barefoot. In the major-
ity of cases, the patient has been able to recall
some sort of trauma, such as a laceration or con-
tusion of the foot, which occurred several months
prior to the onset of symptoms. Such trauma
probably furnished the site through which the or-
ganism gained entrance.
The fungi found in cases of mycetoma may be
any of a number of different species belonging to
the botanical orders Actinomyces or Hyphomy-
cetes (fungi imperfecti). Lesions caused by fungi
of the former order are called actinomycoses and
lesions caused by fungi of the latter order are
Dr. Meyerding is from the Section on Orthopelic Surgery,
Mayo Clinic, ana Dr. Evert is a Fellow in Surgery, Mayo Foun-
dation, Rochester, Minnesota.
called maduromycoses. In this country, actinomy-
coses are far less common in the feet than in other
parts of the body, while maduromycoses are sel-
dom found elsewhere than in the extremities. For
practical purposes, the pathologic lesion of my-
cetoma is the same regardless of the type of in-
fectious agent.2’4’5,7’8
A mycetoma is characterized clinically by its
chronicity, which may be measured in terms of
years, and by its relatively painless course. The
lesion may involve a certain region extensively but
it seldom spreads to other parts of the body. It
has been described as a small subcutaneous swell-
ing which is somewhat tender and has an indis-
tinct base fixed to the underlying tissues. The
swelling may be nodular or may appear to be an
abscess or vesicle. After a variable period, from
a few weeks to many months or even years, the
swelling softens, breaks open and discharges a se-
rous fluid containing small yellow, black or red
granules which are fungus colonies and which are
pathognomonic of the condition. The sinuses thus
formed usually heal within a few days but from
time to time other sinuses appear singly or in
groups until the involved region is covered by
them. Ultimately the swelling spreads until the
whole part assumes a characteristic globoid ap-
pearance which is manifest in the foot as great
thickening and loss of the plantar concavity. The
lesion involves the subcutaneous tissues primarily
but it may extend into the bones in the later
stages. On pathologic examination the lesion is
seen to consist of a honeycomb of sinuses sur-
rounded by dense fibrous tissue. The process
rarely spreads beyond the extremity and the pa-
tient’s general condition may remain good. In
100 successive cases reported by Bocarro, the le-
sions were distributed as follows : ninety-three on
the foot, three on the hand, two on the leg and
one each on the scapular and sacroiliac regions.
Roentgenograms have shown no change until
late in the course of the disease, when changes
characteristic of the spread of a contiguous infec-
tious process appear. The bone then shows peri-
ostitis, moth-eaten rarefaction and, ultimately, de-
struction with osteomyelitis and ankylosis.
April, 1947
407
MYCETOMA— MEYERDING AND EVERT
In most of the cases which have been reported,
the disease has progressed steadily regardless of
treatment. While the classic therapeutic agent,
potassium iodide, has been of little benefit, sulfon-
Fig. 1 (a) Anteroposterior roentgenogram of the right foot
and ankle shows extensive osteomyelitis involving the tarsal,
metatarsal and phalangeal bones, with ankylosis. (b) Lateral
view shows involvement of the astragalus, the os calcis, tarsus and
metatarsus and phalanges with destructive changes and exten-
sive ankylosis (this is a picture of long-standing osteomyelitis
and ankylosis), (c) Scars and discoloration with thickening of
the foot in a case of long-standing Madura foot.
amide therapy has been followed by temporary
improvement in two cases reported recently. Ade-
quate amounts of the new antibiotics have not, to
our knowledge, been employed in the treatment.
We believe that streptomycin and penicillin may
be of value and should be given a thorough trial
in the early stages before extensive changes in
the bones have occurred. In most cases surgical
excision has been the ultimate recourse. The exci-
sion should include a wide region of tissue about
the diseased part, since local excision has fre-
quently been followed by recurrence. Since the
patient’s general health is seldom affected, there
apparently’ is no urgency about surgical treatment,
and amputation of the extremity is resorted to as
a rule only after years of recurring sinus forma-
tion with marked swelling and repeated periods
of disability.
Report of Cases
Case 1. — A railroad car repairman, forty-four years
of age, reported for examination at the clinic because of
pain in the right foot of eleven years’ duration. He
had been a resident of Iowa for many years. He stated
that about fourteen years prior to his admission a
weight had fallen oq the dorsum of his right foot.
Three years afterward he had noticed a pain in the
distal portion of the right foot, followed by a swelling
surrounded by a region of inflammation. A month later,
swelling broke down into multiple draining sinuses which
healed within a few days. Similar episodes recurred at
irregular intervals several times a year. Each time the
sequence of symptoms was the same, starting with a
rather sudden pain followed by a swelling which lo-
calized into multiple pustules. When the pustules opened,
they discharged a thick yellow or red material contain-
ing “small white lumps.” The foot became somewhat
larger after each episode. Four months prior to the pa-
tient’s admission, the most recent swelling had occurred
after a blow on the foot. During the course of his ill-
ness, he had consulted numerous physicians, had received
various forms of treatment and had had two operations
on the foot. He further stated that eleven years prior
to his admission three masses of tissue- had been re-
moved from the dorsal and medial aspects of the foot.
Nine years before admission a piece of bone had been
removed from the dorsum, and the plantar aspect of the
foot had been drained. Cultures had been reported neg-
ative at that time.
Physical examination showed the patient to be a well-
developed and well-nourished man in no distress with
a temperature of 98.2° F. The entire right foot was
swollen, indurated and covered by multiple small scars,
some of which contained open sinuses with “punched-
out” openings about 1 mm. in diameter. The swelling
extended a short distance proximal to the malleoli. The
patient had limited flexion and extension of the ankle
and he was unable to invert or evert the foot. There
were palpable lymph nodes in the right inguinal region.
One of us made a clinical diagnosis of Madura foot on
inspection and advised cultures for mycetoma.
The examination also disclosed the results of urinaly-
sis to be normal except for some pus cells; the floccula-
tion reaction was negative ; the concentration of hemo-
globin was 14.2 gm. per 100 c.c. of blood ; the sedimen-
tation rate (Westergren) was 48 mm. per hour; roent-
genograms of the thorax were normal. A culture of the
discharge from the foot showed a fungus, which was
identified as Monosporium apiospermum. The roent-
genograms of the right foot showed “osteomyelitis” in-
volving the tarsus, the os calcis and the proximal por-
tions of the metatarsal bones, with destruction and anky-
losis of the regional joints.
The patient was not particularly disabled and was
permitted to return to his work. He was advised to con-
sider amputation if he should become severely inca-
pacitated (Fig. 1, a, b and c).
403
Minnesota Medicine
MYCETOMA— MEYERDING AND EVERT
Case 2. — A man, thirty-two years of age, came for ex-
amination because of a swelling of the right foot, which
had been present for ten years. The patient was a la-
borer who lived in Indiana. Ten years prior to his ad-
mission, while at work, he had noticed a gradual onset
of aching pain in the dorsum of the right foot. Eight
and a half years prior to the examination he had no-
ticed the right ankle had become swollen, painful and
warm, and the skin had a purplish discoloration. The
pain and swelling partially resolved after about one
week but thereafter the patient had similar attacks at
irregular intervals three to five times each year. Six
years before coming to the clinic he had had a red in-
durated area on the dorsum of the foot which opened
and discharged a thick yellow material for several
weeks. Similar sinuses appeared in various parts of the
foot thereafter.
Examination showed the patient to be a healthy young
man in no distress. The temperature was 98° F. The
right foot was warm and swollen, and the skin about
the ankle was indurated. There were numerous depressed
pigmented scars over this area, and on the posterior as-
pect of the ankle there were two firm red swellings.
The remainder of the examination revealed negative re-
sults of urinalysis and flocculation test ; a concentration
of hemoglobin of 14.4 gm. per 100 c.c. of blood and a
leukocyte count of 7,100 per cubic millimeter of blood;
the sedimentation rate (Westergren) 10 mm. per hour.
The roentgenograms of the right foot and ankle did not
reveal any significant changes. A biopsy of the lesion at
the site of the two small abscesses on the medial aspect
of the ankle was performed ; thin yellowish gray p<us
was removed. Microscopic examination revealed granu-
lomatous tissue containing tiny abscesses in which were
filamentous masses of fungi. These fungi had no chlam-
ydospores and the organism appeared to be one charac-
teristic of a maduromycosis rather than an actinomy-
cosis. Attempts to culture the organism were unsuc-
cessful.
The patient was given roentgen therapy and potassium
iodide was prescribed. He was advised to have amputa-
tion of the foot if the condition seriously handicapped or
disabled him.
Case 3. — A woman from Texas, forty-eight years of
age, reported for examination because of drainage from
the left heel of three years’ duration. She stated that
about three and a half years prior to her admission at
the clinic she had had a fall from a ladder and had
struck the ground firmly with her left heel. The heel
had become painful and discolored following this and
was painful whenever she walked. Six months later the
heel had become red and swollen and her physician had
incised the plantar surface with negative findings. Some
weeks later a spontaneous discharge appeared and
formed a sinus, which soon healed, but similar swellings
and drainage appeared about the ankle at one-month to
two-month intervals thereafter. From time to time vari-
ous treatments, including incision, curettage, excision,
cautery, local applications and roentgen therapy, had been
tried without noticeable effect. The patient commented
that the material from the sinuses occasionally contained
masses which looked like “popcorn.” She had little pain
and was able to walk on the heel whenever an abscess
was not forming. A culture which had been taken six
months prior to her examination at the clinic was re-
ported as showing “Madura fungus.”
Examination showed the patient to be a well-developed
healthy-looking person in no distress. The temperature
was 99° F. The left heel contained three sinuses, one
of which was exuding a thick purulent material. About
the sinuses was an area of erosion and ulceration. The
plantar surface of the heel was moderately tender. The
foot was held in a position of equinus and the calf was
slightly atrophied. The urinalysis and the flocculation
test gave negative results. The concentration of hemo-
globin was 11.6 gm. per 100 c.c. of blood; erythrocytes
numbered 4,290,000 and leukocytes 5,100 per cubic milli-
meter of blood. The sedimentation rate (Westergren)
was 27 mm. per hour. The roentgenograms of the tho-
rax were normal. The roentgenograms of the left foot
showed some cortical irregularity of the os calcis and
osteitis in the posterior inferior portion. Repeated cul-
tures from the sinuses of the foot failed to demon-
strate any fungi, although Staphylococcus aureus and
Pseudomonas were found. A biopsy of the heel was
performed. The subcutaneous tissue was found to con-
tain several necrotic regions and proved to be involved
in a chronic granulomatous process containing mycotic
fungi with morphologic characteristics of Actinomyces.
One week later the involved region of the left heel was
widely excised. It was found to contain multiple subcu-
taneous abscesses which extended deeply to involve the
underlying bone. After this operation, the incision healed
well and a split-skin graft was applied. Four weeks
later, however, several tender areas appeared in the base
of the incision, from which there was a purulent drain-
age. Three weeks afterward the leg was amputated at
the junction of the upper and middle thirds of the left
tibia. The postoperative convalescence was uneventful
and the patient returned home in good condition.
Case 4. — A merchant, thirty-nine years of age, a native
of Mexico, came to the clinic for examination because of
a swelling on the palm of the left hand of seventeen
years’ duration. He stated that seventeen years prior to
consultation, at a time when he was working on a farm,
a pimple had developed on the left palm. The lesion
gradually enlarged without particular pain and dis-
charged purulent material from time to time. It had
never healed. Two operations four and three years pre-
viously and two courses of roentgen therapy two years
previously had not been beneficial.
Examination showed the patient to be a well-developed
and well-nourished man in no distress. The temperature
was 98° F. The left hand was thicker than the right
and there was an indurated area over the base of the
left first metacarpal bone in which there were about ten
small draining sinuses from which exuded purulent ma-
terial containing granules. The urinalysis and the floc-
culation test gave negative results. The concentration
of hemoglobin was 16.3 gm. per 100 c.c. of blood ; leu-
kocytes numbered 8,000 per cubic millimeter of blood.
The roentgenograms of the thorax were normal. The
discharge from the hand was found to contain pinhead-
(Contmued on Page 411)
April, 1947
409
Case Report
INTESTINAL ASCARIS DIAGNOSED ROENTGENOGRAPHICALLY
IN MINNESOTA
R. S. LEIGHTON, M.D., and R. J. WEISBERG, M.D.
Minneapolis, Minnesota
DURING the last twenty-five years, a number of re-
ports have been published of the diagnosis of
roundworm infestation by means of the x-ray examina-
tion. Due to the return of a great many veterans from
tropical theaters, ascaridiasis is now appearing in the
North Central United States, where it would hardly
have been considered prior to the recent war. The case
Fig. 1. Roentgenogram following barium enema shows ascaris
in terminal ileum. The worm produces a bandlike area of de-
creased density of sinuous character indicated by arrows.
herein described is reported not as something new but
because it is felt worth while under the circumstances to
call attention of physicians to this new problem and to
re-emphasize the little known fact that many cases may
be diagnosed only by means of x-ray study.
Case Report
R. W., a thirty-one-year-old veteran who had had
service in the Southwest Pacific, reported to the Vet-
erans Hospital in Minneapolis on September 18, 1946,
complaining of diarrhea and occasional low abdominal
cramps. The onset of his illness apparently dated back
From the Departments of Roentgenology and Medicine of the
U. S. Veterans Hospital, Minneapolis, and the Departments of
Radiology and Physical Therapy, University of Minnesota.
410
to March, 1945, at which time he was treated for ame-
biasis in an army hospital in the Philippines. His symp-
toms cleared up after one month’s treatment, and he was
well until September, 1945, when his difficulty recurred.
He was studied in an army hospital at that time, and
stool studies were negative for ova and parasites. He
was discharged with a diagnosis of anxiety state and
MErpiC
i 2 3 4 5
Fig. 2. Photograph of worm following expulsion.
psychoneurosis. Since that time he continuously had
mucus but no gross blood. Occasional cramps was the
only other symptom.
He was studied during the summer of 1946 at the
Minneapolis Veterans Hospital, at which time the stools
were found to be free of ova and parasites, and a procto-
scopic examination to 25 cm. revealed a normal colon.
A barium enema done on July 1, 1946, revealed a nega-
tive shadow in the terminal ileum which was reported as
probably representing a single large ascaris (Fig. 1). An
upper gastrointestinal x-ray study was normal. Be-
cause of nervousness and diarrhea he was hospitalized
on September 18, 1946, for further investigation.
Physical examination was entirely normal except for
some slight tenderness in the right upper quadrant of
the abdomen. Laboratory workup, including stool ex-
aminations, yielded nothing of note.
Because of the positive x-ray report for ascaris and
the lack of any other positive findings, it was decided to
conduct a therapeutic test in spite of the absence of ova
in the stool. After preparation with magnesium sulfate,
one gram of hexylresorcinol was given on an empty
stomach. Twenty-four hours later another dose of mag-
Minnesota Medicine
CASE REPORT
nesium sulfate was given, and an 8-inch male ascaris
lumbricoides (Fig. 2) was recovered from the stool.
Full clinical recovery occurred immediately following ex-
pulsion of the worm.
Discussion
Diagnosis of ascaridiasis was first made by means of
x-rays by Fritz in 1922. In 1925 Forsell showed definite-
ly the value of roentgen examination in this disease and
stated that if the infestation was by male worms, x-rays
offered the only available means of definitive diagnosis.
Fiessly in 1942 reported a case in which a single male
worm was found by x-ray examination and another in
which the diagnosis was made in a patient whose stools
were normal.
Our case again demonstrates the value of the exami-
nation in the frequent cases of single male infestation.
It should be pointed out that whereas the worm is clear-
ly seen on the barium enema films, it could not be made
out when the barium was given by mouth. Several in-
vestigators report visualization with oral barium. W hen
the disease is suspected, it cannot definitely be ruled out
by examination by either route. Only the positive find-
ings are of real significance.
References
1. Fritz: (Quoted by Fiessly.2
2. Fiessly, R. : Ascaridiasis and radiography. Gastroenterologia,
67:64, 1942.
3. Forsell: Quoted by Fiessly.2
4. Levi, S. : Diagnosis of ascaridiasis by roentgenography.
Med. Bull. Med. Theatre Op., 3:12-15, (Jan.) 1945.
5. Weir, D. C. : Roentgen diagnosis of ascariasis in the ali-
mentary tract. Radiology, 47:284-286, (Sept.) 1946.
MYCETOMA OR MADURA FOOT
(Continued from Page 409)
sized black granules which proved to be colonies of
fungi belonging to the genus Madurella. On biopsy, the
skin of the left thenar eminence was reported to be typi-
cal of maduromycosis. The patient was given a course
of roentgen therapy and potassium iodide, with tem-
porary improvement. Three years after the examina-
tion, the patient’s left index finger and the involved
portion of the palm were excised elsewhere. He was
then free of symptoms until eighteen months later when
there was recurrence of the disease. In a letter received
four and a half years later, the patient wrote : “I am
reconciled to amputation.”
Comment
An analysis of these cases shows that two of
the patients were inhabitants of the north central
part of the United States who had never been to
the tropics but whose occupations kept them out
of doors. One patient was a native of Texas. The
mycetoma of the hand, which is so rare a condi-
tion as to be a curiosity, was found in a patient
who was a native of Mexico and who had been
doing agricultural work at the time he acquired
the disease. Two of the patients who had lesions
of the foot gave a definite history of antecedent
trauma. The infectious agent was found to be
Monosporium -apiospermum (order Hyphomy-
cetes) after study of cultures in one case. In the
other two cases, the morphologic examination re-
vealed an organism of the order Hyphomycetes
once, an organism of the order Actinomyces once,
and gave an equivocal result once. Positive iden-
tification of the fungi is a matter of some scientific
interest in this rare condition, but it depends on
difficult cultural techniques and it is not essential
to the diagnosis of the condition. These three
cases of Madura foot and the case of maduromy-
cosis of the hand have been presented in order to
call attention to an unusual suppurative condition
characterized by a granular discharge, the course
of which is chronic and relatively painless.
References
1. Bocarro, J. E. : An analysis of one hundred cases of my-
cetoma. Lancet, 2:797-798, (Sept. 30) 1893.
2. Boyd, M. F., and Crutchfield, E. D. : A contribution to the
study of mycetoma in North America. Am. J. Trop. Med.,
1:215-289, (July) 1921.
3. Burns, E. L. ; Moss, Emma S., and Brueck, J. W.: Myce-
toma pedis in the United States and Canada; with a report
of three cases originating in Louisiana. Am. J. Clin Path.,
15:35-49, (Feb.) 1945.
4. Chalmers, A. J., and Archibald, R. G. : A Sudanese maduro-
mycosis. Ann. Trop. Med., 10:169-222, (Sept.) 1916.
5. Chalmers, A. J., and Christopherson, J. B. : A Sudanese
actinomycosis. Ann. Trop. Mea., 10:223-282, (Sept.) 1916.
6. Clough, F. E. : Madura foot. West. J. Surg., 53:153-156,
(May) 1945.
7. Dixon, J. M. : Sulfanilamide therapy in Madura foot. Vir-
ginia M. Monthly, 68:281-282, (May) 1941.
8. Gellman, Moses, and Gammel, J. A.: Madura foot; a third
case of monosporosis in a native American. Arch. Surg.,
26:295-307, (Feb.) 1933.
9. Gottlieb, A.: Madura foot or mycetoma; report of 2
cases. West. J. Surg., 52:264-265, (June) 1944.
10. Hatch, W. E., and Wells, A. H.: Actinomycosis of the
urinary bladder complicating a case of Madura foot. J.
Urol., 52:149-152, (Aug.) 1944.
11. Peters, J. T. : A clinical cure of Madura foot. Am. J.
Trop. Med., 25:363-365, (July) 1945.
12. Symmers, Douglas, and Sporer, Andrew : Maduromycosis
of hand ; with special reference to heretofore undescribed
foreign body granulomas formed around disintegrated
chlamydospores. Arch. Path. 37:309-318, (May) 1944.
13. Wood. D. A.: Maduromycosis of the ankle; report of case.
California & West. Med., 62:119-121, (Mar.) 1945.
April, 1947
411
History of Medicine In Minnesota
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester, Minnesota
(Continued from March issue)
Don J. Lathrop was born at Aurora, New York, 1851, was educated in the
local district schools, and at the age of nineteen years entered the Medical
School of the University of Buffalo, New York, from which he was graduated
in February, 1872. Millard Fillmore, later to be President of the United
States, was at that time chancellor of the university, and from his hands Dr.
Lathrop received his diploma.
In the spring of 1872, just out of medical school, Dr. Lathrop settled in
Granger, Bristol Township, Fillmore County, Minnesota, succeeding in prac-
tice Dr. Henry Jones, who was moving to Preston. In Granger he spent the
remainder of his life, the only resident physician and surgeon in the village.
For a few years, beginning in 1872, Dr. Lathrop owned and operated a drug
store, which in 1877 he sold to a Mr. Andrews. In a business directory of
that period he was listed as physician, druggist and notary. Records suggest
that he was an able and progressive member of his profession, for in 1880
he was one of the eleven physicians in the county who replied to the request
of the State Board of Health for help in compiling statistics on diphtheria in
Fillmore County in the period from November 1, 1879, to November 1, 1880.
On July 4, 1882, Dr. Lathrop, in firing a patriotic salute, was terribly in-
jured and disfigured about the face by the premature discharge of the can-
non; one eye was destroyed and he almost completely lost the sight of the
other. In spite of his handicap he thereafter carried on his medical practice
and, it has been said, even attempted to perform surgical operations. In a
news item of November 18, 1886, it appeared that a few days previously
Dr. Frank (perhaps Dr. Adam Frank, of Iowa), had “skillfully performed
the operation necessary to insert a pair of artificial eyes which any stranger
would not recognize as unnatural. The change in Dr. Lathrop’s looks is
marvelous. His neighbors and friends call it wonderful and join in thanks to
Dr. Frank, whose professional work uniformly gives satisfaction.”
Dr. Lathrop lived until May 2, 1888. (This date is from the records of the
Masonic Blue Lodge, of Preston, an order which Dr. Lathrop joined on Sep-
tember 8, 1876.) He was succeeded in practice in his community, as has been
told, by Dr. J. Herbert Darey, newly arrived from the East.
Dr. Leprohon, according to a business directory of 1882-1883, was in Lanes-
boro, Fillmore County, in those years; in succeeding volumes of the same
work his name did not appear. Reference to official medical directories of
Minnesota disclosed that R. E. Leprohon in 1879 was graduated from the
412
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HISTORY OF MEDICINE IN MINNESOTA
Medical Department of the University of Bishops College, Canada, and that
on July 31, 1885, two years after the passage of the Medical Practice Act of
1883, Dr. Leprohon, then living in La Crosse, Wisconsin, was licensed to
practice in Minnesota, and received state certificate No. 1088 (R). In 1907,
and probably much earlier, Dr. Rodolphe E. Leprohon, a graduate of the
Medical Department of the University of Bishops College in 1879, was living
in Montreal, Quebec, Canada.
Thomas Little was one of Fillmore County’s earliest physicians, inasmuch
as he was established in the thriving little village of Elliota, Canton Town-
ship, prior to 1858. Elliota, platted four years earlier by Captain Julius W.
Elliott, its first settler and first postmaster and blacksmith, was an important
mail station at the crossroads of several stage lines and the home of various
business enterprises.
In this hopeful place, which was to suffer disappointment of its ambitions,
Dr. Little opened offices on Saint Paul Street and published a professional
card which declared him to be physician and surgeon and dealer in drugs and
medicine, paints, oils and so forth.
After 1887 Dr. Little practiced in Minnesota under an affidavit ; some time
between 1887 and 1890 he moved from the state to Dickinson County, Iowa,
which is just across the line from Jackson County, Minnesota.
Andreas (Andrew) Pederson Lommen, son of Peder J. Lommen and Maria
Arntson Lommen, was born at the farm home in Spring Grove Township,
Houston County, on May 10, 1867. Peder Lommen, a native of Norway,
came to America in 1851 and for two years farmed in Dane County, Wis-
consin, before settling in Houston County. Marie Arntson came with her
parents from Norway to Houston County in 1861. Mr. and Mrs. Lommen
were married in that county and there spent their lives. They had four
children, all of whom were fine citizens: Christian, Dean of the Medical De-
partment of the University of South Dakota, in Vermillion, until his death;
Andreas; Sarah Lommen (Mrs. Ning) Eley, of Des Plaines, Illinois; and
Belle, a retired teacher, formerly on the faculty of the University of Iowa, of
late years residing in San Diego, California.
Andreas Lommen, when a young boy, was a pupil in the rural schools near
his home and in the graded schools of the village of Spring Grove ; later ht
studied for two years at Gales College, in Galesville, Illinois/from which he
was graduated. After teaching rural school in 1890 and 1891 he entered the
University of Minnesota, taking one year of academic work before enrolling
in the medical school, from which he was graduated in June, 1895. Licensed
in the same month to practice medicine in the state, he at once established
himself in Mabel, Fillmore County, not far from his boyhood home. The
successful practice which he built up in his two years in the community
was a prelude to more extensive work in another section of the county. In
1897, favorable opportunity offering in Lanesboro, he moved to that village,
where for the next forty-five years he was an able and kindly physician, loved
and honored, true to the ethics of his profession, and a willing and no less
able public servant.
A man of practical wisdom and foresight. Dr. Lommen was of value in
many positions of responsibility. He held office as county physician and
county health officer, was active in the county, state and national medical
associations, and was chairman of the board of education, and for nine terms
April. 1947
413
HISTORY OF MEDICINE IN MINNESOTA
was mayor of Lanesboro. He was a member of the Bethel Lutheran Church,
the Independent Order of Odd Fellows and the Yeomen, charter member
and medical adviser of the Sons of Norway and charter member of the
American Legion. During World War I he was a captain in the Medical
Corps of the United States Army, stationed at Camp Shelby, Mississippi,
until his honorable discharge in 1918. His interests outside his professional
and civic life lay in his home and family, his books, garden and farm. In
his long years in Lanesboro he saw many physicians come and go. Two
names, like his own, that are identified with the welfare of the community,
beginning prior to 1900, are those of Dr. Johan C. Hvoslef (1839-1920). who
settled in Lanesboro in 1876, and Dr. Frederick A. Drake (1870- ), in
Lanesboro since 1896.
Andreas Lommen on June 3, 1897, was married to Stella Johnson, daughter
of Rasmus and Maria Hellickson Johnson, of Newburg, a village near Mabel.
Dr. and Mrs. Lommen had four children, one of whom, Doris Estelle, died
young. Of the three who were living at the time these notes were compiled,
Robert M. Lommen, an electrical engineer, was in Milwaukee, Wisconsin;
and Flelen M. Lommen, a teacher, and Andrew Paul Lommen, an attorney,
were in Lanesboro. After the entrance of the United States into World
War II, Andrew Paul Lommen became a lieutenant in the administrative
branch of the United States Air Corps, stationed at Tampa, Florida. A
grandson of Dr. Lommen is Paul Warren Lommen.
In gradually failing health for more than a year before his death, Dr.
Lommen spent the last few weeks of his life at the Veterans Hospital at
Wood, Wisconsin, where he died on September 16, 1942, at the age of
seventy-five years. The cause of death was stated as cerebral thrombosis with
contributory heart disease, coronary arteriosclerosis with myocardial damage
and insufficiency. Burial was in Lanesboro.
T. E. Loop was one of the earliest physicians in Fillmore County, estab-
lished there perhaps in the middle or late fifties. Search has added nothing
to the solitary known fact that he was one of the founders and the first
secretary of the Fillmore County Medical Society, which was organized in
the office of Dr. Lafayette Redmon, at Preston, on October 17, 1866. That
Dr. Loop, then of Spring Valley, was one of this choice group of six phy-
sicians drawn from various parts of the county, is presumptive evidence of
his ability, intelligence and co-operative spirit.
George Allen Love was born on March 3, 1850, at Woodstock, McHenry
County, Illinois, the son of Robert Love and Agnes Dixon Love, both of
whom were natives of Glasgow, Scotland. Shortly after their marriage Mr.
and Mrs. Robert Love, intent on a home in the Middle West of America,
came over from Scotland in a sailing vessel. They first settled in Illinois,
later for several years were in and near Manchester, Iowa, and finally moved
to Minnesota, in June, 1856, to take a homestead in York Township, Fillmore
County. George was then six years old. The other children, all sons, were
William, Robert, John and Andrew. In later years William and Robert
managed the home farm, John became a druggist, and Andrew a teacher
and manager of a teachers’ agency in Fargo, North Dakota.
George Love began his formal education at Liberty School in York Town-
ship and in 1867, then seventeen years old, he entered the public schools of
Preston, to study for three years. Beginning in 1870, he studied medicine for
414
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HISTORY OF MEDICINE IN MINNESOTA
more than a year in the office of Dr. John A. Ross, of Preston, preparatory
to entering the Bennett Eclectic College of Medicine and Surgery, in Chi-
cago. After his graduation late in 1874 with the degree of doctor of medicine,
he practiced his profession for a few months in the village of Whalen and
then for two years was in partnership with Dr. Ross in Preston. Their pro-
fessional card, which appeared in the Fillmore Oounty Republican for January
8, 1875, set forth that Ross and Love, physicians and surgeons, had their
office on Main Street, just in rear of the post office, that the office was open
day and night and that all calls were promptly attended to.
In 1876 Dr. Love began the independent practice that was to continue for
fifty-four years. On December 31, 1883, under the new law on medical prac-
tice, he received state certificate No. 669 (E). At this period his office was
“three doors south of Tibbetts’ Drug store, upstairs.” He worked alone
until 1912, when he was joined by his son, Dr. George R. Love, in a partner-
ship which was to last eighteen years. In the fifty-six years of his professional
career many medical practitioners came and went in the village and the com-
munity. Among the best known who were in Preston prior to 1900 were John
A. Ross, Henry Jones, Lyman Viall, Charles H. Jacobson and James H.
Phillips.
George Allen Love was the typical country doctor in the highest tradition,
medical practitioner, counsellor, friend, and to all relationships he brought
manners that were not only courteous but almost Chesterfeldian, an old
acquaintance has recalled. He never refused a call, gave time, skill and
knowledge without thought of financial remuneration, and in addition fre-
quently gave financial aid to the needy. It is remembered that he often said,
“It’s not so easy for a man to die,” and that when death was near in a home
in which he was physician, he stayed by to be of aid and comfort to the dy-
ing and to the family.
In the early years of scattered communities and few telephones it was
common for Dr. Love to be away several days at a time on visits to the
sick, for when he reached the home to which he had primarily been called, he
would find waiting a neighbor of the patient to summon him to another home
miles distant, and so it would continue. Roads of course were poor or non-
existent, and travel in wet weather, through deep clay mud and across open
streams, sometimes bridged with structures of uncertain strength, offered
many hazards. During the time of spring freshets it was not unusual for
both horses and passenger to be obliged to swim to shore; in the winter
Dr. Love, like others, often had to extricate his horses from snowdrifts on
the roads, shoveling them free and unhitching and leading them out one at a
time. When epidemics of pneumonia, scarlet fever, whooping cough and
measles, seasonal in the spring, kept the physician almost constantly on the
road, the horses suffered; Dr. Love enjoyed and valued fine roadsters and,
until the automobile came into use, kept four or five in his stables, so that
no one of them should be overworked.
Ethical and loyal to his profession, Dr. Love was no less progressive, keep-
ing in touch with medical advance by periods of study at Rush Medical Col-
lege, by reading the medical literature and by active membership in medical
associations. He is said to have been an early member of the Fillmore Coun-
ty Eclectic Medical Society, which was organized in 1869, the year before
he began his medical study with Dr. Ross, and which functioned until 1876.
He was elected to membership in the Fillmore (later Fillmore-Houston)
County Medical Society, the Southern Minnesota Medical Association, the
April, 1947
415
HISTORY OF MEDICINE IN MINNESOTA
Minnesota State Medical Association and the American Medical Association.
A general practitioner, he was physician and surgeon and druggist, com-
pounding his own medicines. For more than twenty years, well into the
1900’s, he was active in public health work, aiding the State Board of Health
and serving on local county and village boards as chairman or as member.
In 1886 he was a member, with Dr. J. H. Phillips and Dr. C. H. Robbins, of
the newly created medical examining board of the Bureau of Pensions in the
county. When the “black diphtheria” broke out, he guarded the community
carefully, and to avoid exposing his family to the disease he took living
quarters away from his home. In one of his reports to the State Board of
Health, in 1886, he stated that the May inspection was preceded by a notice
in the newspaper and that “inspection found the town 40 per cent cleaner
than last year. ... A few matters needing attention were promptly attended
to. . . . Conditions of county house and jail unsatisfactory. Notice to county
commissioners to attend to same.” During World War I Dr. Love was
medical examiner for the local draft board.
Not a politician, he nevertheless took a keen interest in politics, local, state
and federal, and although he inclined strongly toward the Democratic Party,
he supported the candidate whom he considered best qualified for office, re-
gardless of affiliation. For several years county chairman of the party, he
was instrumental in bringing William Jennings Bryan to Preston during a
presidential campaign, to the astonishment of incredulous Preston folk who
believed that the great orator would not spend time on a village.
Dr. Love was a member of the Methodist Church of Preston and served as
trustee on the church board. Of strong fraternal interest, he was a Mason
( a member since December 6, 1876, of the Preston Blue Lodge, A. F. and
A. M.; the Preston chapter of Royal Arch Masons; the Malta Commandery,
Knights Templar; and the Minneapolis Consistory No. 2, Scottish Rite); a
member of the Independent Order of Odd Fellows, and of the Modern Wood-
men of America. His library, which was a fine one, was built up chiefly of
volumes on medicine, history, travel and biography.
George Allen Love was married on March 5, 1877, to Mary Jane Kingston,
who was born at Lenora, Amherst Township, Fillmore County, the daughter
of the resident minister. The Reverend William Kingston. Dr. and Mrs. Love
had eight children: Claudine died at the age of sixteen from typhoid fever.
Bessie became a school teacher who, in the early nineteen-forties, was in
Eugene, Oregon. George E. Love, who was graduated from the Medical
School of the University of Minnesota, from 1912 was in partnership with
his father until the death of the older man in 1930; Dr. G. R. Love died in
1941. Frederick Andrew Love, also a graduate of the Medical School of the
University of Minnesota, became a practicing physician in Carlos, Minne-
sota. William was graduated from the Dental School of Northwestern Uni-
versity, Chicago, and practiced dentistry for six years in Preston ; during
World War I he entered the army, was shellshocked in service and because
of the resulting disability has since been a patient in the Veterans Hospital
at St. Cloud, Minnesota. Elwyn, also a dentist, a graduate of the Dental
College of the University of Minnesota, followed his profession for seven-
teen years; he subsequently gave up dentistry and became a clerk in the
post office at Preston. Helen became a school teacher, employed in the
schools of Preston. Maclaren, like his brother William, was graduated from
the Dental School of Northwestern University and has practiced dentistry in
Preston.
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HISTORY OF MEDICINE IN MINNESOTA
On December 4, 1930, in Preston, Dr. George Allen Love died from a
stroke. It is high tribute that his children remember him as a friend and
boon companion. No name in the community is recalled with greater respect
and honor than his, for his worth as a citizen, his ability as a physician and
his kindly, unselfish and unstinted service to the sick.
That Adolph Mac, a medical practitioner, had his office on Grove Street,
Rushford, in the late sixties is a matter of record, in Mervin’s Business Di-
rectory for 1869-1870, but other than this brief item information about him
is lacking.
Alexander MacDonald, although not a practicing physician in Fillmore
County until 1901, when he settled permanently in the community of Chat-
field, had been in Minnesota, in Austin, Mower County, and subsequently in
Ortonville, Big Stone County, since 1883. Biographical data fortunately have
been available and are included here in supplement any accounts of Dr.
MacDonald’s early professional career in the state that may appear in the
narratives from other counties.
Alexander MacDonald was born at Perth, Lanark County, Ontario, Canada,
on November 6, 1856, the son of Joseph MacDonald and Margaret Mac-
Pherson MacDonald. The parents were natives of Scotland; the father, a
farmer, blacksmith and bailiff, was born at Perth, the mother near Sterling.
Mr. and Mrs. MacDonald had five children: Jessie (Mrs. Webster), Henry,
Margaret, Joseph and Alexander. One of the maternal uncles of these chil-
dren, the owner of large lumber interests, lived in Ottawa. Their paternal
grandfather, a member of a military band, was present at the bombardment of
Copenhagen by the British in 1807, and in the War of 1812 he served with
the British, it is believed, and after the war remained in America, settling
on a tract of government land near Ottawa, Canada.
In Canadian schools and colleges Alexander MacDonald received his
formal education, his preliminary and academic training in the grade schools
of Paisley, Bruce County, Ontario, and at the Galt Collegiate Institute, at
Galt, from which he was graduated in 1877. At Galt the head master was
Dr. Tassie, M.A., so well known as a strict disciplinarian that many boys
from a distance, even from the United States, were sent to him ; cricket and
La Crosse were the two games that he considered respectable ; baseball and
football were “Yankee” and taboo. In the spring of 1877 Alexander Mac-
Donald went to Toronto to take the examination (which he passed) for ma-
triculation in the Medical School of McGill University, at Montreal. During
the summers of 1877, 1878, and 1879 he studied medicine under Dr. Peter
Maclaren (McGill, 1861) at Paisley, and in 1883 he was graduated from Mc-
Gill University with the degrees of M.D. and C.M. (Master of Chirurgery).
Near the close of his medical course Dr. MacDonald for several months
gained valuable experience and credit by substituting in the Montreal Gen-
eral Hospital for an intern who had been taken ill. At McGill he came under
the teaching and influence of Dr. William Osier, then a professor of physi-
ology : “The greatest pathologist and diagnostician the world over and still
the greatest. Dr. Osier had a magnetic presence and was adored by the whole
student body. Under his training I was enabled to have the credit, the honor,
of passing the best bedside examination of the year 1883.”
In the year of his graduation Dr. MacDonald came to the Middle West
and began the practice of medicine in Austin, Mower County. He was then
April, 1947
417
HISTORY OF MEDICINE IN MINNESOTA
a member of the Medico-Chirurgical Society of Montreal. In that year he
served as president of the board of pension examiners of Austin. On January
23, 1884, under the Medical Practice Act of 1883, he was licensed in Minne-
sota, receiving certificate No. 767 ; in 1887 he received licenses to practice
medicine in Wisconsin and Iowa. In Austin, where by 1885 he had gained a
widespread practice, he established a dispensary for the more efficient treat-
ment of his patients. In 1888, in the interest of science, he volunteered to
serve the United States Public Plealth Department in fighting yellow fever
but because he was not immune to the disease his offer was not accepted.
From 1897 to 1901 Dr. MacDonald practiced medicine in Ortonville, Minne-
sota, and it was there that he suffered the loss by fire of valuable and irre-
placeable records, books, and clinical magazines, as well as his fine surgical
instruments and electrical equipment. In Ortonville he served as secretary
of the board of examiners of Civil War pensioners.
On September 30, 1890, Alexander MacDonald was married to Margaret
Anna Forster, a school teacher in the community of Chatfield, who was born
on January 8, 1861, of English parents, on a farm in Orion Township, Olm-
sted County, near Chatfield. Dr. and Mrs. MacDonald had one son, an only
child, William Joseph Alexander MacDonald, born in 1893, whose life was a
credit to his home and his country. Student and athlete, he was a graduate
from the Law School of the University of Washington, at Seattle; in 1917
he was captain of the university track team and competed in the mile and
the two mile runs. In World War I he entered the army and soon became a
first lieutenant in the Rainbow Division ; when he was at corps school in
France, he received highest standing in tactics and was recommended for a
majority. On the morning of October 14, 1918, Lieutenant MacDonald was
killed in action in the Argonne. Pie was awarded the Distinguished Service
Cross; and MacDonald Field, of the University of Washington, was named
for him “for all time.”
During World War I Dr. MacDonald offered his services to the army but
because he was past the age limit his offer was refused. He is a Presby-
terian and a member of the Independent Order of Odd Fellows, and has
served as a medical examiner for the Modern Woodmen of America. He has
said of himself that as a business man he was a “poor collector;” his sym-
pathies were always with the tellers of hard luck stories.
During the years of his active and heavy practice, although Dr. MacDonald
did not identify himself with medical associations, he kept abreast of medical
advance by study and by reading the medical literature, a habit which he
continues. He has had especial interest and pleasure in the reading of his-
tory, the classics and the works of Dickens, Thackeray and Scott and, well
versed in French, for many years he read a daily French newspaper. One of
his hobbies, which developed during his recuperation after an illness, has
been searching locally for ginseng.
For many years after he settled in Chatfield, in 1901, a promising location
and near Mrs. MacDonald’s relatives, he maintained his office in his home.
Of late years, because of ill health, he has not followed his profession and
has lived in retirement in a comfortable home in the country near Chat-
field. Mrs. MacDonald died suddenly at home from a stroke on August 29,
1943. She was survived by her husband and by one sister, Mrs. H. P. Foote,
of Saint Paul.
(To be continued in the May issue)
418
Minnesota Medicine
President s Hettel
MEDICAL BENEVOLENCE
The yearning of nearly every human being to care for something other than himself is
one of the most praiseworthy traits of man. Strangely, this characteristic is found not only
among the good and virtuous but it has been manifest in many who were evil or even de-
praved. In a free society, then, these may be taken as universal principles : that sympathy is
excited by suffering ; that cruelty is counteracted by benevolence ; that new evils are met by
new remedies ; and that the injustice of some provokes the charity of others.
Thus it is that, even at a time when the energies of all members of our association are so
greatly needed in the attempt to care for the sick, and despite the confusing and obstructive or-
ganizational tasks which demand our attention nearly every day, the better side of our nature
asserts itself and we find time to reflect concerning the condition of colleagues who are less
fortunate than we with respect to possession of this world’s goods. We realize that some
members of our profession have reached the age of retirement practically destitute. We know
that some younger practitioners who have been incapacitated by early illness have found
themselves and their wives and children without means of support. We are familiar with the
sad plight of some widows of physicians. Our awareness of these calamitous situations, I
believe, will impel us to try to mitigate them.
Already, physicians of Illinois, of Pennsylvania and probably of other states have come to
grips with this problem. Several years ago the House of Delegates of one state medical
association created a Committee on Medical Benevolence. Among other duties, this com-
mittee searches for members of the medical profession who are in poor health and who need
financial assistance. Also, the committee is instructed to search for widows of former mem-
bers of the society or their dependent children who need aid. The committee decides as to
the eligibility of prospects who are discovered and as to the amount of money which is to
be provided. The records are subject to annual audit but names of beneficiaries do not appear
on the auditor’s report and no one other than members of the committee and the auditor
knows who the beneficiaries are.
One of the programs just described was begun with an appropriation of $5,000 from the
treasury of the state medical association. Since then other appropriations have been added.
At one time a drive was made among the members of the association for money to augment
the permanent fund. The response to this request was unbelievably gratifying. There are
other sources of funds. For example, a number of elderly patients of members of the as-
sociation have added codicils to their wills by which they have left money to the fund. Other
philanthropic individuals also have made contributions.
Interesting problems have developed as a result of such efforts. For instance, the widow
of a prominent surgeon found herself almost destitute after all expenses had been paid fol-
lowing the sudden death of her husband. Her name was added to the list of beneficiaries of
the state medical association. In another case, a young physician, with two children, con-
tracted tuberculosis. He was confined to a sanatorium for eight months. All his expenses
were met by the medical benevolence fund. The beneficiary’s name was never divulged. An
aged physician, after his retirement, had set up a new residence in Florida but had failed to
leave his new address with his state association. Nevertheless, he was discovered in his new
home when, after ten years there, he became ill and needed assistance. His problems were
solved by the contributions from the fund and his economic safety was assured until his
death. Many stories of this kind could be related.
The development of a medical benevolence project in our state organization, and perhaps
also in the American Medical Association, is something I would like to witness and in which
I would like to participate. To care for our own quietly, seems particularly appropriate in
an essentially humanitarian organization such as ours ; especially so when we consider that o£
a number of those who will need our care it can be said: “These were honored in their
generations, and were the glory of their times.”*
*Ecclesiasticus XLIV, 7.
President, Minnesota State Medical Association
April, 1947
419
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
MINNESOTA CANCER SOCIETY
r I ’HE Minnesota Cancer Society, along with the
American Cancer Society, of which it is a
component part, has shown a phenomenal increase
in membership and activity in recent years. The
American Cancer Society, originally known as the
American Society for the Control of Cancer,
languished for a number of years, until business-
men began to lend their services, and the Wom-
en’s Field Army was organized to participate in
the raising of funds. In 1940 the national fund-
raising campaign netted about $400,000; this year
it is anticipated that the amount raised will reach
$16,000,000. In Minnesota alone, over $228,000
was contributed last year by more than 43,000
individuals and 4,000 corporations. Forty per
cent of Minnesota’s yearly contribution, ear-
marked for research, goes to the national organi-
zation and is apportioned to various university
medical schools.
The objectives of the American Cancer So-
ciety are ( 1 ) research into the causes of cancer,
(2) education of the public and the medical pro-
fession, and (3) provision of medical care for
needy cancer sufferers with emphasis on these
activities being placed in the order mentioned.
For a number of years another organization,
the National Cancer Foundation, incorporated
originally as the National Foundation for the
Care of Advanced Cancer Patients, has been rais-
ing funds on a national basis for the care of
incurables. This organization has apparently felt
that more emphasis should be placed on this ob-
jective. It is unfortunate that this organization,
with a most worthy objective, should have
changed its name to the National Cancer Founda-
tion, a name so similar to the American Cancer
Society as to confuse the public. The designation
of March each year for a Foundation fund-rais-
ing campaign, just preceding the April campaign
of the American Cancer Society, is still further
confusing to the public. One national cancer or-
ganization should be sufficient. It might be noted
that the National Cancer Foundation has not
received the approval of the Minnesota Com-
munity Research Council, a state-wide commit-
tee established since the war to provide reliable
information on organizations soliciting funds.
After due deliberation, the Executive Com-
mittee of the Minnesota Cancer Society decided
that the greatest need at present in the cancer
problem in Minnesota is the provision of suitable
quarters for research at the University. Minne-
sota was one of the first universities to estab-
lish a cancer research department, but at present
it has a crying need for expanded facilities. The
society therefore presented a check for $75,000
for this purpose to Dr. H. S. Diehl, dean of medi-
cal sciences of the University Medical School,
at its annual meeting on March 8, 1947. Dr. Diehl,
in accepting the gift for the University, indicated
that the donation would doubtless be used to help
defray the cost of providing suitable quarters for
cancer research in the new Mayo Memorial build-
ing.
Someday the cause of cancer will be found.
At present, $5,000,000 ($1,500,000 appropriated
by the Federal government and $3,500,000 by the
American Cancer Society) are devoted to cancer
research. When we consider the governmental
appropriations for research in various other lines
— two billions in the development of the atomic
bomb, for instance — the amount devoted to can-
cer research does not seem adequate for a dis-
ease which during the war period caused twice
as many deaths in our country as the war itself.
We do not necessarily advocate increased Federal
subsidies for cancer research. Increased contribu-
tions to the American Cancer Society should pro-
vide sufficient funds to carry on the needed re-
search, with the assurance that the ultimate goal
will someday be reached.
FADING INK
HP HE use of ink which does not fade and which
is photogenic — that is, which is reproduced
clearly in photostatic copies for all records where
permanency is essential — is not a new subject.
Insurance companies and departments of vital
420
Minnesota Medicine
EDITORIAL
statistics have insisted for years on the use of
black or blue-black ink in the filling out of applica-
tion blanks or certificates. Such records are of a
permanent nature and are photographed, in the
case of birth and death records, sometimes years
later.
The popularity of so-called ball-point pens
equipped with long-lasting cartridges has brought
to the fore the subject of the use of non-fading
ink, which produces a smooth dark line, for im-
portant documents. Bail-point pens are manu-
factured by a number of firms. The inks in sev-
eral brands of these pens were tested about a
year ago by the National Bureau of Standards,
and all were found to fade quickly. Some manu-
facturers have been attempting to improve the ink
used in these pens by adding compounds which
are known to be light resistant. Tests have shown
that writings made with these modified products
have been found to leave a readable residue after
exposure to a period of radiation equivalent to
100 hours of June sunlight. However, these im-
proved inks are by no means in all pens.
The use of non-fading ink for physicians’
records is of considerable importance. It was
considered of sufficient importance by one clinic
in Minnesota to justify the manufacture of its
own ink for the past twenty years and the in-
sistence on its use by all members of the group.
At the request of the Division of Vital Statis-
tics of the Minnesota State Department of Health,
the attention of the profession is called to the
obvious importance of the use of non-fading, black
or blue-black ink in filling out birth and death
certificates.
TUBERCULOSIS SURVEYS IN MINNESOTA
TN mass surveys for cases of hidden tuberculo-
-^-sis, the use of the 70 millimeter photofluoro-
graphic unit affords a distinct advantage over
the usual method of Mantoux testing followed
by examination of positive reactors on a 14 by
17-inch x-ray film. While the initial cost of a
photofluorographic outfit is considerable, the over-
all cost in mass surveys is said to amount to about
35 cents per individual.
The detection of pulmonary tuberculosis by
means of the 70 millimeter film has proved suffi-
ciently accurate to warrant its use. Some prac-
tice is required to determine which individuals
require a retake on a large film. Those individ-
uals who show the usual involvement character-
istic of pulmonary tuberculosis are referred to
their family physician for determination of the
presence of an active lung lesion. Although
the x-ray is only a record of shadows, it is ad-
mittedly the most valuable single diagnostic aid
in pulmonary tuberculosis. The referring of the
individual back to his family physician places the
responsibility of determining the need for treat-
ment directly in his hands. It is to be hoped that
the physicians of the state, cognizant of the im-
portance of x-ray findings, will co-operate in
every way in the mass surveys being made and
about to be made.
The Ramsey County Public Health Associa-
tion has purchased a 70 millimeter x-ray unit
and, in co-operation with the Saint Paul Health
Department, has examined several thousand indi-
viduals in the health department quarters of the
Court House. Each roll of film provides for 350
exposures, and the ease with which this number
of pictures can be taken in a day is impressive.
In April this unit will make a survey in North
Saint Paul and then return to another section
of Saint Paul.
In May a unit provided by the United States
Public Health Service, in co-operation with the
Hennepin County Tuberculosis Association and
the Minneapolis Health Department, will attempt
to x-ray the entire population of Minneapolis.
This is the first time the attempt will have been
made to cover a large city. Success will depend
on the co-operation of all its citizens. It is a fore-
gone conclusion that a certain number of unrec-
ognized cases of pulmonary tuberculosis, as well
as some instances of other abnormal chest condi-
tions, will be unearthed. If the Minneapolis sur-
vey runs smoothly, doubtless the procedure will
be carried out in other large cities.
One word of warning should perhaps be offered
to the profession. Many cases of healed pul-
monary tuberculosis will be revealed. These indi-
viduals should be accurately classified and not
subjected to active treatment.
The 16,000,000 hospital admissions and the
undetermined additional millions of people seen
in outpatient departments yearly provide a fertile
field for x-ray detection of tuberculosis. A few
hospitals x-ray each patient admitted, as well as
all hospital employes. The incidence of tubercu-
losis in this group is naturally high, and its detec-
tion is beneficial not only to the affected patient
April, 1947
421
EDITORIAL
but as a protection to other patients and hospital
personnel. According to Tuberculosis Abstracts
for April. 1947, the United States Public Health
Service is about to approve funds for the place-
ment of several hundred photofluorographic units
in hospitals unable to provide them for themselves.
INTRAVENOUS ETHER— AN AID TO
COLLATERAL CIRCULATION
TX his discussion of Dr. Joseph Borg’s thesis
Aon “Peripheral Arterial Embolism,” presented
before the Minnesota Academy of Medicine and
appearing in this issue of Minnesota Medicine,
Dr. Moses Barron described his experience in the
use of ether intravenously in a patient suffering
from arterial embolism — a procedure called to his
attention in Toronto.
Our attention has been drawn to an article by
Katzf in which he described the development of
his present technique in the use of ether intra-
venously in the treatment of ischemia of the ex-
tremities due to diabetic and senile arteriosclerosis,
Buerger’s disease and Raynaud’s disease. Using
himself as a guinea pig, Katz promptly found
that intramuscular injections of ether alone or in
peanut oil were very painful. The addition of
benzocaine made the injections less painful but,
even with the addition of penicillin, six of thirty-
four patients so treated developed deep ulcers.
The result, however, of intramuscular injection
of this mixture of ether, peanut oil, benzocaine
and penicillin, proved the marked beneficial effect
of ether in these patients and led him to try the
administration of ether intravenously. The safe-
ty of this method had long ago been established
in producing anesthesia. He began with 10 c.c.
of ether in 90 c.c. of either normal saline, 1/6
molar lactate solution, or 5 per cent dextrose in
distilled water, given very slowly. A stinging
sensation and the production of thrombosed veins
at the site of the injection soon led him to dilute
the solution to 10 c.c. of ether in 190 c.c. of
diluent. In his last twenty-two patients he di-
luted the ether still further, giving 25 c.c. in 1,000
c.c. of diluent daily.
In his reported series of sixtv-six cases treated
intravenously, good results were obtained in fifty-
fKatz, Robert A.: Impending ischemic gangrene; new non-
surgical therapeutic suggestions. New Orleans M. & S. J., 98:543,
(June) 1946.
eight. Relief of pain and improvement in circu-
lation were outstanding. No deleterious side ef-
fects on the blood, kidneys or other tissues were
noted.
How the beneficial effect of ether is produced
in these patients suffering from local ischemia
from one cause or another, is not known. Pre-
sumably the ether increases the collateral circu-
lation in the affected limb. The inefficacy of
remedies so far proposed for the alleviating of
the suffering of these unfortunate individuals
makes the trial of an apparently effective remedy
well worth while.
BRONCHIAL ASTHMA
(Continued from Page 393)
a special problem, and predisposing causes for the
development of overt asthma should be controlled.
If this is done wisely, there need be no inferior
complex.
In conclusion, let us all recognize the handi-
caps and hazards which all potentially allergic
individuals must encounter and not permit them
to become asthmatic. Let us study each individual
asthmatic with the intention of keeping his
threshhold of immunity to allergins high so that
his occasional paroxysms may not become fre-
quent or chronic, and so no one may reach the
status asthmaticus or suffer from often long-
delayed, serious pathological consequences of the
malady.
References
1. Barach, A. L. : Physiologic method's in the diagnosis and
treatment of asthma and emphysema. Ann. Int. Med.,
12:454, 1938.
2. Cooke, R. A., and Vander Veer, A. J. : Human sensitiza-
tion. J. Immunol., 40:521, 1924.
3. Council of Chemistry and Pharmacy: Theophylline ethyl-
endiamine. New and Non-official Remedies. Chicago:
Am. Med. Assn., 1946.
4. De Kruif, Paul : God's own medicine. Reader's Digest,
48:15, (June) 1946.
5. Desjardins, A. U. : Action of roentgen rays and radium
on the heart and lungs. Am. J. Roentgenol., 28:567, 1932.
6. Hyde, R. W. : Diagnosis of allergic states in selectees.
New England J. Med. 227 :241, (Aug. 13) 1942.
7. McElin, T. W., and Horton, B. T. : Clinical observations
on the use of benadryl, a new anti-histamine substance.
Proc. Staff Meet., Mayo Clin., 20:417-429, (Nov. 14) 1945.
8. Prausnitz, Carl, and Kustner, H : Studien iiber Ueber-
empfindlichkeit. Centralbl. f. Bacteriol., 86:160, 1921.
9. Rackeman, Frances M. : Depletion in asthma. J. Allergy,
16:136, (May) 1945.
10. Schilling, F. : Treatment of chronic bronchitis and asthma
by x-ray. Lancet, 1:1780, 1909.
11. Unger, Leon: Bronchial Asthma. Springfield, Illinois, and
Baltimore. Charles C. Thomas, 1945.
422
Minnesota Medicine
REPORT OF THE HOUSE OF DELEGATES— AMERICAN MEDICAL
ASSOCIATION
December 9-11, 1946
There are several features about the December meet-
ing of the House of Delegates of enough importance to
warrant reporting to the members of the Minnesota
State Medical Association.
First, is the question of the Rich report. A year ago,
the Board of Trustees of the American Medical As-
sociation recommended that there be a complete survey
made of the workings of the Association. They em-
ployed a firm called the Rich Associates to make a
thorough examination into American Medical Associa-
tion affairs. As a result of this investigation, the or-
ganization of the Association is now divided up into
different divisions.
One is the editorial division, which is under the super-
vision of Dr. Morris Fishbein, who is editor of The
Journal of the American Medical Association and Hy-
geia and has charge of all other publications of the As-
sociation.
Another division is devoted to public relations, which
is to be under the guidance and direction of the Gen-
eral Manager of the Association. The duty of this
division will be exactly what its title implies — Public
Relations. The department has now been set up and is
in operation ; already it is showing good results.
A third division is concerned with medical economics.
Much attention has centered lately on legislation for
compulsory health insurance, regimentation of medicine,
et cetera, which has been recently introduced not only
in the national Congress but in state legislatures as
well. To study matters of this kind is the purpose of
the medical economic division. Posts in this division
have all been filled by competent men chosen by the
Trustees of the American Medical Association.
Generally speaking, there were many more matters,
of no particular consequence, that needed to be checked
and which could be corrected. Most of these suggestions
for improving the Association’s internal workings were
accepted with good grace by the Delegates.
The entire Rich report, with one exception, was very
instructive and for the good of the AMA. The one
exception was the question of the alliance between the
American Medical Association and the National Physi-
cians Association. This report was not favorable. How-
ever, further questioning of Mr. Rich revealed that this
was not based on a thorough enough investigation of
the National Physicians Association. Mr. Rich promises
to continue the investigation until June, at which time
he plans to bring in a much more exhaustive report.
The House of Delegates is looking forward to hearing
more about this at the annual meeting in Atlantic City.
A second item taken up by the delegates which war-
rants attention is the question of the revision of the
Constitution and By-Laws of the American Medical
Association. What was presented in this connection
was, in reality, not a. new constitution and by-laws but
rather a correlation of many proposed changes, passed
upon previously and admitted as amendments, but never
brought together in a concise form. The job of correl-
April, 1947
lating all of these amendments represents a lot of hard
work on the part of the committee.
The third matter on the program was a discussion
of the progress in the field of prepayment medical serv-
ice. From the discussions it was apparent that the
American Medical Association has a well-rounded pro-
gram, which provides for co-ordination of efforts at the
state as well as the national level.
The next important item was probably the report by
Dr. Boone, Rear Admiral in the Navy, on the conditions
in coal mining districts. He reported on housing con-
ditions and medical problems ; and from his report it
was learned that health and sanitary conditions are de-
plorable in some areas. It is hoped that miners, unions
and mine operators can get together on a program which
will provide better housing, better living condtitions and
better medical care. For this particular purpose a cer-
tain amount is to be deducted from the price of each
ton of coal mined ; this amount is to be turned over to
the Union. The method by which the Union shall han-
dle this money is yet to be determined, and it was agreed
by the House of Delegates that the medical profession
“should play a leading role in the evolution of these
plans for medical care” and should assume leadership
in the formulation and establishment of reasonable and
practical programs that will benefit the people. Devel-
opments in this field will bear watching by every physi-
cian. (For more details on Rear Admiral Boone’s re-
port, see Minnesota Medicine, February, 1947, Pages
190-192.)
Another important item is the present plans that are
being made for a very elaborate Centennial Celebration
in Atlantic City in June, which will feature a great
many distinguished speakers from this country and from
foreign countries.
An important discussion was held on the question of
rural medical care, which seems to be a number one
problem in the practice of medicine in the United States
at the present time. A broad program was outlined call-
ing for better qualified doctors in rural districts, better
distribution of health centers and more nurses.
Delegates heard an interesting report from Dr. A. C.
Ivy of Chicago, who was delegated by President Tru-
man to investigate Nazi medical experiments made dur-
ing the war. As a result of hearing about these ex-
periments, certain principles to be followed in making
experiments using human beings as subjects were agreed
ppon by the delegates. (1) Voluntary consent of the
individual upon whom the experiment is to be made
must be obtained before proceeding with the experiment.
(2) The danger in each experiment must be thoroughly
investigated previously by animal experimentation. (3)
The experiment must be performed under proper medical
protection and management. These general principles
were accepted by the delegates ; apparently none of them
were followed in the Nazi human experimentation pro-
gram.
(Continued on Page 444)
423
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D.. Chairman
COUNTY OFFICERS HEAR PROGRESS
REPORTS ON MSMA PROGRAMS
Recent accomplishments of the medical pro-
fession in Minnesota, as well as medical economic
problems still facing state doctors, were reviewed
when the officers of local medical societies com-
posing the Minnesota State Medical Association
gathered in Saint Paul March 1 for their annual
County Officers meeting.
That rapid strides have been made by the
profession in at least two fields — prepayment med-
ical service and veterans’ medical care — was ap-
parent in the progress reports of those two pro-
grams, which during the past year have material-
ized from mere plans into actual organizations.
Operation of the new Veterans Medical Serv-
ice division, which began functioning February
10, were described. Dr. Richard P>. Hullsiek,
Minneapolis, Chief Medical Officer of the Re-
gional office of the Veterans Administration, told
the delegates about the VA program and how the
Veterans Medical Service division fits into the
government setup. Mr. Philip J. Lemm, who
has been directing the work of the new division,
gave the doctors a general, over-all picture of
how it operates.
Veterans Number About 400,000
Dr. Hullsiek estimated that the veterans in the
state, eligible for benefits at federal expense, num-
ber between three and four hundred thousand.
Included in these benefits, he said, are rehabilita-
tion, educational training, pensions, insurance and
medical service.
The work of the Veterans Medical Service
division has been complicated. Dr. Hullsiek point-
ed out, bv the slowness of the Washington VA
office to approve Part II of the fee schedule de-
veloped by the State Association Veterans com-
mittee.
Part I, appended to the contract executed be-
tween the VA and the MSMA — containing as it
does only some forty-eight items — barely scratch-
es the surface of services that doctors will find it
necessary to perform. This means, Dr. Hullsiek
said, that the twenty-five-year-old VA fee sched-
ule must still operate for the bulk of the services
rendered by the doctors. However, all possible
pressure is being exerted on the Washington
office to remedy this situation, and pending ap-
proval of Part II in its entirety, assurance has
been given that some fifty or sixty items under
Part II, selected by the Regional Office for their
frequency in authorization requests, would be
appended to the contract immediately, Dr. Hull-
siek said. It is hoped to have ninety-five per
cent of the veterans medical service handled
through the State Association VMS division in
a very short time.
Prepayment Medical Service Program
Dr. O. I. Sohlberg, president of the Minne-
sota Medical Service, Inc., the prepayment plan
approved by the House of Delegates last Decem-
ber to co-ordinate its services with the Minnesota
Hospital Service Association, reported to the
county officers that the board of directors was
working hard to secure an executive director and
to put the corporation on a functioning basis.
Minnesota Hospital Service has been more than
co-operative, Dr. Sohlberg said, and it will be just
a matter of weeks before Minnesota Medical
Service will be ready to start operations. Litera-
ture explaining its services in detail will be avail-
able soon.
Another report heard by the county officers
dealt with conferences between the MSMA and
the Insurance Liaison committees which are set-
ting up a program that will serve as a second arm
to broaden the base for prepayment medical in-
surance coverage in Minnesota.
Co-operation with Insurance Companies
Dr. B. J. Branton, co-chairman of the five-
member MSMA liaison group, appointed by the
424
Minnesota Medicine
MEDICAL ECONOMICS
Council at the direction of the House of Dele-
gates in December, explained the objectives of
the Conference Liaison committee in this way:
“Co-operation of medical groups with insurance com-
panies is a normal procedure if for no other reason than
the fact that up to now no better way has been found
to eliminate the financial barrier between the patient and
the doctor and the patient and the hospital than through
recognized insurance companies providing the indemnity
on a guaranteed cost basis.
“Financial barriers, not the doctors, are the cause of
inadequate medical care which low income groups re-
ceive under existing conditions,” Dr. Branton declared,
“and providing adequate medical care by eliminating
these financial barriers stretches into the fields of eco-
nomics, education, human relations, government and
even politics, unfortunately.”
“The Liaison committee,” Dr. Branton want on, “is
only a part of the national setup developed by the Coun-
cil on Medical Service of the AMA, and it will work
wholeheartedly with the Council as it co-ordinates its
activities with those of insurance companies.”
Liaison Committee to Set Minimum Standards
Minimum standards will be agreed upon soon
by the Conference Liaison committee, Dr. Bran-
ton announced, and the companies in the state,
which after careful scrutiny meet the approval of
the State Insurance Commissioner and the MSMA
committee, will be given opportunity to apply for
approval of the AMA. In this way Dr. Branton
explained, there will be a double check — locally
and nationally — before approval is granted in the
state.
While medical service contracts are now being
written by companies individually at an acceler-
ated rate, under the stimulus of activities by the
state medical association, it is felt that the medical
profession’s approval of contracts that meet mini-
mum standards will greatly benefit the public
in the protection and security afforded under these
contracts, Dr. Branton said.
Rural Health a “Perennial Issue"
Rural health, which has been converted into a
“perennial issue” by the Michael Davises and Sen-
ator Murrays in their carefully conceived plans
to foster government medicine in this country,
was discussed with all its ramifications lay Dr. L.
W. Larson of Bismarck, area chairman of the
AMA committee on Rural Medical Service. Said
Dr. Larson :
“Medical care is only a part of the problem of rural
health. Good housing, adequate and balanced diets,
health education, sanitation, immunization against com-
municable diseases, hygiene, dental care and instruction
for expectant mothers and infant care, are of equal
importance.”
Expanded public health activities through the
development of full-time county or regional health
units will solve much of these extra-medical com-
ponents of the rural health problem, according to
Dr. Larson.
“Let us recognize,” Dr. Larson urged, “that there are
problems involved in rural health, and that, as physicians,
we have a responsibility to help correct them through
a constant effort to raise medical standards and to de-
velop a spirit of co-operation with any and all people
who are honestly concerned with the welfare of our
rural population.”
Lay Speakers at Rural Health Conference
As an expression of their appraisal of current
medical care in rural areas, Dr. Larson quoted
two lay speakers at the Second Annual Conference
on Rural Health, held in Chicago in February.
To quote Albert S. Goss, Master of the National
Grange :
“. . . Thus we see that the high cost of adequate
medical care relative to farm income and the lack of
modern medical facilities in rural areas adds up to a real
problem. When we add to this problem the abuses of
overcharge and unethical practices that some doctors
are guilty of, and which most of us have been the vic-
tims of, it adds up to an overwhelming demand for
better medical service.”
In what amounts to a blunt indictment of medi-
cine that could scarcely be considered a true pic-
ture of conditions as they are known to exist gen-
erally, Mr. Goss has charged, Dr. Larson said,
that “the feeling has become more and more gen-
eral that the medical associations, instead of de-
voting their chief efforts to the improvement of
medical standards, have been more interested in
eliminating competition in the medical field !” Mr.
Goss, as quoted by Dr. Larson, maintains that
this is the reason that medical service is “not only
much more costly, but much more difficult to se-
cure.” Mr. Goss has further said that rural
America is “up in arms” over the inadequacy of
medical service resulting from this attempt by
medical associations to monopolize the field.
Mr. Mertz Takes Milder Approach
Reporting further on the Chicago Conference,
Dr. Larson quoted from the somewhat milder
April. 1947
425
MEDICAL ECONOMICS
remarks of Edward H. Mertz, administrative as-
sistant in the Department of Education of the Na-
tional Farmers Union, who spoke of deficiencies
in a more conciliatory vein. Mr. Mertz, Dr.
Larson said, cited the following wants and needs
of rural people in the way of medical and health
services :
E More doctors, dentists and nurses closer to
them
2. More hospitals and clinics in their com-
munities
3. Better housing and sanitary facilities
4. Sufficient income to absorb their costs
From the statements of these two men, Dr. Lar-
son said, it may be concluded that rural people
believe that there are not enough doctors and hos-
pitals in rural areas, and that medical care is too
expensive.
"Medicine Has Outgrown Horse and
Buggy Days"
Looking at the contributing causes for this lack
in health facilities, Dr. Larson maintained that
the reasons for the lack are fairly obvious to the
medical profession. To quote him :
“Medicine has outgrown the horse and buggy days
just as agriculture has. Farmers think nothing of driv-
ing 25 to 50 miles to do their shopping. In fact, many
farmers consult the doctor in that trading center during
the same marketing or shopping trip. In so doing they
by-pass the physician in the small town en route— that
is, if there is one left. Why? Because the practice of
medicine has changed from the horse and buggy days
when the doctor could carry his entire diagnostic and
therapeutic armamentarium in one bag. Today he needs
special equipment and diagnostic aids, both technical
and professional, which he cannot possibly bring to the
patient. The obvious answer is to bring the patient to
the doctor.’’
While the profession itself is doing everything
it possibly can to induce more doctors to locate
in rural areas, Dr. Larson said, it realizes that a
complete medical and hospital service cannot be
developed at every crossroads, but that such serv-
ice can be developed in the larger communities
which are the trading centers. In order that the
wave of emotional enthusiasm for the construction
of a hospital in almost every small town and city
will be guided in the right direction, the AMA
and every state medical association is co-operating
in an advisory capacity with lay committees
throughout the country.
Many of the shortcomings charged to the medi-
cal profession are due to the lack of aggressive
leadership in health education by local doctors.
To overcome this difficulty, Dr. Larson said, state
medical associations, as well as county medical
societies, must become inculcated with a spirit of
public welfare and leadership in worthwhile health
movements.
A second, final installment of the review of the dis-
cussions held at the 1947 County Officers Meeting will
appear in this column in the next issue of Minnesota
Medicine.
NITROGEN BALANCE AND ITS
CLINICAL APPLICATION
(Continued from Page 398)
4. Co Tui; Barcham, et al. : The construction and use of a
bedside ergograph. Ann. Surg., 120:120-123, (July) 1944.
5. Co Tui; Wright, A. M. ; Mulholland, J. H.; Breed, E. S.;
Burcham, I., and Gould: Studies in surgical convalescence.
II. A preliminary study of the nitrogen loss in exulates
in surgical conditions. Ann. Surg., 121:223-230, (Feb.)
6. Co Tui: Mulholland, J. H. ; Wright, A. M., and Vinci,
V. J. : Nitrogen metabolism, caloric intake and weight loss
in postoperative convalescence. Ann. Surg., 117:512-534,
(April) 1943.
7. Duncan, G. G. : The problem of nutrition in the treatment
of the prolonged hospitalized patient. M. Clin. North Amer-
ica, 30:349-363, (March) 1946.
8. Elman, R.; Sachar, L. A., anl Horvitz, A.: Studies on
hypo-albuminemia produced by protein deficient diets. J.
Exper. Med., 75:455-459, (April) 1942.
9. Goldman, D. : Metabolic changes occurring as the result of
deep roentgen therapy. Am. J. Roentgenol., 50:392-399,
(Sept.) 1943.
10. Hartzell, J.; Winfield, J. S., and Sivin, J. L. : Plasma, vita-
min C, and serum protein levels in wound disruption.
J.A.M.A., 116:660-674, (Feb. 22) 1941.
11. Hirshfield, J. W. ; Abbott, W. E. ; Pilling, M. A.; Heller,
C. G. ; Meyer, F. ; Williams, H.; Richards, A., and Obi, R. :
Metabolic alterations following thermal burns. Arch. Surg.,
50:194-200, (April) 1945.
12. Howard, J. E. ; Parson, W. ; Stein, K. E. ; Eisenberg, H.,
and Reidt, V. : Studies on fracture convalescence. I. Nitrogen
metabolism after fracture and skeletal operations in healthy
males. Bull. Johns Hopkins Hosp., 75:156-168, (Sept.) 1944.
13. Howard, J. E. ; Winternitz, J.; Parson, W. ; Bigham, R. S.,
and Eisenberg, H. : Studies on fracture convalescence.
II. The influence of diet on posttraumatic nitrogen deficit
exhibited by fracture patients. Bull. Johns Hopkins Hosp.,
75:209-224, (Oct.) 1944.
14. Post, J., and Patek, A. J. : Serum proteins in cirrhosis of
the liver: nitrogen balance studies on five patients. Arch.
Int. Med., 69:83-89, (Jan.) 1942.
15. Sprinz, II.: Malnutrition. M. Clin. North America, 30:
363-384, (March) 1946.
16. Taylor, F. H. L. : Abnormal nitrogen metabolism in burns.
Science, 97:423, (May 7) 1943.
17. Thorton, T. F., Jr.; Adams, W. E., and Schafer, P. W.:
Hypoproteinemia in thoracic surgery: A clinical study.
Surg., Gynec. & Obst., 79:368-373. (Oct.) 1944.
18. Wangensteen, O. H. : Abdominal surgery in old age. Jour-
nal-Lancet, 64:178-183, (June) 1944.
426
Minnesota Medicine
Minnesota Academy of Medicine
Meeting of December 1L 1946
The regular monthly meeting of the Minnesota Acad-
emy of Medicine was held at the Town and Country
Club, on Wednesday evening, December 11, 1946. Din-
ner was served at 7 o’clock and the meeting was called
to order at 8:10 by the president, Dr. S. E. Sweitzer.
There were fifty members and one guest present.
Minutes of the November meeting were read and
approved.
In regard to attendance at meetings, Dr. Hall made
a motion that a letter be written to those who had not
attended the required number of meetings during the
year, calling their attention to the ruling in the Consti-
tution regarding attendance. Motion was seconded and
carried.
The annual election of officers resulted in the follow-
ing being elected for the year 1947 :
President Dr. E. M. Hammes, Saint Paul
Vice President Dr. T. A. Peppard, Minneapolis
Secretary-treasurer Dr. A. E. Cardie (re-elected)
The scientific program followed.
Dr. L. R. Boies, Minneapolis, read his Inaugural The-
sis.
MENIERE'S DISEASE: ENDOLYMPHATIC
HYDROPS
LAWRENCE R. BOIES, M.D.
Minneapolis, Minnesota
Although Meniere described a condition characterized
by the symptoms of vertigo, deafness and tinnitus in
1861, it has only been within the past ten years that
pathologic changes within the inner ear have been de-
scribed to account for these symptoms.
We have in our literature concerning this symptoma-
tology a confusion of terms. “Meniere’s syndrome,”
or “Meniere’s symptom complex” and the term “pseudo-
Meniere’s disease” in cases of vertigo without auditory
symptoms or neurologic signs, are all commonly used.
There are several conditions which can produce this
triad of symptoms, among which there now seems to
be a clear-cut clinical entity in the nature of a labyrin-
thine hydrops. The evidence for this has been obtained
from a microscopic study of temporal bones from per-
sons who were known in life to have experienced severe
and repeated attacks of vertigo accompanied by hearing
loss and tinnitus, without any other morbidity to associate
with the causation of these symptoms.
Some of the references in the literature to Meniere s
papers have indicated that his original description was
concerned with a case of labyrinthitis. In a search for
Meniere’s account of his “classic case,” McKenzie9
failed to find an adequate description to fit our present
conception of the clinical characteristics of the disease
which bears Meniere's name. However, Simonton13 in
an exhaustive review of the literature in 1940 refers to
six articles published in 1861 by Meniere, most of them in
the Gazette Medicate de Paris. He personally translated
these papers. I am indebted to him for a copy of the
pertinent portions of these translations which show that
Meniere did describe with clarity the symptomatology
as we know it today.
The first microscopic observations on the temporal
bones of persons known to have had severe attacks of
vertigo, deafness, and tinnitus during life were described
in 1938 by Hallpike and Cairns.7 Lindsay8 corroborated
their findings in 1942. To date, histopathologic findings
on twenty-one temporal bones from seventeen cases have
been reported. The pathologic findings indicate a laby-
rinthine hydrops, from which it seems reasonable to
conclude that it is the effects of this hydrops which pro-
duces the morbidity. To date, however, we have no
definite evidence of the etiology of the hydrops.
The most constant histopathologic finding is a dilata-
tion of the cochlear duct (Fig. 1). In some cases,
dilatation had occurred in the saccule, the utricle, or the
ductus reuniens. Other changes of a degenerative nature
were noted in the maculae or cristae. A localized laby-
rinthitis occificans was also noted.
Before Hallpike and Cairns made their observations,
Mygind and Dederding10 in 1932 had advanced the
hypothesis that the symptoms of Meniere’s disease are
due to a “waterlogging” of the labyrinth. This inspired
certain chemical investigatons which have not estab-
lished definite etiologic factors but have resulted in
medical therapeutic measures which though empirical
are widely used today. Furstenberg and his co-woik-
ers5>6 in 1934 reported observations from which they
concluded that the tissues responsible for Meniere’s
disease were sensitized to the sodium ion, and that if
retention of sodium is prevented and its elimination
promoted, patients suffering from the disease may be
relieved. Shelden and Horton12 in 1940 reported obser-
vations on the use of histamine to relieve the symptoms
of Meniere’s disease. These investigators expressed the
belief that the factor most likely to be responsible for
Meniere’s disease is an alteration in the permeability of
the capillary walls with secondary edema of the middle
ear, and that histamine is an important agent in affect-
ing capillary permeability. Williams16 regards the symp-
toms of Meniere’s disease as a manifestation of an in-
trinsic physical allergy which in his experience may
respond to treatment with nicotinic acid.
Clinical Manifestations
Symptoms. — In a typical case of Meniere’s disease,
the patient complains of vertigo, tinnitus, and deafness.
427
April, 1947
MINNESOTA ACADEMY OF MEDICINE
Fig. 1. Section from the temporal bones of a forty-seven-year-
old man who fell during an attack of vertigo, suffered a fracture
of the skull and died from a subdural hematoma. He had been
examined in 1939 at the Mayo Clinic, where a diagnosis of
Meniere's disease was made. He was reported to have had
normal hearing through the speech frequencies in his right ear.
i there was a loss of 30 decibels for low tones, in-
cluding the 2048 cycles. A cold caloric test showed a diminished
response on the left side. The results of his general physical
and neurologic examinations were normal.
(The temporal bones were sent to Dr. John R. Lindsay of
the University of Chicago, who supplied the author with serial
sections of these bones, one of which is pictured here. Dr
Lindsay has reported this case in detail: Meniere’s disease"
Arch. Otolaryng., 39:313, 1944.)
is ? horizontal midmodiolar section through the right
cochlea. The ductus cochlearis is normal. The loss of Reissner’s
membrane in the upper coil is an artifact. The vessels are
congested, and extravasated red blood cells are present in the
internal meatus and the lamina cribosa and are invading the
spiral ganglion (a). The spiral ganglion of the basal coil
shows degeneration (b).
B is a vertical midmodiolar section of the left cochlea. The
ductus cochlearis is greatly dilated and herniating through the
helicotrema. I he blood vessels are congested, and some extra-
vasated blood is present in the internal meatus. The spiral
ganglion shows degenerative changes in the basal coil.
1 he vertigo is the most disturbing symptom and may
overshadow the other two. As a rule, it occurs suddenly,
without warning, and may occur while the victim is at
rest, even during sleep. A history is not infrequently
given of the occurrence of an attack as the patient turns
. over in bed, or on awakening, or on getting out of
bed. The duration of the vertigo may vary from a few
428
minutes to a few days, or in a subacute form for weeks
or months. In the majority of cases, the patient describes
his vertigo as rotatory, in which he feels that objects
about him are whirling or that he is whirling. However,
a labyrinthine disturbance can occur in which the whirl-
ing sensation is absent but in which the patient experi-
ences a swaying sensation or a sense of weakness or
movement in which there is actually no sense of rotation.
The deafness in Meniere’s disease usually is cf the
nerve type affecting the high tones first and may be
severe. It tends to fluctuate but may be progressive,
confined to one ear, or affect both ears in different
degrees. The degree of deafness is not diagnostic.
I innitus is the most variable symptom of the triad.
Its cause has not been established. If both ears are
involved, the tinnitus is usually present in the more
involved of the two ears.
Diagnosis. — Inasmuch as two of the symptoms, the
vertigo and tinnitus, are subjective, the patient’s descrip-
tions of his symptoms are very important.
I he caloric test will as a rule reproduce the vertigo
that the patient describes. The results of this test are
not, however, diagnostic of Meniere’s disease. Crowe2
has reported a series of cases in which the caloric test
was normal in 35 per cent, subnormal in 19 per cent,
and that in 29 per cent the labyrinth of the affected side
failed to react (17 per cent were not tested).
In considering a diagnosis of Meniere’s disease, it is
important to exclude chronic middle ear disease, lesions
of the central nervous system, cardiovascular disorders,
et cetera, as a cause of vertigo.
Treatment. — Two forms of treatment are in Current
use. The medical treatment should be tried in all cases
first ; surgical therapy should be reserved for severe
cases which do not respond to medical treatment. The
efficacy of all treatment should be considered in light
of the fact that long remissions in the symptoms may
occur in this condition. Mild cases are helped by the
use of sedatives.
The sodium-free diet of Furstenberg, Lashmet, and
Lathrop has been referred to previously in this paper.
They recommend a special diet avoiding salt and low in
sodium. Ammonium chloride, an acid-producing salt, is
administered in six 7)4 grain capsules three times daily
during meals. This drug is taken for three days and then
omitted for two days. The treatment is continued for
several weeks and is gradually discontinued according to
the patient’s condition.
Desensitization to histamine was recommended by
Shelden and Horton12 during the acute stage of
Meniere’s disease. They used a dosage of 1.9 milligrams
of histamine acid phosphate dissolved in 250 cubic
centimeters of normal physiologic salt solution and
administered intravenously in approximately an hour
and a half. The treatment was repeated on two or
three successive days. 1 here have been some modifica-
tions of this dosage.
Dr. A. B. Baker, who has had an extensive experience
with histamine therapy at the University Hospital in
Minneapolis, now uses the following method : 2.75 milli-
Minnesota Medicine
f
MINNESOTA ACADEMY OF MEDICINE
grams of histamine acid phosphate in 250 cubic centi-
meters of normal saline are given intravenously to
outpatients daily for fourteen consecutive days. The
administration is given right after a full meal. About
two and a half to three hours are taken for each treat-
ment. A glass or two of milk is given by mouth during
the treatment. Four additional treatments on alternate
days are then given so that the full course takes a total
of eighteen treatments. The patient is then put on 50
milligrams of benadryl twice daily for six weeks.
Talbott and Brown15 have reported success in the
control of Meniere’s disease by the adminstration of a
potassium salt with the patient on a normal diet.
If medical treatment fails to control the vertiginous
attacks of Meniere’s disease, the patient then has re-
course to more certain benefits from surgical therapy.
This is particularly true if the disease is unilateral as
evident from symptoms and signs referable to one ear
only. Five different surgical procedures have been de-
scribed. Dandy3 was an exponent of nerve section.
Portmann11 described a destructive operation on the
saccus endolymphaticus. Wright17 has had considerable
success with the injection of alcohol into the labyrinth
by way of the oval window. Cawthorne1 has reported
a large series of cases with a high percentage of success-
ful results by performing a labyrinthotomy and excising
a piece of the membranous labyrinth. Day1 has ad-
vocated opening the external semicircular canal anl
coagulating the membranous labyrinth with a weak dia-
thermy current (Fig. 2). It is a relatively simple proced-
ure in which there is the possibility of preserving
some of the residual hearing. Sullivan14 has recently
been able to accomplish this by a limited coagulation of
the vestibular portion of the labyrinth, carrying out this
part under the magnification of a dissecting microscope.
Because of the relative simplicity of Day’s procedure
with a possibility of preservation of residual hearing
function, this operation seems destined to be generally
adopted. In the past two years, I have performed this
operation on five cases. Brief case histories of these
patients follow :
Case Reports
Case 1.- — R. J., a thirty-nine-year-old public health
nurse, was first examined on August 21, 1943. She
gave a history of having had recurrent attacks of vertigo
for ten years with some loss of hearing and a low-
pitched tinnitus in her left ear. She had been treated
after the method of Furstenberg and his co-workers
and had had a trial of histamine desensitization. A
neurosurgeon had recommended nerve section.
Hearing tests revealed a normal response in the
right ear and a marked depression in the left ear,
approximately the 70 decibel line through each frequency
except for the 2048, which was at the 40 decibel line.
A labyrinthotomy on the left ear was recommended.
The patient decided to consider this procedure and
meanwhile to try nicotinic acid therapy.
The patient was next examined on August 31, 1944,
by which time she had decided to undergo surgery be-
cause the attacks were incapacitating her. Caloric tests
were performed after the method of Kobrak. The reac-
tions were within normal limits on each side.
A labyrinthotomy on the left ear with coagulation of
the membranous labyrinth after the method of Day was
performed on September 11, 1944. Convalescence was
Aprii . 1947
uneventful except for a moderate amount of vertigo
which gradually disappeared. Following a week in the
hospital and three additional weeks of rest, she was
able to resume her duties . as a public health nurse,
which included driving a car in her work.
Fig. 2. A sketch of the exposure used to reach the horizontal
semicircular canal which is fenestrated by use of a motor-driven
dental burr. A small diathermy point is then inserted forward
to the vestibule and a weak coagulating current turned on for
two or three seconds. The wound is closed tightly and heals by
primary union.
(The postaural route is considered to be preferable to the
endaural route for these cases, because in the latter a period
of epithelization is usually required before drainage ceases from
the external meatus. The postaural wound is usually sealed
and the ear dry in one week and no further dressing is required.)
The remaining hearing in the operated-upon ear was
lost as a result of the operation. She was re-examined
on several occasions during the first year following the
operation. There was no recurrence of her symptoms.
Case 2. — M. G., a forty-nine-year-old man, a clerk,
had had “Meniere’s disease” for eight years. He had
undergone extensive study and treatment at a United
States Veterans Hospital. This included trials of hista-
mine and the Furstenberg method. The patient stated
that he had been deaf in the right ear for a number of
years and believed that his deafness was due to mumps;
he had experienced a ringing as long as the deafness.
Hearing tests revealed an absolute deafness in the
right ear and normal hearing in the left ear. Caloric
tests after the method of Kobrak revealed a subnormal
reaction in the right ear and a normal reaction on the
left side.
A labyrinthotomy with coagulation of the membranous
labryinth was performed on November 7, 1945. Con-
valescence seemed slow. The patient seemed to fear a
recurrence of the severe vertiginous attacks which he
had experienced before this operation. He was last
examined ten months after this operation at which time
he had experienced no recurrence of his attacks.
Case 3. — J. P., a sixty-six-year-old man, a machinist,
was first examined on December 7, 1945, at a hospital
where he was convalescing from a gall-bladder opera-
tion. This operation had been done to relieve attacks
of dizziness. His left ear had begun to “go bad”
almost a year previously. The ringing which had been
bad in the left ear had decreased somewhat.
Hearing tests revealed a marked loss in each ear —
at the 45 decibel level by air conduction for the speech
frequencies in the right ear and at the 60 decibel level
in the left ear. The caloric tests with water at 68°F.
429
MINNESOTA ACADEMY OF MEDICINE
showed a reaction within normal limits on each side.
The patient lived alone and was in imminent fear of an
attack. He was hospitalized and given intravenous
histamine daily for one week. His vertiginous attacks
continued.
A labyrinthotomy was performed on the left ear on
January 23, 1946, and the membranous labryinth coagu-
lated after the method of Day. Convalescence was slow
but otherwise uneventful. The patient has been free
of his vertiginous attacks since the operation.
Case 4. — E. L., a forty-one-year-old man, a deaf
mute, had been unable to work because of attacks of
vertigo. He had tinnitus in the left ear.
Caloric tests after the method of Kobrak revealed
a normal reaction in the right ear and a definitely sub-
normal response on the left side.
A labyrinthotomy was performed on the left ear on
April 1, 1946. Convalescence was uneventful. There
was no recurrence of symptoms six months after the
operation.
Case 5.— J. L., a man, aged sixty-five, retired, had
been incapacitated for one and a half years because of
severe attacks of vertigo. He was unable to go out on
the street because of fear of falling down. He had had
some dizziness fifteen years previously and stated that
he had been deaf in the right ear for ten years. He had
had some tinnitus in both ears.
Hearing tests revealed a normal level for one of his
age in the left ear and a 75 decibel level of air conduc-
tion for the speech frequencies in the right ear. Caloric
tests after the method of Kobrak revealed no response
in the right ear and a normal one on the left side.
A labyrinthotomy was done on the right ear on April
8, 1946, and the membranous labyrinth coagulated with
diathermy. Convalescence was slow but otherwise un-
eventful. To date, this patient has had no recurrence
of his vertigo.
Summary
A microscopic study of the temporal bones of a num-
ber of persons known to have had Meniere’s disease
during life has revealed evidence of a labyrinthine
hydrops.
When medical therapy (histamine desensitization, the
use of a sodium-free diet combined with the admin-
istration of ammonium chloride, or treatment with
potassium chloride or with nicotinic acid) does not
produce relief, a labyrinthotomy followed by coagula-
tion of a limited portion of the membranous labyrinth
offers a practically certain cure when the disease is
confined to one side.
The labyrinthotomy is a simpler operation than nerve
section. The simplest form is accomplished by making
a fenestra through the bony wall of the horizontal semi-
circular canal. If this is followed by mild and limited
coagulation of the membranous labyrinth, the symp-
toms of Meniere’s disease are controlled and there is
a possibility of preserving some hearing.
Five cases operated upon by the method of Day are
reported. Relief from the attacks of vertigo was
obtained in each case.
References
1. Cawthorne, T. E. : The treatment of Meniere’s disease.
J. Laryng. & Otol., 58:363-370, 1943.
2. Crowe, S. J. : Meniere's disease. Medicine, 17:1, 1938.
3. Dandy, W. E. : Surgical treatment of Meniere’s disease'.
Surg. Gynec. & Obst., 72:421, 1941.
4. Day, K. M. : Labyrinth surgery for Meniere’s disease.
Laryngoscope, 53:617-630, 1943.
5. Fursteuberg, A. C. ; Lashmet, F. IL, and Lathrop, Frank:
Meniere’s symptom complex : medical treatment. Ann.
Otol., Rhin. & Laryng., 43 :1035-1046, (Dec.) 1934.
6. Furstenberg, A. C. ; Richardson, George, and Lathrop,
F. D. : Meniere’s disease. Arch. Otolaryng., 34:1083, 1941.
7. Hallpike, C. S., and Cairns, H. : Observations oir the
pathology of Meniere’s syndrome. J. Laryng. & Otol.,
53:625, 1938.
8. Lindsay, J. R. : Labyrinthine dropsy and Meniere’s dis-
ease. Arch. Otolaryng., 35:853, 1942.
9. McKenzie, Dan : Meniere’s original case. T. Laryng. &
Otol., 39:446-449, 1924.
10. Mygind, S. H., and Ded'erding, D. : The significance of
wattT metabolism demonstrated by experiments on the
ear. Acta otolaryng., 17 :424, 1932.
11. Portmann, G. : The saccus endolymphaticus, and an opera-
tion for draining the same for relief of vertigo. J. Laryng.
& Otol., 42:809, 1927.
12. Shelden, C. H., and Horton, B. T. : Treatment of Meniere’s
disease with histamine administered1 intravenously, l’roc.
Staff Meet., Mayo Clin., 15:17, 1940.
13. Simonton, K. M. : Meniere’s symptom complex: a review
of the literature. Ann. Otol., Rhin. & Laryng., 49:80-98,
1940.
14. Sullivan, Joseph: Personal communication.
15. Talbott, John H., and Brown, Madelaine R. : Meniere’s
syndrome. J.A.M.A., 114:125, 1940.
16. Williams, H. L. : Intrinsic allergy as it affects the ear,
nose, and throat : the intrinsic allergy syndrome. Tr. Am.
Acad. Ophth., 48:379-412, (July-Aug.) 1944.
17. Wright, A. J. : Labyrinthine destruction in the treatment
of vertigo by the injection of alcohol through the oval
window. J. Laryng. & Otol., 53 :594-597, 1938.
Discussion
Dr. A. M. Snell, Rochester: I should like to com-
pliment Dr. Boies on his excellent presentation of a
difficult subject and on his appraisal of the Day opera-
tion. I was particularly glad to hear him state his
criteria for diagnosis. Much has been said and written
about the treatment of Meniere’s disease, but in many
instances these criteria have not been defined exactly.
This practice has tended to cast an unfavorable light
on some methods of treatment which have been ad-
vocated.
I have had the opportunity of seeing a number of
patients whom Dr. Horton has treated with histamine at
the Mayo Clinic, and there have been some very en-
couraging results. When the disease has been of short
duration, this therapeutic program seems to work out
very well, but many patients with disease of long stand-
ing have not been benefited by this or any other type
of medical treatment. There are certainly many patients
in this last-mentioned group who deserve the possible
benefits of the operation which Dr. Boies has described.
Dr. Kenneth Phelps, Minneapolis : Dr. Boies’ thesis
is an excellent presentation of the most recent ideas
concerning Meniere’s disease. It brings out several
points :
1. The very recent observations on the pathology of
Meniere’s disease are given although just how hydrops
of the labyrinth causes intermittent attacks of Vertigo
and progressive loss of hearing is not well understood.
2. Even with better knowledge of the pathology, we
do not know what causes this disease. Treatment of
the cause is, therefore, impossible.
3. Dr. Boies’ experience with the Day operation is
very hopeful. This procedure relieves the patient of his
symptoms by destroying his labyrinth, and, as Dr. Boies
very carefully states, “offers a chance of preserving the
residual hearing.” Hearing is very poor in most patients
who have had Meniere’s disease for years, so it is not
of major importance.
I would like Dr. Boies to tell us what success he has
had with medical treatment.
430
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
Dr. Hewitt B. Hannah, Minneapolis : I appreciated
hearing Dr. Boies this evening because I have had an
opportunity of watching some of these patients over the
last two years. I had seen one of these patients before
he was operated upon, and he was extremely dizzy and
had been bedridden for a long time. Dr. Boies operated
on him, and since the operation he has been free from
symptoms. The other one was a nurse. I did not see
her before the operation but I saw her afterward, and
she is very happy over her recovery.
The differential diagnosis is not always too easy.
Any one who has dizziness, noises in the ear and some
loss of hearing should be studied from the standpoint
of the nervous system to be sure that the patient does
not have an acoustic tumor or pathology in the cere-
bellum. In the patients whom Dr. Boies operated upon,
there had been- no evidence of such tumor of the
acoustic nerve or pathology in the central nervous sys-
tem. I understand that Dr. Dandy had operated over
four hundred patients by cutting the eighth nerve.
Cutting this nerve as it leaves the stem is a much more
formidable procedure, and it takes a man with skill
of a surgical character, similar to Dandy, to get by
with this type of procedure.
Dr. Gordon Kamman, Saint Paul: I was interested
in Dr. Boies’ approach to Meniere’s syndrome. _ The only
reason it is any of the neurologist’s business is because
of the differential diagnosis. Meniere’s disease itself is
purely an end organ disease and does not fall within
the province of a neurologist. However, certain other
conditions have to be eliminated by differential diagnosis
before one considers the treatment of Meniere’s syn-
drome. I would like to ask Dr. Boies how many cases
he has had of bilateral Meniere’s disease. In consider-
ing the surgical treatment of this condition, one must
always recognize the possibility of the same process
occurring on the good side. If hearing is going to be
destroyed by surgery, I think that it is very important
that the patient knows before operation of the possi-
bility of the same process occurring on the opposite
side and the possibility of his ending up with a bilateral
deafness. It is my understanding that by coagulation of
the horizontal semicircular canal one destroys the hear-
ing in that ear?
I feel that Dr. Boies’ approach to the surgical treat-
ment of Meniere’s syndrome offers us a great deal. In
the few cases that I have had the temerity to treat, I
have always been disappointed with the long-range re-
sults. True, with intravenous histamine, large doses
of nicotinic acid, sometimes the Furstenburg diet,
large doses of potassium, and other medical measures,
we are able to bring about temporary improvement in
the symptoms. However, I think that most cases eventu-
ally end as surgical candidates. The simplicity of Dr.
Boies’ approach, the lack of surgical risk, and the short
period of hospitalization certainly are enough to rec-
ommend Dr. Boies’ operation.
Dr. C. N. Hensel, St. Paul : Dr. Boies has clearly
defined his criteria for surgical intervention in patients
with persistent vertigo in Meniere’s syndrome, namely,
failure to relieve them of their incapacitating vertigo by
medical management, and he has reported five patients
in whom he has obtained complete relief by an ingenious
and nonhazardous operation, and therefore he suggests
to us tonight that this is the procedure we should
choose in such cases.
Having had some experience in the medical manage-
ment of cases similar to those he has described, I cannot
accept as our only recourse an operation which, while
it relieves vertigo, renders the operated ear permanently
deaf.
People with vertigo in the middle age group are
numerous and the majority are not subject to labyrin-
April, 1947
thine hemorrhage. Most of them appear to be suffering
from a momentary functional derangement of the
labyrinth due apparently to imbalance of the blood supply
with resultant increased local capillary permeability
and local edema and labyrinthine hydrops.
It seems that several factors may play a part in this
syndrome, i.e., increased retention of the sodium ion
with increased retention of fluid, local vasoconstriction
and local vasodilatation. Harris and Moore of the
Crile Clinic first called attention (in 1940) to the vaso-
constriction factor. They recalled that physicians treat-
ing pellagrins found a high percentage with rotational
vertigo, which seemed to be on a nutritional basis. So
these physicians started in to treat their patients suffer-
ing from Meniere’s syndrome with large doses of
thiamine chloride with success. Then they tried treat-
ing such patients with nicotinic acid, with unsatisfactory
results.
Finally, they combined the treatment and gave thia-
mine chloride 10 mg. twice daily by mouth and nicotinic
acid 50 mg. five times a day, and began to get results.
They noted that within two weeks half of their cases
began to improve, and within six weeks seventeen out
of twenty cases had been entirely relieved and that the
final three cases were improved. They were impressed
that the majority of their vertiginous patients had
peculiar dietary habits, were either vegetarians or carbo-
hydrate addicts, or consumed inadequate proteins due
to faulty dentures.
Since reading their article, I have observed and treated
at least five patients with Meniere’s syndrome, observing
strict restriction of sodium chloride and fluids and giv-
ing adequate doses of thiamine and nicotinic acid.
One woman who improved has been lost track of
since she removed to California. The others have all
continued to maintain their equilibrium and be free from
vertigo for from two to five years.
The most dramatic patient was a bond salesman, aged
fifty-eight, who had to retire in March, 1941, because
of attacks of sudden “falling” vertigo. He has been free
from attacks of vertigo for the past five years on a low-
salt low-fluid diet and has been taking 30 mg. thiamine
and 300 mg. nicotinic acid a day. In spite of the fact that
he has developed intermittent claudication and his
blood pressure has risen from 160/90 to 200/100, he
is continuously free from attacks of vertigo.
Therefore, I believe that unless such a thorough-going
and meticulous regime has been instituted and failed,
we should not have recourse to surgical intervention.
Dr. Boies, in closing: Dr. Phelps asked what experi-
ence I had from medical treatment. Most of the patients
I have seen with vertigo, tinnitus and deafness have
been referred to me by internists or general prac-
titioners and the medical treatment has usually been
carried out by them. The mild cases and some that are
more severe seem to respond to these various forms
of treatment. It has been my observation that the best
results have been obtained with histamine. In the
University Hospital the cases have been treated by Dr.
A. B. Baker, who has given them intensive histamine
therapy for fourteen days and then followed this by
treatment on alternate days until a total of eighteen
treatments have been received. The mild and some
moderately severe cases seem to have been controlled
in a fair measure. However, there seems to be a lack
of permanency to this treatment.
When there is bilateral involvement, it is difficult
to differentiate as to the actual site of the phenomenon
which produced the symptoms. Fortunately, most of
the cases seem to be unilateral. In the cases I have
reported, the nurse had gone five years without develop-
ing symptoms on the opposite side, and another patient
had gone ten years. In cases of marked changes in the
ear with extensive dilatation of the cochlear duct, 1
rather believe that these changes are irreversible.
431
MINNESOTA ACADEMY OF MEDICINE
PERIPHERAL ARTERIAL EMBOLISM
JOSEPH F. BORG, M.D.
Saint Paul, Minnesota
Peripheral arterial embolism presents a problem in
diagnosis and treatment which is of challenging im-
portance. Where large vessels are involved, the result
is usually gangrene leading to death in approximately
90 per cent of all patients with expectant treatment or
amputation. These poor results are emphasized in the
experience with this type of case at Ancker Hospital
over the past thirteen years, in which eleven cases of
peripheral arterial embolism were diagnosed and no
recoveries recorded. Such disappointing experiences
point to a woefully inadequate awareness of the thera-
peutic possibilities available and emphasize the need for
calling attention to this problem. The results of mis-
sionary efforts of this nature are seen in the reports on
this subject from Sweden, and it has been well shown
that many lives will be saved and amputations prevent-
ed where the profession is alert to its responsibility.
This thesis attempts to review the significant contribu-
tions to the subject and to call attention to the im-
portance of recent advances in the treatment of this
condition.
Peripheral arterial embolism presents an emergency of
great urgency. It is a condition which is usually seen
first by the general practitioner or the internist, espe-
cially the cardiologist. It is upon them that the responsi-
bility lies for treatment in which delay cannot be per-
mitted. Recent reports emphasize the value of medical
measures, but reliance on them alone is dangerous, and
it must be recognized that surgery in the form of em-
bolectomy must always be considered and, where indi-
cated, must be carried out within a time interval which
will give the most favorable results. It has never fallen
to the lot of any one physician to accumulate a large
series of cases, but the consensus as revealed in case
reports in the literature points to a modern concept of
the condition and its treatment which materially im-
proves the outlook for these patients. The two factors
which are most important are early recognition of the
condition and the availahlity of a surgeon competent to
do vascular surgery.
Historical
Until the turn of the century, arterial emboli were
only of pathologic interest. The idea of removing the
offending embolus had been considered, but it was not
until 1895 when Ssabanejeff first attempted the surgical
removal of an embolus from the femoral artery in a
case of a twenty-eight-year-old woman with rheumatic
heart disease. Moynihan (1907) and Handly (1907)
next approached it unsuccessfully. In 1907 Stewart
reported the first attempt in this country. In 1909
Murphy30 unsuccessfully operated to remove a femoral
embolus four days after the onset. The first success-
ful embolectomy, left femoral, was performed by Lahey
in 1911 on a patient thirty-eight years of age with mitral
stenosis, on whom operation was performed six hours
after the onset. In 1912 Einar Key,15 in Sweden, did
the first of his series of embolectomies on fifteen pa-
tients which he reported in 1921 with the first review
of the literature, embracing forty-five cases with thirteen
successful results. Key so well educated the Swedish
profession that by 1927 he was able to report 145 Swed-
ish cases with eighty-six successful results out of a
total of 216 cases collected from the literature. So slow-
ly did the American profession become aware of the
therapeutic possibilities of embolectomy that in 1928
Pemberton37 was able to collect only twenty cases re-
ported in the United States and Canada. Even the
British failed to heed the work of Key because it was
1925 before the first successful embolectomy was re-
ported in England. Subsequently reviews of the subject
have been made by Reed and Andrus (1927), Andrews
and Harkins (1932), Pearse (1933), Danzis (1933),
Linton (1941), Pratt (1942), Lesser (1943), and notably
McClure and Harkins (1943) who have presented the
most comprehensive recent review, based on 690 re-
ported cases. The increasingly favorable results of ther-
apy insistently emphasize the need for an enlightened
attitude toward the problem.
Incidence
The incidence of peripheral emboli is much greater
than the reports would indicate. Many cases of report-
ed gangrene or arterial thrombosis are probably pri-
marily embolic, especially wdiere large vessels, notably
those proximal to the radial and popliteal arteries, are
involved. Out of 690 embolectomies reported, 382
were Swedish cases collected by Key16 up to 1936,
emphasizing again the attention paid to the condition in
Sweden and the inadequacy of domestic reports as a
guide to incidence. Murray31 reported thirty cases in
the Toronto General Hospital in five years preceding
1936. Lund24 found fifty-five cases in the Boston City
Hospital in seven years prior to 1937. Forty-six cases
were reported by McKechnie and Allen28 over a ten-
year period. Agar1 reported seven cases in five patients
in three years from 28,000 hospital admissions at Leeds.
Eleven cases reviewed here have been recorded at
Ancker Hospital, Saint Paul, over a thirteen-year period.
Incidence is about the same in both sexes.28 Study of
129 cases by Danzis4 revealed an average age of forty-
nine years, the range being seventeen months to eighty-
two years. Most of them occurred between the ages of
thirty and seventy, with the peak decade being fifty to
sixty years.
Pathogenesis
Arterial emboli are caused by the breaking off of
pieces of thrombi, the majority of which come from
the left side of the heart. Rarely they may originate
from thrombophlebitis or phlebothrombosis and find
their way to the arterial tree through a patent foramen
ovale. The great majority may be traced to rheumatic
mitral or arteriosclerotic heart disease, frequently with
auricular fibrillation, in which thrombi form in the left
auricle. Others come from mural thrombi which form
as a result of myocardial infarction. Danzis41 states
that 70 per cent are of pure cardiac origin and that
most of the rest are of cardiac origin associated with
some disease such as diabetes, arteriosclerosis, or thy-
432
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
roid disease. Rarely the embolus may come from an
arterial thrombus attached to an arteriosclerotic plaque
of a large vessel. McKechnie and Allen28 reported that
of forty-six cases, forty-one were of cardiac origin,
two from pelvic carcinoma, one had a patent foramen
ovale, one was arteriosclerotic, and one followed a cerv-
ical rib operation. Pearse,36 reviewing 296 cases, found
the following known source distribution :
Per cent
Heart disease 69.2
Postoperative states 13.0
Infection and trauma 2.1
Arteriosclerosis 2.1
Aneurysm 1.8
Abortion and delivery 1.8
Miscellaneous 2.8
Phlebitis 0.3
When an embolus is sent out into the arterial tree, it
usually passes the hazards of the innominate, left com-
mon carotid and left subclavian arteries, the reason for
which is not entirely clear. Depending on its size, it
then passes on to lodge in some more distant part of
the arterial system, usually at a bifurcation. Riddell39
states that only 12.1 per cent of emboli reach the upper
extremity while 87.9 per cent reach the lower.
On lodging, the sudden insult to the artery sets up
a reflex arterial spasm which is extremely important in
affecting the clinical course and outcome of the acci-
dent. After a variable period of time, changes occur in
the endothelial wall which lead to the formation of a
secondary thrombus. Key16 states that this thrombus
may start as early as two hours after lodgment or may
not appear as late as twenty-four hours, the longest
reported period between the onset and operation
without gangrene. This probably depends on the amount
of reflex arterial spasm present Land the extent of ef-
fective collateral circulation. Linton21 states that sec-
ondary thrombi may occur as early as nine hours.
These thrombi propagate distally and may completely
plug all the tributaries and ramifications of the vessel,
being hard to remove. On the other hand, proximal
propagation is usually only a few centimeters and is
easily removed.
Emboli experimentally produced by Murray32 revealed
no reaction in the vessel wall at six hours, considerable
change with adhesion at twenty-four hours, and a firm
thrombolic adherence at forty-eight hours with an inva-
sion of the clot and vascular wall by leukocytes.
Considerable attention must be paid to the role played
by reflex arterial spasm in this condition, the relief of
which is important in treatment. That traumatic vascu-
lar spasm is important clinically has been long recognized
but little heeded. The occurrence of this condition fol-
lowing external trauma was first reported in 1915 by
Fritz Kroh, and forty-four cases were reported up to
1935 in a review by Montgomery et al.29 That vascular
occlusion will produce the same result is generally ac-
cepted. The distally propagated thrombosis following
occlusion is often very much narrower than that above
the embolus, a fact which can hardly be explained other-
wise than by spasm. Also, the experimental and clinical
surgical observations of these vessels, together with the
clinical relief and return of distal arterial pulsation ob-
TABLE I.
Site of Embolus
No. Cases
Per cent
Lungs
113
1.8
Kidney
74
1.2
Spleen
60
1.0
Brain
32
.52
Extremities
15
.24
Intestines
16
.1
Liver
1
.016
TABLE II. PERCENTAGE DISTRIBUTION
OF PERIPHERAL EMBOLI
Site
Dickinson .
(15)
De Takats
(16)
Key
(3)
Aorta
4.5
10.1
4.5
Iliac
17.0
18.3
17.3
Femoral
5.5
39.1
54.5
Popliteal
11.0
9.8
11.3
Axillary-brachial
12.0
16.0
11.8
tained by vasodilating means, papaverine, local arterial
sympathectomy, spinal anesthesia, paravertebral block,
and lumbar sympathectomy, point toward this being a
pernicious action amenable to treatment which may im-
prove the outlook for circulatory restoration and obviate
the necessity for embolectomy.
Gangrene, usually of the dry type, is the end result
of clinically significant peripheral emboli. Due to the
excellent collateral circulation of the arm, it is not
commonly found here, but where the circulation cannot
be restored by embolectomy or by the release of vascular
spasm permitting adequate collateral circulation, gan-
grene is the usual result. This of course necessitates
amputation which is often fatal due to the poor condi-
tion of the patient as a result of the primary condition
and the usually advanced age.
Site of the Embolus
Vascular emboli may lodge in any part of the body.
According to Bull,3 in a study of embolic incidence in
6,140 autopsies, only the intestines and liver showed less
of an incidence than the extremities (Table I).
It is noted that the lungs were most commonly in-
volved as would be expected with the much greater
probability of occurrence following thrombophlebitis or
phlebothrombosis. However, it is not likely that these
figures reflect at all the true incidence since the relative
care in searching for them varies, and the liklihood of
detection is much greater in the case of the brain,
spleen and kidneys where much more meticulous search '
for pathology is made. As shown, the extremities were
involved in .24 per cent of all autopsies.
A peripheral embolus usually lodges at the site of an
arterial bifurcation where there is a definite decrease
in the size of the distal branches. The lower extremity
is involved seven times as often as the upper. Table II
shows the percentage distribution of emboli in the more
important locations as determined by several investi-
gators.
April, 1947
433
MINNESOTA ACADEMY OF MEDICINE
Symptoms
Considerable variation occurs in the initial manifesta-
tions of peripheral embolism. Key16 states that the
onset is usually one of sudden pain in the extremity,
but from numerous other descriptions it becomes clear
that while pain of maximum severity at the outset is
probably most common, it is by no means invariable.
McClure et al27 state that premonitory distress may
be due to small emboli, not incapacitating, or to the
movement of one which has straddled a bifurcation
without being large enough to close either branch totally
and which later slips into one or the other, causing
major symptoms. Johnson14 states that the initial dis-
tress may vary from a numbness to an acute pain, fol-
lowed later by coldness, tingling, stiffness and paralysis
or paresis. Dickinson8 in reporting five cases stated
that four had only slight pain at the onset but that
all cases complained of numbness and inability to use
the extremity as the first symptom. Rykert et al41 in a
series of thirty-six cases found pain to be initial in 64
per cent. It was of maximum severity at the onset in
53 per cent, the others complaining of minor distress
becoming maximal after an interval. Of the latter 47
per cent, pain, numbness and coldness coincided in six
cases, while in the remainder the onset produced numb-
ness and coldness followed later by pain.
The course of symptoms is usually that of the pain,
numbness, and tingling lasting from twenty-four to
seventy-two hours, followed by the lesser distress of
ensuing gangrene or by the picture of vascular insuf-
ficiency. These latter are dominated by an ischemic
neuritis with paroxysms of pain over large areas of no
particular nerve distribution, vasomotor changes, hyper-
esthesia, coldness and intermittent claudication, and occur
in those cases with sufficient collateral supply to pre-
vent gangrene but not vascular insufficiency. Volkmann’s
contracture may be a sequel of this course of events.
The mechanism of pain production is of Considerable
interest. Two distinct factors are involved and deter-
mine the nature of its initial manifestation. Where pain
is maximum at the onset it appears to be due to reflex
vascular spasm from irritation of the endothelium by
the lodging embolus. This pain is sudden, very distress-
ing, aching, and is located over the site of the embolus.
The origin of this pain is suggested in its response to
measures for the relief of vascular spasm such as papav-
erine, paravertebral block, and lumbar sympathectomy
as well as observations of the spastic state of the in-
volved vessel.
On the other hand, Lewis19 has nicejy shown the part
played by ischemia in the production of pain following
arterial occlusion. This pain is due to ischemia of
somatic musculature. It is not found in the occlusion
of vessels serving organs without striated muscle, such
as the brain, lungs or spleen. It starts first as a numb-
ness, tingling and coldness with pain occurring later,
located principally in a position distal to the level of
the actual obstruction. It occurs about thirty minutes
following the occlusion, depending on the muscular
activity of the extremity involved. This pain is not
affected by relief of spasm except insofar as spasm
release provides sufficient improvement in the collateral
circulation to relieve the ischemia.
Study of the mechanism of pain therefore has pointed
the way to the most effective medical measures of treat-
ment available and offers some hope for the satisfac-
tory treatment of a few cases without surgery. This
will be further discussed under treatment.
Signs
On physical examination the earliest signs are those
of pallor, loss of arterial pulsation and temperature re-
duction. Pallor is early of a waxen hue, or it may be
a marbling. Later it becomes a blotchy cyanosis which
comes to show the demarcation limited by collateral
circulation. Loss of arterial pulsation is most important
in diagnosis and determination of the site of the embolus.
Usually the site will be found to be at the bifurcation
above the level of loss of pulsation. This, however,
may be confusing because, as Agar1 points out, a long
or propagating embolus may show pulsation in the mass
at some distance below the lodging place. Thus in com-
mon femoral embolus it is possible to have a pulsation
below Poupart’s ligament. Temperature change, cold-
ness, is a sign as well as a symptom. It, too, is important
in diagnosis and is generally easily recognized by gross
examination. Skin thermometry is not necessary al-
though it may aid in the determination of the line of
demarcation.
Within a short time diminished muscular power lead-
ing to paralysis supervenes. With it there are diminished
sensory findings with diminution or loss of reflexes.
Anesthesia of the stocking type below the site of the
embolus may be found.
Several hours after the onset the clinical picture may
he confused by the appearance of secondary venous
thrombosis. This will cause a tendency to swelling and
localized tenderness of previously empty veins.
Gangrene will appear in the cases with untreated or
unsatisfactorily restored circulations in degree depend-
ent on adequacy of collateral circulation. This depends
on a number of factors including the age of the patient
with the varying degrees of arteriosclerosis in possible
collateral vessels and the adequacy of the general circu-
lation. In animal experiments Melzner (quoted by De
Takats7) has shown that where the collateral arterial
pressure below the site of ligation is less than 15 milli-
meters of mercury thrombosis and gangrene result.
The incidence of gangrene in reports varies consider-
ably, with marked decrease under modern methods of
treatment, both medical and surgical. McKechnie et al28
reported an incidence of 45 per cent gangrene in a series
of forty-six cases of emboli seen over a ten-year period.
In this series the age factor is shown in that the in-
cidence was 73 per cent after the age of sixty, and 32
per cent in younger patients.
Differential Diagnosis
While the diagnosis of embolism may be clear cut,
difficult or impossible', it is not usually troublesome al-
though at times some- confusion may enter. The rela-
tively sudden onset of the described symptoms and signs
in an individual with the usual underlying causes should
434
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
make one immediately suspicious of the possibility.
Where the onset is not so abrupt, more difficulty may be
encountered. Arterial spasm without embolus may
produce a similar picture but this is practically always
on a basis of trauma, the history of which can be elicited.
Primary arterial thrombosis can also produce this syn-
drome but practically never occurs above the popliteal,
ulnar or radial arteries, and smaller artery obstruction
is usually cared for by adequate collateral circulation.
Assisting in its elimination is the elicitation of a history
of long-standing symptoms of coldness, numbness, in-
termittent claudication, cramps, and paresthesias months
or years before complete obstruction of gradual onset
occurs in an individual with arteriosclerosis, often dia-
betic.
Thrombophlebitis should not be confusing, the local
pain and tenderness, the cyanosis, the peripheral edema
and increased temperature and the presence of arterial
pulsation usually sufficing to identify it. Occasionally
in phlebitis the arterial pulse may temporarily disappear
due to vascular spasm. Also, the secondary venous
thrombosis following arterial occlusion must not be al-
lowed to confuse the picture. Buerger’s disease likewise
exhibits a clinical picture which is usually not difficult
of differentiation although sudden occlusion may be the
first symptom.
Arteriography has proved of very little assistance in
diagnosis. It may help in locating the site of an em-
bolus, but it is not a practicable procedure and is not
considered necessary because the embolus nearly always
is to be found at the bifurcation above the level of the
physical findings.
Treatment
As McClure et al27 state : “Because of the urgency
of the situation, early diagnosis and prompt decisions
are essential. As in perforated ulcer and many other
surgical conditions, the number of hours after onset is
one of the chief factors affecting the prognosis.” Before
the use of anticoagulant therapy with or without surgical
intervention, this was so true that, by some, embolectomy
was considered useless after ten hours. More recently,
assisted by the anticoagulants, surgery has accomplished
a marked improvement in results, even in cases where
treatment was delayed, and embolectomy where indi-
cated can now be done with a far greater promise of
success than formerly. “It is never the operation which
kills the patient but the disease which makes the opera-
tion necessary” (Griffiths9).
Medical treatment is always justifiable at the start
but should not be carried on alone more' than the few
hours which will suffice to determine its effectiveness.
Relief of pain is effected by opiates, which should not
be withheld. The position of the extremity may be im-
portant. Formerly it was considered wise to elevate it,
but more recently has been accepted the practice of
lowering it 10 to 15 degrees to assist the collateral circu-
lation by gravity (De Takats7 and Barker et al2)'.
Whisky has been advocated by Barker et al2 in doses
of \l/2 ounces every four hours. It is a good vasodilator.
Probably more effective for relief of reflex spasm is
papaverine which has come into use in the last decade.
After it had been shown that atropin was useless, Denk5
tried papaverine intravenously in a patient fourteen hours
after the onset and noted about thirty minutes later
by capillary microscopy a dilatation of vessels which
lasted about three hours. Repeating the injections, he
observed that after the fourth injection the vessels re-
mained open. He reported ten cases in which it was
used, in six of which he obtained good results and in
four of which the outcome was not a success. On the
other hand, Griffith9 reports unsatisfactory results from
the use of papaverine. No well-controlled series throws
any light on its real value, but it seems fair to assume
that if results are to be obtained, it will be determined
by the result of a single intravenous injection of one-
half to one grain of papaverine hydrochloride intra-
venously. If no restoration of circulation results within
an hour, it should be regarded as ineffective.
Sympathetic block has been advocated by Barker et al2
if papaverine is ineffective. Roome40 reports the prompt
and complete relief of pain following such treatment in
two cases, but except for casual mention, it has few
champions. Probably it deserves a better trial than it
has been afforded, since the results can be evaluated
in a short time if papaverine is found useless.
These medical measures deserve carefully observed
trial, and since not more than an hour or two need
elapse before an adequate evaluation of their results is
possible, their use is well justified. In all cases the
surgeon should be immediately called and preparations
for operative treatment made ready. Where medical
measures are unsuccessful, restoration of circulation is
possible only by embolectomy. Due to relatively recent
introduction of measures to relieve vasospasm and pre-
vent coagulation, the literature dealing with arterial
embolism is predominantly surgical. While it is ob-
vious that there is a greater tendency to report good
results than poor ones, and while there - are no large
series of embolectomies performed by one surgeon, suffi-
cient reports are available to establish beyond doubt the
effectiveness of the surgical approach in saving lives
and limbs. It is not the province of this paper to deal
with the technical aspects of surgical treatment which
are adequately covered elsewhere.
In 1943, 690 cases with' embolectomy were gathered
by McClure et al27- in a comprehensive review with re-
sults that are definitely encouraging. As pointed out
by Lund40 the experience of the surgeon in this work is
of great importance and it would serve greatly the gen-
eral results obtained if this work could be concentrated
in the hands of one or two surgeons in a community.
Lund24 showed that in a period of six years following
the first embolectomy at the Boston City Hospital in
1925, he could divide experience into two periods of three
years each. These showed materially improved later
results in the second period due entirely to improved
skill. In the first three years he had 25 per cent suc-
cessful results and a 67 per cent mortality, whereas
in the second three years he showed 46 per cent suc-
cesses and 27 per cent mortality. Where the legs only
were involved, the earlier group showed 18 per cent
successes and 64 per cent mortality, while the latter
showed 55 per cent successes and 22 per cent mortality.
April, 1947
435
MINNESOTA ACADEMY OF MEDICINE
In a series of twenty-nine cases without operation, 8
per cent recovered and the mortality was 85 per cent.
These figures speak for themselves.
Regardless of experience of the surgeon it is agreed
that the most important factor leading to success is
the reduction of the interval between onset and opera-
tion. Johnson14 states that results are poor after ten
hours, nil after forty-eight hours. Dickinson8 says they
are good under eight hours, poor after twenty-four
hours. Agar1 reports a “reasonable” chance under six
hours, with recovery rare after twelve hours. McKech-
nie et al28 would avoid delay over three hours, obviously
difficult to prevent. Lund24 reported no successes after
nine hours. Murray31 in an early report of nine suc-
cesses out of seventeen cases showed that eight of these
were in patients operated under six hours. Key,16 in
reporting 382 collected cases with 22.5 per cent good
results, found that among those operated upon under
ten hours, the outcome was successful in 55.8 per cent.
Danzis,4 in estimating the influence of the time interval
between onset and operation on the outcome, found that
under four hours 62 per cent showed restored circula-
tion; from four to eight hours, 50 per cent; from eight
to twelve hours, 25 per cent; and from twelve to twenty-
four hours, 21 per cent. He found no authentic report
of success after forty-eight hours, explaining any such
successes on probable collateral circulation development.
The foregoing results are those obtained without the
use of anticoagulants and comprised the great majority
of reported cases up to this time. A new chapter in
treatment seems to have been added with the introduction
of heparin, which will be discussed later.
While the importance of early diagnosis and treat-
ment cannot be too strongly stressed, it is recognized
that very occasionally results may be obtained in cases
with delayed operation so that the opportunity should not
be denied on that basis alone, especially with the anti-
coagulants available.
The risk of surgery is relatively small in these cases
even though the patients are often very ill and not in-
frequently quite old. While mortality following opera-
tion is not insignificant, it is so much better than in
non-interference that operation is rarely contraindicated
even though the risk seems grave. Emphasized by
McClure et al, Pemberton37 states, “There is no estab-
lished operative procedure of equal simplicity, frought
with so little risk, with such dramatic potentialities,
that has been so woefully neglected as embolectomy.”
Choice of anesthesia is not difficult. Danzis4 states that
the type of anesthesia is noncontributory to the out-
come. Considering the gravity of the underlying disease,
it is difficult to accept that without reservations. Local
anesthesia, however, is favored by most authors. Re-
gional or block anesthesia was advocated by Danzis.
Spinal anesthesia has been recommended by some, but
opposed by others because of the hypotension which will
further impair an already diminished circulation.
Multiple operations have been necessary in a number
of patients who had recurrent emboli, and they have
been well tolerated. That recurrent embolism should be
treated surgically is well supported by the several cases
reported in whom the tendency to embolism stopped
and recovery ensued.
The use of anticoagulants has divided the history of
treatment of arterial emboli into two periods, that before
and that after their introduction. Dicoumarol is too
recent to judge its value adequately but the results, in
conjunction with heparin, are promising. Heparin, how-
ever, has been an outstanding boon to the vascular sur-
geon, and the results obtained have established its place
in therapy. Practically all reports of cases operated
upon since 1940 indicate the use of heparin. Discov-
ered about 1916 by Howell, it was not until about ten
years ago that a sufficiently purified solution was pre-
pared for satisfactory clinical use. Widely distributed
in body tissues, especially lung and liver, its action in
the body is probably that of an antiprothrombin. Large
amounts of it are liberated in anaphylactic shock mak-
ing the blood incoagulable for long periods. Its fate
in the body is unknown. Experimentally its value in
vascular disease was suggested by the results of Mur-
ray and Best33 who found the removal of experi-
mental emboli from dog arteries was always followed
after twenty-four to seventy-two hours by thrombus
formation plugging the artery, whereas this was pre-
vented in all cases by the use of heparin. Clinically they
report an unfavorable case in which operation was under-
taken twenty-five hours after the onset of symptoms
involving both common iliac and femoral arteries. Re-
moval of the emboli revealed “some stickiness of intima,”
but with heparin circulation was restored. The pa-
tient died on the fifteenth postoperative day, and autop-
sy revealed perfectly healed vessels. These authors
suggest the use of heparin in inoperable cases to prevent
further extension of the thrombus and preserve the
maximum amount of collateral blood supply. Broth11
reports a case of tumor (sarcoma) embolus in which
he had to reopen his incision four times because of throm-
bolic plugging of the artery after closure. The fifth
clearing of the artery was associated with heparin ther-
apy, local and general, and recovery resulted. Nu-
merous other authors have since attested to the value of
heparin in conjunction with embolectomy.
Heparin is administered intravenously. Some workers
insist on its continuous administration in an amount suf-
ficient to keep the coagulation time at fifteen minutes,
usually requiring a flow of 25 to 30 drops per minute
of a saline solution containing 100 milligrams of heparin
to 1,000 cubic centimeters. The coagulation time should
be tested every few hours to determine the rate of
administration. Lesser18 advocates the use of 100 milli-
grams of heparin every three hours to avoid the large
amounts of fluid given when the continuous flow is used.
He states that at the end of three hours the coagulation
time is still satisfactorily prolonged. This suggestion
has merit, especially in those cardiovascular patients
who should have a restricted fluid intake.
Dicoumarol will probably have an important place in
therapy in association with heparin. Of recent introduc-
tion, few reports are available. Wetherell42 reports
four cases in which it was successfully used. Barker
et al2 report six cases with good results, one patient
dying of heart failure as the result of an underlying
436
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MINNESOTA ACADEMY OF MEDICINE
myocardial infarction. Where used, the dosage must
be guided by the prothrombin time, considerable care
being exercised to avoid overdosage which may other-
wise result. Its disadvantage lies in its delayed action,
forty-eight hours or more being necessary to determine
how high the prothrombin time will go, and in the
marked variability in its action on different patients. Its
great advantage lies in its being given by mouth. Hepa-
rin is always used with it at the start and discontinued in
about forty-eight hours or when the prothrombin time
reaches 20 to 30 per cent of normal.
Considering the foregoing, a suggested program of
treating arterial emboli is presented :
1. Treatment must be started immediately.
2. Room temperature of 80° to 85° F. is used. Heat
is to be avoided.
3. Lower the extremity and wrap in cotton.
4. Give 1 ounce of whisky every three hours.
5. Administer papaverine to 1 grain intravenously.
6. If circulation is” not restored in one hour, sympa-
thetic block may be tried.
7. If sympathetic block is not effective, embolectomy
is performed following the administration of heparin.
Results
While the results of the surgical approach in the treat-
ment of arterial emboli predominantly attest to its value,
consideration must be given to those dissenters who have
not been impressed with it and mention must be made
of passive vascular exercise as developed by Reid and
Herrmann. Rykert et al41 found embolectomy unsatis-
factory and reported 50 per cent restoration of circula-
tion by passive vascular exercise. They advise against
embolectomy. Linton,22 in fifteen cases treated by pas-
sive vascular exercise, was able to save the circulation
in nine. Lund,23 in considering the latter, finds no justi-
fication for it, but Linton22 believes it may be of use
following embolectomy. There is, therefore, insufficient
data to indicate that passive vascular exercise is to be
seriously considered. Undoubtedly there are cases with
unusually good collateral circulation where medical
measures might save an extremity, but too often the lat-
ter will leave a vascular insufficiency with ischemic
symptoms and signs which might be avoided with mod-
em surgical approach.
The earlier reports of surgical treatment show a
considerable variation in results, possibly reflecting in
part the variations in experience, surgical ability and
individual factors in the patients contributing to success
or failure. As previously stated, for a long time em-
bolectomies were reported only by the Swedish workers.
In 1921-1922 Key15 quoted thirteen successes out of
forty-five cases. The first embolectomy in Great Britian
was reported in 1925, and up to 1934 only twenty cases
had been reported there, with 50 per cent success. Key’s
review16 of 382 Swedish cases to 1936 showed 59.4 per
cent mortality, 22.5 per cent good circulatory results,
and 18.1 per cent recoveries after amputation. If only
the cases operated upon under ten hours are included,
good results were obtained in 55.8 per cent. Nystrom
(quoted by McClure et al5) reported that of thirty-nine
embolectomies performed in one clinic, about half were
followed by satisfactory circulation. Griffiths, reporting
fifteen years’ experience to 1940, had eleven successful
results in twenty attempts. Four of these successes
involved the arms.
Late studies of surgical results are not common, milk-
ing the report of Strombeck42 on late results especially
interesting. His collection of 372 Swedish cases showed
early results comparable to those of Key.16 Following
these through he states that of the successful results
three-fourths of the patients were alive at the end of a
year, one-half at the end of three-years, one-third at
the end of five years, and one-eighth at ten years. Key,16
reporting results on forty-eight cases from one hospital,
states that most were alive at two to three years, one-
third alive at ten years and two were alive after fifteen
years.
The American reports have been on the whole less
favorable. As late as 1942 Dickinson8 reported five
deaths out of six patients, following embolectomies,
four of which were after a greater than ten-hour inter-
val. Out of three cases, Massey and Steiner26 had two
recoveries, in both of which operation was performed
within three and one-half hours. Linton22 reports only
four recoveries out of twelve patients. Rykert et al41
had an unsuccessful experience with eleven embolec-
tomies. They state that they had 20 per cent recovery
on symptomatic therapy and did not advise embolectomy.
Zierold44 reported 87 per cent mortality in eleven surgi-
cal cases as against 72 per cent in the non-operative
cases. Koucky et al,17 reporting twenty-five cases at
Cook County Hospital between 1928-1938, had three
embolectomies with three deaths. On the other hand,
McClure et al27 had three successful embolectomies in
eight patients. Lesser18 reported four successful surgi-
cal results in three patients after intervals of four and
one-half, twelve, thirteen and fourteen hours. Griffiths’9
series of five patients who were operated upon showed
three successful results. One of these, after a seventeen
and one-half hour interval, developed an ischemic con-
tracture. Murray31 reported seventeen operations in a
series of thirty peripheral emboli. Nine of these pa-
tients made good recoveries (eight were operated upon
under six hours), while eight had the circulation re-
stored but died of other causes, some embolic. Lund’s
experiences24 at Boston City Hospital, fifty-five peripheral
emboli in seven years, showed no successes after nine
hours had elapsed. Among those not operated upon,
8 per cent recovered while 35 per cent of twenty-seven
operated upon recovered.
While these results stress the value of early opera-
tion, the reported satisfactory outcomes13 after thirty-
nine and twenty-seven hours without anticoagulants,
show that delay alone does not contraindicate surgery,
even though the chance of success is small.
The most significant era of surgery in arterial em-
bolism seems to have been opened in the last few years
with the introduction of anticoagulants as adjuncts to
surgery, and the few reports available show a marked
improvement in results from embolectomy. It has been
possible to collect fifty-two cases in which heparin has
been used, a few in conjunction with dicoumarol. Fifty
April, 1947
437
MINNESOTA ACADEMY OF MEDICINE
recoveries are reported. While controlled series are not
available, the reports leave little doubt as to the results.
Among the earliest advocates of heparin therapy, Murray
and Best33 in 1938 reported five embolectomies with four
recoveries. In 1940, Groth11 reported a case in which
a sarcoma tumor embolus was removed from a femoral
artery in which thrombus occlusion occurred at the site
of and immediately after closure of the artery four times.
Following the fourth thrombosis heparin was used
locally and intravenously and a satisfactory result was
obtained. McFarlane25 reported a case of mitral stenosis
in which four successive emboli were treated surgically
and heparinized with good results, after which no further
episodes occurred. Lindgren and Wilander20 reported
eight embolectomies with seven successes, in one of
which operation was performed after a four and one-
half day interval. Ravdin and Wood38 described a suc-
cessful operation on a saddle embolus of the bifurcation
of the aorta.
Lesser,18 using 100 mg. of heparin every three hours
reported four successful operations following four and
one-half, twelve, fourteen and thirteen hour intervals.
Murray34 described seventeen embolectomies in which
the circulation became and remained normal in all. This
is the most impressive series of heparin treated embo-
lectomies. Later lie35 described five consecutive suc-
cessful aortic embolectomies. One of these was especial-
ly interesting in having three other emboli, two femoral
and one cerebral, with recovery from all. The recur-
rences all came several days after heparin associated
with previous operations had been stopped. Two of his
patients developed further emboli in spite of heparin and
died.
Reported from so many diverse authors, these results
of embolectomy with heparin treatment are remarkable
in comparison with the earlier results reported.
Report of Cases
The following experiences with peripheral arterial
emboli at Ancker Hospital, St. Paul, have prompted the
present discussion of the subject.
Case 1.—. Mrs. E. G., aged seventy-seven, with diabetes
and congestive heart failure, was admitted to the hos-
pital three days after the onset of pain in the left leg,
with absent femoral pulsation in a cold, white leg. She
was moribund and died forty-eight hours later.
This patient is obviously an example of neglect in
early care and in her moribund condition not a subject
for embolectomy.
Case 2. — Mrs. A. G., aged sixty-four, with hyperten-
sive heart disease and auricular fibrillation, was admit-
ted to the hospital with severe pain of sudden onset in
the left leg of twenty-four hours’ duration. The leg
was cold with blotchy cyanosis and no pulsation below
the femoral artery. Embolectomy was suggested thirty
hours after onset but refused by the surgeon. Ampu-
tation one week later was followed by gangrene in the
stump and death occurred after one month.
While this was a comparatively late case, embolectomy
should probably have been attempted.
Case 3. — Mrs. W. C., aged sixty-one, with rheumatic
mitral and aortic valvular disease, was in the hospital
convalescing from congestive heart failure. On April
30, 1941, she was awakened with severe pain in the right
foot followed by numbness of the leg with coldness,
pallor and marbled cyanosis. No arterial pulsation in the
femoral artery or lower could be elicited. A line of
demarcation appeared below the knee. Symptomatic
treatment was given. Death occurred nine days later.
Autopsy showed thrombus formation in the right ex-
ternal iliac artery and the left auricle.
This case offered a favorable opportunity for em-
bolectomy which should have been tried in the absence
of response to symptomatic therapy.
Case 4 — Mr. F. A., aged fifty, with no significant his-
tory, was well until the onset of a diarrhea three, days
before admission to the neurological service on June 5,
1943. Three hours before admission, pain of gradual
onset appeared in the right hip, progressing to an ex-
cruciating character. On admission the leg was cold,
paralyzed and the pulses not felt. A diagnosis of em-
bolism was made, but a surgeon was not consulted.
Nine hours later he developed severe lower abdominal
pain with diarrhea and died nine hours later. Autopsy
showed thrombosis of the common iliac artery extend-
ing 6.5 centimeters into the aorta. There was also a
purulent pericarditis and pyelonephritis.
Here again was a case where clinically the indications
for surgery were present. The general condition as re-
vealed at autopsy would doubtless have prevented re-
covery, but they were not diagnosed antemortem.
Case 5. — Mr. J. L., aged fifty-nine, with history of a
stroke in 1939, was admitted October 21, 1941, to the
surgical service with severe pain of sudden onset and
coldness of the left leg of two days’ duration. Surgery
was not considered, dry gangrene resulted and supra-
condyloid amputation was performed November 4, 1941.
The patient died one week later. Autopsy showed
marked coronary disease with left ventricular mural
thrombus, and the pathologist considered the leg lesion
to be thrombotic.
The relatively late appearance of this case mitigated
against a successful surgical result, but it probably
should not have been considered hopeless.
Case 6. — Mrs. A. B., aged sixty-two, was admitted to
the hospital June 1, 1939, with a history of hypertensive
heart disease with decompensation. Twenty-four hours
before admission she experienced pain in the right foot,
followed by numbness and shooting pain in the leg.
Examination showed congestive heart failure and numb-
ness and coldness in the right leg below the inguinal
ligament. Pulse, which was felt in the femoral artery,
stopped 2 inches below the inguinal ligament. Surgery
was not considered, and symptomatic therapy (includ-
ing papaverine) was unsuccessful. Death resulted Tune
28, 1939. Autopsy revealed rheumatic mitral endocard-
itis and occlusion of the right common iliac artery.
Again, while twenty-four hours elapsed before seen,
this patient might have benefited by surgery. The
occlusion when first seen was below the level of the
inguinal ligament, being later propagated proximally
to involve the common iliac artery.
438
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
Case 7. — Mrs. J. E., aged twenty-six, a hospital pa-
tient with pulmonary tuberculosis and rheumatic heart
disease, on August 22, 1940, complained of severe
pain in the right leg, alternating with numbness. The
leg was white and waxy. Surgery was not considered,
and death occurred twenty-four hours later. Autop-
sy was denied.
This was the second case in which recognition of
the embolus was possible almost immediately after
the lodgement, and the patient was probably a likely
candidate for surgery. The tuberculosis did not appear
to be a contraindicating factor.
Case 8. — Mrs. H. L., aged seventy-six, with a diag-
nosis of coronary arteriosclerosis and cardiac decompen-
sation, was admitted to the hospital six hours after the
onset of pain in the left hand, followed by coldness and
pallor in the arm, with no arterial pulsation in the ax-
illary artery or distally. The surgeon was not consulted.
She was treated symptomatically and died sixty hours
later. Autopsy was denied.
This patient would probably not have benefited by
operation in view of the failure to live longer than sixty
hours following admission. Seen early, however, she
should probably have had the opportunity of attempted
embolectomy.
Case 9. — Mrs. J. O. D., aged thirty-five, was well until
admission for a stabbing pain in the rectum and lower
back, the onset of which was twelve hours before she
was seen. This pain radiated to the back of both legs
and was associated with numbness, coldness, paralysis,
absent femoral pulsation, and mottled discoloration of
the left leg to the knee. After a short period of im-
provement of the heart and general condition, she pur-
sued a downhill course to death in two weeks. Autopsy
showed a left common iliac occlusion, mitral stenosis,
recent myocardial infarction and ventricular mural
thrombus.
This patient in retrospect appears to have been 'a good
candidate for embolectomy when first seen. Operation
was apparently not considered.
Case 10. — Mr. M. D., aged seventy, with no significant
history, was admitted two weeks after the sudden onset
of a severe pain in the right leg which later turned blue
and cold. A line of demarcation was present below the
knee. He had coronary heart disease with auricular
fibrillation. Death occurred twenty-four hours after
admittance. Autopsy was refused.
This patient was obviously not a candidate for surgery.
Case 11. — Miss E. E., aged seventy-six, with mitral
stenosis and auricular fibrillation, had had a severe pain
in the right arm three weeks before admission, followed
by inability to use the arm. One day before admission
she had a similar severe pain in the left leg. No pulsa-
tion was found in the right axillary and left popliteal
arteries and tributaries. Severe pain persisted in the
leg and arm. Operation was not considered. Sympto-
matic treatment was used, and the patient died one month
later after a gradual downhill course. Autopsy was
denied.
This patient did not develop gangrene, and it is diffi-
cult to determine the effect of the emboli on the out-
come. It is likely that an operation would not have
altered the clinical course, but embolectomy might have
added much to her comfort. Indications for surgery
must be regarded as questionable in this case.
Three cases of gangrene were noted in the records in
which emboli may have been the etiology. In one of
these there was thrombosis of the aorta and common
iliac arteries while in another there was thrombosis of
the external iliac artery. In all three the clinical his-
tories could have been interpreted as indicating embol-
ism.
A review of thjs unimpressive collection of failures
in treatment reveals several deficiencies which are not
uncommon where the profession is not alert to the
problem. Delay in admission is not always the fault
of the physician, but it is not uncommonly so. One
patient was obviously not amenable to treatment, having
been admitted two weeks after the onset. Two patients
were admitted after two to three days’ delay; three
were admitted after an interval of twenty-four hours.
In the light of earlier experience these would not have
been considered good candidates. On the other hand,
two patients developed their emboli while in the hos-
pital, and three were seen after intervals of three, six,
and twelve hours respectively. These should all have
been considered for surgery. A more serious indict-
ment, however, is the lack of consideration of the surgi-
cal approach. In only one case was the surgeon asked to
see the patient and in this he advised against surgery.
In only one case was the patient admitted to the surgical
service, and that after an interval of twenty-four hours.
Operation was not considered. In all other cases the
patients were admitted to non-surgical services and op-
eration was never considered. First among the lessons
to be gleaned from this study, and important if nothing
else is learned, is the fact that the profession is in-
sufficiently alert to this problem and much may be
gained by intelligently directed dissemination of infor-
mation in this direction.
Discussion
Location of an embolus necessitates certain considera-
tions in treatment. Greater risk than is apparent may
be associated with involvement of the popliteal artery
because of the danger to the collateral circulation about
the knee. Special consideration to emboli in the arm
is necessary because of the better collateral circulation
available. It is believed by several (Lund, DeTokats)
that operation in an upper extremity is seldom indi-
cated. Lund’s analysis24 showed that embolectomy in
the arm is twice as likely to be successful as in the
leg although the ultimate results, as far as life is con-
cerned, show little difference if no operation is per-
formed. Gangrene did not occur in Lund’s non-operative
cases, doubtless influencing greatly his opinion. Gan-
grene, though infrequent, does, however, occur in the
upper extremity and there must be considerable doubt
as to the wisdom of non-operative treatment in the arm
if medical treatment over a short time is not success-
ful.
Embolism in the aorta deserves special recognition
because of its serious implications when not operated
upon and because of the promising results from opera-
April, 1947
439
MINNESOTA ACADEMY OF MEDICINE
tion. Spontaneous recovery is rare but has been reported.
In 1921 Hesse12 collected a series of forty-two cases, the
embolus being- located at the bifurcation in twenty-five
cases, in the abdominal aorta above the bifurcation in
twelve, and in the thoracic aorta in two. Sudden death
was rare, over half living a week or more. Griffith9
in 1938 collected reports of 128 cases, twenty-seven with
operations and nine successes. The latest available col-
lection is that of McClure27 in 1943, who found seven-
teen successful cases. The most impressive group is
that of Murray,35 who reports five successful cases,
in all of whom heparin was used. There is some dif-
ference of opinion as to the surgical technique, but the
consensus is that the extraperintoneal abdominal approach
is advisable. With a prepared surgeon at hand, the
treatment of aortic embolism at the present time appears
promising.
The recent report of Barker et al2 in which medical
treatment is advocated and a series of six consecutive
recoveries reported, with no failures, is extremely inter-
esting. Nothing approaching this has been reported else-
where, and their recommended regime, which is essen-
tially that advised earlier in this paper (except that they
would wait twelve hours for relief or spasm), certainly
merits trial. These patients had waited as long as twen-
ty-four hours before therapy was started. It must be
noted that the authors did not claim that recovery meant
an entirely normal circulation, for usually persistent im-
pairment or absence of arterial pulsation or evidences
of mild to moderate arterial insufficiency with ischemia
remained. Function, to a degree only, was restored in
all. Such limitation of response must temper one’s
enthusiasm for medical treatment especially in view of
the good results, as regards adequate circulation, re-
ported by Murray.
Further experience with surgical approach assisted
by beparin and dicoumarol will indicate how long
it is safe to risk medical treatment. It would seem
possible to determine the results of antispasmodic ther-
apy within a few hours’ time, placing less of a risk on
the surgical treatment when it becomes necessary.
Summary
The complete failure to save a single life in the com-
plete series of eleven cases of peripheral arterial emboli
in a large municipal hospital over a period of thirteen
years is analyzed.
The factors predisposing to unsatisfactory therapy
are :
1. Failure in calling early medical attention.
2. Lack of prompt hospitalization and medical care
when first seen.
3. Lack of general awareness of medical treatment on
the part of the general practitioner and internist who
see the cases first.
4. Lack of awareness of the satisfactory results which
surgery can provide.
5. Lack of surgeons properly trained and interested
in this problem.
A review of broad cross-section of experience with
this problem is given.
A plan is outlined for the treatment of peripheral ar-
terial occlusion that promises much more successful re-
sults in these cases than have been heretofore obtained.
References
1. Agar, H. : Peripheral arterial embolism. Brit. M. T
2:101, 1943.
2. Barker, N. W. ; Hines, E. A., Jr., and Kvale, W. F. : Acute
arterial occlusion. Minnesota Med., 29:250, 1946.
3. Bull, P. : Quoted by McClure et al.21
4. Danzis, Max: Arterial embolectomy. Ann. Surg.. 98-249
1933.
5. Denk, W. : Zur Behandlung der arteriellen Emboli. Munch.
Med. Wchnschr., 81:437, 1934.
6. DeTakats, G. : Vascular accidents of the extremities. J.A.
M.A., 110:1075, 1938.
7. De Takats, G. : Arterial occlusion. Am. I. Sure., 33:60.
1936.
8. Dickinson, A. M.: Embolism of the peripheral arteries.
Am. J. Surg., 57:508, 1942.
9. Griffiths, D. L. : Arterial embolism. Lancet, 2:1339, 1938.
10. Griffiths, _ D. L. : Quoted by McClure et a!.27
11. Groth, K. : Tumor embolism of the common femoral artery.
Surgery, 8:617, 1940.
12. Hesse, E. : Uber die Embolie und Thrombose der Aorta
abdominalis under ihre operative Behandlung. Arch. f. klin.
Chir., 115:812, 1921.
13. Hopkins, P. : Peripheral arterial embolectomy. Brit. M.
J., 2:117, (July 28) 1945.
14. Johnson, M. L. : Thromboembolic phenomena. Northwest
Med., 41:241, 1942.
15. Key, E. : Uber Embolectomie. Acta chir. Scandinav.,
54:339, 1921-22.
16. Key, E. : Embolectomy. Brit. J. Surg., 24:350, 1936.
17. Koucky, J. J.; Beck, W. C., and Hoffman, J. M.: Peri-
pheral arterial embolism. Am. J. Surg., 50:39, 1940.
18. Lesser, A.: Embolic arterial occlusion of the lower ex-
tremities. J.A.M.A., 112:285, 1943.
19. Lewis, T. : Pain in embolism. Clin. Sc., 2:237, 1936.
20. Lindgren, S., and Wilander, O.: Use of heparin in vas-
cular surgery. Act. med. Scandinav., 107:148, 1941.
21. Linton, R. R. : Peripheral arterial embolism. New Eng-
land J. Med., 224:189, 1941.
22. Linton, R. R.: Acute peripheral arterial occlusion. New
England J. Med., 216:871, 1937.
23. Lund, C. C. : Embolectomy for peripheral embolism. Surg.,
Gynec. & Obst., 69:117, 1940.
24. Lund, C. C. : Arterial embolism. Ann. Surg., 106:880,
1937.
25. McFarlane, J. A.: Multiple emboli treated surgically. Brit.
M. J., 1:971, 1940.
26. Massey, L. W. C., and Steiner, P. : Peripheral arterial em-
boli. Lancet, 1:245, 1944.
27. McClure, R. D., and Harkins, H. N. : Recent advances in
the treatment of peripheral arterial embolism. Surgery,
14:747, 1943.
28. McKechnie, R. E., and Allen, E. V. : Study of 100 cases
of Embolism and thrombosis. Proc. Staff Meet., Mayo
Clin., 10:678, 1935.
29. Montgomery, A. H., and Ireland, J.: Traumatic segmentary
Arterial spasm. J.A.M.A., 105:1741, 1945.
30. Murphy, J. B. : Embolism of the iliac artery. J.A.M.,
52:1601, 1909.
31. Murray, D. W. G. : Embolism in peripheral arteries. Canad.
M.A.J., 35:61, 1936.
32. Murray, G. D. W. : Heparin in thrombosis and embolism.
Brit. J. Surg., 27:567, 1939-40.
33. Murray, G. D. W., and Best, C. H. : The use of heparin
in Thrombosis. Ann. Surg., 108:163, 1938.
34. Murray, G. : Heparin in thrombosis and blood vessel surgery.
Surg., Gynec. & Obst., 72:340, 1941.
35. Murray, G. : Aortic embolectomy. Surg., Gynec. & Obst.,
77:157, 1943.
36. Pearse, H. E., Jr.: Embolectomy for arterial embolism of
the extremities. Ann. Surg., 98:17, 1933.
37. Pemberton, J. de J. : Embolectomy, report of three cases.
Ann. Surg., 87:642, 1928.
38. Ravdin, I. S., and Wood, F. C. : Saddle embolus of the
Aorta. Ann. Surg., 114:834, 1941.
39. Riddell, V. H. : Embolectomy. Proc. Roy. Soc. Med., 30:
684, 1937.
40. Roome, N. W. : Sympathetic blockade in peripheral vascular
Accidents. Canad. M. A. J., 44:594, 1941.
41. Rykert, H. E., and Graham, D.: Some problems in the
diagnosis, prognosis and treatment of acute arterial occlu-
sion. Am. Heart J., 15:395, 1938.
42. Wetherell, F. S. : Arterial embolism of the extremities.
New York State J. Med., 44:35, 1944.
44. Zierold, A. A.: Treatment of arterial embolism. J.A.M.A.,
101:7, 1933.
47. Strombeck, J. P. : The late results of embolectomy per-
formed on arteries of the greater circulation (Sweden 1913-
32). Acta. chir. Scandinav., 77:229, 1935-36.
Discussions
Dr. A. A. Zierold, Minneapolis: It has been extreme-
ly interesting to hear this excellent review of a subject
which should be of considerable interest to everyone.
440
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
Dr. Borg has stated that peripheral arterial embolism is
much more common than we are led to believe. I be-
lieve this statement can be borne out by each one’s per-
sonal experience if carefully recorded. Some years
ago, at the instigation of Dr. George Fahr, I became
interested in arterial embolism and in the course of about
eighteen months collected twenty-eight cases which were
treated surgically and which were reported. During
the years following, I have accumulated fifteen or sixteen
more. As my interest has subsided, I have seen fewer
and fewer cases. The basis for any remarks which I
may have to offer is this personal experience.
All of the cases to come under my observation were
secondary to some cardiac disorder and the arterial em-
bolus was in each instance a fragment of some cardiac
thrombus. Following the lodgment of an embolus at
some narrowed point in the artery, usually a major
bifurcation, what is called a secondary thrombus devel-
ops. Properly speaking, this is not thrombus but intra-
vascular clotting, which is characterized by the appear-
ance of fibrin threads. It is this long distal clot which
most often defeats any surgical procedure. As Dr.
Borg has stated, it is common experience that the ma-
jority of arterial emboli lodge in the lower extremity
at the bifurcation of some major vessel. The diag-
nosis of peripheral arterial embolism is relatively simple.
The cardinal points Dr. Borg has emphasized. The
difficulty in treatment is to impress on the house staff
the necessity for early diagnosis. When gangrene be-
comes evident, treatment is limited to amputation. There
are several methods of determining the location of a
peripheral embolus and the extent of the damage in-
curred. Of these, I believe the best to be palpation of
the affected vessel itself. Irrespective of oscillometer
readings, color or temperature changes, a peripheral
embolus can be located definitely by the following rule :
If a peripheral arterial embolus exists, it will be found
at the first major bifurcation above which there is pulsa-
tion. For example, if a femoral pulse can be felt above
the profunda femoris but not below, the embolus will
be found at the union of the profunda femoris with the
main trunk.
The prognosis in the surgical treatment of embolism
is dependent upon two factors, elapsed time following
onset and the degree of occlusion of the vessel follow-
ing the lodgment of the embolic mass. If the artery
is suddenly and completely occluded by an embolus, no
clots, either proximal or distal, will form. If, however,
the vessel is incompletely blocked and there is a leak-
age about an irregularity of the embolus, a long tail-like
clot will form which cannot be removed from the distal
portion of the artery. In either event, the shorter the
elapsed time the better the prognosis. In occlusion of
the major vessels of the upper extremity, it has been my
experience that surgical treatment has not been necessary.
Likewise, emboli at the bifurcation of the popliteal ves-
sel, if untreated, rarely result in gangrene. If gangrene
does develop, it is unusual that more than the tips of the
toes are lost. In my hands, the surgical treatment of
emboli at this point is no better, if as good, as medical
treatment. In my own cases, 75 per cent survived opera-
tion but of all the cases only 30 per cent maintained ade-
quate circulation through the affected vessel. It is prob-
able that, with a careful use of heparin, dicoumarol, and
papaverine, this figure will be considerably increased.
Dr. Moses Barron, Minneapolis : Dr. Borg presented
a very interesting paper on the embolic phenomena in
peripheral blood vessels. He showed that we cannot be
top optimistic about the results of present-day treatment
although the use of anticoagulants seems to have im-
proved the results. My experience with this type of
case is very small. In two cases in which I was asso-
ciated where embolectomy was performed, both patients
died. In one case treated medically, the patient sur-
vived. This patient had been seen several weeks pre-
April, 1947
viously, and she was suffering with an advanced case of
heart failure. One day I was called and informed that
the patient had suddenly developed pain in one leg with
resulting numbness. She was sent to the hospital where
I saw her about twelve hours after the onset. I gave
her papaverine subcutaneously, applied warmth and rais-
ed the head of the bed about 12 inches. The foot ap-
peared cold and the patient could not move either thg
foot or toes. She appeared very weak, almost in shocK.
She complained of pain in the foot especially at night.
The next morning when I saw her the leg had turned
a grayish cyanotic color and this at once showed the
seriousness of the condition. The next day blotches were
scattered over the leg from the knees downward and
the line of demarcation was present around the leg just
below the patella. I had been in Toronto several weeks
previous where there was presented a method of treat-
ment of peripheral vascular disease which appeared to
be promising. Since the method caused no serious reac-
tions, I decided to try it on this patient. I mixed 25
c.c. of ordinary anesthetic ether witfi 1,000 c.c. of normal
saline and added 150 mg. of niacine. This mixture was
given intravenously very slowly so that it would take
at least two hours to run in. The next morning the
leg appeared definitely better ; on the second day after
the treatment the discoloration had completely disap-
peared and only faint blotches remained. The patient
was feeling better. The blocking of the artery appeared
to be just below Poupart’s ligament at about the bifurca-
tion of the profunda femoris. No pulsation was evident
anywhere below this point. She was given twelve daily
injections, then a rest of a week and then another dozen
injections. The change in the circulation was most
striking. The color of the leg returned to normal, she
was able to move the foot and wiggle the toes. How-
ever, no pulsation appeared in the arteries. I then started
sitting her up with the feet dangling. At first this
caused much pain ; the length of time of sitting up
had to be increased very slowly. Because of the finan-
cial status of the patient, I had to send her to the Gen-
eral Hospital for further treatment. Several weeks
after her admission there, I was informed by the resi-
dent that she was getting definitely better.
This case shows what this type of treatment can do
in arterial obstruction. Of course, one does not know
the final result yet. I would strongly urge the use of
this method of treatment for peripheral vascular disease.
Even ulcers seem to respond well to this method. The
crust and discharge of ulcers may be cleared up by spray-
ing with ether and applying ether packs on cotton.
Dr. Gordon Kamman, Saint Paul : One of the cases
which Dr. Borg mentioned was in Ancker Hospital and
on my service. I saw this patient about six hours after
the onset of the arterial embolism which, in this case,
was in the popliteal artery. It is one of the cases for
which the surgeons did not do anything.
I would like to ask Dr. Barron and Dr. Borg what
becomes of the embolus when medical treatment is used?
Is the embolus dissolved, does it canalize, or does it
j ust seem to vanish ?
Dr. Barron : The theory of this treatment is that
the injection causes an increase in the collateral circula-
tion. The amount of canalization of thrombosed ves-
sels is often very great. I recently had a patient who
developed complete thrombophlebitis of the jugulars on
the left side of the neck. She was at the time confined
to bed with acute rheumatic fever. She was given di-
coumarol for several days and then it was stopped.
Subsequently the jugular veins appeared to be back again
to normal with apparently a complete absorption of the
thrombosis. It is, therefore, possible to have extensive
canalization of the clot.
( Continued on Pape 447)
441
♦ Reports and Announcements ♦
AMERICAN ASSOCIATION ON
MENTAL DEFICIENCY
The seventy-first annual meeting of the American
Association on Mental Deficiency will be held at the
Lowry Hotel, Saint Paul, Minnesota, May 28-31, 1947,
inclusive. The association has a membership from the
fields of medicine, psychology, education and social work.
All interested persons who are not members are in-
vited to attend. A fee of 50 cents will entitle them to
admission to any and all meetings. There will be an
open meeting Wednesday night, May 28, in the ball-
room of the Lowry Hotel, for which there will be no
charge.
Dr. Edward J. Engberg, Minnesota School of Feeble
Minded, Faribault, Minnesota, is national chairman on
Membership and co-chairman of the Arrangements Com-
mittee.
AMERICAN COLLEGE OF PHYSICIANS
AND SURGEONS
President of the Minnesota Chapter of the American
College of Physicians and Surgeons, a society for general
practitioners, is Dr. F. G. Benn, Minneapolis.
Other officers are Dr. A. J. Lewis, Henning, and Dr.
Stanley Kucera, Lonsdale, vice presidents, and Dr. A. E.
Ritt, Saint Paul, secretary-treasurer. Dr. Charles Don-
aldson, Foley, is president-elect.
Originated less than a year ago, the American College
of Physicians and Surgeons is made up of general
practitioners, with its main purpose to inform the fam-
ily doctor of the practices and problems facing the gen-
eral practitioner. In addition to the state organization,
regional chapters have been formed throughout the
state.
Saint Pcml Regional Chapter. — Officers of the Saint
Paul chapter are Dr. A. E. Ritt, president; Dr. James
L. Benepe, president-elect ; Dr. E. J. Fogelberg and Dr.
C. C. Cooper, vice president ; Dr. G. P. Wenzel, secre-
tary-treasurer ; and Dr. E. V. Davis and Dr. P. C.
Roy, members of the board.
Fergus Falls Regional Chapter. — Organized in Octo-
ber, 1946, the Fergus Falls chapter has as its officers 1 )r.
Edward W. Humphrey, Moorhead, president ; Dr. C.
H. Pierce, Wadena, president-elect ; Dr. S. B. Seitz,
Barnesville, and Dr. C. J. Lund, Fergus Falls, vice
presidents ; and Dr. E. C. Hanson, New York Mills,
secretary-treasurer.
CRIPPLED CHILDREN'S CLINICS
Crippled children of Minnesota will have an oppor-
tunity for medical examination and advice at eleven
district clinics to be conducted by the Crippled Children’s
Services of the Minnesota Division of Social Welfare,
Jarle Leirfallom, director, announced this week.
These clinics, which are a part of the year-round serv-
ice financed by the federal and state government, are
for crippled ch ldren and young people under 21 years
of age. Vocational tests and advice will be given to
those over fourteen years of age.
The schedule for the clinics is as follows :
Worthington, March 29 — serving Nobles, Jackson, Mur-
ray, Rock, Pipestone, and Cottonwood counties.
St. Cloud, April 12 — serving Stearns, Benton, and
Sherburne counties.
Austin, April 19 — serving Mower, Freeborn, Steele,
and Dodge counties.
Thief River Falls, April 25 — serving Pennington,
Marshall, and Red Lake counties.
Thief River Falls, April 26 — serving Roseau and Kitt-
son counties.
Detroit Lakes, May 3 — serving Becker, Clay, and
Mahnomen counties.
Virginia, May 9 — serving St. Louis and Koochiching
counties.
Grand Rapids, May 10 — serving Itasca and Cass coun-
ties.
Brainerd, May 17 — serving Crow Wing, Wadena,
Todd, Cass, Mille Lacs, and Aitkin counties.
Faribault, May 24 — serving Rice, Goodhue, Scott, and
Dakota counties.
Morris, June 7 — serving Stevens, Pope, Douglas, Grant,
Traverse, and Big Stone counties.
Moose Lake, June 14 — serving Aitkin, Carlton, Pine,
Kanabec, Lake, and Cook counties.
Two orthopedic surgeons, a pediatrician, vocational
rehabilitation workers, public health nurse, physical thera-
pists, other nurses, and medical social workers are in-
cluded on the staff.
The following organizations are co-operating with
the Crippled Children’s Services in the clinic program :
Minnesota-Dakota Orthopedic Society, Northwestern
Pediatric Society, Minnesota Public Health Association,
Gillette State Hospital for Crippled Children, Division
of Vocational Rehabilitation, the Minnesota State Medi-
cal Association and the local Medical Society.
MINNESOTA PATHOLOGICAL SOCIETY
The regular meeting of the Minnesota Pathological
Society of the University of Minnesota Medical School
was held on Tuesday, March 18, in the Medical Science
Amphitheater. Dr. A. B. Baker spoke on “Bulbar
Poliomyelitis : New Interpretations of the Clinical-
Pathological Picture.” Dr. M. B. Visscher then spoke on
“Physiological Problems in Poliomyelitis.”
MINNESOTA SOCIETY OF NEUROLOGY
AND PSYCHIATRY
The regular dinner meeting of the Minnesota Society
of Neurology and Psychiatry was held at the Town and
Country Club, Saint Paul, on Thursday evening, March
11, 1947.
The following were accepted into active membership :
Drs. Philip K. Arzt, Kendall B. Corbin, Donald R.
Reader, Marvin Sukov, and Leonard A. Titrud.
(Continued on Page 444)
442
Minnesota Medicine
IN CONSTIPATION OF PREGNANCY . . .
“SMOOTH AGE”
MANAGEMENT
Pressure on the pelvic bowel by the enlarged uterus
and impaired abdominal muscle tone account,
to a great extent, for the high incidence of
constipation in pregnancy.
Smooth, gentle, normal evacuation — the desired action
in pregnancy constipation management — is afforded
by the "smoothage" of Metamucil.
By providing soft, plastic, water-retaining bulk,
Metamucil promotes normal, easy peristaltic movement.
Metamucil is the highly refined mucilloid of Plantago
ovata (50%), a seed of the psyllium group, combined
with dextrose (50%), as a dispersing agent.
METAMUCIL
is the registered trademark of
G. D. Searle & Co., Chicago 80, Illinois.
SEARLE
April, 1947
RESEARCH
IN THE SERVICE OF MEDICINE
443
WOMAN’S AUXILIARY
MINNESOTA SOCIETY OF
NEUROLOGY AND PSYCHIATRY
(Continued from Page 442)
Dr. Edmund W. Miller presented his inaugural thesis
on “Personality Changes Observed in Prefrontal Lobec-
tomized Patients.” Dr. Reynold A. Jensen read a paper
entitled “The Emotional Factors in Ulcerative Colitis
in Children.”
HERMAN JOHNSON MEMORIAL LECTURE
Dr. Frank G. Dickinson, economist and insurance
specialist who recently became director of the Bureau
of Medical Economic Research of the American Medi-
cal Association, has been selected to give the annual
Herman Johnson Memorial lecture to the senior class
of the medical school at the University of Minnesota.
This lecture, which has been given each year since
1938 in memory of Dr. Herman M. Johnson of Dawson,
is provided for in a fund established by the House of
Delegates of the Minnesota State Medical Association
soon after Dr. Johnson’s death in 1935.
The address this year is to be given May 28 at 4
p.m., in the large amphitheater of the medical school
on the University Campus.
In view of Dr. Johnson’s deep interest in medical
economics and social problems, the subject for this lec-
ture and the speaker are usually chosen from the eco-
nomics field or from the field of public service. Dr.
Dickinson is particularly well qualified to give the type
of message which this lectureship calls for. Famous
for his football rating system which he developed as a
hobby, Dr. Dickinson has long been associated with eco-
nomics— as a teacher, an author and an insurance con-
sultant.
Dr. Dickinson is currently making an intensive study
for the American Medical Association of the problem
of equalizing the supply of and demand for medical
service in this country.
The Johnson Lectureship will be Dr. Dickinson’s third
appearance in the Twin Cities. His first visit was in
1940 when he came to award the Rockne Memorial
trophy to the University of Minnesota; his second, his
appearance at the banquet of the County Officers meet-
ing, held in Saint Paul in March of this year.
REPORT OF HOUSE OF DELEGATES
AMERICAN MEDICAL ASSOCIATION
( Continued from Page 423)
By and large, having a House of Delegates meeting
in the interim between regular meetings of the Ameri-
can Medical Association provides the delegates with
an excellent opportunity to concentrate on business af-
fairs without any outside interference or attractions. It
is hoped that every physician who possibly can will make
arrangements to be in Atlantic City in June to attend
the centennial celebration of the American Medical As-
sociation.
W. A. Coventry, M.D.
A. W. Adson, M.D.
E. W. Hansen, M.D.
F. J. Savage, M.D.
WOMAN’S AUXILIARY
AMA AUXILIARY BULLETIN
A few more months and the members of the Woman’s
Auxiliary to the American Medical Association will be
arriving in Atlantic City, New Jersey, for their annual
convention, June 9-13.
Have you made your reservation? If not, send your
request at once to Dr. Robert A. Bradley, Chairman
Subcommittee on Hotels, 16 Central Pier, Atlantic City,
New Jersey.
HENNEPIN COUNTY
The annual Public Relations meeting was held at
the Medical Arts Lounge March 7, with Mrs. Frank
T. Cavanor as general chairman.
Representatives from many women’s organizations
were guests, to hear a lecture on “Hormones from Ado-
lescence to the Prime of Life,” by Dr. Nora Winther,
gynecologist at the Llniversity of Minnesota Student
Health Service.
Mrs. Elmer M. Rusten gave a talk on health bills in
the Minnesota Legislature.
MOWER COUNTY
Mrs. F. H. Rosenthal was hostess to the Woman’s
Auxiliary of the Mower County Medical Society, Febru-
ary 24, at her home.
Mrs. P. A. Lommen reported on the last co-ordinating
council meeting. Council dues were paid, and Mrs. L.
G. Flanagan made a motion that each member pay $2.00
toward the auxiliary project of the year and $1.00 to
the Cancer Control Fund.
RANGE MEDICAL AUXILIARY
Organization of the Range Medical Association Auxili-
ary took place in Hibbing on February 13, when wives
of physicians belonging to the Range Medical Associa-
tion held their initial meeting at the home of Mrs. Rob-
ert L. Bowen.
Attended by representatives from Virginia, Buhl,
Chisholm, Keewatin, Grand Rapids and Hibbing, the
meeting brought into being an organization which auto-
matically becomes a branch of the St. Louis County
and Minnesota State Medical Auxiliaries.
The constitution and by-laws of the State Medical
Auxiliary were read by Mrs. Robert Murray, who also
briefly reviewed the histories of four medical auxiliaries
of which she has been a member. To simplify future
work, it was decided that all officers serving at one time
should be from the same geographical section of the
Range. Hibbing was chosen to be the first district
under this plan.
Mrs. Robert L. Bowen was selected as chairman of
the Nominating Committee and was instructed to pre-
pare a slate of officers for the election to be held at the
next meeting. As members of her committee she named
Mrs. L. W. Johnsrud, Hibbing; Mrs. Edward T. Clark,
Buhl ; Mrs. Clarence Jacobson, Chisholm ; Mrs. E. R.
Loofborrow, Keewatin; and Mrs. L. W. Morsman,
Hibbing.
444
Minnesota Medicine
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April, 1947
445
IN MEMORIAM
In Memoriam
DOMNICK PATRICK DEMPSEY
Dr. Domnick P. Dempsey, of Kellogg, Minnesota,
died November 30, 1946, at St. Mary’s Hospital, Roches-
ter, following a fracture of the hip sustained in a fall.
He was seventy-six years of age.
Dr. Dempsey was horn at Clermont, Iowa, on Sep-
tember 9, 1870. After receiving a B.S. degree from Val-
paraiso University in 1903, he obtained his medical edu-
cation at Creighton Medical School in Omaha, graduat-
ing in 1906. He interned at St. Mary’.s Hospital in Min-
neapolis, and opened an office in Kellogg, Minnesota,
and in Wabasha, Minnesota, in conjunction with Drs.
Lester and Doherty in 1907.
He was elected president of the Wabasha County
Medical Society in July, 1912. The subject of his pres-
idential address at the annual meeting in 1913 was “The
Press as a Factor in Public Health Work.” Again
elected president in 1928, he entitled his address in 1929,
“Let Us Try,” which was a plea for all members of the
medical profession to live up to the highest principles
of professional ethics. In 1942 he was elected vice
president of the society, and in 1943, in the absence of
the president who was serving with the armed forces,
Dr. Dempsey again gave the presidential address, which
was entitled “A Few Remarks on Obstetrics,” relating
some of his interesting experiences during thirty-six
years of practice.
At the time of his death, Dr. Dempsey was on the
staff of St. Elizabeth’s Hospital, Wabasha, and was
an affiliate member of the Wabasha County Medical
Society, the Minnesota State and American Medical
Associations.
He is survived by a sister who lives in Dubuque,
Iowa, and by several nephews and nieces in Iowa and
Nebraska.
* * *
Note: More complete information having been re-
ceived on the life of Dr. Dempsey, since publication of
the obituary in the February issue, and in order to cor-
rect the mispelling of his first name, this second sketch
of his life is published in this issue.
WALTER I. LILLIE
Dr. Walter I. Lillie, former associate in ophthalmology
at the Mayo Clinic and since 1933 a resident of Phila-
delphia, died suddenly on February 21, 1947.
Dr. Lillie was born November 5, 1891, at Grand
Haven, Michigan. He received his M.D. degree at the
University of Michigan in 1915 and the degree of M.S.
in ophthalmology from the University of Minnesota in
1922. He interned at the University of Michigan Hos-
pital in 1916 and practiced at Flint, Michigan, before
joining the Mayo Clinic in 1917. At the time of his
death Dr. Lillie was professor of ophthalmology at
temple University School of Medicine and head of the
Department of Ophthalmology at Temple University
Hospital, Philadelphia.
Dr. Lillie was certified as a specialist in ophthalmology
in 1929 and was a member of the American College of
Surgeons, the American Ophthalmological Society, and
the American Academy of Ophthalmology and Otolaryn-
gology.
In 1932 Dr. Lillie spent six weeks in Shikarpur, In-
dia, at the Seth Heranand Charitable Eye Hospital and
shared in the operative work of the annual clinic being
held by Mr. H. T. Holland, F.R.C.S.
He was married on August 30, 1916, to Opal C. Jones,
who survives him. His brother, Dr. H. I. Lillie, is
chief of the Section on Rhinology and Otolaryngology
of the Mayo Clinic.
WINFORD PORTER LARSON
Dr. Winford Porter Larson, Professor of Bacteriology
and Immunology at the University of Minnesota died,
January 1, 1947 of staphylococcic bacteriemia. Dr. Lar-
son was born at Poy Sippi, Wisconsin, March 7, 1880.
He received the M.D. degree from the Illinois Medical
School in 1904, and afterwards spent seven years in
postgraduate study at Berlin, Paris, Vienna, and Copen-
hagen. He was appointed Instructor in Bacteriology
and Immunology at the University of Minnesota in
1911, and was made Head of the Department in 1918.
He was a member of the Society of Bacteriologists, the
Association of Pathologists and Bacteriologists, and the
Association of Immunologists. During his long career
he developed a strong department at Minnesota which
embraced fundamental bacteriological studies as well as
Medical Bacteriology.
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446
Minnesota Medicine
IN MEMORIAM
His published scientific papers covered a number of
subjects and were more than forty in number. His
earliest significant publication was to demonstrate that
children receiving milk from herds of cattle infected
with contagious abortion gave evidence of becoming
infected with the organism. This was probably the
earliest work on the demonstration of the occurrence of
undulant fever in man.
His basic interest was the physical chemistry of bac-
teria which was the concern of many of his papers.
He was the first to demonstrate that the form of bac-
terial growth and cultures was not a character of the
organ, but of the relationship of the organ to the medium
in which they were growing. He studied the effect of
high pressure on microbes and showed that they could
be exploded by realeasing them suddenly from high pres-
sure. A number of his scientific studies had to do with
the effect of surface tension depressants on bacterial
growth and toxin formation. He became especially in-
terested in immunizing against diphtheria and scarlet
fever and was the first to effect a method of protecting
against these diseases by active immunization with de-
toxified bacterial toxins. During his years of research
he carried out numerous investigations on the bac-
teriology of lobar pneumonia and was the first to de-
velop an active anti-pneumococcus serum made from
rabbits.
At the time of his death, his active investigations
concerned the nature of post pneumonic encephalitis and
had developed evidence that this was due to abnormal
blood clotting associated with the recovery processes.
E. J. Bell
CLIFFORD G. SALT
Dr. Clifford G. Salt, Minneapolis, died February 13,
1947, at the Swedish Hospital, following a prolonged
illness. He was sixty-five years of age.
Dr. Salt was a graduate of the University of Ohio
and received his medical degree from the University of
Minnesota in 1921. He was a member of the Hennepin
County Medical Society, the Minnesota State and Ameri-
can Medical Associations. He is survived by his widow,
three sons, Terry, John and Thomas, and a daughter,
Celia, all of Minneapolis.
MINNESOTA ACADEMY OF MEDICINE
Peripheral Arterial Embolism
(Continued from Page 441)
Dr. Borg, in closing: Dr. Kamman’s question has
been answered, I think. I would simply state that a great
number of emboli in the upper extremity require no sur-
gical treatment. However, the last two cases which I
had the opportunity of seeing had upper extremity em-
boli. One patient had numerous embolic phenomena.
He called me as soon as his pain came on in the hand.
I recognized what had happened and found he had a
hand in which no radial pulsation could be felt. I gave
him intravenous papaverine and inside of half an hour
the color returned in the hand and the numbness disap-
peared. I do think we cannot regard all upper extremity
emboli as innocuous.
The meeting adjourned.
A. E. Cardle, M.D., Secretary
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April, 1947
447
Of General Interest
At an annual reunion dinner on February 25, Dr.
R. O. Quello, Minneapolis, was elected president of
the Twin City St. Olaf Club.
* * *
Dr. H. R. Butt, Rochester, discussed “Hepatitis” at
a meeting of the Woodbury County Medical Society in
Sioux City, Iowa, on February 20.
if: Jfc
Dr. L. E. Prickman, Rochester, spoke on “Brucellosis”
at a meeting of the West Concord Farm Bureau held
in West Concord on March 6.
* * *
At a meeting of the Sedgwick County Medical So-
ciety, Wichita, Kansas, early in March, Dr. B. E.
Hall, Rochester, presented a paper entitled “Radio-
active Phosphorus Therapy.”
* * *
Dr. H. A. Roust, Montevideo, after seventeen years
in the same office building, has moved to the Bauman
Building in Montevideo, where he has opened a six-
room office.
* * *
Dr. Thomas Lowry, Minneapolis, has announced the
association of Dr. Herbert F. R. Plass in the practice
of internal medicine, with offices at 629 Medical Arts
Building.
* * *
Dr. Frank E. Mork, Anoka, has been elected vice
president of the St. Andrew’s Hospital staff in Minne-
apolis, thereby becoming a member of the Executive
Board governing the hospital.
* * *
Dr. Ralph L. Estrem has reopened his medical practice
in Fergus Falls. Dr. and Mrs. Estrem and their son
recently returned from Panama where Dr. Estrem was
stationed while in the army.
* * *
At a postgraduate refresher course at the University
of Kansas School of Medicine on March 10, Dr. R. D.
Pruitt, Rochester, spoke on “Treatment of Acute Myo-
cardial Infarcation” and “The Precordial Electrocardio-
gram.”
* * *
Carrying out a long-contemplated plan, Dr. M. I.
Hauge, Clarkfield, has moved his offices from the lower
floor of the Clarkfield Hospital to a new suite in a
more centrally located office building.
* * *
“Total Gastrectomy with Esophagoduodenal Anasto-
mosis” was the subject of a talk by Dr. J. T. Priestley,
Rochester, at a meeting of the Central Surgical Asso-
ciation held in Chicago in February.
* * *
Dr. John F. Madden, Saint Paul, addressed the Polk
County Medical Society at Frederic, Wisconsin, on
February 20, speaking on “The Treatment of Common
Skin Diseases.”
^ *
Dr. Benedik Melby, Blooming Prairie, was married
to Miss Julia Hendrickson of that city on March 3.
Shortly after the ceremony the couple left for Chicago
where they planned to spend several days.
* * *
On February 28, Dr. Wilford F. Widen, Minneapolis,
gave a talk on “The Game of Life” at the annual Fa-
thers’ and Sons’ banquet sponsored by the Brotherhood
of Ebenezer Lutheran Church in Minneapolis.
* * *
At a meeting of the Minnesota Occupational Therapy
Association in Minneapolis on February 22, Dr. E. C.
Elkins, Rochester, presented a paper and a motion pic-
ture on “Physical Rehabilitation of the Paraplegic.”
* * *
During March, Dr. T. A. Bargen, Rochester, traveled
to Buneos Aires, Argentina, to participate in a Na-
tional Medical Convention. On the way he stopped to
deliver addresses at meetings of the Medical Society of
Puerto Rico at San Juan, Puerto Rico, and the Assembly
of Medicine at Rio de Janerio and Sao Paulo, Brazil.
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448
Minnesota Medicine
OF GENERAL INTEREST
Dr. B. T. Horton, Rochester, was guest speaker at
the Founders’ Day banquet of the Phi Chi medical
fraternity held in Saint Paul on February 27. Dr.
Horton discussed recent advances in the treatment of
nerve deafness.
* * *
Dr. Charles E. Stafford, Baudette, received official
notice on February 28 that he had been promoted to
the rank of major in the army medical corps. During
the war Dr. Stafford served for two years in the
Philippines and in Australia.
* * *
Dr. R. C. Radabaugh, Hastings, has announced that
Dr. W. D. Holcomb, formerly of Colorado Springs,
Colorado, has joined him as an assistant. Dr. Holcomb,
a graduate of Boston University, has been in general
medical practice in Colorado.
* * *
The village council of North Saint Paul recently
named a street in honor of Dr. E. W. Cowern, who has
practiced in the village since 1903. Located on Colby
Hill in the new Country Club Heights addition, the
street has been named Cowern Place.
* * *
A new medical magazine, Postgraduate Medicine, has
Dr. Charles W. Mayo, Rochester, as its editor-in-chief.
The new publication, which released its first issue on
February 28, is the official bulletin of the Interstate
Postgraduate Medical Assembly, an organization devoted
to the extension of medical knowledge.
* * *
Among recent lecturers at the Center for Continua-
tion Study at the University of Minnesota have been
Dr. J. D. Camp, Rochester, who spoke on “Malacic Dis-
eases of Bone,” and Dr. J. M. Waugh, Rochester, who
discussed “Vaginal Plastic Operations” and “Vaginal
Hysterectomy and Anticoagulant Therapy.”
*
Pequot Lakes obtained a new physician when Dr.
James E. Fearing, formerly of Virginia, became asso-
ciated with Dr. T. E. Eyres early in March. When Dr.
Eyres leaves in June to take postgraduate work at the
Cook County Hospital in Chicago, Dr. Fearing will take
over the practice.
* * *
Five of the Minnesota surgeons who participated in
a sectional meeting of the American College of Surg-
eons, held in Omaha on March 14 and 15, were Drs.
Frederick G. Kolouch, John L. McKelvey and Edward
T. Evans, Minneapolis, and Drs. John S. Lundy and
Edgar Allen, Rochester.
^ ^
Stressing the advances that medicine is making in
determining the cause of cancer, Dr. R. W. Kearney,
Mankato, discussed progress in medicine at a dinner
meeting of the Mankato Business and Professional
Women’s Club on February 18. The meeting was held
in observance of the club’s annual health program month.
* jK *
A conference on the treatment of experimental polio-
myelitis in animals, held in New York on February 21,
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449
April, 1947
OF GENERAL INTEREST
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2527 2nd Ave. S.. Minneapolis, Phone At. 7369
was attended by Dr. Raymond N. Bieter, head of the
Department of Pharmacology in the University of Min-
nesota Medical School. The conference was sponsored
by the National Foundation for Infantile Paralysis.
* * *
Dr. A. H. Wolf, Harmony, recently sold his office
equipment and medical practice to Dr. Carl G. Nelson,
formerly of Minneapolis. Dr. Nelson, who has begun
his practice in Harmony, graduated from medical school
in 1942 and later spent almost three years in the army,
two years of which were in overseas service.
* * =K
The University of Minnesota regents at their monthly
meeting on February 14 named Dr. William B. Tucker
as a clinical associate professor of medicine. Dr. Tuck-
er, who is chief of the tuberculosis service at the Veter-
ans Hospital in Minneapolis, will serve part time at the
University.
* * *
Dr. J. Hartman, in charge of the Soudan Hospital
for the past year and a half, has resigned his position
and moved to Portland, Oregon, to enter private prac-
tice. The hospital, owned by the Lenont-Peterson Clinic
of Virginia, has been taken over by Dr. T. P. Mollers
of Mountain Iron.
* * *
Dr. H. Waltman Walters, Rochester, has been ap-
pointed to the National Advisory Cancer Council of the
United States Public Health Service. Dr. Walters, who
graduated from Dartmouth College and did graduate
work in surgery at the University of Minnesota, is a
surgeon at the Mayo Clinic and professor of surgery
in the Mayo Foundation.
* * *
Certification to the American Board of Internal
Medicine has been awarded Dr. Randall Derifield,
Hibbing, it was announced March 1.
Dr. Derifield, a staff member of the Mesaba Clinic,
was a lieutenant colonel in the army during the war and
served overseas for thirty months, the greater part of
which lime was spent in New Caledonia.
* * *
Attended by more than 200 Izaak Walton members
from throughout the state, a testimonial dinner was
held in Rochester on February 20 to honor Dr. M. M.
Hargraves, Rochester, the new state president of the
organization. Past and present state and national of-
ficers of the Izaak Walton League were included in
the group which gathered to salute Dr. Hargraves.
* * *
In Stillwater, Dr. R. J. Tosewski and his staff are
now established in a new suite of offices on South
Main Street. Decorated and furnished with an emphasis
on patient comfort, the office suite consists of a recep-
tion room, children’s room, examination and consulta-
tion rooms, as well as a modern x-ray room and dark-
room.
* * *
In charge of a veterans’ psychiatric service, recently
inaugurated in Minneapolis by the Hennepin County Red
Cross, is Dr. Eric K. Clarke, assisted by Dr. Stanley
G. Law and Dr. William Fleeson of the Minnesota
Psychiatric Institute. The psychiatric service, located
in offices at 1111 Nicollet Avenue, Minneapolis, is avail-
able to veterans and members of their families.
* % *
A new staff member of the Worthington Clinic is
Dr. John Stam, formerly of Minneapolis, who began
practice in Worthington on March 17.
Dr. Stam, a graduate of the University of Illinois
Medical School, interned at Cook County Hospital,
Chicago, and was a resident in pediatrics at North-
western Hospital, Minneapolis. For a time he prac-
ticed general medicine at La Grange, Illinois.
* * *
Dr. Richard H. Picha, recently discharged from the
army, plans to enlarge the St. Louis Park office which
he shares with Dr. A. C. Stahr, and to continue his
Hopkins practice. A graduate of the University of Min-
nesota, Dr. Picha has practiced in St. Louis Park for
thirteen years. While in the army, he worked in
anesthesia and general surgery at hospitals in Michigan,
Indiana and Illinois.
* * *
The Glenwood Clinic, a twenty-three room, air-con-
ditioned structure erected by Dr. M. B. Dahle, Glen-
wood, was officially opened on March 15. Occupied by
Dr. Dahle and Dr. P. A. Swedenburg, the new clinic
building contains a ward, an operating room, x-ray
laboratory, physiotherapy and eye-ear-nose-throat de-
partments, three suites of offices, a four-room dental
suite, and a large reception room.
450
Minnesota Medicine
OF GENERAL INTEREST
Dr. Joseph L. Arko, Hibbing, attended a course in
ophthalmology from February 17 to 21 at the Center
for Continuation Study at the University of Minnesota.
* * *
Among those from the Duluth area who attended the
meeting of officers of county medical societies of the
Minnesota State Medical Association, held in Saint Paul
on March 1, were Dr. D. W. Wheeler, president, and
Dr. Elizabeth Bagley, secretary-treasurer, of the St.
Louis County Medical Society.
* * *
Dr. Francis W. Lynch, Saint Paul, clinical associate
professor of dermatology at the University of Minne-
sota, was guest speaker at a meeting of the Northwest
District Medical Society held on February 27 in Minot,
North Dakota. Speaking on epidemic ringworm of the
scalp, Dr. Lynch described how the disease has been
treated in school children in Saint Paul during the
past two years.
^ ^ ^
In an exchange of cigars with Dr. Charles W. Brown,
Minneapolis, on February 26, Dr. William A. O’Brien,
director of postgraduate medicine at the University of
Minnesota, thought he had developed diplopia.
Dr. O’Brien was passing out cigars to celebrate the
arrival of a baby daughter, his sixth child. Dr. Brown
for the same reason was passing out cigars, only his
came in doubles. Mrs. Brown had given birth to twins.
5*1 5*C
With the recent reappointment by Governor Young-
dahl of two members whose" terms expired January 1,
1947, and the appointment of one new member, the State
Board of Health now consists of Drs. T. B. Magath,
Ruth E. Boynton, F. W. Behmler, and E. S. Platou;
-W. L. Webb, D.D.S. ; Gustav Bachman, Pharm.D. ; F.
E. Bass, C.E. ; L. M. Thompson ; and M. Sidney He-
deen, D.O., succeeding Dr. A. G. Schulze, who has
resigned. * * *
Dr. C. C. Burlingame, former assistant superintendent
of the Fergus Falls State Hospital, is now head of a
large neurological clinic in the East, with twenty-one
physicians on his staff, and with offices in New York,
Boston, and New Haven, Connecticut.
While in Fergus Falls, Dr. Burlingame attracted na-
tional attention for his work in wiping out typhoid fever
among the patients at the state hospital . During World
War II he was a member of General Marshall’s staff.
He has recently completed a medical survey in France,
Germany and England.
* * f *
Dr. Joseph B. Gaida, St. Cloud, has announced the
association of Dr. John E. Conway as a specialist in
eye, ear, nose and throat diseases.
Dr. Conway, a graduate of the University of Wis-
consin Medical School in 1940, interned at Ancker Hos-
pital, Saint Paul, and took postgraduate training in eye,
ear, nose and throat diseases at the University of Min-
nesota. He was assistant resident in 1941-42, and chief
resident in 1942-43, in the Eye, Ear, Nose and Throat
Department of Ancker Hospital. While in the army, he
was chief of the Eye, Ear, Nose and Throat Depart-
ments of army hospitals at Herrington and Topeka,
Kansas.
* * *
Dr. Fred J. Pratt, Jr., who recently returned from
the East where he had been doing postgraduate work
since his release from the army, is now associated with
his father, Dr. F. J. Pratt, Sr., and with Dr. G. M.
Koepcke at 801 Physicians and Surgeons Building, Min-
neapolis.
Dr. Pratt, a graduate of the University of Arkansas
Medical School, interned at Minneapolis General Hos-
pital and had a year of residency there in eye, ear, nose
and throat diseases. While in the army, he was stationed
at the Nautilus Veterans Hospital, Miami Beach, Flori-
da, in charge of the Eye, Ear, Nose and Throat De-
partment.
* * *
Sponsored by Sigma Xi, scientific fraternity, Dr. Gay-
lord W. Anderson, director of the School of Public
Health at the University of Minnesota, discussed ad-
vances in medicine during World War II, at a special
lecture on February 25 in Northrop Memorial Audi-
torium at the University. During the war Dr. Ander-
son was director of the Division of Medical Intelligence
in the office of the Surgeon General. ,
Earlier in the month Dr. Anderson spoke to the
Faculty Women’s Club at the University on the type
of work done by his division -during the war, work that
included the compilation of climatic, health and sanitary
evidence from every part of the world.
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April, 1947
451
OF GENERAL INTEREST
A pioneer physician of the border country, Dr. Robert
Hugh Monahan, Sr., International Falls, has retired
after forty years of active practice.
Dr. Monahan, a graduate of Hamline University Medi-
cal School and the University of Minnesota, practiced
in International Falls from 1909 to 1917 and again from
1940 to 1947. He enlisted in the army in 1917 and,
while stationed in England, studied orthopedics under
Sir Robert Jones, one of the outstanding orthopedic
surgeons of the time. Following the war, Dr. Monahan
practiced in Minneapolis and was a staff member of
St. Barnabus Hospital for twenty years.
Returning to International Falls in 1940, he served
on the Selective Service examining board in addition
to maintaining a private practice and helping to manage
the local hospital. Recently, his son, Dr. R. H. Monahan,
Jr., after service in World War II, returned to the city
to resume medical practice.
Dr. Monahan, Sr., began his retirement in late Janu-
ary by leaving for California for the remainder of the
winter.
* * *
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The U. S. Civil Service Commission has announced
an examination for filling Medical Officer positions.
These positions are located in various Federal agen-
cies, in Washington, D. C. ; in the U. S. Public Health
Service and the Indian Service, throughout the United
States; and in the Panama Canal Service, in the Panama
Canal Zone. Salaries range from $4,149 to $5,905 a
year, with higher salary rates for the Canal Zone posi-
tions. No written test will be given for these positions.
To qualify, all applicants must be graduates of a medical
school of recognized standing and must also meet other
requirements which include experience and training in
the field of medicine. The age limits are 45 years for Pan-
ama Canal Zone positions and 62 years for other posi-
tions. These age limits are waived for persons entitled to
veteran preference (up to the age of 62 for the Panama
Canal Service and without limitation for other agencies).
Interested persons may secure information and appli-
cation forms from most first- and second-class post
offices, from Civil Service regional offices, or from the
U. S. Civil Service Commission, Washington 25, D. C.
Applications must be filed not later than April 22, 1947.
HOSPITAL NEWS
New finance manager of the Northern Minnesota
Hospital, International Falls, is F. R. Willey, formerly
of Minneapolis, it was announced March 1. As part of
a new policy, patients now entering the hospital will be
required to make an advance payment of one week’s
expenses unless they hold acceptable hospitalization in-
surance.
* * *
The third appointment within thirteen months of a
new head for the Minneapolis Veterans Hospital, Dr.
Erwin J. Rose has been named manager of the hospital
to succeed Colonel Harry E. Caldwell.
In answer to the charges made recently by the Veter-
ans of Foreign Wars and the Disabled American Veter-
ans organizations, that the tuberculosis wards at the
hospital were mismanaged, investigators from the head-
quarters of the Veterans Administration announced that
patients in the Minneapolis hospital receive better care
than anywhere else in the country.
The Veterans Administration stated that Colonel
Caldwell would be assigned to another post, and that
Dr. Rose’s appointment had been under consideration
for several months.
^ 'Jf.
W. Dayton Shields has been appointed administrator
of Asbury Hospital, Minneapolis, to replace Lydia
A. Miller who retired on March 1 after nineteen years
as superintendent.
Mr. Shields, a graduate of the University of Min-
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Minnesota Medicine
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nesota Business School, formerly was in the administra-
tive office of Swedish Hospital, Minneapolis. For three
years during the war he was associated with an army
general hospital unit, and following the war, he took
a course in hospital administration at Northwestern
University.
On February 28 Northwestern Hospital, Minneapolis,
opened a new laboratory which contains one of the
most modern blood transfusion services in the country.
Housed in a new wing -of the building, the laboratory
is divided into sections for bacteriology, chemistry,
hematology, tissue pathology, and blood processing and
storage. As part of the equipment for the blood bank,
the laboratory has a precipatron, a type of air-condition-
ing unit, which removes dust and bacteria from the
rooms in which blood and plasma are processed.
In charge of the laboratory is Dr. Sheldon H. Stuur-
mans, pathologist for Northwestern Hospital.
❖
From the hospital planning committee in Blue Earth
has come word that excellent progress is being made to-
wards the erection of a community memorial hospital.
At present, funds for construction of the hospital total
over $90,000. Since January 1 about $20,000 in cash
payments on new and old pledges have been added.
In February committee members conferred with Dr.
Viktor O. Wilson, of the Minnesota State Department
of Health, in regard to design and methods of man-
agement of the proposed hospital. Members of the com-
mittee include Homer Enterline, Elmore; Clifford Kittel-
son, Frost; Walter Schwen and John Frundt, Blue
Earth.
^ ^
In Westbrook a drive is in progress to collect funds
for the erection of a hospital to be known as the Dr.
Henry Schmidt Memorial Hospital.
% sfc %
An open meeting was held in Paderewski Hall, Brow-
erville, on February 27, to discuss possibilities of using
Federal funds under the Hill-Burton Act to improve
hospitalization facilities in Todd County. Principal
speakers at the meeting were Dr. Viktor O. Wilson,
representative of the State Department of Health and
head of the Hospital Licensing Division, in Minnesota,
and K. A. Kirkpatrick, Minnesota Farm Bureau hos-
pitalization director.
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INSTRUMENTS • TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494
April, 1947
453
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
THE COMPLEAT PEDIATRICIAN. Practical, di-
agnostic, Therapeutic and Preventive Pediatrics. Wil-
burt C. Davison, M.A., D.Sc., M.D., Professor of
Pediatrics, Duke University, etc. 5th ed. Price, $3.75
with order ; $4.00 on credit. Durham, N. C. : Duke
University Press, 1946.
The Compleat Pediatrician, now in its fifth edition,
has become a sine qua non among all those who wrestle
with the innumerable problems and diagnostic difficul-
ties of children.
The reviewer has been familiar with this book for
many years, and it would be about the last book he
could spare.
When the pediatrician runs into a peculiar situation,
when nothing seems to add up exactly right, it will be
seldom indeed that he will not get a lead of some kind
from this book that will set him on the right path.
It is a veritable encyclopedia of information, well sifted,
condensed, practical and comprehensive. It is a book
which every pediatrician will want on his desk and
which he will consult first in every pediatric quandary.
C. H. SCHROEDER, M.D.
MODERN MANAGEMENT in Clinical Medicine.
Frederick K. Albrecht, M.D. 1238 pages Ulus. Price
$10.00. Baltimore : Williams & Wilkins Company,
1946.
This book is a compilation of our present knowledge
of modem medicine, written in a manner the average
doctor enjoys. The author must have devoted a tre-
mendous amount of effort and time in collecting the
valuable information presented. Each subject is dis-
cussed thoroughly, and still the style is not verbose. An
Practical Nursing Course
Nine months' course open to high school
graduates or women with equivalent
education.
For further information
write
Mrs. Lydia Zielke, Supt. of Nurses
FRANKLIN HOSPITAL
501 Franklin Avenue Minneapolis 5, Minnesota
example of this is the chapter dealing with the subject
of endocrinopathies.
The use and rationale of the newer drugs is discussed
fully. Illustrations throughout are very helpful.
Although the author intended this book for the doc-
tor’s office, it would be a very practical addition to the
library of the intern, general practitioner or clinician in
any specialty.
Joseph M. Ryan, M.D.
A BLIND HOG’S ACORNS. Cary P. McCord, 311
pages. Price, $2.75. Chicago; Cloud, Inc., 1946.
Taking the title of his book from a remark made in
his youth that “even a blind hog gets an acorn once in
a while,’’ the author shows by a series of interesting
anecedotes that a medical man with his wits about him
can solve many baffling problems in an industrial prac-
tice.
I. T. A.
Classified Advertising
LOCUM TENENS WANTED — For period from April
20 to June 10. A. I. Arneson, M.D., Morris, Minne-
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WANTED — Associate in general practice. Good
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phone or arrange personal interview. L. J. Holm-
berg, Canbv, Minnesota.
WANTED — Assistant physician, Southwestern Minne-
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with full maintenance. Position offers unusual op-
portunity for training in all phases of tuberculosis
work and sanatorium management. Write or apply
in person. Southwestern Minnesota Sanatorium,
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WANTED — -Physicians, class A graduates, with or
without psychiatric experience, licensed in Minnesota
or will obtain Minnesota license promptly. Full main-
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FOR SALE — G. E. new model fluoroscopic and
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FOR SALE — Spencer microscope, $185.00; or Leitz
microscope, $75.00. Both just returned from factory.
Telephone ALdrich 8402 (Minneapolis), or write E-14,
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When in need of a PHYSICIAN, DENTIST, OFFICE NURSE, TECHNICIAN, MEDICAL SECRETARY, or
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Minneapolis, Minn. — GE. 7839 The Medical Placement Registry st. 5PauiHaMi™n— GA!n67i8
OLIVE H. KOHNER, Director
454
Minnesota Medicine
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
INSTRUMENTS • TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494
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MURPHY LABORATORIES
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St. Paul: 348 Hamm Bldg. Ce. 7125
If no answer, call Ne. 1291
Hall & Anderson
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April, 1947
455
MEAD JOHNSON & CO., EVANSVILLE 21, INDIANA
There is no shortage now of AMIGEN for parentera[ use. There is no shortage now of PROTOLYSATE for oral use.
1 U8. NET (434 GMJ
Like Amigen, Protolysate is an enzymic
digest of casein and consists of amino
acids and polypeptides. Like Amigen,
Protolysate supplies the nitrogen es-
sential for maintenance, repair and
growth.
Unlike Amigen, which may be em-
ployed both orally and parenteraily,
Protolysate is designed only for oral
use.
PROTOLYSATE
For Oral Administration
^ dry enzymic digest of casein containing 1
ac|ds and polypeptides, useful as a source of
'l> absorbed food nitrogen when given ori
b> tube. Protolysate is designed for admir
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MEAD JOHNSON a co
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The function of Amigen and Protolysate
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Administered in adequate amounts,
they prevent wastage of protein, restore
previous losses, or build up new body
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1 000 ce. flasks
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456
Minnesota Medicine
r7/ie f/ff i/i fie/ct spotlights the slender, nimble
undulating form of Treponema pallidum to establish
a diagnosis of syphilis. The prognosis may be dark if the patient fails
to receive adequate therapy.
MAPHARSEN is a dependable arsenical, with
years of clinical experience and millions of administered doses
testifying to its effectiveness.
MAPHARSEN is one of a long line of Parke-Davis preparations
whose service to the profession created a
dependable symbol of significance in medical therapeutics —
MEDICAMENTA VERA.
MAPHARSEN ( Oxophenarsine Hydrochloride)
in single dose ampoules of 0.04 gm. and
0.06 gm.; boxes of 10 ampoules. Multiple dose,
hospital size ampoules of 0.6 gm., in boxes of 10.
PARKE, D AY I fk & COMPA IN Y • DETROIT :J2, MICHIGAN
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MINNEAPOLIS 2, MINNESOTA
458
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 May, 1947 No. 5
Contents
Protein and Amino Acid Therapy.
Robert Elman, M.D., Saint Louis, Missouri 493
The Relationship of Infectious and Serum
Jaundice.
John G. Rukatnna, M.D., and Edward L. Tuohy,
M.D., Duluth, Minnesota 498
A Plan for the Detection of the Source of
Rectal Bleeding.
Harold E. Hullsiek, M.D., Saint Paul, Minnesota. 503
The Cruveilhier-Baumgarten Syndrome.
William D. Sicher, M.D., Rochester, Minnesota. . . 506
Sulfadiazine Granulocytopenia and Thrombocy-
topenia Complicating P'regnancy with Survival.
Robert Sukman, M.D., and Nels M. Strand jord,
M.D., Saint Paul, Minnesota 509
Veterinary Medicine.
Louis A. Buie, M.D., Rochester, Minnesota 512
Clinical-Pathological Conference :
Cor Pulmonale.
A. J. Hertzog, M.D., and A. M. McCarthy,
M.D., Minneapolis, Minnesota 514
Case Report:
Arthus Phenomenon Induced by the Local
Application of Penicillin.
E. B. Moors, M.D., and David State, M.D.,
Minneapolis, Minnesota 517
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. (Continued from April
issue.)
Nora H. Guthrey, Rochester, Minnesota 519
President’s Letter :
Medical Service Area is Key to Physician
Distribution 526
Editorial :
Schools for Practical Nurses 527
Trimethadione (Tridione) in Petit Mai 528
Demerol 528
CARE 528
The State Meeting 529
Medical Economics :
County Officers Hear Progress Reports of MSMA
Programs (Continued from April issue ) 531
Border State Doctors Must Heed Narcotic
Regulations 533
Minnesota State Board of Medical Examiners. . . . 533
Minnesota Academy of Medicine :
Meeting of January 8, 1947 535
Penicillin in the Treatment of Syphilis.
S'. E. Sweitzer, M.D., Minneapolis, Minnesota. . 535
Minneapolis Surgical Society :
Meeting of May 6, 1947 539
Lumbar Retroperitoneal Ganglioneuroma. (Sum-
mary only )
Lawrence M. Larson, M.D., PhD. (Surg.)... 539
Congenital Diaphragm of the Duodenum. (Sum-
mary only) ' -
Wallace I. Nelson, M.D., F.A.C.S 539
Minnesota State Medical Association :
Roster of Officers and Members 541
Reports and Announcements 570
Woman’s Auxiliary 574
In Memoriam 576
Of General Interest 582
Book Reviews 589
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918,
May, 1947
459
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
G. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — $3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions — $3.50
The right is reserved to reject material submitted for editorial or advertising columns. 1 h>
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
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SUPERINTENDENT
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Minnesota Medicine
Amniotin, a complex of truly natural
estrogens, has been helping physicians
level the vicissitudes of the menopause
for over seventeen years. A wide range
of forms and potencies permits notable
flexibility and precision in dosage.
The objective of using “the minimum
dosage at the longest possible intervals
compatible with the control of
symptoms”1 is readily attained. Once
symptoms are controlled parenterally,
the patient may be easily maintained
1. Watson , B. P .: J. Clin. Endocrinology 4:571 (Dec.) 1944.
orally on a gradually reduced dosage.
Amniotin is highly purified,
,)
standardized in International Units.
TRADEMARK
MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858
When Nitrogen Balance
Must Be Kestored
In the correction of protein insufficiency, or in the maintenance
of nitrogen balance, accumulating evidence substantiates the dic-
tum that hydrolyzed protein substances should be employed only
when oral feeding of protein foods is impossible or not feasible.
It has been shown experimentally1 when hydrolysates of pro-
tein are injected at two different rates (i.o and 1.5 mg. of
nitrogen per Kg. of body weight per minute), the more rapid
injection rate results in a higher excretion of both free amino
acids and peptides. The authors ventured that even in the pres-
ence of a definite demand for protein replenishment, nitrogen
excretion is mainly controlled by the kidney threshold.
In a recent survey, Ravdin2 stated that “When oral feeding
is used, whole foodstuffs should be given. There is no beneficence
in feeding protein hydrolysates unless there is evidence of faulty
digestion. Feeding of mixtures of polypeptides and amino acids
may result in an absorption rate of amino acids which is more
rapid than can be resynthesized by the liver, especially when
the function of this organ is not normal.”
When protein foods are ingested, the contained amino acids
are released slowly and in a sustained manner during the course
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As a source of protein, meat ranks high among the foods of
man. It is 96 to 98 per cent digestible, and its protein is bio-
logically adequate, capable of satisfying every protein need of
the organism.
1. Editorial: J. Am. Dietet. A., 22: 106 3 (Dec.) 1946.
2. Ravdin, I.S.: Some Problems of Protein Deficiency,
Connecticut M.J., 11:7 (Jan.) 1947.
The Seal of Acceptance denotes that the nutri-
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are acceptable to the Council on Foods and
Nutrition of the American Medical Association.
AMERICAN MEAT INSTITUTE
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462
Minnesota Medicine
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trogen.’" It is more active o rally than any other synthetic or
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Minnesota Medicine
to convert
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“The ideal in therapy. . . is to convert the diabetic
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1. Stabilize the patient as well as possible on a
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gle dose of 15 or 20 units of ‘Wellcome’ Globin
Insulin 30 minutes or more before breakfast.
2. Adjustment to 24 -hour control: Gradually
adjust the Globin Insulin dosage to provide
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sugar level of less than 150 mgm. or sugar-free
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Minnesota Medicine
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benzedrine sulfate (racemic amphetamine sulfate, S.K.F.) Tablets aild UlixiT
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Minnesota Medicine
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Send for 12-page descriptive booklet
CahdUrfhen
ELECTRO-PHYSICAL LABORATORIES, INC., 298 Dyckman St., New York 34, N. Y.
ELECTROCARDIOGRAPHS, ELECTROENCEPHALOGRAPHS, SHOCK
THERAPY APPARATUS, AND SPECIAL ELECTRONIC EQUIPMENT
Distributed by
C. F. ANDERSON CO., INC.
901 MARQUETTE AVENUE MINNEAPOLIS 2, MINN.
Aay, 1947
469’
Corbohydtote for Suppi*W*nli,,9 ^
°R INFANT FEEDING
Directed £$jj& by
,5^Iol'NS ' MALTOSE DE)^Iri^SE
,VW5 ’-abiespoonfuls equal X n oz'
i<;0 calories per ft «*• . iw-
MINIMIZES GASTROINTESTINAL DISTRESS
Gastrointestinal distress attribu-
table to the presence in the intestinal
tract of excessive amounts of readily
fermentable sugars can be minimized
by specifying CARTOSE* as the
mixed carbohydrate to be used in
modifying milk for infant feeding
formulas.
CARTOSE supplies balanced pro-
portions of nonfermentable dextrins
in association with maltose and dex-
trose, thus providing spaced absorp-
tion.
Its content of dextrins favors the
development of a preponderant bene-
ficial acidophilic intestinal flora.
CARTOSE
Mixed Carbohydrates
Available in bottles containing 1 pt.
through recognized pharmacies only.
♦The word CARTOSE is a registered trademark of H. W.
Kinney & Sons, Inc.
H. W. KINNEY A SONS , INC.
COLUMBUS, INDIANA
470
Minnesota Medicine
rLAST SHIELDS
SSTETRICAL
JPERVISORS SAY
‘Convinced of t
over other
'<•«>« core."
n«ir soperi-
"letbods of
;<o*< '° *
"Excellent reception by both
JgjjatienH an4 nurses.,,
happy to recommend con*
tinued use at our hospital/*
A new technique for postpartAm breast care.
Note flange and
circular groove . . .
a patented
feature.
PLAST I SHIELJDS are transparent
shields, formed to receive the breast. They have an
extruded central portion to loosely receive the nipple.
Made from a plastic which does not/react with skin or milk, they
are moulded and /hand-finished to assure perfect
smoothness and comfort /A flange around the circumference
with a circular groove in its inner surface forms
a suction to hold the shield firmly to
the breast. Used with either a hospital
binder or brassiere. The method is adaptable
as a simple standard routine
technique, usable in both hospital and home.
ADVANTAGES:
1. Prevents irritation of nipples by
clothing.
2. Protects nipples and breasts from
infection.
3. Reduces nursing discomfort.
4. Simplifies nipple care.
5. Eliminates use of ointments, gauze, etc.
6. Increases patient’s comfort.
7. Easily sterilized by patient, after each
nursing, thus saving nurse’s time.
8. Shortens latent period of nursing.
9. Minimizes milk seepage and soiling of
clothing.
1 0. Corrects certain cases of flat or par-
tially inverted nipples.
1 1. Not affected by ordinary antiseptics.
Now being successfully used in many hospitals throughout
the Morthwest for routine postpartum breast care.
For further information write
PLAST I SHIELD, INC
Minneapolis, Minnesota
♦
May, 1947
I
471
PENICILLIN ADMINISTR
is safe, simple, and
fast with TUBEX®
Before injecting aspirate to insure
that needle is not in a blood vessel.
• Designed for immediate injection —
no transfer from ampul to syringe.
• Administration is rapid — 300,000 units
injected in less than 30 seconds.
• Tubex has a special safety feature — by
aspirating, it is easy to make certain that
a blood vessel has not been entered.
• Positive plunger of the syringe elimi-
nates awkward administration.
Prolonged therapeutic blood levels (12 to 24 hours) have frequently been observed
after a single injection of 300,000 units. Nearly all cases of acute gonorrhea are
cleared up by a single injection. Other susceptible coccal infections respond to
one or two injections per day.
Available in 1 cc. Tubex, 300,000 units of penicillin calcium, with Tubex
needle (20 gauge, lh£ inch). The Tubex syringe is supplied separately.
Tubex syringes and needles, developed and produced by J. Bishop & Co., are
used exclusively by Wyeth Incorporated.
TUBEX PENICILLIN
in Oil and WAX
®
® Reg. U. S. Pat. Off.
WYETH INCORPORATED • PHILADELPHIA 3, PA,
472 Minnesota Medicine
Yes , and experience is the best teacher in smoking too!
THAT wartime cigarette shortage was a real
experience to smokers. Millions of people
smoked more different brands than they would
normally try in a lifetime. And out of the com-
parisons of that experience^ -sy many more
smokers came to prefer Camels that today
more people are smoking Camels than ever
before.
We don’t tamper witli Camel quality.
Only choice tobaccos, properly aged, and
blended in the time-honored Camel way ,
are used in Camels.
According to a recent Nationwide survey*
More Doctors smoke Camels
R. J. Reynolds Tobacco Co., Winston-Salem, N. C.
May, 1947
t/ian any ot/ier cigarette
473
FIGURE 1 — Patient
-thin type of build
with bi|bnins faul-
I fy body mechanics.
The Camp adjust-
ment provides a
more stable pelvis,
i allowing patient to
"draw in" the ab-
Idominat muscles
thus gradually ac-
quiring a gentle
lumbar curve.
;
FIGURE 2 — Patient
— intermediate type
of build. Strain of
lumbosacral joint
predisposes to other
strains. For protec-
tion of the joints in
the lumbar region
from recurrent strain
and also as an aid
in relieving the pain
of acute conditions.
Camp lumbosacral
supports have
proved effective.
//e of?
The Lumbosacral and Lower Lumbar Regions
C/yyVP SUPPORTS offer advantages
• • • Give firm support to the
low back; the support is easily
intensified by re-inforcement
with pliable steels or the Camp
Spinal Brace.
• • • Afford a more stable pelvis
to receive the superincumbent
load.
• • • Allow freedom for contrac-
tion of abdominal muscles un-
der the support in instances of
increased lumbar curve (fig. 1).
• • • Are removed easily for pre-
scribed exercises and other
physical procedures prescribed
by physiatrist or physician.
S. H. CAMP and COMPANY • JACKSON, MICHIGAN
W orld's Largest Manufacturers of Scientific Supports
Offices in New York • Chicago • Windsor, Ontario • London, England
474
Minnesota Medicine
This Ritter Unit is positioned
at left, with Surgical Cuspidor
at right of chair.
This Ritter Unit is for the physician who prefers to work with
instruments and medicaments at right, Ritter Surgical Cus-
pidor at left of chair.
This type of Ritter Unit, with
Swinging Cuspidor, is position-
ed at right of chair.
Here the Ritter Unit, also with
Swinging Cuspidor, is placed
at left of chair.
with the correct RITTER ENT UNIT for your special needs
As your practice increases, modern, energy-saving equipment will
become essential — to extend your skill to more patients without added
strain.
Ritter ENT Units are designed to fit your individual operating tech-
nique. Each centralizes precision instruments, medicaments, compressed
air, vacuum and waste disposal facilities within arm’s reach . . . enables
you to work smoothly, effortlessly for long periods.
Shown here are the four types of Ritter Units. Now is the time to
choose the Unit which can best help you meet the demands of your
expanding practice.
Write for Our Ritter Catalog
Distributed by
PHYSICIANS AND HOSPITALS SUPPLY C0.# Inc.
MINNEAPOLIS MINNESOTA
May, 1947
475
1 National Research Council
Bull. No. 109. 1943. pp. 18-21.
of all past days.”1 Slight deficiencies should not be ignored "as
if they were without effect,” for "partially, indeed slightly de-
ficient diets eaten regularly and periodically over many years
have their consequences.”1 Such nutritional delinquency often
takes its greatest toll under the stress of illness, surgery, preg-
nancy, lactation, or accident. For depleted tissues, Upjohn vita-
mins provide a wide range of dosage forms for therapy or
supplementation, in preparations adapted to oral and paren-
teral administration in the practice of medicine and surgery.
Upjohn
UPJOHN VITAMINS
476
Minnesota Medicine
30 day wonder
The new-born infant is truly a "30- day wonder” taking in his
stride the sudden changes birth imposes and adjusting accord-
ingly. The rapid increase in weight is, alone, a feat no adult could
duplicate. The right start on the right feeding is of vital import-
ance—particularly during the first 30 days when infant mortality
is at its highest and when he not only must regain his birthweight
but keep on gaining if he is to survive.
'Dexin' has proved an excellent "first carbohydrate" because of
its high dextrin content. It (l) resists fermentation by the usual
intestinal organisms,- (2) tends to hold gas formation, distention
and diarrhea to a minimum, and (3) promotes the formation of
soft, flocculent, easily digested curds.
Simply prepared in hot or cold milk, 'Dexin' brand High Dextrin
Carbohydrate provides well-taken and well-retained nourishment.
'Dexin' does make a difference. Literature on request
HIGH DEXTRIN CARBOHYDRATE
BRAND
Composition — Dextrins 75% • Maltose 24% • Mineral Ash 0.25% • Moisture
0.75% • Available carbohydrate 99% • 115 calories per ounce • 6 level packed
tablespoonfuls equal 1 ounce • Containers of twelve ounces and three pounds •
Accepted by the Council on Foods and Nutrition, American Medical Association.
‘Dexin’ Reg. Trademark
BURROUGHS WELLCOME & CO. (U.S.A.) INC., 9 & 11 East 41st St., New York 17, N. Y.
May, 1947
477
CHEMICAL COMPANY, INC.
NEW YORK 13, N. Y. • WINDSOR, ONT.
A recent conservative estimate places the incidence
of peptic ulcer at 5 per cent of the population, or
about 6,500,000 persons in the United States.* The
great majority of this vast group of patients need a
year-in and year-out program of rest, diet and acid
neutralization.
Creamalin, the first aluminum hydroxide gel, readily and
safely produces sustained reduction in gastric acidity.
With Creamalin there is no compensatory reaction by
the gastric mucosa, no acid "rebound, ” and no risk of
alkalosis. Through the formation of a protective coating
and a mild astringent effect, nonabsorbable Creamalin
soothes the irritated gastric mucosa. Thus it rapidly
relieves gastric pain and heartburn, and helps in the
healing of peptic ulcers as well as in the prevention of
ulcer recurrence.
Supplied in 8 fl. oz., 72 fl. oz.
and 16 fl. oz. bottles.
* Bureau of Health Education, A.M.A. Hygeia, 24:352, May, 1946.
478
Minnesota Medicine
Now in Service!
If you can picture in your mind’s eye a two-mile
column of R-39 Units, placed end to end, you’ll
have a good idea of the popularity of this particular
model, and the vast amount of diagnostic service
it is rendering daily in the offices of specialists, and
in clinics and hospitals everywhere.
Why the R-39’s great popularity?
1. It is an all-round diagnostic unit, yet is so
compactly designed that it can be accommo-
dated in a small floor space.
2. Has ample power (100 ma. and 85 kvp) for
general radiographic and fluoroscopic diag-
nosis.
3. Its unusual flexibility facilitates positioning
of the patient vertically, angularly, or hori-
zontally.
4. Its double-focus genuine Coolidge tube serves
both over and under the table.
5. The simple-to-operate, refined control system
assures a consistently fine quality of work.
You, too, may find the Model R-39 ideally adapt-
able to your particular needs. Why not investigate,
by writing today for complete information. Address
Dept. 26 16, General Electric X-Ray Corporation,
175 W Jackson Blvd., Chicago 4, 111.
May, 1947
X-RAY CORPORATION
479
Hot weather
presents no
problem when
Lactogen /
is used for
infant
feeding
• • • because
^o&ucif.NC «?.;
...when refrigeration is not available,
each feeding may be prepared sepa-
rately. The doctor can always advise
the mother to prepare individual LAC-
TOGEN feedings whenever the baby
is ready for his bottle. Preparing each
LACTOGEN feeding just before feed-
ing time safeguards the baby against the
danger of nutritional upsets caused by
bacteriological changes in the formula.
EASY TO PRESCRIBE
LACTOGEN + WATER = FORMULA
1 LEVEL TABLESPOON 2 OUNCES 2 FLUID OUNCES
40 CALORIES 20 CALORIES
(APPROX.) PER OZ. (APPROX.)
No advertising or feeding directions except to physicians. For feeding
directions and prescription pads, send your professional blank to
Nestle’s Milk
Products, Inc.
155 EAST 44TH ST., NEW YORK, 17, N.Y.
480
Minnesota Medicine
3 " Prmnrin ” tangibles . . . plus
“Pmmirin" is orotiy effective
“Premarin” is well tolerated
“Premnriu” provides rapid symptomatic relief
and as a sequel to the control of subjective symptoms, there is the emotional
or feeling of well-being which is so frequently reported by patients on
" therapy. "Premarin" has proved to be a valuable therapeutic medium for
of the menopause and other manifestations of estrogenic deficiency.
permit flexibility of dosage and enable the physician to fit estrogenic therapy
the particular needs of the patient, "Premarin” is supplied in two potencies —
tablets of 1.25 mg. and 0.625 mg. Also available in liquid form, containing 0.625 mg.
in each 4 cc. (1 teaspoonful).
^Although the principal estrogen in "Premarin" is sodium estrone sulfate, it also contains
other equine estrogens . . . estradiol, equilin, equilenin, hippulin . . . which are also
present as water soluble sulfates. The water solubility of conjugated estrogens (equine!
assures rapid absorption from the gastrointestinal tract.
CONJUGATED ESTROGENS
(equine)
AYERST, McKENNA & HARRISON Limited
22 EAST 40TH STREET. NEW YORK 16, N. Y.
May, 1947
481
^'Tpf'806
'tso&ie#
3,350,000
Borden’s prescription specialties are flexibly adaptable to cope
with the sharply increased number of your infant feeding
effectively
problems.
BIOLAC-a complete infant formula (only
vitamin C supplementation needed) for infants
deprived of mother’s milk.
DRYCO-a powdered, high-protein, low-fat,
moderate carbohydrate milk food ideally suited
for all formulas.
BETA-LACTOSE —an exceptionally palatable,
highly soluble milk sugar for formula modi-
fication.
MULL-SOY -a hypo -allergenic emulsified soy
food for infants and adults allergic to milk
proteins. The 1:1 standard dilution approxi-
mates cow’s milk in fat, protein, carbohydrate
and mineral content.
KLIM - a spray-dried whole milk with soft curd
properties essential in infant feeding and
special diets. Particularly valuable when avail-
ability or safety of fresh milk is uncertain.
liorden prescription products are available at all drug stores.
Complete professional information mag be obtained on request.
^ “VJ •
BORDEN’S PRESCRIPTION PROOWTS DIVISION • 350 MADISON AVENUE. NEW YORK if N^ Y:
482
Minnesota Medicine
World of new hope in petit mal
One important fact stands out in the rapidly expanding clinical
record of Tridione: Thousands of children formerly handicapped
in school and play by petit mal, myoclonic or akinetic seizures
are finding substantial relief through treatment with Tridione.
In one test, Tridione was given to 150 patients who had not
received material benefit from other drugs.11 With Tridione,
33% became seizure free; 30% had a reduction of more
than three-fourths of their seizures.; 21% were moderately
improved; 13% were unchanged, and only 3% became
worse. In some cases, the seizures, once stopped, did not
return when medication was discontinued. Tridione also
has been shown to be beneficial in the control of certain
psychomotor epileptic seizures when used in conjunction
with other antiepileptic drugs.12 Wish more information? Just
drop a line to Abbott Laboratories, North Chicago, Illinois.
Tridione
REG. U. S. PAT. OFF.
( Trimeth a dione, Abbott)
BIBLIOGRAPHY
1. Richards, R. K., and Everett, G. M.
(1944), Analgesic and Anticonvulsant
Properties of 3,5,5-Trimethyloxazoli-
dine-2,4- dione (Tridione), Federation
Proc., 3:39, March.
2. Goodman, L., and Manuel, C. (1945),
The Anticonvulsant Properties of Dim-
ethyl-N-methyl Barbituric Acid and 3,5,
5-Trimethyloxazolidine-2,4-dione (Tri-
dione), Federation Proc., 4:119, March.
3. Goodman, L. S., Toman, J. E. P. and
Swinyard, E. A. (1946), The Anticonvul-
sant Properties of Tridione, Am. J. Med.
1:213, September.
4. Richards, R. K., and Perlstein, M. A.
(1946), Tridione, a New Drug for the
Treatment of Convulsive and Related
Disorders, Arch. Neurol, and Psychiat.,
55:164, February.
5. Lennox, W. G. (1945), The Treatment
of Epilepsy, Med. Clin. North America,
29:1114, September.
6. Thorne, F. C. (1945), The Anticonvul-
sant Action of Tridione: Preliminary Re-
port, Psychiatric Quart., 19:686, Oct.
7. Lennox, W. G. (1945), Petit Mal Epi-
lepsies: Their Treatment with Tridione, J.
Amer. Med. Assn., 129:1069, Dec. 15.
8. Lennox, W. G. (1946), Newer Agents
in the Treatment of Epilepsy, J. Pediat.
29:356, September.
9. DeJong, R. N. (1946), Effect of Tri-
dione in Control of Psychomotor Attacks,
J. Amer. Med. Assn.. 130:565, March 2.
10. Perlstein, M. A., and Andelman, M.
B. (1946), Tridione: Its Use in Convulsive
and Related Disorders, J. Pediat. 29:20,
July.
11. Lennox, W. G. (1946), Two New
Drugs in Epilepsy Therapy, Am. J. Psy-
chiatry, 103:159, September.
12. DeJong, R. N. (1946), Further Ob-
servations on the Use of Tridione in the
Control of Psychomotor Attacks, Am. J.
Psychiatry, 103:162, September.
May, 1947
483
KOROMEX JELLY
• Fastest Spermicidal Time
measurable under Brown and Gamble technique
• Proper Viscosity
for cervical occlusion
• Stable Over Long Period of Time
pH consistent with that of the normal vagina
• and in addition
time-tested clinical record
ACTIVE INGREDIENTS: Boric acid 2.0%, oxyquinolin benzoate
0.02% and phenylmercuric acetate 0.02% in a base of glycerin,
gum tragacanth, gum acacia, perfume and de-ionized water.
Prescribe Koromex Jelly with Confidence
, . . send for literature
HOLLAND-RANTOS COMPANY, INC., 551 FIFTH AVENUE, NEW YORK 17, N. Y.
484
Minnesota Medicine
An Appeal to You.. Doctor
SCHOOL OF
PSYCHIATRIC
HURSIF1G
•
MID-YEAR CLASS
will start in
June
•
Candidates for the
June class should
make reservations at
once. School and
health record must be
reviewed and corres-
pondence completed
prior to acceptance.
An acute shortage exists in the nursing field. The problem of
supplying an adequate number of well-trained nurses to the
medical profession has become a difficult one. Tour help in
recruiting candidates for training schools is greatly needed.
In your wide acquaintance, you possibly know of many girls
who could be interested in becoming a nurse. As a leading
citizen of your community you are in a position to assist them
in their vocational choice. A trained nurse is a benefit to both
your patient and yourself. We are prepared to refer the student
nurse back to you on completion of her training.
A Career in Nursing Offers:
• Training in a highly paid profession
. A secure position unaffected by economic depression
. Work with skilled professional men and women
. The best preparation for marriage
Glenwood Hills Hospitals, beautifully located on the outskirts of
Minneapolis, are currently offering to qualified applicants a one year
course in the School of Psychiatric Nursing. All phases of the sub-
ject are skillfully presented by a capable and experienced faculty. Class-
room and laboratory study is combined with an interesting program
of actual work on the ward. Regular classes begin in January, June,
and September.
Here is an opportunity to attain a useful higher education and
still enjoy the beauty of summer to its fullest. Swimming,
boating, hiking, and golf are a few of the recreational pastimes
available to the student nurse. Tuition is free. We will be
happy to send full information on request. A postcard is suf-
ficient. Address Miss Margaret Chase, R.N., B.S., Director,
School of Nursing, Glenwood Hills Hospitals.
. Our hospitals must be staffed
• Our sick must be cared for
. Our doctors must have nurses
eniudod
s
os
3i a
s
3501 Golden Valley Road : Route Seven : Minneapolis, Minn.
May, 1947
485
w
1
MERCK VITAMIN REVIEWS
CONCISE,
CONVENIENT
•
• Signs and Symptoms of
Deficiency.
• Daily Requirements and Dosage.
SOURCE OF
• Distribution in Foods.
VITAMIN
• Methods of Administration.
INFORMATION
• Clinical Use in Specific
1
A limited number of complete sets of these informative booklets
has been gathered in a convenient slip-cover container, designed
for ready reference. These are available as long as the supply
lasts. The coupon is for your convenience.
MERCK & CO., Inc., RAHWAY, N. J.
Please send me a complete set of Merck Vita-
min Reviews in convenient slip-cover container.
. State .
486
Minnesota Medicine
May, 1947
487
PYOKTANIN SURGICAL GUT
Plain and ')wmalije4
Manufactured Since 189S by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia.
• • •
Price ttit
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE G NONBOILABLE
Sizes 000 — 00 — 0—1 — 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
• • •
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FDR SALE BY SURGICAL DEALERS AND DRUGGISTS
488
Minnesota Medicine
catch it on the wing!
Whip the bar across and you’ve caught that fleeting evidence
of pathology surely, clearly, quickly . . . because it’s a Picker S-4
Automatic Serialographic Table you’re operating. The Picker S-4
offers the most advanced and inclusive facilities for automatic spot-film
radiography, in both gastro-intestinal and myelographic fields.
sets the pace in X-ray
Brown & Day, Inc.
62-64 East 5th St.
ST. PAUL, MINN.
THE PICKER AUTOMATIC SERIALOGRAPHIC TABLE
Your local Picker representative is as near as
your ’phone. He’ll be glad to tell you of the
many advantages of this fine x-ray apparatus.
May, 1947
489
Mf) 1 Beginning placement of diaphragm
HU. I on introducer.
UA A Beginning insertion of
11U. * diaphragm.
NO. 2 Diaphragm placed on introducer.
NO. 3 Application of jelly to diaphragm. NO. 5 Placement of diaphragm.
The insertion and correct placement of the "RAMSES"* Flexible
Cushioned Diaphragm are simplified by the use of the "RAMSES"
Diaphragm Introducer as illustrated.
Our booklet, "Instructions For Patients", will be found helpful in
guiding patients in the proper use of the "diaphragm-jelly technique".
A supply will be sent to physicians on request.
UL1UD OUnMIL/, iflU 423 WEST 55th ST.. NEW YORK 19. N. Y.
The word "RAMSES" is a registered trademark of Julius Schmid, Inc.
490
Minnesota Medicine
Music provides a retreat
from the anxieties and cares of
the moment, where, in imagina- I
tion, you live in a world care-
free and gay. /
The superb new Capehart IS
offers you preferred passage \
to this wonderland of music.
This magnificent instrument re-
creates the living presence of
the artists and instruments
themselves as it flawlessly re-
produces the recorded music
of your choice.
Model illustrated is the
Capehart Georgian i
McGowans /
23 W. SIXTH ST. /
ST. PAUL 2, MINN. V
May, 1947
401
Interested in
CIGARETTE ADVERTISING?
( ^
Claims, words, clever advertising slogans do
sell plenty of products. But obviously they do
not change the product itself.
That Philip Morris are less irritating to the
nose and throat is not merely a claim. It is the
result of a manufacturing difference proved *
advantageous over and over again.
But why not make your own tests ? Why not
try Philip Morris on your patients who smoke,
and confirm the effects for yourself.
* Laryngoscope, Feb. 1935, VoL XLV, No. 2, 149-154
Laryngoscope, Jan. 1937, Vol. XLV11, No. 1, 58-60
Philip Morris
Philip Morris & Co., Ltd., Inc.
119 Fifth Avenue, N. Y.
TO PHYSICIANS WHO SMOKE A PIPE:
We suggest an unusually fine new blend— Country Doctor Pipe Mixture. Made
by the same process as used in the manufacture of Philip Morris Cigarettes.
mr
49 2
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 May. 1947
PROTEIN AND AMINO ACID THERAPY
ROBERT ELMAN, M.D.
Saint Louis, Missouri
IT is only within the past decade or two that the
importance of protein intake has become ap-
preciated. In discussing this subject, it will be
necessary to consider both protein and its build-
ing stones, i.e., amino acids, which normally fur-
nish the medium of exchange between protein in
the food and body protein, as well as between
various body proteins.
The subject of protein and amino acid therapy
has a wider interest than merely one of nutri-
tion inasmuch as many surgical conditions result
in a loss of blood and exudate, which are essen-
tially protein-containing fluids. In this sense also,
transfusions of blood and plasma, which are also
protein-containing solutions, come under consider-
ation in the discussion of protein and amino acid
therapy.
General Considerations
The importance of protein may be expressed
by a statement attributed to Rubner that “protein
contains the magic of life, ever newly created,
ever dying.” This dynamic view of protein metab-
olism was prophetic, for it was only in the past
decade or two that the same conclusion was
reached by Shoenheimer and his co-workers,
whose fundamental studies were based on the
employment of the latest tool of biological re-
search, the labeled or isotopic molecule, which is
one of the useful contributions of nuclear physics,
whose more spectacular application resulted in
the atomic bomb.
It is important to realize that proteins are quite
diverse in their function, varying from the cir-
From the Washington University School of Medicine and
Barnes Hospital, St. Louis, Missouri.
Presented at a joint meeting of the Minneapolis Surgical Society
and the Hennepin County Medical Society, Minneapolis, Minne-
sota, January 6, 1947.
May, 1947
culating plasma proteins, the hemoglobin impris-
oned in the red cells, the protoplasm of tissue
cells, to the hormones and enzymes, all protein
molecules. Secondly, proteins vary in size and
shape, from the relatively small insulin molecule
to the tremendous globulin, which has a molecular
weight of 250,000. Shape varies from the rela-
tively spherical contour of albumin to the long,
stringy appearance of the fibrous proteins such
as gelatin and keratin. Thirdly, proteins vary in
their amino acid composition, which is probably
the reason why one protein must be broken down
to amino acids before another protein can be
synthesized.
Amino acids circulate in the blood like glucose
probably because of the fact that they act as a
medium of exchange between the proteins of the
food and the various proteins within the body.
The actual amount of amino acids circulating in
the plasma is similar to the amount in glucose,
i.e., about 80 mg. per 100 c.c. Changes in their
level have received rather limited study. If there
is any analogy with the information contributed
by the study of the glucose level in the blood, a
great field for future research should follow fur-
ther investigation of the concentration of amino
acids in the blood.
Historical Survey
In L. B. Mendel’s book on nutrition, The
Chemistry of Life, there is an interesting discus-
sion of the history of the various food elements.
It is only within the past hundred years that the
Hippocratic idea of a universal food element was
shown to be untrue. Prout in 1830 first showed
that there were at least three different food ele-
ments, i.e., carbohydrate, protein and fat. Mul-
493
PROTEIN AND AMINO ACID THERAPY— ELMAN
der, a Dutch biochemist, first gave protein its
name, although Magendie first noted that pro-
tein is characterized by its content of nitrogen,
not possessed by carbohydrate or fat. This con-
tribution of Magendie, however, was overshad-
owed historically by the studies of Lavoisier, who
preceded him and Liebig, who followed him.
The early workers in nutrition felt that pro-
tein was a very important and essential element
in the diet, an idea which remained unchallenged
until the work of Chittenden, who not only
showed that a low protein intake in normal in-
dividuals was consistent with health, but who
also claimed that any increase in the protein
intake was detrimental to general health. This
idea was supported by the traditional view that
a high protein intake is harmful in diseases of
the kidneys. Because of this and other reasons,
most physicians in the early part of this cen-
tury tended to neglect protein as an essential part
of the diet, particularly in disease.
It was only after World War I that the im-
portance of protein was re-emphasized. This
change was based upon observations of Maver
and of Kohman, of Mendel and Peters, and
later of Weecb and others, who showed
that nutritional edema was directly connect-
ed with a fall in the plasma proteins ( hypopro-
teinemia). In 1933 Jones and Eaton first showed
that postoperative edema was due to protein de-
pletion. In the past ten years numerous observ-
ers have shown beyond question the importance
of protein depletion in the production of post-
operative difficulties of many kinds. We may ac-
cept as proven the importance and even the es-
sential nature of protein intake in the main-
tenance of normal function, particularly during
and after operation.
This does not mean that the other elements in
the diet, i.e. water, energy, vitamins and salts, are
not also important. Indeed, it is only by a con-
sideration of all of them that normal physiological
function may be maintained. However, the im-
portance of calories and vitamins in particular has
been so emphasized in recent years that protein
needs have slipped into the background, and
it will be part of my purpose to bring forward
into more realistic juxtaposition its relation with
the other elements. An adequate intake of this
element is necessary in order to maintain normal
function of surgical, and indeed, of all patients.
494
Relation of Body Protein to Plasma Albumin
Plasma albumin is the most important fraction
of the plasma proteins as far as the physiologic
function of the circulating plasma is concerned,
and is involved in nutritional and other types of
deficiency. Yet this protein comprises a rela-
tively small total amount, i.e., about ISO gm. |
There are by contrast many thousand grams of i
protein in the rest of the body. The quantitative
relationship between albumin and the rest of the
body proteins seems to be a relatively constant one
during conditions of depletion as well as during
repletion. 1 his is an important consideration be-
cause it explains the reason why such tremendous
amounts of protein are necessary to correct an
albumin deficiency in the blood, i.e., so much is
required to replace body protein at the same time
as the plasma albumin is being corrected. From
the data of Weech as well as from data ob-
tained in our laboratory, this relationship is ex-
pi essed b} a ratio of thirty to one. In other words,
in a nutritionally protein-deficient individual, only
1 gm. out of every 30 gm. ingested and assimil-
lated is available for the correction of hypopro-
teinemia. The rest is required for the correction
of deficiencies in the rest of the body.
The Recognition of Protein Deficiencies
Exact laboratory methods for the recognition
of protein deficiencies have been used by many
workers in the field. T lie results may be studied
by those interested in the mechanisms. They are
usually too complicated for ordinary clinical use.
Moreover, these laboratory methods have been
used so extensively and have been correlated
with such definite clinical manifestations that the
average clinician need not worry about carry-
ing them out. I hese laboratory methods will be
merely mentioned but not described. They are
(1) determination of nitrogen balance, (2) biop-
sy of the liver with study of its histological ap-
pearance and/or chemical composition, and (3)
study of the blood including both the hemoglobin
in the red cells as well as the plasma proteins.
( )f the three methods mentioned above, studies
of the blood have probably been the most exten-
sive, particularly plasma protein determinations.
I he difficulty with such measurments is the fre-
quency with which normal values are obtained in
patients who are obviously protein-deficient. The
reasons for this discrepancy are many, but have
been discussed in detail elsewhere. Suffice it
to say that such determinations are really not
Minnesota Medicine
PROTEIN AND AMINO ACID THERAPY— ELMAN
necessary and that the average clinician can meet
his responsibility in most cases in a satisfactory
manner, without recourse to such measurements,
by knowledge of the bedside features of protein
deficiency, which will now be discussed.
Acute Protein Deficiency. This type of de-
ficiency is easy to detect from the history alone.
Any patient who has lost a significant amount
of protein-containing fluid will suffer from acute
protein deficiency, particularly acute hypopro-
teinemia. It will perhaps suffice to mention the
clinical conditions under which such loss occurs,
noting that in many cases hemoglobin as well as
plasma protein is lost at the same time. These
conditions include the following : severe hemor-
rhage, extensive burns, intestinal obstruction, peri-
tonitis, empyema, pneumonia, severe tissue in-
jury, extensive draining wounds or sinuses.
In all of these conditions, it is clear that pro-
tein-containing fluid leaves the blood stream either
to the outside, into the tissues, or into the body
cavities. The clinical manifestations produced by
such acute loss will vary with its degree and
rapidity. The production of surgical shock is
the most severe result of such loss, but abdominal
distension from edema of the intestinal tract as
well as suppression of urine from a fall in the
colloidal osmotic pressure of the blood will also
be observed in many instances.
Chronic Protein Deficiencies. — Here the loss of
protein occurs because of tissue breakdown with
excretion of urea and ammonia in the urine, and
therefore may be measured by calculating the
total nitrogen output in relation to the intake.
Some loss of nitrogen is normal, but in certain
diseases, particularly in fever and extensive trau-
ma, this destruction is tremendous and may lead
to the loss of as much as 2 pounds of muscle pro-
tein tissue a day.
The history of the case will obviously enable
the physician to know whether excessive loss of
protein tissue has actually occurred. But more im-
portant, a history of the dietary intake will be
decisive in evaluating the degree to which such
a loss has been prevented. Obtaining a dietary
history is not always easy, but a serious attempt
should be made, and inquiry as to the amount of
milk, meat and eggs will often indicate how much
or how little proein the patient has actually tak-
en.
Bedside manifestations of chronic protein de-
ficiency are numerous and even in absence of a
history should lead the physician to a correct
estimate. Loss of body weight with due regard
to the influence of edema, both hidden and overt,
is of obvious importance. Faulty wound healing
is a late manifestation, as is the appearance of
decubitus ulcers. An impaired resistance to in-
fection and a reduction of hepatic function have
also been shown to follow chronic protein de-
ficiency. Nutritional edema is perhaps the most
striking bedside evidence of hypoproteinemia ;
yet it varies tremendously in its appearance and
disappearance, and can very seldom be correlated
accurately with the level of serum protein. There
are undoubtedly many factors beside protein de-
ficiency which determine when and where nu-
tritional edema will appear. Moreover, nutritional
edema is not always visible ; it occurs in the in-
testinal wall, thereby leading to various dis-
turbances in gastrointestinal function, and may
appear at areas of intestinal trauma as, for ex-
ample, after anastomoses, and lead to symptoms
of obstruction.
The early manifestations of protein deprivation
are difficult to describe because they are so non-
specific. There is some evidence, however, to
show that general malaise and loss of strength,
particularly after operation, and usually attributed
to the procedure in many instances, are due to
protein deprivation inasmuch as they are often
absent when protein starvation is avoided.
Therapy
It is an oversimplification to say that ordering
an adequate high-protein diet will prevent Or cure
protein deficiencies. In the first place, special de-
vices are frequently necessary in sick patients in
order to assure an adequate intake. In the second
place, the parenteral channel is sometimes needed
for one or more reasons. In the following dis-
cussion treatment will be divided into the cor-
rection of acute in contrast to chronic deficiencies.
Acute Protein Deficiencies. — Therapy is usual-
ly rather simple and effective, because a trans-
fusion of either whole blood or plasma replaces
at once what is missing, and is permanently ef-
fective as long as no further losses occur. It is
obviously important that these acute losses be
replaced as soon as possible, and indeed in the
case of bleeding at operation, the loss can be
May, 1947
495
PROTEIN AND AMINO ACID THERAPY— ELMAN
corrected almost at once. On the other hand,
when the loss occurs through damaged capillaries,
there is some evidence to show that correction is
best made several days later, when the damaged
capillaries are no longer permeable, in order to
insure against further loss of the injected material.
Such delay, however, is obviously dangerous when
the loss has been so great as to lead to surgical
shock. In such cases, the replacement must not
only be immediate, but it must be rapid in order
to prevent the irreversible changes which occur
when the circulation remains impaired for a long
period of time.
Chronic Protein Deficiencies. — There are two
general features which should be emphasized.
First, an adequate intake must be started at the
very beginning — in other words, the first day the
patient comes under our care. If protein dep-
rivation persists, the problem becomes magni-
fied greatly. It is much harder to correct a chron-
ic protein deficiency than it is to prevent it. Sec-
ond, an adequate protein intake cannot be left
to chance nor to the usual types of dietary pro-
cedures.
The oral route is obviously the best for the
administration of protein. It is not only the
cheapest, but it is probably the most effective
physiologically. Protein may be administered or-
ally either in the form of whole protein separated
from natural food, or as a part of natural food
substances. Protein may also be administered in
the form of amino acid mixtures which in some
instances have advantages over whole protein —
for example, when it is advisable to spare the
need for digestion, which may be impaired. When
the physician wishes to administer larger amounts
of protein than can be assimilated in the form
of whole protein, amino acids may be used, or
when he wishes to combat hyperacidity, amino
acids are better buffers than whole protein. It
should be emphasized, however, that hydrolyzed
protein must have a high biological value, and
that a large enough amount must be given each
day. Thus far, the taste of hydrolyzed protein
preparations has been a distinct disadvantage ex-
cept in the case of tube feeding.
The problem of anorexia in sick patients re-
quires devices which permit the ingestion of a
large amount of protein in a relatively small vol-
ume, preferably as liquids rather than solids. It
is probably permissible to sacrifice some of the
caloric requirements in order to insure a large
protein intake. As a working rule, 100 gm. each
of protein and glucose may be set as the probable
minimum intake. By adding skimmed milk pow-
der and pure casein to whole milk properly flav-
ored, one may devise a palatable liquid drink
which in one glass will contain about 25 to 35
gm. of protein and about 300 to 400 calories.
This may then be ordered three or four times a
day, and the physician thereby is assured that
protein starvation will certainly not occur.
Larger amounts may be given to extremely
malnourished patients. As much as 200 to 300
gm. of protein and up to 5,000 calories have ac-
tually been given to hospital patients when ade-
quate supervision and care were provided. Tube
feeding may sometimes be necessary and, of
course, presents no unusual problem except for
the necessity of using liquid food.
Parenteral Protein Feeding. — The parenteral
route for the injection of needed protein must
only be used on the most definite indications.
This is so because any parenteral, particularly in-
travenous injection, is potentially dangerous.
While the incidence of untoward reactions may
not be great, they do occur and will obviously
be less when this method of therapy is used least.
On the other hand, the injection of protein ma-
terial intravenously will permit great improve-
ment in surgical and other care, and even be di-
rectly responsible for the saving of human life,
particularly in the case of transfusions.
Protein can be injected intravenously either in
the form of plasma and whole blood or as so-
lutions of amino acid mixtures which are at
present available only as preparations of hydro-
lyzed protein. The two forms of parenteral pro-
tein administration usually have entirely different
indications but are frequently necessary in the
same patient, but usually at different times.
Whole protein, in the form of whole blood or
plasma transfusions, generally is indicated for the
correction of acute protein deficiencies, as dis-
cussed above. Sufficiently large amounts must be
given, usually a liter or more, and adequate pre-
cautions taken. In the case of chronic protein
deficiency, whole blood and plasma may also be
indicated, but usually are an adjunct to the use
of amino acid mixtures and not the sole method
of introducing protein as food.
For parenteral protein feeding, plasma is much
4%
Minnesota Medicine
PROTEIN AND AMINO ACID THERAPY— ELMAN
more expensive than amino acid mixtures and has
a further disadvantage of introducing protein in
an unphysiological manner. It is probable that
the protein thus introduced is broken down to
amino acids before being utilized. By contrast,
appropriate amino acid mixtures represent the
physiological manner in which food protein is
assimilated from the gastrointestinal tract. The
use of amino acids makes it possible now to fur-
nish an almost complete parenteral diet. Up un-
til the introduction of hydrolyzed protein for
parenteral use, such patients suffered protein
starvation. Now, one may give one liter of in-
travenous fluid containing four of the five es-
sential nutritional elements, i.e., water, glucose,
amino acids and salt. This is possible because at
least one preparation, i.e., Amigen solution, con-
tains in one liter 50 grams of hydrolyzed protein,
50 grams of glucose and 2.5 grams of sodium
chloride plus minimal amounts of other salts. As
utilized by the author, 1 liter of this solution is
given in the morning and one in the afternoon
during periods when the patient is unable to eat.
Adequate vitamins are given separately.
The indications for the use of the parenteral
channel are many, including primarily those pa-
tients unable to take any nourishment by mouth,
or patients in whom complete rest of the gastro-
intestinal tract is indicated. This includes pa-
tients with intestinal obstruction, vomiting from
any cause, general peritonitis, postoperative an-
astomoses, certain cases of ulcerative colitis or
regional ileitis, and advanced malnutrition. In
addition, the parenteral route will also be utilized
as a supplementary method of introducing protein
nourishment in patients unable to take a large
amount of protein by mouth.
The danger of reaction following intravenous
injections has been studied rather widely. It is
very real in the case of both whole blood and
plasma transfusions, and is also present in such
complex mixtures as hydrolyzed protein. In a
series of 3,000 consecutive injections of Amigen
solution by the author, twenty-two reactions, or
an incidence of 0.8 per cent occurred, consider-
ably less than was seen with plasma and whole
blood transfusions during a similar interval. Con-
traindications to the injection of hydrolyzed pro-
tein are, first, any solution which is not absolute-
ly crystal clear, and second, the development of
any sign of sensitivity. Pyrogenic reactions, on
the other hand, while they call for discontinuance
of the injection, are not contraindications in a
strict sense, since subsequent injections may be
carried out without necessarily provoking a simi-
lar effect.
REPORT OF ATOMIC BOMB CASUALTY COMMISSION
A number of interesting facts relating to the Japanese
who survived at Hiroshima and Nagasaki were dis-
closed in the report of the Atomic Bomb Casualty Com-
mission released by the War Department at a recent
press conference held in the office of the Surgeon
General.
Following are some highlights of the commission’s
report, which was reviewed and cleared by the Atomic
Energy Commission prior to issuance :
“Members of the commission have been impressed
during their observations of atomic bomb survivors by
the fact that many of the burns have healed with ac-
cumulations of large amounts of elevated scar tissue,
the so-called keloids,” said the report.
During the months of October and November, 1945,
a study was conducted on 124 male inhabitants of Hiro-
shima. Examinations disclosed that, in 43 cases, the
number of spermatocytes in the ejaculated sperm w?as
less than 5,000 per cubic millimeter, or “absolutely
sterile,” in the words of Prof. Tsuzuki. Ten other cases
were “relatively sterile” and the remaining 71 were nor-
mal.
“A reformation of the spermatocytes occurs in one
month, so the recovery of damage to spermatocyte for-
mation will be delayed more than that of the damage
of white blood cells. The shorter the distance, the more
severe was the damage. The damaging influence on
the number of spermatocytes was observed in the area
within a radius of three kilometers (about two miles)
from the ground center. Within a radius of 2.5 kilo-
May, 1947
meters there appeared some sterile cases. Within a radius
of 1.5 kilometers one-half of the cases showed sterility.”
Women who were in an early stage of pregnancy
“have taken a normal course since the bombing,” said
Dr. Tsuzuki.
“It is already experimentally proved both in botany
and zoology that there is a possibility of producing
malformation of descendants ‘when the sexual cells are
affected in some degree by radioactive energy. The
question, if this fact is applicable to the human beings
or not, will be made clear by further observations.
“We have already clear evidence that the human
sexual cells are also affected by the atomic bomb in-
juries. There is a possibility of malformation of the
descendants, if the sexual cells should be affected selec-
tively, without any severe damage to the other organs
or tissues.
Heretofore, conflicting figures have been presented
on the number and character of casualties at Hiroshima
and Nagasaki. Dr. Tsuzuki quotes the Hiroshima, pre-
fecture as estimating, 19 days after the explosion, the
dead at 46,185; the missing at 17,429; the severely in-
jured at 19,691 ; slightly injured, 44,979, and other suf-
ferers at 235,656. Six months after the catastrophe, the
toll of dead and missing stood at 92,133, excluding the
military dead. The total number of Hiroshima dead
may be set at 100,000, according to the Japanese pro-
fessor. The Nagasaki prefecture set that city’s toll at
23,753 dead, 1,924 missing, 23,345 wounded and 89,025
other sufferers. — From News Notes, Office of the Sur-
geon General, April, 1947.
497
THE RELATIONSHIP OF INFECTIOUS AND SERUM JAUNDICE
JOHN G. RUKAVINA. M.D., and EDWARD L. TUOHY. M.D.
Duluth. Minnesota
Tlj'PIDEMICS of jaundice are a regular war
■^“'accompaniment, and the more widespread the
conflict, the more civilians and military personnel
fall victims. This fact has made it certain (with-
out the added incubus of the recent war) that this
form of infectious jaundice is a transmissible dis-
ease and, as such, must be distinguished from
jaundice caused by drugs, toxins, degenerative
and infectious processes of known bacterial ori-
gin. and neoplastic and calcific obstruction, lhe
older term “catarrhal jaundice” is gradually yield-
ing place to the term “infectious hepatitis.” \ he
older term greatly overstressed the factor of ex-
trahepatic ductal swelling. Using the material
from a local epidemic of infectious jaundice oc-
curring in 1944, Fee and Tuohy44 reported a
high incidence of this type, and by profile studies
of various laboratory procedures (with special
emphasis upon information provided by quanti-
tative urobilinogen estimations in the stool and
urine) they established means of differentiating
intra- and extra-hepatic jaundice.
The accepted entity of infectious jaundice pro-
vides a needful opportunity for clinicians to fa-
miliarize themselves with the habits and propen-
sities of viruses in general: their immunological
identification, selective localizations and the mech-
anisms of natural defense of the host. Since
biological inhibiters and mold extracts are known
to lack specificity in most bowel infections, the
maintenance, for example, of the gamma globulin
fraction of the circulating and tissue plasma, with
a background of a good functioning liver, becomes
paramount. Furthermore, behind this liver ade-
quacy stands a sufficient diet with suitable protein
content. Now that a general consensus obtains as
to the transmissibility of the jaundice virus (of
various types), many papers and reports are in
the current literature dealing with the routes of
entrance into the host, and how defense against
the virus may be planned. Identification of the
virus comes first to mind : whether one common
virus accounts for this transmissible type of jaun-
dice, or whether there are several distinct or pos-
From the Department of Medicine, The Duluth Clinic and
St. Mary’s Hospital, Duluth, Minnesota.
sibly related forms. Since the morphological tag-
ging of viruses is still far behind that of living
bacteria, measures other than morphological iden-
tification are utilized.
Another form of intrahepatic jaundice, also
closely identified with the events of the war and
known as “homologous serum jaundice,” is pres-
ently furnishing many fruitful studies. It first
got prominent attention after some of the earlier
military recruits were vaccinated for yellow fever.
Later on as transfusions of banked blood and the
giving of plasma became routine procedures on
the battle field, this type of jaundice in some areas
exceeded the totals of infectious jaundice where
no transmission via the route of human blood
could be incriminated. Lest it be assumed that
this only concerns the armed forces in action or
in the various hospital cantonments, the writers
wish to report two cases of homologous serum
jaundice, one terminating in death, with the same
subacute liver atrophy so well described by the
various authors reporting their military experi-
ence. In each instance these women developed
their jaundice sixty to eighty days after abdom-
inal operations, in the course of which blood
transfusions were given as precautionary meas-
ures.
Doubtless, since the termination of war, there
has been less and less epidemic jaundice. The
usual caution of directors of blood banks will, of
course, dictate the rejection of all donors with
recent illnesses, not to mention previously jaun-
diced persons.
One of the authors (J. R.) has reviewed the
extensive literature bearing upon the relationship
between infectious hepatitis and serum jaundice.
This digest is offered in an attempt to find out
how much these entities have in common and
wherein they differ. It is hoped that the reader
will find stimulation and understanding in re-
viewing what our active medical men have been
able to accomplish in this field of research de-
spite the overwhelming difficulties and confu-
sion of a military service spread around the world.
World War II has provided much material for
498
Minnesota Medicine
INFECTIOUS AND SERUM JAUNDICE— RUKAVINA AND TUOHY
these various studies. Since routine epidemic
and endemic infectious jaundice has long been
studied, the liver damage associated with serum
jaundice has been conspicuously stressed.
The following primary aims are set forth in
attempting to group the recent studies : ( 1 ) to
establish with certainty the entity of homologous
serum hepatitis; (2) to catalogue the consensus
of opinion as to its experimental reproduction ;
(3) to point out the likenesses and dissimilarities
of homologous serum hepatitis and infectious
hepatitis, and (4) to demonstrate in the last analy-
sis that the “artificial” disease has a higher mor-
tality rate, longer incubation period, and a re-
duced element of contagion.
Transmission of Infectious Hepatitis Via
Natural and Experimental Routes
Since infectious hepatitis occurs in well-known
epidemics, many studies attest the correctness of
this clinical inference.3’9,11 The agent is present
in the blood stream before the onset and during
the jaundice; it is also present in the feces and
possibly in the nasal washings in the acute
stages.19 MacCullum and Bradley,24 Havens et
al20 used such material establishing effective proof
of transmissibility. The latter group fed nine
volunteers samples of infectious sera or feces,
producing the disease in five after an incubation
period of from twenty to eighty-four days (av-
erage thirty-seven days). Neefe and co-work-
ers32 fed pooled specimens of feces from patients
with infectious hepatitis to tw’elve volunteers,
hepatitis occurring within twenty-six days in six
of the twelve subjects. They were able to prove
conclusively, using infectious materials from an
epidemic at a boys’ and girls’ summer camp near
Philadelphia, that the agent responsible for the
epidemic was water-borne. This experiment ap-
peared to them to be the first satisfactory evidence
of the natural water-borne transmission of a
virus disease to man.
The traditional use of laboratory animals as
vectors or intermediary hosts has met with failure
because animals are refractory. Cameron,5 Paul
et al,37 Findlay and Martin,13 Oliphant and co-
workers,36 Sawyer and his group,40 and others
made such attempts without infecting the animals
used. The work of continental European inves-
tigators indicating positive results lacks confirma-
tion in this country.37 Recently MacCallum and
Miles25 rechecked the question of animal trans-
mission. Inoculating Wistar rats, that had been
placed on a diet deficient in protein, with blood
and feces of infections hepatitis patients, followed
by nine blind passages of tissues of these rats,
these men were able to produce liver necrosis,
and/or hemorrhage into the lymph nodes, gastric
and intestinal walls and tissues of the lung. Ihus
these studies suggested to them that they were
dealing with a transmissible disease caused by a
virus, and hinted that hypoproteinemia in their
animals made their livers susceptible. Bearing
this new evidence in mind, one finds clinical sup-
port in the recent report of Snell, Wood, and
Meienberg.41 They studied thirty-two cases of
serum jaundice occurring on an average of eighty-
four days following military trauma. All had
received blood or plasma after injury. The mor-
tality rate was relatively high — 19 per cent. Fhe
seriousness of the course of the disease in wound-
ed men was attributed by them to a nutritional
depletion which added to their vulnerability.
Serial passage of the disease in man has been
reported on two occasions.18’19 By using the hu-
man volunteer technique some of the properties
of the agent have been determined.
1. Both the icterogenic agent in homologous
serum jaundice36 and that of infectious hepati-
tis18’19 have been- found to be heat resistant at
56° C. for one-half hour and also to pass bac-
teria-tight filters.
2. As in serum jaundice, the agent is present
in the blood stream during the active phase.5’19’24
3. Its presence in the feces14,19’24 and urine14,46
has been similarly demonstrated.
Numerous substances have been used in the
production of infectious hepatitis by the oral route.
Voegt46 claimed to have caused the disease suc-
cessfully by oral administration of duodenal fluid,
urine, and hemolyzed red blood cells. MacCal-
lum and Bradley,24 by feeding infectious feces
to volunteers suffering from arthritis, claim to
have produced the disease, although their results
with nasopharyngeal washings were less convinc-
ing. Havens and co-workers19,20 added weight to
these observations by their studies of material se-
cured from American and British troops in the
Middle East and Mediterranean area. They gave
fecal material in capsules, as well as urine and
stool extracts, which had been filtered and dried.
Two of three volunteers contracted jaundice after
twenty to twenty-two days.
May, 1947
499
INFECTIOUS AND SERUM JAUNDICE— RUKA VINA AND TUOHY
A number of reports emphasize the parenteral
route as a means of producing the disease. Cam-
eron,5 using serum and whole blood secured from
infectious cases, produced the typical picture in
six of seven volunteers by intramuscular injec-
tion. Voegt46 (9), in an earlier monograph, and
others19’24’36 using various parenteral routes re-
ported similar results.
Homologous Serum Hepatitis
Homologous serum jaundice, a highly artificial
entity, presents a more difficult problem in etiol-
ogy. By definition, it is a form of hepatitis which
usually occurs from six weeks to six months after
the injection of certain samples of whole blood,
serum, or plasma.22 It implies that blood drawn
from a nonjaundiced individual, or from one not
known to be ill at the time, has gone into a blood
bank pool. There is no doubt in the minds of
many students of liver pathology that this entity
has been commonly overlooked in the differential
diagnosis of hepatitis ; and with the greater use
of blood and blood products (especially in view
of the early release of excess armed forces plas-
ma) this question becomes even more important.
Peculiarly enough, serum jaundice has not been
observed as yet after the injection of normal
serum albumin and normal serum gamma globu-
lin which were derived from 250 to 5,000 bleed-
ings pooled for plasma fractionation.
The literature is replete with reports that the
disease has been associated with the use of prophy-
lactic measles serum.26’28’29’38 MacNalty26 ob-
served jaundice among thirty-seven of eighty-two
to 109 persons who had received this substance
from the same material pool. Propert38 reported
not only that seven children developed jaundice
after injection of convalescent measles serum but
that there was definite evidence that two play-
mates developed jaundice approximately two
months after contact with the injectees! Mumps
serum has also been implicated.2’27’28’31 One
study27 noted that hepatitis developed in 101 of
266 men inoculated with mumps convalescent plas-
ma. Yellow fever vaccines in human serum drew
especiallv widespread comment and attention due
to the experiences of the United States Army6’7’8
in 1942. Findlay, Martin, and Mitchell,16 in an
intensive study of 689 cases of yellow fever vac-
cine hepatitis, occurring in military personnel
during World War II, stressed the importance
of the clinical, pathological, etiological, and epi-
500
demiological features. Great emphasis was also
placed on four cases suffering from post-inocula-
tion hepatitis without jaundice, suggesting to them
the greater need for consideration of hepatitis
occurring in a forme frustre without recognizable
jaundice. More emphasis, then, must be placed
on serum hepatitis sine ictero in living subjects.
Turner45 and his colleagues carefully studied 4,-
083 cases of post-inoculation hepatitis at Camp
Polk, Louisiana, the hepatotoxic agent being pres-
ent in yellow fever vaccine, lot 369. The clinical
picture with especial reference to the nervous
system manifestations in severe cases was stressed.
Other studies12’15’17’36’42 have added further data
to our increasing knowledge of post-inoculation
hepatitis.
Reports dealing with the experimental injection
of some of these sera are of interest. Oliphant36
experimentally produced jaundice in volunteers
by inoculation of two lots of yellow fever vac-
cine containing pooled serum, and also by inocu-
lation of serum from eleven patients who had
previously received yellow fever vaccines carried
in human serum. Evidence was also presented
that the icterogenic substance was absent from
the blood stream two and one-half months after
the disappearance of the jaundice. They made
the novel observation that this agent might be
neutralized with ultra-violet radiation.
Beeson1 reported that seven persons who had
received transfusions of blood or plasma at the
time of an injury or surgical operation devel-
oped jaundice one to four months after the trans-
fusion. Steiner’s experiences add to these re-
ports.43 Rappaport39 observed thirty-two cases
of jaundice in military personnel following trans-
fusion with plasma or blood. He opined that,
apart from infectious hepatitis, transfusions may
serve as the commonest current cause of jaundice
in the armed forces. Jaundice due to plasma or
serum has been further noted in scattered re-
ports.4,28,29,34 Neefe and others34 related the 100
per cent occurrence of hepatitis in nine men in-
oculated experimentally with plasma or yellow
fever vaccine containing human serum. Bradley,
Loutit, and Maunsell4 discovered that 57 per
cent of their cases developed jaundice forty-nine
to 107 days after infusion with pooled serum.
Morgan and Williamson29 commented on the fact
that 18 per cent of their patients developed jaun-
dice forty-nine to 107 days after transfusion of
liquid pooled plasma or reconstituted dried serum.
Minnesota Medicine
INFECTIOUS AND SERUM JAUNDICE— RUKAVINA AND TUOHY
The agent of serum hepatitis produces jaundice
inconsistently when administered by the parenter-
al route. Oliphant and co-workers, using yellow
fever vaccine and serum for vaccine-induced
jaundiced persons, caused the disease to appear in
thirty of 189 cases tried. MacCallum and Bauer
observed two cases of jaundice when five volun-
teers were studied. Neefe34 reported varying
results with the inoculation of mumps convales-
cent serum, mumps passage material, and yellow
fever vaccine. Paul37 and others, reported a high-
er incidence of positive takes.
Serum jaundice has been transmitted in one
case23 by feeding serum and in three cases in
which the icterogenic serum was swallowed ac-
cidentally by laboratory workers.41 On the whole
there is basic agreement by most observers that
the oral administration of feces from homologous
cases of serum hepatitis does not produce hepa-
titis. There is some evidence that nasopharyngeal
washings carried the etiologic virus.13 One is
hard pressed to explain the observations of two
authors34’38 who felt that through contact with
patients suffering from serum hepatitis, four per-
sons developed a jaundice that did not appear to
them to be the epidemic type. Were these true
contact cases?
Differences of the Disease Entities
Thus, the problem of similarity or dissimilarity
of the agents of serum and infectious hepatitis,
despite all this research, still retains some secrets.
The similarities have been commented upon ; the
differences remain of prime interest. Many in-
vestigators have emphasized that the death rate is
higher in serum hepatitis than the 0.2 to 0.4 per
cent characteristic of infectious hepatitis. Neefe
et al33 point out the fact that the temperature in
infectious hepatitis usually is observed to be above
100°F. (orally), while that of serum jaundice
usually does not exceed 100°F. Further they em-
phasize the fact that the incubation period in the
artificial disease is prolonged sixty or more days.
However, one must continually make allowance
for the variable icterogenic “capacity” of the sera
used which may well explain the variation in rates
at which serum jaundice is produced as well as the
difference in length of incubation period. Trans-
mission differences require consideration. Multi-
ple routes in experimental transmissions are com-
mon in infectious hepatitis, while efforts at feces
transmission of serum hepatitis have generally
met with failure32 — hence the observation that it
is not a relatively contagious disease.
The Problem of Homologous Cross Immunity
Since a number of investigators do not believe
that the aforementioned criteria are sufficiently
adequate for differentiation, antigenic studies in-
volving immunity and cross immunity techniques
have been utilized.
There is general consensus that a single attack
of infectious hepatitis produces a degree of im-
munity.5’16 Further, the infrequency with which
this lesion occurs after thirty-five years of age
suggests an age-acquired immunity, or an appar-
ent subclinical childhood attack. Neefe and his
group33 have demonstrated experimentally that
immunity to serum jaundice following infectious
hepatitis does exist, while volunteers were found
to be resistant to reinfection with the infectious
hepatitis type up to at least eight months after
recovery from hepatitis which had been induced
by the same agent.
Homologous immunity in serum hepatitis has
been discussed by Oliphant35 who reinjected ten
persons with yellow fever vaccine twelve to eight-
een months after hepatitis had been induced by
inoculating yellow fever vaccines or samples of
similarly induced icterogenic serum. Ten nor-
mals were used as controls. Three of the latter
developed hepatitis while none of the test group
were so afflicted. Neefe33 confirmed this view.
The data on cross immunity, however, leaves
much to be desired. The assembled data presents
conflicting conclusions. One investigational
group27 reported that of an army unit of 175
men developing serum hepatitis following prophy-
lactic inoculation of a mumps convalescent serum,
eleven of these cases had a history of “catarrhal”
jaundice in childhood. Another group16 was im-
pressed by the apparent reduced susceptibility to
serum hepatitis of persons who had previously
had the infectious type. In striking contrast,
Witts,47 quoting Gordon, stated that previous
homologous serum hepatitis might actually in-
crease susceptibility to infectious hepatitis. Oli-
phant's35 view that “recovery from homologous
serum jaundice results in immunity to reinocula-
tion with serum from acute cases of infectious
hepatitis or with icterogenic yellow fever vaccine
and that the immunity persists for at least twelve
to eighteen months” has been challenged. Lack of
data as to the age of the subjects seems to nullify
May, 1947
SO!
INFECTIOUS AND SERUM JAUNDICE— RUKAVINA AND TUOHY
the above observation on the basis of decreased
susceptibility to infectious hepatitis of persons
over thirty-five years of age.
These recent investigations concerning cross
immunity might be considered as pioneer work.
Currently, Neefe and co-workers,33 further ex-
ploring the problem, conclude that the hepatitis
which occurred in the serum hepatitis resistant
test group (five cases), following inoculation with
infectious hepatitis test material, was not due to
“reactivation of the serum hepatitis agent, to rein-
fection with that agent after disappearance of
the previously demonstrated resistance or to break-
down of that resistance by an overwhelming dose
of the same agent.” Rather they felt that the
hepatitis was due to the infectious material with
which the cases were reinoculated. The absence
of cross immunity suggested to them a difference
either on the basis of an antigenic variation in
strain of a single type of virus agent or on tin*
basis of two different types of virus agents. These
researches bring up the possibilities of various
strains of virus as is well known with the higher
bacteria.
Summary
1. Despite the difficulty objectifying virus
types, these known forms of hepatitis are accept-
ed as viral in origin and are just as definite etio-
logically as is measles or small pox.
2. Homologous serum hepatitis brings in a
route of human transmission that involves the
provinces of vaccine prophylaxis and human blood
or serum replacement.
3. Paul and Havens37 and Neefe and Stokes32
have commented upon the relationship existing
between the causal virus of serum jaundice and
infectious jaundice and think they are distinct.
It will be recalled that all viruses may have com-
mon propensities.
4. There is no need of denying anyone needed
blood, plasma or serum ; but the relatively small
chance of transmitting serum jaundice should
tighten up the indications for transfusions and the
careful survey of donors for blood banks.
References
1. Beeson, P. B. : Jaundice occurring one to four months
after transfusion of blood or plasma. J.A.M.A., 121 : 1332,
(April 24) 1 943.
2. Beeson, P. B. ; Chesney, G., and McFarlan, A. M. : Hepa-
titis following injection of mumps convalescent plasma.
Lancet, 1 :814, (June 24) 1944.
3. Blumer, G. : Infectious jaundice in the United States.
J.A.M.A., 81:353, (Aug. 4) 1923.
4. Bradley, W. H. ; Loutit, B. M., and Maunsell, TC. : An
episode of homologous serum jaundice. Brit. M. J., 2:268,
(Aug. 26) 1944.
5. Cameron, J. D. S. : Infective hepatitis. Quart. J. Med.,
12:139, 1943.
6. Circular Letter No. 95, Office of the Surgeon General:
Outbreak of jaundice in the army. J.A.M.A., 120:51,
(Sept. 5) 1942.
7. Editorial: J.A.M.A., 119:110, 1942.
8. Editorial: Catarrhal and human serum jaundice, T.A.M.A.,
122:746, (July 10) 1943.
9. Editorial : Epidemic hepatitis or catarrhal jaundice. T.A.-
M.A., 123:636, (Nov. 6) 1943.
10. Editorial: Hepatitis after transfusion. Brit. M. J., 2:279,
(Aug. 26) 1944.
11. Editorial: Problem of infectious hepatitis. T.A.M.A.,
122:1186, (Aug. 21) 1943.
12. Findlay, G. M., and MacCallum, F. O. : Hepatitis and
jaundice associated with immunization against certain virus
diseases. Proc. Roy. Soc. Med., 31 :7 99, (May) 1938.
13. Findlay, G. M., and Martin, N. H. : Jaundice following
yellow fever immunization. Transmissioi by intranasal
installation. Lancet, 1 :678, (May 29) 1943.
14. Findlay, G. M., and Wilcox, R. R. : Transmission of
infective hepatitis bv feces and urine. Lancet, 1 :2 12,
(Feb. 17) 1945.
15. Findlay, G. M. ; MacCallum, F. O., and Murgatroyd, F. :
Observations bearing on etiology for infective hepatitis
(so-called epidemic catarrhal jaundice). Tr. Roy. Soc. Trop.
Med. & Hyg., 32:575, (Feb.) 1939.
16. Findlay, G. M. : Martin, N. H., and Mitchell, J. B. :
Hepatitis after yellow fever inoculation. Relation to in-
fective hepatitis. Lancet, 2:301, (Sept. 2) 1944; 2:340,
(Sept. 9) 1944); 2:365, (Sept. 16) 1944.
17. Fox, J. P. ; Manso, C. ; Penna, H. A., and Para, M. :
Observations on the occurrance of icterus in Brazil follow-
ing vaccination against yellow fever. Am. J. Hvg., 36:68,
(Sept.) 1942.
18. Havens, W. P. : Properties of the etiological agent of
infectious hepatitis. Proc. Soc. Exper. Biol. & Med.,
58:203, (March) 1945.
19. Havens, W. P. : Paul, J. R. ; Van Rooyen, C. E. ; Ward,
R. ; Drill, V. A., and Allison. N. H. : Human transmis-
sion of infectious hepatitis bv the oral route. Lancet, 1 :202,
(Feb. 17) 1945.
20. Havens, W. P. ; Ward, R. ; Drill, V. A., and Paul, J. R. :
Experimental production of hepatitis by feeding icterogenic
materials. Proc. Soc. Exper. Biol. & Med., 57 :206, (Nov.)
1944.
21. Hoft'bauer, F. W. : Infectious hepatitis. Minnesota Med.
Foundation, 5:105, (June) 1945.
22. Jane way, C. A. : Present status of homologous serum
jaundice. Bull. U. S. Army M. Dept., 5 :3, (Jan.) 1946.
23. MacCallum, F. O., and Bauer, D. J. : Homologous serum
jaundice, transmission experiments with human volunteers.
Lancet, 1 :622, (May 13) 1944.
24. MacCallum, F. O., and Bradley. W. H. : Transmission
of infective hepatitis to human volunteers. Lancet, 2:228,
(Aug. 12) 1944.
25. MacCallum, F. O., and Miles, J. A. R. : A transmissible
disease in rats with material from cases of infective hepa-
titis. Lancet, 1 :3, (Jan. 5) 1946.
26. MacNalty, A. S. : Acute infectious jaundice and admin-
istration of measles serum. Reprint, Chief Medical Office,
Ministry Health, London, 1937.
27. McFarlan, A. M., and Chesney, G. : Hepatitis and mumps
convalescent serum. Epidemiology of the hepatitis. Lan-
cet, 1 : 8 1 6, (June 24) 1944.
28. Memorandum prepared by medical officer of the Ministry
of Health : Homologous serum jaundice. Lancet, 1 :83,
(Jan. 16) 1943.
29. Morgan, H. V., and Williamson, D. A. J. : Jaundice fol-
lowing administration of human blood products. Brit. M.
J., 1:750, (June 19) 1943.
30. Neefe1, J. R., and Stokes, J. : An epidemic of infectious
hepatitis apparently due to a waterborn agent. T.A.M.A.,
128:1063, (Aug. 11) 1945.
31. Neefe, J. R. ; Miller, T. G., and Chornack, F. W. : Homol-
ogous serum jaundice. A review of the literature and a
report of a case. Am. J. M. Sc., 207 :626, (May) 1944.
32. Neefe, J. R. ; Stokes, J., and Reinhold, J. G. : Oral ad-
ministration to volunteers of feces from patients with homol-
ogous serum hepatitis and infectious (epidemic) hepatitis.
Am. J. M. Sc., 210:29, (July) 1945.
33. Neefe, J. R. ; Stokes, J., and Gellis, S. S. : Homologous
serum hepatitis and infectious (epidemic) hepatitis. Ex-
perimental study of immunity and cross immunity in volun-
teers, a preliminarv report. Am. J. M. Sc., 210:561, (Nov.)
1945.
34. Neefe, J. R. : Stokes, J. ; Reinhold, J. G., and Lukens,
F. D. W. : Hepatitis due to injection of homologous blood
products in human volunteers. J. Clin. Investigation, 23:
836, (Sept.) 1944.
35. Oliphant, J. W. : Infectious hepatitis: experimental study
in immunity. Pub. Health Rep., 59:1614, (Dec. 15) 1944.
36. Oliphant, J. W. ; Gilliam, A. G., and Larson C. I.. : Jaun-
dice following administration of human serum. Pub. Health
Rep., 58:1233, (Aug. 13) 1943.
37. Paul, J. R. ; Havens, W. P. ; Sabin, A. B., and Philip,
C. B. : Transmission experiments in serum jaundice* and
infectious hepatitis. J.A.M.A., 128:911, (July 28) 1945.
38. Propert, S. A. : Hepatitis after prophylactic serum. Brit.
M. J., 2:677, (Sept. 24) 1938.
(Continued on Page 513)
50 2
Minnesota Medicine
A PLAN FOR THE DETECTION OF THE SOURCE OF RECTAL BLEEDING
HAROLD E. HULLSIEK. M.D.
Saint Paul, Minnesota
BLEEDING from the rectum, either as the
patient’s chief complaint or as one of several
symptoms, is of common occurrence. It is fre-
quently disregarded, judged as meriting little con-
cern, but it should always be investigated since it
may be the first evidence of malignant disease.
The source is to be found and, if possible, erad-
icated. If this is impossible, one should at least
be able finally to assure one’s self and the patient
of the absence of serious disease. One of the rea-
sons for the frequent neglect or mistreatment of
individuals with this complaint is the lack of a
plan in the search for its cause.
tempted to arrange a graphic representation of the
methods I have for years more or less automati-
cally followed. Before proceeding further, I
might say that this discussion does not apply to
those persons with massive rectal hemorrhage and
in whom the primary concern is the treatment of
shock and blood loss.
In all cases involving rectal bleeding, a careful
history is of value and is occasionally diagnostic
of itself. Is the blood bright or dark, liquid or
coagulated? Is it passed unaccompanied by, or
mixed with, the stool? Is it merely on the toilet
tissue ? Estimates by the patient of the amount of
A PLAN FOR THE DETECTION OF THE SOURCE OF RECTAL BLEEDING
I. History
II. Inspection.
III. Digital examination.
IV. Anoscopic examination.
A. Cause found and easily remedied.
B. Cause found requiring lengthy or j
extensive treatment iy. Proctoscopic examination.
C. Cause not found. j A. Cause easily remedied.
B. Lengthy or extensive 1
treatment. rVI. X-ray of colon.
C. Cause unfound. )
In a recent and very complete article on the sub-
ject, an author states that “a complete proctologic
study including proctosigmoidoscopic examina-
tion, examination of the stools, and an x-ray of
the colon” should be done for all patients with
rectal bleeding. Now the plain fact is that this is
not necessary for all patients of this type, and,
while every practitioner knows this, often he is
not certain as to the one in whom it is necessary.
The same writer lists some seventy conditions
which produce blood in the stool, leaving the
reader’s mind filled with a bewildering confusion
of causes but with few concrete suggestions as to
how to proceed. If his rule is followed — and
much the same advice is given in most articles on
this subject — many patients will be subjected to
arduous and unnecessary investigation and ex-
pense. On the other hand, if it is not followed,
some very serious conditions may remain undis-
covered. With the above in mind, I have at-
Read before the Ramsey County Medical Society, Saint Paul,
Minnesota, March 31, 1947.
May, 1947
blood passed are to be evaluated with caution, but
often one may get some idea of the quantity. Do
the bowels move daily and as usual for that par-
ticular patient, or has there been a definite change
in bowel habits? If constipated, what measures
have been undertaken to overcome it, and are they
successful? If the bowels move frequently, is the
movement an actual stool or does it simply repre-
sent an urge to move the bowels, producing
blood, gas, and a semi-liquid material? Does the
bleeding have associated with it itching, burning,
or prolapse? If there is pain, what type is it and
how long does it last ? For example, a sharp cut-
ting pain experienced at the moment of passing
the stool and continuing for several hours after-
ward, gradually becoming less severe, together
with streaking of blood, is almost pathognomonic
of fissure. How long has the bleeding been going
on and does it occur daily? A history of a change
in bowel habits of from one or two movements a
day to several bloody and watery discharges, to-
503
RECTAL BLEEDING— HULLSIEK
gether with weight loss, is of course suggestive of
malignancy in a person of middle age. On the
other hand, the same story in a young individual is
more likely to be an ulcerative colitis. The patient
with a story of something protruding after stool,
which he is able to replace himself, in all likeli-
hood has no more than prolapsing piles. The
search for anything is made much easier by a
knowledge of what to look for and where to look,
and careful questioning will frequently bring out
clues as to both.
Inspection
This should be done with the patient in the left
lateral or Sim’s position, with a good light, cotton
swabs, applicators both loosely and tightly
wrapped, probes, a waste basket for the conveni-
ent disposal of used material, and a stool for the
examiner to sit on at a convenient level in rela-
tion to the patient. Most of the things needed for
a competent rectal examination are part of every
physician’s equipment, but unless arranged for a
rectal examination, oftener than not, they are not
conveniently accessible. 1 may appear to be stress-
ing a minor point, but I firmly believe that the
difference between a very good rectal examination
and a very bad one may depend on no more than
this. There are a number of conditions causing
bleeding which may be seen on inspection. Anal
condylomata, an excoriated pruritic skin, minor
injuries, or a true anal fissure or ulcer may be
the source of blood seen on the toilet paper. A
ruptured abscess or the external opening of a
fistula, prolapse, prolapsing hemorrhoids, a pro-
lapsing polyp, or an epithelioma of the anus may
be easily seen. The common anal fissure in the
anterior or posterior commissures may be diag-
nosed by inspection only, and if a bleeding fissure
can be seen by simply everting the anal opening
and looking, there is no point in making procto-
scopic examinations or taking x-rays. In fact,
there is little reason in looking for anything the
hard way if it can be found by the easy way first.
Digital Examination
Regardless of the patient’s story or the findings
on inspection, all these people should have digital
examinations. That this point needs to be im-
pressed is remarkable, but experience proves that
it does. Too many individuals are given advice
and treatment without benefit of examination.
The patient should be in the Sim’s position with
the examiner first seated on the stool, and then
standing. The flexor surface of the finger should
be directed forward, and then with the examiner
standing, it should be directed toward the sacrum,
at which time the finger can be made to pass into
the rectosigmoid junction in most patients. It is
quite impossible to do this with the finger directed
forward as in an examination of the prostate.
The size of the canal can be calculated and the
amount of spasm estimated; if the pain is too
great or the canal too small, the little finger may
be used and, especially after some practice, much
information may be obtained this way. Sphincter
tone, abnormal relaxation, and the degree of anal
fibrosis may be determined, as well as an estimate
of the length of the anal canal. Masses encoun-
tered may be tumors, anal papillae, cysts, foreign
bodies, including fecal impactions, and occasionally
a submucous abscess may be felt. Uncomplicated
internal piles cannot be felt. Following the digital
examination, an anoscopic examination is to be
done for all patients with blood in the stools.
Anoscopic Examination
This gives us first an appraisal of the color and
texture of the anal mucosa and reveals at once the
presence or absence of inflammation. A hemor-
rhagic proctitis or a low ulcerative colitis may be
seen through an anoscope. The presence of hem-
orrhoids may be noted, and by rubbing them with
an applicator, one finds out whether or not they
bleed easily. If no blood has been seen but ap-
pears immediately on rubbing the pile, it is very
likely that this same pile has bled on movement
of the bowels. A pile may have bled rather freely
an hour or two before examination and show no
sign of bleeding at the time, but if it bleeds on
rubbing, it is a likely offender. Is there a dis-
charge and, if so, is it mixed with blood, is it
purulent material, or is it mucus? The opening
of a draining sinus may be seen, as may a torn
crypt. We may see inflamed papillae cryptitis,
internal prolapse, tumors, foreign bodies, and now
and then parasites. A granulation-filled pocket in
the posterior commissure sometimes is productive
of blood while giving no other sign.
Having completed the anoscopic examination
the question as to further investigation arises. It
is either necessary or it isn’t. About some patients
one is certain, about others there may be some
question. It is plain that, for example, a patient
with a fissure that bleeds before one’s eyes, and
whose history suggests nothing else, does not re-
504
Minnesota Medicine
RECTAL BLEEDING— HULLSIEK
quire a proctoscopic examination and an x-ray of
the colon. Neither does one with a fecal impaction
or a granulating pocket in the posterior commis-
sure. Cancer of the rectum itself has already
been ruled out by the digital examination. Fur-
ther examination may be deferred if the bleeding
cause has been found and in addition if it can
be corrected easily and quickly and with the loss
of little time. Which patients then require a proc-
toscopic examination?
Proctoscopic Examination
Of all these people, those with obvious and
easily corrected conditions may be eliminated at
least for the time being, from our consideration.
The second group consists of those in whom the
source has been found but where the remedying
of the condition requires lengthy treatment or ex-
tensive surgery. For example, though a patient
has obviously bleeding piles, he should have a
proctoscopic examination before operation, since
even a hemorrhoidectomy is too extensive a pro-
cedure to undertake before eliminating the pos-
sibility of an accompanying carcinoma. On the
other hand, if the bleeding can be stopped by
means of three or four injections of quinine and
urea hydrochloride into the hemorrhoidal area,
little time will be lost, and if additional bleeding
occurs from another source, further investigation
may be carried out. Do not prolong treatment and
do not subject the patient to an extensive opera-
tion without having done a proctoscopic examina-
tion. The third group in which a proctoscopic ex-
amination is to be done is, of course, that in
which the source of bleeding has still not been
discovered.
Proctoscopic examination should be done be-
fore, and not following an x-ray study of the
colon. In a large proportion of patients with rec-
tal or colonic disease, the diagnosis may be made
by digital, anoscopic, and proctoscopic examina-
tion, without recourse to the barium enema and
x-ray. On the other hand, not infrequently a pa-
tient is dismissed on the basis of negative x-ray
findings alone, while having a tumor which, al-
though justifiably missed by x-ray, can be seen by
the proctoscope or felt by the finger. Proctoscopic
examination should be done following prepara-
tion by means of a plain water enema and, if de-
sired, may easily be done in one’s office. Unless
one confines his work to proctology, he is unlikely
to have a proctoscopic table, but the procedure
May, 1947
may be carried out satisfactorily on the ordinary
examining table with the patient in the knee-
shoulder position. Through the proctoscope the
color and texture of the mucosa is noted, and the
presence or absence of inflammatory change or of
ulcers may be visualized. Anomalies in the size
and direction of the lumen, varicositis, endome-
triosis and tumors may be seen. Blood may be
seen and, if the examination is made carefully, ;t
sometimes can be clearly seen to be coming from
higher up in the sigmoid than the area being
viewed. It is clear that there will be a number of
patients in whom, up to this point, no bleeding
source has been found, who will now, by means of
the proctoscope, be eliminated as candidates for
further investigation. Certain conditions will be-
come apparent, suggesting definite lines of treat-
ment of longer or shorter duration, or operative
procedures of greater or lesser extent. Which pa-
tients should be subjected to examination by
means of the x-ray?
Again we have each patient falling into one of
three classes. The first class consists of those in
whom the bleeding point has been found and is
easily corrected. A patient with a hemorrhagic
proctitis limited to the rectum, for example, need
not have a colon film. If treatment can be easily
and quickly carried out, x-ray may be deferred
for the time being, and if no recurrence of the
bleeding is noted, it need not be done at all. A
polyp in the rectum is one of the few findings
which merely show that my plan is not an in-
flexible one. Rectal polyps are accompanied by
polyps beyond the proctoslgmoidoscopic area in
50 per cent of cases ; thus, even though a bleeding
rectal polyp is found, x-ray of the colon should
be done. The second class is made up of those
patients in whom the source has been found but
who require prolonged treatment or extensive sur-
gery for its correction. The third class is made up
of those in whom, as yet, the source of bleeding
is still undiscovered.
The above represents an attempt to plan the
investigation of patients complaining of rectal
bleeding in such a way that, as we pass to the
more complicated procedures, a patient is not
dismissed at any point without due consideration
for his safety. It is an attempt to go always as
far in the investigation as we should for security’s
sake and, yet, not to undertake needless pro-
cedures.
505
THE CRUVEILHIER-BAUMGARTEN SYNDROME
Report of Case
WILLIAM D. SICHER, NLD.
Rochester, Minnesota
T) ORTAL hypertension, regardless of its
cause, results in the development of collateral
circulation if it exists long enough and is severe
enough. The principal venous communications
which may develop to relieve portal hypertension
are as follows :5 ( 1 ) The collateral pathways be-
tween the gastric veins and the esophageal veins
may develop ; when these develop excessively, the
esophageal varices so frequently encountered in
cases of portal hypertension appear. (2) The
veins of the colon and duodenum may develop
communications with the left renal vein. (3) The
accessory portal system of Sappey may play a
part in the collateral circulation. Branches pass
in the round and falciform ligaments to join the
epigastric and internal mammary veins and the
azygos vein through the diaphragmatic veins. Oc-
casionally a single large vein may pass from the
hilus of the liver to the umbilicus by way of the
round ligament. The development of this pathway
produces the well-known caput medusae in the
periumbilical region. Usually this large single
vein is a markedly dilated parumbilical vein ;
more rarely it is a patent umbilical vein. (4) The
intestinal veins may communicate with the infe-
rior vena cava or its branches, by way of the veins
of Retzius. (5) Communications between the in-
ferior mesenteric veins and the hemorrhoidal
veins may be used. (6) Rarely a collateral path-
way between the portal vein and the inferior vena
cava bv way of a patent ductus venosus may be
established.
Another collateral pathway may be established
occasionally through the interposition of a small
patent upper portion of the umbilical vein, the
“Rest-Kanal” of Baumgarten, between the portal
system and the epigastric veins as discussed bv
Armstrong and his associates.1
In 1835 Cruveilhier4 commented on a case pre-
viously reported by Pegot6 in which signs of por-
tal hypertension and dilated abdominal veins with
a caput medusae, as well as a parumbilical venous
murmur were present. The significant findings at
necropsy were (1) a small grossly normal liver,
(2) a large indurated spleen and (3) a persistent
and dilated umbilical vein. In 1907 Baumgarten8
From the Mayo Foundation, Rochester, Minnesota.
reported a case in which the clinical and patholog-
ic findings were similar to those reported by Cru-
veilhier. In Baumgarten’s case microscopic stud-
ies of the liver revealed only minimal periportal
fibrosis and no true cirrhosis. Baumgarten sug-
gested that patency of the umbilical vein and con-
genital hypoplasia of the liver and portal system
might be the underlying etiologic factors of the
clinicopathologic picture described.
To date more than sixty cases of Cruveilhier-
Baumgarten disease, Cruveilhier-Baumgarten syn-
drome and Cruveilhier-Baumgarten cirrhosis have
been reported.
In 1942 Armstrong and his co-workers1 care-
fully reviewed and analyzed the fifty-three cases
which had been reported up to that time and pre-
sented two cases of their own. They suggested
that the term “Cruveilhier-Baumgarten disease”
be reserved exclusively for those cases in which
the original criteria of Cruveilhier and Baumgar-
ten were satisfied. These consist of the clinical
picture of portal hypertension with excessive um-
bilical circulation and the necropsy findings of a
patent umbilical vein, atrophy of the liver with
little or no fibrosis, and usually splenomegaly.
These findings may possibly represent a distinct
disease entity. They also proposed that the term
“Cruveilhier-Baumgarten syndrome” be used to
designate a larger group of cases in which the
same clinical picture of portal hypertension with
excessive umbilical circulation is present, but in
which other underlying disease processes are re-
sponsible for the clinical picture.
Armstrong and his associates found that only
six of the fifty-three cases previously reported and
one of their own cases satisfied the original cri-
teria of Cruveilhier and Baumgarten and could
be called cases of Cruveilhier-Baumgarten disease.
In the rest of the cases the clinical picture of por-
tal hypertension with evidence of excessive um-
bilical circulation in the form of abdominal mur-
murs or thrills was present. In some of these
cases, however, the portal hypertension was the
result of such conditions as cirrhosis of the liver,
vascular occlusion or anomaly, or the umbilical
vein was not patent and the collateral circulation
in the umbilical region was through other chan-
506
Minnesota Medicine
CRUVEILHIER-BAUMGARTEN SYNDROME— SICHER
nels. In others the patients were still living at the
time their cases were reported, permission for
necropsy had not been obtained or the descriptions
of the findings at necropsy were inadequate for
evaluation.
Since the review just mentioned, at least six
more cases2’3’7’9’10 of the clinical syndrome have
been reported, only one of which can be consid-
ered as belonging to the group of cases of bona
fide Cruveilhier-Baumgarten disease. Thus if this
group of cases does represent a distinct etiologic
and clinicopathologic disease entity, it is certainly
one of rare occurrence since only eight cases have
been reported to date to my knowledge.
Report of Case
A white man, a mechanic, twenty-three years old, was
first seen at the Mayo Clinic on April 15, 1942. For
two vears prior to registration he had been employed
in an aircraft factory where he had been exposed every
few days to various industrial solvents, including cai -
bon tetrachloride, benzene and acetone. In July, 1941,
lassitude, mild anorexia and general loss of pep were
noted. In February, 1942, he left his job to go to
Arizona and to do outdoor work. The symptoms just
mentioned cleared rapidly and he felt essentially well for
about a month. In March, 1942, nausea, anorexia and
diarrhea developed rapidly. Two days after onset he
suffered from a fairly severe bout of cramplike abdomi-
nal pain, and he began to note abdominal enlargement.
Exploratory laporatomy was performed elsewhere. Two
gallons (8,000 c.c,) of ascitic fluid were removed and
cirrhosis of the liver was found. The ascitic fluid con-
tinued to form, and edema of the ankles developed.
Paracentesis was performed on two occasions, the last
one on April 6, 1942. During the nine days prior to
registration at the clinic, ascites was considerably less
marked and seemed to be progressively diminishing.
The past history, family history and review of sys-
tems were noncontributory.
The patient was well developed and well nourished.
He weighed 163 pounds (73.9 kg.). The blood pres-
sure was normal. The liver was enlarged to 2 to 3
cm. below the right costal margin. The spleen was not
palpable. There was probably a small amount of free
fluid in the abdomen. Peripheral edema and icterus were
not noted. Several spider angiomata were present
on the hands and arms. The veins of the upper part
of the abdomen were enlarged only a little, if at all.
A slight thrill could be felt over the lower end of the
sternum, and a rough blowing murmur could be heard
in this region. This murmur was loudest on inspiration
and it was almost abolished by expiration.
Results of urinalysis, determination of concentration
of hemoglobin, erythrocyte count, differential blood
count, blood smear, routine serologic tests for syphilis,
and roentgenograms of the chest were all within normal
limits or were negative. The value for serum bilirubin
was 3.0 mg. per 100 c.c. and the van den Bergh reaction
was indirect. The value for the cholesterol varied be-
tween 123 and 175 mg.; that for cholesterol esters was
77 mg., for lecithin 214 mg., for fatty acids 275 mg.
and for total lipoids 394 mg. per 100 c.c. of plasma.
The prothrombin time was 22 seconds as compared
to an average normal of 18 seconds. The sulfobromopli-
thalein test of liver function revealed a grade 2 reten-
tion of dye, on the grading basis of 1 to 4. 1 he sedi-
mentation rate of erythrocytes was 1 mm. at the end
of one hour by the Westergren method. Urobilinogen
was found to be present in the urine in dilutions up to
1 :8. None was present in dilutions of 1 : 16.
The patient was instructed in the use of a high car-
bohydrate diet and vitamin supplements and was dis-
missed.
The patient returned to the clinic on July 9, 1942,
for a checkup. He was feeling well, he could wear his
old clothes, and he thought the fluid had left the abdo-
men. He had noted edema of the ankles on only one
occasion while on a long bus trip. His only complaint
was of a mild discomfort in the right upper quadrant
of the abdomen immediately after eating. He weighed
179 pounds (81.2 kg.). Physical examination at this
time revealed no free fluid in the abdomen. The liver
was enlarged and could be felt 2 to 3 cm. below the
right costal margin. The spleen was not palpable.
There was no telangiectasia. The urine was normal.
The value for bilirubin was 1.9 mg. per 100 c.c. of
serum and the van den Bergh reaction was direct. The
prothrombin time was 21 seconds as compared to an
average normal of 19 seconds. A sulfobromophthalein
test of liver function revealed a grade 2 retention of the
dye. The patient was dismissed with instructions to
continue his dietary regimen and the taking of vitamin
supplements.
The patient was not seen again until June 6, 1945. He
had felt well after his last visit to the clinic until May
13, 1945. He had worked full time and had had no evi-
dence of ascites or edema. He had not been exposed
to industrial solvents except for a short period in De-
cember, 1944, when he had overhauled an airplane and
inhaled fumes from what he called “dope” and ‘thin-
ner,” containing ethyl and methyl alcohol, acetone and
benzene. On May 13, 1945, he suddenly vomited some
material that looked like coffee grounds and passed a
tarry stool. He did not faint and transfusions were
not necessarv. He was hospitalized in his home com-
munity. One week later he noted a rapidly developing,
large abdominal swelling. 1 his proved to be due to
ascites, and paracentesis was done three times before
his return to the clinic. The intravenous use of mer-
curial diuretics was without benefit. He had no other
symptoms except those associated with the volume of
his ascites.
On admission the patient weighed 169 pounds (76.7
kg.). He was well developed and well nourished. Blood
pressure was normal. Physical examination of the chest
revealed slight elevation of the diaphragm on both sides.
The abdomen was greatly distended, globular and tense.
A fluid wave was elicited. The liver was enlarged to
4 cm. below the right costal margin. The spleen could
not be palpated. There was slight edema of the legs,
507
May, 1947
CRUVEILHIER-BAUMGARTEN SYNDROME— SICHER
Fig. 2. Stethogram of the abdominal murmur. The top trac-
ing is the sound recording. The middle tracing is the electro-
cardiogram and the lower one is the respiratory tracing.
lower end of the sternum and xiphoid process. A loud
continuous venous murmur could be heard over this
and a surrounding region measuring about 6 by 9 cm.
This murmur had a rushing, almost whistling charac-
ter that could be compared to the sound of wind. It
was greatly increased by deep inhalation and was par-
tially subdued by forced exhalation (Fig. 2).
The urine was normal. The concentration of hemo-
globin was 14.9 gm. per 100 c.c. of blood. Erythrocytes
numbered 3,810,000 and the leukocytes 4,700 per cubic
millimeter of blood. Roentgenograms of the chest re-
vealed no abnormalities. Roentgenoscopic examination
of the esophagus revealed esophageal varices. Procto-
scopic examination revealed no varices or hemorrhoids.
The value for the blood urea was 36 mg. per 100 c.c.
The value for the cholesterol was 123 mg., for the
cholesterol esters 62 mg., for lecithin 189 mg. and for
fatty acids 156 mg. per 100 c.c. of plasma. The con-
centration of protein was 5.4 gm. per 100 c.c. of serum
and the albumin-globulin ratio was 1.27:1. A sulfo-
bromophthalein test of liver function: revealed retention
of the dye, grade 3. The prothrombin time was 25 sec-
508
onds as compared to an average normal of 18 seconds.
For twenty-one days the patient was on a conserva-
tive program of 4 mg. of synkamin (vitamin K) by
mouth daily, rest and a high-carbohydrate, high-protein,
Fig. 3. Cirrhosis of liver (x80).
low-fat diet with vitamin supplements. At the end of
this period the prothrombin time was 23 seconds and
the patient’s condition had not changed essentially. Par-
acentesis was carried out three times in the course of
the twenty-one days because of the rapid accumulation
of ascitic fluid. The amount of fluid obtained varied
between 4,500 and 7,600 c.c. The fluid was clear and
straw colored with a .specific gravity of 1.011 and it
contained 250 cells per cubic millimeter. Abdominal
exploration, which was carried out on June 28, 1945,
revealed a large hobnail liver and a firm spleen enlarged
to about six times the normal size. The spleen and
peritoneum were not adherent. Microscopic examina-
tion of a specimen removed from the liver revealed
portal cirrhosis (Fig. 3). A large, single, dilated vein
was found in the falciform ligament. It could not be
definitely established whether this was a patent umbilical
vein or a parumbilical vein. Omentopexy was per-
formed.
Comment
Many cases will appear which can be placed ac-
curately in the group with Cruveilhier-Baum-
garten syndrome by virtue of definite evidence
of disease processes, such as hepatic cirrhois.
(Continued on Page 534)
Minnesota Medicine
scrotum and penis. Over the lower part of the thorax
and upper and lateral parts of the abdomen the super-
ficial veins were dilated (Fig. 1). A thrill was felt in
a region measuring about 2 cm. in diameter over the
Fig. 1. Dilated venous channels. A is region where the
thrill was palpable. Large ellipse, B, is region over which the
murmur was heard (infra-red photograph).
siiSlillll
SULFADIAZINE GRANULOCYTOPENIA AND THROMBOCYTOPENIA
COMPLICATING PREGNANCY WITH SURVIVAL
Report of a Case
ROBERT SUKMAN, M.D., and NELS M. STRANDJORD. M.D.
Saint Paul, Minnesota
THE ROLE of sulfonamides in the production
and treatment of agranulocytosis needs fur-
ther clarification. The neutropenia due to sul-
fonamides has been classified as an acquired type
of allergic as well as specific phenomenon. It
is apparent that severe and frequently fatal agran-
ulocytosis may result from the prolonged or in-
termittent use of sulfonamides. Park8 is of the
opinion that the agranulocytosis due to a sulfon-
amide drug occurs after an initial sensitizing dose
to which there is no reaction. An incubation period
of from six to twenty days follows, after which
continued use of the drug will result in an allergic
reaction characterized by suppression of bone
marrow. It is pointed out that large doses over
short periods of time (not over one week) will not
result in a drug allergy, as will a smaller dosage
over a prolonged period of time. When sulfona-
mides are given for a period of over one week, the
patient should be closely checked with daily blood
counts, and the drug discontinued if a neutropenia
develops. The sensitivity to the drug may be of
short duration, and in some cases after recovery
from a sulfonamide agranulocytosis the drug may
again be used without the production of neutro-
penia.1 However, should the sulfonamide be
used again, it should be given in ascending doses
and with careful hematological control. Patients
sensitive to one of the sulfonamides are not nec-
essarily sensitive to another sulfonamide.
The patient with agranulocytosis does not die
because of lack of granulocytes per se, but due to
sepsis developed secondarily in the absence of
granulocytes. Cases in the literature7 have been
reported in which sulfonamides have been contin-
ued in the face of severe agranulocytosis. If the
sepsis was controlled, the bone marrow recovered
its ability to produce granulocytes, with a favor-
able outcome. However, if possible, the toxic
agent should be discontinued and another antibio-
tic substituted to control or prevent sepsis.
At present the drug of choice in the treatment
of sulfonamide agranulocytosis is penicillin. Dam-
From the Aneker Hospital, Saint Paul, Minnesota.
May, 1947
eshek,4 and Russek, et al.9 have reported successful
results. This antibiotic substance not only has a
bacteriostatic action but also does not depress the
bone marrow. In addition to the control of the
sepsis it is advisable to use other supportive meas-
ures. Whole blood transfusions, if used within
twenty-four hours after being drawn, still contain
the desired platelets and white blood cells and
should be used if available. Folic acid,3 a liver
concentrate in purified crystalline form, has been
shown to increase the total leukocytes and also the
percentage of granulocytes. If the infection pres-
ent is caused by an organism not sensitive to
penicillin, other antibiotics such as streptomycin
may be used. Cameron2 reports a fatal case in
which penicillin controlled the staphylococcus in-
fection but not the pyocyaneous septicemia.
There have been many cases of sulfonamide
agranulocytosis, few of which have been reported.
Of those reported, the majority of patients with
mild attacks have survived ; however, in most of
the “full blown” cases death has resulted.
Purpura hemorrhagica is a possible serious,
hough infrequent, complication of sulfonamide
drug therapy. Gorham et al.5 in reviewing eight
cases found a mortality of SO per cent. In three
of the four fatal cases the drug was continued
after the purpura had occurred. In the four
cases in which recovery resulted, the drug was
discontinued at the first sign of hemorrhagic
manifestations. The total amount of drug ad-
ministered varied from 5.5 gm. to 48 grn. This
indicates a difference in individual suscepti-
bility. Kracke6 has shown by daily blood counts
on patients receiving sulfonamide therapy that
there is a depression of the platelets on the first
day of treatment and a decided increase in plate-
lets on the first day after treatment is discontin-
ued. Thrombocytopenia precedes the purpura.
Therefore, if a marked reduction in the platelets
is found, the drug should be discontinued imme-
diately. In practice, platelet counts being rather
impractical, one can obtain an accurate estimation
of the platelets by examining the differential
509
SULFADIAZINE GRANULOCYTOPENIA— SUKMAN AND STRANDJORD
TABLE I. BLOOD EXAMINATION RECORD
Date
Hemoglobin
in
Grams
Red
Blood Cells
in Millions
White
Blood
Cells
Differential
Sed.
Rate
Platelets
Transfusion
P
L
M
E
B
8- 2-46
7.0
1.8 M.
2,700
49
51
91 mm. /hr.
500 c.c. W. B.
8- 3-46
12.4
3.14 M.
850
35
63
1
1
10,000
3,000 c.c. W. B.
8- 4-46
11.8
2.95 M.
2,050
1,000 c.c. W. B.
500 c.c. Plasma
8- .5-46
8.5
2.62 M.
850
69
29
2
12,000
1 ,500 c.c. W. B.
8- 6-46
10.2
4.38 M.
2,150
51
31
13
5
1,000 c.c. W. B.
8- 7-46
12.2
3.9 M.
3,250
77
23
8- 8-46
12.2
3.7 M.
6,450
86
10
4
14,000
8- 9-46
12.0
3 71 M.
1 1 ,950
72
25
2
i
28,000
8-10-46
12.4
4.26 M.
9,300
81
14
5
36,000
8-12-46
12.2
4.98 M.
7,500
78
18
4
32 mm. /hr.
121,000
8-13-46
11.2
3.83 M.
9,300
65
26
9
8-14-46
11 0
3 64 M.
6,400
51
43
6
140,000
8-15-46
12.6
3 93 M.
7,000
56
35
9
184,000
8-16-46
11.8
3.76 M.
6,200
67
25
8
148,000
8-17-46
12.8
4.28 M.
6,500
63
33
4
162,000
8-21-46
11.4
6,100
49
49
2
8-28-46
10.2
5,450
36
48
13
3
134,000
8-30-46
13.2
4.0 M.
8,350
50
45
5
100,000
9- 6-46
9,300
29
67
4
140,000
9-20-46
13.0
6,100
30
65
5
9-28-46
13.0
4.85 M.
6,550
***
25 mm, /hr.
11-25-46
12.7
5,650
50
43
4
1
2
smear. With a marked thrombocytopenia the
platelets will usually disappear from the smear.
Case History
On August 1, 1946, Mrs. A. K., a forty-three-year-old
white woman, entered Ancker Hospital with the chief
complaints of hemoptysis, occurring five days previously,
and weakness of five months’ duration. She was eight
months pregnant, the last menstrual period having been
on December 3, 1945. She was a para seven, gravida
seven. The history indicated that in June, 1946, the
patient had developed frequency and burning on urina-
tion and she had been given 1 gm. of sulfadiazine three
times a day for a period of two days. For the past
five months, the patient had complained of severe weak-
ness, swelling of the ankles, and fainting spells. For the
past month there had been a daily elevation of tempera-
ture to 100° orally. To treat an anemia, her private
physician had given her iron, calcium and vitamins.
One week previous to admission the patient had again
been given 1 gm. of sulfadiazine three times a day for
a period of six days. Because of the hemoptysis the
patient was referred to Ancker Hospital to rule out tu-
berculosis.
Physical examination on admission revealed a well-
developed and apparently well-nourished white woman..
The skin and mucous membrane showed marked pallor.
The pulse was 128 per minute and the blood pressure
was 110 systolic and 82 diastolic. The uterus was en-
larged corresponding to an eight months’ pregnancy.
Laboratory examination disclosed a hemoglobin of
7 gm., a red blood count of 1,^00,000, a white blood
count of 2,700, a differential of 51 per cent lymphocytes
and 49 per cent polymorphonuclear cells. Few platelets
were found on the smears. The x-ray revealed an
essentially normal chest.
On the second hospital day, the patient developed a
severe diarrhea, having large malodorous, watery, gross-
ly bloody stools. There was marked retching and vom-
iting. She developed large areas of ecchymosis over
the entire body. Her temperature became elevated to
103° and the blood pressure fell to 98 systolic, 60
diastolic. She was given whole blood transfusions and
penicillin, 50,000 units every three hours intramuscularly.
On the third hospital day, the patient, having become
dyspneic and cyanotic, was placed in an oxygen tent.
At this time her white count had fallen to 850, and
her platelet count was 10,000 (Table I). Many new
areas of ecchymosis were found in the mucous mem-
branes as well as in the skin.
Because of the viable fetus and the critical condition
of the patient, permission was granted and preparations
made for postmortem section if the patient should ex-
pire undelivered. On August 4, 1946, at 12:45 A.M.,
after a total labor of two hours and five minutes, the
patient was delivered of a 6-pound 6-ounce living baby
girl. The delivery was carried out with the patient in
bed, under an oxygen tent and with aseptic technique.
A first degree mucosal laceration was sustained, but
because of the severe bleeding, sutures were required.
Twenty hours post partum, the patient developed severe
intra-uterine bleeding, resulting in shock. Intra-uterine
packing and oxytocic drugs were used to control the
hemorrhage. The pack was removed forty hours later.
On August 6 the patient developed acute urinary
retention requiring repeated catheterizations over a pe-
riod of six days.
On August 8 the patient had an elevation of tempera-
ture to 105° orally and developed pneumonia. The x-ray
disclosed a patchy infiltration of the mid-portion of the
base of the left lung. The purpuric lesions in the skin
increased in number and the patient developed jaundice.
Penicillin was increased from 50,000 to 100,000 units
every three hours. Sixteen days later, x-ray of the
chest showed complete resolution of the infiltration.
On August 11 the patient was removed from the
oxygen tent. At this time she developed a fecal
impaction, following the removal of which she devel-
oped an elevation of temperature to 104°.
On August 18 the patient was much improved clinic-
ally, so penicillin was discontinued. However, on Au-
510
Minnesota Medicine
SULFADIAZINE GRANULOCYTOPENIA— SUKM AN AND STRANDJORD
gust 23 the patient developed severe chills and had an
elevation of temperature to 103.8°. She had swelling
and tenderness in the left breast. A diagnosis of acute
mastitis was made, and the patient was started on peni-
cillin, 40,000 units every three hours.
Fig. 1. Temperature chart. T.R. indicates transfusion reaction,
P indicates pneumonia, and M, mastitis.
On August 28 the patient was considered fully recov-
ered and was discharged to be followed in the out-
patient clinics of Ancker Hospital. Follow-up blood
examinations were satisfactory (Table I).
During the twenty-eight days of hospitalization, the
patient was given 11,900,000 units of penicillin, four-
teen transfusions of whole blood (500 c.c. each), and one
transfusion of plasma (500 c.c.), seventeen 5 mg. tab-
lets of folic acid (total amount available), and was in
an oxygen tent for eight days (Fig. 1). To obtain
the greatest benefit from leukocytes and platelets in the
transfused blood, only fresh blood was used, several
units being less than two hours old when given. The
patient was given parenteral feedings, thiamine chlo-
ride 100 mg. daily, ascorbic acid 200 mg. daily, hyki-
none 1 c.c. (4.8 mg.) daily, and other supportive meas-
ures.
Summary and Conclusions
A case of granulocytopenia and thrombocyto-
penia following sulfadiazine therapy has been re-
ported. To our knowledge this is the fourth case
reported of thrombocytopenia due to sulfadiazine.
The sensitizing dose was 6 gm. The clinical
course was characterized by purpura, hemoptysis,
melena, and depression of all the formed blood
elements. Following parturition, the patient de-
veloped severe uterine hemorrhage, pneumonia
and mastitis. The patient survived with massive
doses of penicillin, multiple transfusions, oxygen,
folic acid and other supportive measures.
Because of the seriousness of the complica-
tions, although infrequent, sulfonamide therapy
should have careful hematological control.
References
1. Bethell, F. H.; Sturgis, C. C.; Mallery, O. T., Jr., and
Rundles, R. W. : Blood, a review of the recent literature,
granulocytopenia and agranulocytosis. Arch. Int. Med., 74:
131-152, (Aug.) 1944.
2. Cameron, J. D., and Edge, J. R. : Agranulocytosis after
sulphonamide sensiticemia penicillin therapy, death from ps.
pyocyanea septicemia. Brit. M. J., 2:688-689, (Nov.) 1945.
3. Daft, F. S., and Sebrell, W. H. : The successful treatment
of granulocytopenia and leukopenia in rats with crystalline
folic acid. Pub. Health Rep., 58:1542-1545, (Oct.) 1943.
4. Dameshek, Wm., and Knowlton, H. C. : The use of peni-
cillin in treatment of sulfonamide agranulocytosis. Case re-
port. Bull. New England M. Center, 7:142-148, (June) 1945.
5. Gorham, L. W.; Propp, S.; Schwind, J., and Climenko,
D. R. : Thrombocytopenia purpura caused by sulfonamide
drugs. Three cases. Am. J. M. Sc., 205:246-257, (Feb.)
1943.
6. Kracke, R. R., and Townsend, E. W. : Effect of sulfona-
mide drugs on blood platelets; report of 2 cases of thrombo-
cytopenic purpura and experimental studies on patients re-
ceiving sulfonamide drugs. J.A.M.A., 122:168-173, (May)
1943.
7. Nixon, N. ; Eckert, J. F., and Holmes, K. B. : The treat-
ment of agranulocytosis with sulfadiazine. Am. J. M. Sc..,
206:713-722, (Dec.) 1943.
8. Park, R. G. : Pathogenesis of sulphonamide neutropenia.
Lancet, 1:401-403, (Mar.) 1944.
9. Russek, H. I.; Smith R. H., and Zohraan, B. L. : Sub-
acute bacterial endocarditis complicated by agranulocytosis;
report of case with recovery. Ann. Int. Med., 22:867-870,
(June) 1945.
NAVAL RESERVE
During the months of May and June, a nationwide
effort is being made to interest former navy men in
joining the naval reserve.
The arguments for the desirability of a large naval
reserve, for its effect in preventing future attack by a
foreign war-monger and to provide a substantial base
upon which to build in case of war, are incontestable.
The educational opportunities which can be utilized
by members of the naval reserve cover a wide field.
This enables those in a great variety of vocations to
better themselves. Periodic two-week training cruises
in ships of the reserve fleet afford a desirable way to
obtain concentrated instruction. Members of the naval
air reserve can retain and improve their flying or me-
chanical skills at one of the two dozen naval air stations
now designated as reserve training centers. These cen-
ters, also provide training in radar, sonar, radio, and
electronics.
Time spent in the reserve results in a 5 per cent
increase in base pay for every three years of member-
ship. Veterans of the army or navy between the ages
of seventeen and thirty-nine, as well as non-veterans,
are eligible.
May, 1947
511
VETERINARY MEDICINE
LOUIS A. BUIE, M.D.
Rochester, Minnesota
"PNISEASE is one of the great tragedies of liv-
ing things. It is one expression of a struggle
which is carried on among different forms of life.
Incessantly the conflict goes on without quarter
or armistice. Infectious disease is merely a dis-
agreeable instance of a widely prevalent tendency
of all living creatures to avoid the necessity of
building by their own efforts the materials which
they require to survive. Whenever they find it
possible to take advantage of the constructive
labors of others, they follow that course. Plants,
partly nourished by decaying animal remains,
synthesize new structures bv means of their roots
and green leaves. Animals eat the plants, man
eats both and bacteria attack all. Without bac-
teria to maintain the cycles of carbon and nitro-
gen exchange between plants and animals, all life
probably would cease eventually. Plants would
have no nitrates and no carbon dioxide with which
to maintain their perennial synthesis. Cows and
pigs would have no clover, man would have no
meat and potatoes, rice and tea, beans and fish or
whatever his diet, as governed bv geography, may
be.
Life is, in a sense, an endless chain of para-
sitism. That form of parasitism which we call
“infection” is as old as animal and vegetable life.
Swords and lances, high explosives, and all the
modern engines of war have had less effect on
the fates of nations than plague, typhus fever,
cholera, yellow fever, malaria, typhoid fever,
tuberculosis, smallpox, diphtheria and pneumonia.
Nations have crumbled under their onslaught.
The partial emergence of mankind from the
direful effects of these conditions has been due to
the advancement of science. The tremendous
technical advances made in the science of medi-
cine have modified greatly the nature of its prac-
tice, as well as all of its social and economic re-
lationships. The practice of medicine, once limit-
ed almost entirely to the physician, now enjoys
the participation of many other professions which
are concerned with vital aspects of the medical
problem. In many ways the veterinarian must be
Response of the president of the' Minnesota State Medical
Association at the fiftieth anniversary banquet of the Minnesota
Veterinary Medical Association, Saint Paul, Minnesota, January
7, 1947.
a scientist far beyond the heights that must be
reached by the physician.
Many of the bacterial diseases of animals may
cause serious illness in human beings, and animals
are susceptible to almost as many diseases as are
human beings. Economic problems are not the
only factors which demand that diseases of ani-
mals be controlled and eradicated whenever possi-
ble. There is no doubt that the economic loss to
the livestock industry caused by preventable dis-
ease has been significant, but this problem cannot
be considered to be as vital to man as the effect
of those diseases which are communicable to him.
Basically, the professional activities of veterinar-
ians and physicians are the same. Both are con-
cerned with the diagnosis and treatment of disease
and its control and prevention. Probably the most
important functions of your profession are the
care of sick and injured animals, the protection of
that livestock industry on which the life of our
nation greatly depends and the protection of hu-
man beings against those diseases which are pe-
culiar to animals but which are communicable to
man. Probably in the last instance we shall find
the greatest opportunity for co-operation between
the veterinary and the medical professions. It
would be superfluous for me to discuss before
this organization those conditions which are com-
mon to animals and which are communicable to
man. In fact, it would transcend my capabilities.
But I venture to say that many would manifest
no little surprise should a complete list of these
diseases be recited. One can scarcely believe that
glanders, encephalitis, Malta fever, anthrax,
tuberculosis, milk sickness, some parasitic dis-
eases, swine erysipelas, psittacosis, cowpox, foot
and mouth disease, plague, tularemia, rat-bite
fever, infectious jaundice, Rocky Mountain spot-
ted fever and rabies — yes, all of these and prob-
ably many other diseases — fall into this category.
In humans some diseases, such as rabies, occur
very rarely in this age, because of scientific dis-
covery and attainment. But when it strikes, what
is more ghastly than rabies? A cursory review of
a list such as has been given will dispel at once
any thought that the activities of the veterinary
physician are chiefly concerned with economic
512
Minnesota Medicine
VETERINARY MEDICINE— BUIE
problems. His signal achievement in eradicating
tuberculosis of cattle ; his accomplishments in
dealing with infectious equine encephalomyelitis ;
the service which he has rendered in practically
eliminating glanders as a threat to the health of
human beings ; the fact that he has prevented un-
dulant fever from becoming a major health prob-
lem by his supervision of the milk and meat sup-
ply ; the fact that his co-operation with the medical
profession and the splendid achievement of his
specialists in the fields of pathology and bacteri-
ology have made it possible to control many dis-
eases of a parasitic nature ; all of these accomplish-
ments and many more reveal the heights which
the practice of your profession has attained.
We are living in an age of research. There is
no doubt that the progress of our entire civiliza-
tion is based on the power of the human intellect.
When the spark of genius appears in an in-
dividual, it should be given the greatest oppor-
tunity for development, so that its benefits may
be extended. A new opinion may originate with
a single individual, but the result which such an
opinion may produce will depend on the oppor-
tunity which it is given for development and its
effect on the minds of those who are ready for
its reception.
In veterinary medicine, materials have been col-
lected which present a rich and an imposing ap-
pearance, but unless and until these materials can
be brought to those who are interested in becom-
ing members of your profession, your greatest
ambitions cannot be attained. No doubt many men
and women of your profession who are desirous
of establishing themselves satisfactorily in their
work have been diverted from their purpose by
lack of opportunity for educational advancement.
It is certain that many have failed to adopt this
profession as their life work because of lack of
educational facilities. Many have had to be con-
tented with inferior training. Many of these last,
nevertheless, have succeeded by dint of ceaseless
labor in establishing themselves on a plane above
reproach. Never in the history of your organiza-
tion has there been a greater need or justification
for educational expansion.
I know that your present requirements for a
degree in veterinaxy medicine are two years of
preveterinary training in a recognized university
or college and four years in a veterinary college.
I know that since the war there has been a strik-
ing increase in the number of both men and
women who wish to study veterinary medicine.
I know that at Kansas State College one out of
every seven individuals who registered wished
to study veterinary medicine, but because of lack
of facilities in the various colleges, the number
of students enrolled in veterinary medicine still
shows little increase over that recorded before the
war. I know that in 1945 there were ten veter-
inary colleges in the United States and two in
Canada. Also, I know that since then, Illinois
Missoui-i and California have established schools
of veterinary medicine, but all this is insufficient.
It appears that we may view with optimism the
prospect of such an expansion in our own gi-eat
state university. A similar development is clear-
ly the responsibility of many institutions whose
function is the advancement of the teaching of
medical science. It ill behooves them to linger in
the cloudy obscurity of ancient ideas and prac-
tices. Science and industry recognize the im-
portant role of highly trained, ethical and in-
dependent members of the veterinary profession,
and your colleagues in the medical profession are
proud of your achievements.
INFECTIOUS AND SERUM JAUNDICE
(Continued from Page 502)
39. Rappaport, E. M. : Hepatitis after transfusions. J.A.M.A.,
128:932, (July 28) 1945.
40. Sawyer, W. A. ; Myer, K. F. ; Eaton, M. D. ; Bauer, J.
H. ; Putnam, P., andi Schwenckter, F. F. : Jaundice in
army personnel in the western region of the United States
and its relation to vaccination against yellow fever. Am.
J. Hyg., 40:90, (July) 1944.
41. Snell, A. M. • Wood, D. A., and Meienberg, L. J. : In-
fectious hepatitis with especial reference to its occurrance
in wounded. Gastroenterology, 5 :241, (Oct.) 1945.
42. Soper, F. L., and Smith, H. H. : Yellow fever vaccina-
tion with cultivated virus and immune and hyperimmune
serum. Am. J. Trop. Med., 18:111, (March) 1938.
May, 1947
43. Steiner, R. E. : Five cases of jaundice following trans-
fusion of whole blood or plasma. Brit. M. J., 1:110, (Jan.
22) 1944.
44. Tuohy, E. L., and Fee, J. : Jaundice — A method of decid-
ing where surgical treatment should supplement medical
care. Minnesota Med., 28:981, (Dec.) 1945.
45. Turner, R. H. ; Snavely, J. R. ; Grossman, E. B. ; Buchanan,
R. N., and Foster, S. O. : Some clinical studies of acute
hepatitis occurring in soldiers after inoculation with yellow
fever vaccine : with especial consideration of severe at-
tacks. Ann. Int. Med., 20:193 (Feb.) 1944.
46. Voegt, H. : Abstract. Bull. Hyg:., 17:331, 1942.
47. Witts, L. J. : Some problems of infective hepatitis. Brit.
M. J., 1 :739, (June 3) 1944.
513
CLINICAL-PATHOLOGICAL CONFERENCE
COR PULMONALE
A. J. HERTZOG, M.D.. and A. M. McCARTHY. M.D.
Minneapolis, Minnesota
Dr. A. M. McCarthy: This case (A-46-2348) is that
of a twenty-nine-year-old male who had been admitted
to the Minneapolis General Hospital on several oc-
casions.
In 1927, at the age of nine years, he had an attack of
diphtheria while in Wisconsin, and little is known about
the details of the illness. During the attack of diph-
theria, he developed gangrene of his right leg. The
leg was amputated. A persistent cough followed the
illness. In 1928, he was seen elsewhere because of his
chronic cough. X-rays at this time showed a parenchy-
mal infiltration and fibrosis in the right upper lung that
was thought to be tuberculosis. In 1929 he was treated
for tuberculosis elsewhere. Acid- fast bacilli were never
demonstrated. Artificial pneumothorax of the right side
was maintained for several months and repeated at
various times up to 1938.
He was first admitted to the Minneapolis General
Hospital in 1938 complaining of a chronic cough. His
sputum was negative for acid-fast organisms. Blood
pressure was 100/60. Hemoglobin was 85 per cent
(Sahli) ; leukocyte count was 16,500. Serology was
negative. Urinalysis showed albumin that varied from
a trace to four plus. The clinical impression was pneu-
monia of the left lower lobe. He responded well to
sulfanilamide.
He was next admitted in July, 1940. At this time,
he was suffering from a low grade fever and raising
approximately 2 ounces daily of thick green purulent
sputum. All sputum examinations were negative for
acid-fast bacilli. Lipiodal studies showed a saccular
type of bronchiectasis of the left lower lobe. Urinalysis
showed a trace to four plus albumin with occasional
casts and red blood cells. During this admission, he
developed a spiking fever of 104° with chills. A fric-
tion rub was heard in the left chest. Type 9 pneumo-
cocci were found in his sputum. He responded well
to sulfanilamide.
He was readmitted in March, 1942, because of chills
and fever, weight loss and increased productivity of
his cough. Qubbing of the finger tips of both hands
was noted. There was dullness over the entire right
chest. The left chest was hyperresonant. Crackling
erepitant rales could be heard in both lung fields.
Heart tones were the loudest to the right of the sternum.
His temperature varied from 98° to 102°. Sputums and
gastric lavages for tuberculosis on guinea pig inocula-
tions were negative. X-rays showed cystic bronchiectasis
From the Department of Pathology, Minneapolis General Hos-
pital, A. J. Hertzog, M.D., Pathologist.
with atelectasis of the right lung, and emphysema of
the left lung with cystic bronchiectasis of the base of
the left lung. The heart and mediastinal structures
showed a shifting to the right side of the thorax.
He was readmitted from time to time to the hospital
during the next few years complaining of a cough,
chills, and fever. Each time he responded well to chem-
otherapy and expectorants. Each time his urine showed
from one to four plus albumin with numerous red
blood cells and a few leukocytes per high power field.
In Tune, 1942, his blood pressure was 112/68. A
phenolsulphonthalein test showed a total urinary excre-
tion of 49 per cent dye in two hours. A Congo red
test for amyloidosis showed 62 per cent retention of
dye in the blood in one hour. Concentration tests showed
a specific gravity of urine that varied from 1.006
to 1.020. Electrocardiograms showed a sinus tachy-
cardia.
His next admission was almost three years later in
March, 1945. His temperature varied between 100°
and 103°. He expectorated two to three cups of spu-
tum daily. Venous pressure varied from 17 cm. citrate
to 21 cm. citrate. Liver dullness was noticed 3 cm.
below the right costal margin. A Congo red test showed
60 per cent dye retention in one hour. During this hos-
pital stay, he developed dyspnea, ascites, and edema
of his ankle. He was digitalized. Plasma proteins were
4.58 gm. of albumin and 1.93 gm. of globulin. Sedi-
mentation rate was 67 mm. in one hour. Sputums were
negative for acid-fast bacilli. An electrocardiogram
showed right axis deviation.
He was again seen in June, 1945, because of recur-
rence and increase in dyspnea, ascites and edema of his
ankle. Blood pressure was 94/60. He was markedly
orthopneic and quite cyanotic. The right border of the
heart was 10 cm. to the right of the midline. A loud
blowing systolic murmur was heard best on the right
side of the chest over the second and third interspaces
in the right midclavicular line. His abdomen was dis-
tended with fluid present. The liver edge was not
palpable. There was a two plus edema of his remain-
ing leg. Venous pressure was 17.5 cm. citrate. Congo
red test showed 68 per cent dye retention in one hour.
Hemoglobin was 109 per cent (Sahli). He was still
expectorating large quantities of sputum. He im-
proved with diuretics, digitalis, and penicillin therapy.
He was readmitted in June, 1946, because of in-
creasing dyspnea, orthopnea, and edema. The liver
edge was down to the umbilicus. The neck veins were
pulsating. There was questionable liver pulsation.
514
Minnesota Medicine
CLINICAL-PATHOLOGICAL CONFERENCE
Peripheral edema was four plus. Clubbing of the
fingers was noted. Venous pressure was 23 cm. of
citrate. Circulation time was 18 seconds with calcium
gluconate. Blood urea nitrogen was 34 to 44 mg. per
cent. Abdominal parententesis removed 1,000 c.c. of
fluid. His last admission was in November, 1946. Blood
pressure was 140|/90. Pulse was 120. He was mark-
edly cyanotic and orthopneic. The findings were sim-
ilar to the last admission. Two thousand cubic centi-
meters of fluid were removed from his abdomen. He
became cyanotic and expired on November 25. 1946.
Dr. Herman Kosnitscky : This man was living on
one lung, as his right lung had been completely col-
lapsed by the inflammatory process and repeated pneu-
mothorax for many years. The left lung was emphy-
sematous. Both lungs with lipiodol studies on x-ray
showed a sacular type of bronchiectasis. The question of
amyloid disease arose but the laboratory findings by
the congo red test were not confirmatory. Towards the
latter part of his illness, he began to show signs of con-
gestive right heart failure. This man lived unusually
long with right heart failure. Once right heart failure
occurs in chronic pulmonary conditions, patients usually
die shortly. The earlier diagnosis of tuberculosis of
his right lung was never established by finding acid-fast
organisms.
Intern: What is the mechanism of right heart
failure in this case?
Dr. Hertzog : Pulmonary emphysema is present in
practically all of these chronic chest conditions and,
by interfering with the capillary circulation of the
lungs, becomes the most important factor in the patho-
genesis of cor pulmonale. In emphysema increased
intra-alveolar pressure can be demonstrated. This in-
creased pressure occurs at the expense of the collapsible
capillaries and small blood vessels within the inter-
alveolar septa. The peribronchial fibrosis associated
with the bronchiectasis and the atelectatic right lung
could be contributing factors.
Student : What was the clinical diagnosis in this
case?
Dr. McCarthy : Chronic bronchiectasis with pul-
monary emphysema ; chronic cor pulmonale with con-
gestive right heart failure; and amyloid disease of the
kidneys.
Dr. Hertzog: If there is no further discussion, Dr.
McCarthy will give the autopsy findings.
Autopsy
Dr. McCarthy : The body was that of a young white
male measuring 166 an. and estimated to weigh 120
pounds. There was marked cyanosis particularly of the
face, fingers, and toes. There was an old amputation
of the right leg in the midportion of the thigh. There
was grade 4 edema of the entire left lower extremity.
The toes and fingers showed marked clubbing. There
was present approximately 2,000 c.c. of straw colored
fluid within the peritoneal cavity. The liver margin
was down 10 cm. below the right costal margin. Both
pleural cavities were obliterated by old fibrous ad-
hesions. The right lung was completely collapsed.
Fig. 1. Heart shows marked hypertrophy
and dilatation of right ventricle.
The left lung was large and voluminous. The pericar-
dial sac contained 800 c.c. of fluid. The heart weighed
490 gm. with practically the entire heart composed
of a markedly dilated and hypertrophied right ventricle
with a marked dilation of the pulmonary conus.
The righ ventricular wall measured 0.7 cm. as com-
pared to the left ventricular wall that measured 1.2
cm. The tricuspid valve showed a marked dilation and
measured 14.5 cm. as compared to the mitral valve
with a circumference of 10.5 cm. The pulmonary ring
measured 8 cm. as compared to the circumference of
the aortic valve which measured 7 cm. There was
no evidence of any hypertrophy of the left ventricle.
The coronary arteries showed a minimum of sclerosis
and were patent (Fig. 1).
The right lung weighed 500 gm. and the left lung
weighed 1,220 gm. The right lung was completely col-
lapsed and covered with old dense fibrous adhesions.
On section of this lung there was complete atelec-
tasis present. Evidence of tuberculosis: was not found.
The right main pulmonary artery in its lower branch
near the bifurcation was partially occluded by an
old pale thrombus that was firmly adherent to the wall
of the vessel. The larger branches of the pulmonary
artery were dilated and contained numerous atherom-
atous plaques in their walls. The bronchi on the right
side were greatly dilated and filled with thick purulent
material. This dilation extended out to the periphery
of the lung. The left lung was large and voluminous
and covered by old adhesions. There were numerous
large emphysematous blebs in the upper lobe. On
section of the lung there was rather marked hemor-
rhagic edema present especially in the upper lobe.
The main branches of the pulmonary artery were dilated
and showed rather marked arteriosclerosis in the form
of yellow atheromatous plaques in their walls. The
main bronchi of this lung were dilated and filled with
May, 1947
515
CLINICAL-PATHOLOGICAL CONFERENCE
purulent mucoid material. This dilation of the bronchi
extended out into the smaller bronchi to the periphery
of the lung.
The spleen, liver, and kidneys showed gross evidence
of passive congestion. The remaining organs showed
nothing of note.
Dr. Hertzog : Microscopic examination showed no
evidence of amyloid disease of the kidneys, liver,
or spleen. Congo red stains were negative. The liver
showed long-standing passive congestion. The right
lung showed complete atelectasis with no evidence of
any tuberculosis. The alveoli of the left lung were
dilated with fragmentation of the septa as seen in
emphysema. Although intimal atherosclerosis of the
larger branches of the pulmonary arteries could be
seen, there was a lack of any change within the walls
of the smaller pulmonary arteries. This would indicate
that most of the resistance responsible for the pulmonary
hypertension apparently arose in the small septal ves-
sels. The bronchioles were markedly dilated as seen
in bronchiectasis associated with chronic bronchitis.
The anatomical diagnosis was then: (1) cor pul-
monale with hypertrophy and dilatation of right ven-
tricle; (2) chronic bronchitis and bronchiectasis; (3)
left pulmonary emphysema ; (4) right pulmonary atelec-
tasis ; (5) thrombosis of right pulmonary artery; (6)
atherosclerosis of pulmonary arteries; (7) passive con-
gestion of liver; (8) ascites; (9) left pulmonary edema
and bronchopneumonia; and (10) old amputation of
right leg.
Discussion
Dr. McCarthy : The term cor pulmonale is com-
monly used to describe right ventricular cardiac hyper-
trophy or dilation occurring independently of left ven-
tricular hypertrophy as the result of increased resist-
ance of the blood flow through the pulmonary circula-
tion. Ayerza in 1901 deserves credit for calling our at-
tention to this syndrome. He emphasized the marked
cyanosis, calling them “black cardiacs.” Ayerza and
his pupils stressed syphilis of the pulmonary artery as
the etiological factor. Today there is no reason for
continuing the use of the term “Ayerza’s Disease” other
than of historical interest.
Cor pulmonale is commonly classified into acute and
chronic types. Acute cor pulmonale is usually caused
by massive pulmonary embolism. It is estimated that
it is necessary to occlude at least 60 per cent of the
total pulmonary vascular bed before heart failure oc-
curs. Hence most nonfatal cases of pulmonary em-
bolism do not cause sufficient obstruction of the pul-
monary circulation to cause heart failure. Chronic cor
pulmonale is more common and is due to a wider variety
of causes. Spain and Handler9 have recently given us an
etiological classification based upon alterations in the
thoracic cage, pulmonary vascular system, and pulmo-
nary parenchyma. Clawson3 in a study of 5,000 hearts in
the records of the Pathology Department of the Univer-
sity of Minnesota collected a total of 118 cases of cor
pulmonale up to 1946. The etiological factors in order of
frequency were pulmonary tuberculosis, forty-five cases;
bronchial asthma, twenty-two cases ; bronchiectasis, six-
teen cases; pulmonary embolism or thrombosis, nine
cases; silicosis, seven cases; emphysema, six cases; pul-
monary arteriosclerosis, six cases; chest deformity, six
cases; pulmonary fibrosis, two cases; and pressure of
syphilitic aortic aneurysm on the pulmonary artery, one
case. All of these cases had congestive heart failure at
the time of death.
George Higgins6 at Glen Lake Sanatorium worked on
the problem of hypertrophy of the right ventricle in
pulmonary tuberculosis. He devised a technique where
the ventricles were dissected apart and weighed sep-
arately. He took into account the general debility of
the patient as a result of tuberculosis and with this
debility the decrease in the size of the heart. He found
a 40 per cent incidence of hypertrophy of the right
ventricle associated with pulmonary tuberculosis. He
was of the opinion that the pulmonary emphysema
associated with the tuberculosis was the principal
underlying factor responsible for the increased pul-
monary vascular pressure.
In considering pulmonary arteriosclerosis as a cause
of cor pulmonale, we are interested primarily in changes
in the small arteries and arterioles, as sclerosis confined
to the large arteries cannot cause pulmonary hyper-
tension. Immediately one is faced with the problem
whether pulmonary arteriosclerosis exists as a primary
phenomenon or is secondary to increased pressure within
the pulmonary circulation. The same problem exists
in systemic hypertension. Brenner in 19351 described
what he considered to be primary pulmonary arterio-
sclerosis. Brill and Krygier2 in 1941 reported one case
of their own and analyzed twenty cases from the litera-
ture of primary pulmonary vascular sclerosis. They
were careful to exclude pulmonary emphysema, left
heart failure, mitral lesions or congenital heart lesions
which might have thrown strain on the pulmonary
circulation. Cross and Kobayashi4 recently reported a
case of primary pulmonary vascular sclerosis in a
twenty-month-old infant. Little is known about pul-
monary hypertension and its relationship to pulmonary
arteriosclerosis, the problem being very similar to that
which exists in systemic hypertension. The recent work
of catheterization of the right heart and pulmonary
artery with direct measurements of the blood pressure
within the pulmonary circulation will help throw some
light upon the subject of pulmonary hypertension.
Westermark has devised a simple technique of recording
the pressure within the pulmonary circulation. By
means of a manometer, the expiratory' pressure neces-
sary to collapse the pulmonary vessels on x-ray is di-
rectly proportional to the pressure within the pulmonary
circuit, thus affording a means of early diagnosis of
an existing pulmonary hypertension.
Deformity of the thorax as a cause of cor pulmonale
is relatively rare. Hertzog and Manz5 in 1945 collected
135 cases from the literature and added one of their
own. The mechanism of the increased pulmonary re-
sistance in these cases appears to be largely on the
(Continued on Page 540)
516
Minnesota Medicine
Case Report
ARTHUS PHENOMENON INDUCED BY THE LOCAL APPLICATION
OF PENICILLIN
F. B. MEARS, M.D., and DAVID STATE. M.D.
Minneapolis, Minnesota
ARTHUS, in 1903, 1 noted that if horse serum were
injected subcutaneously into rabbits every six days,
resorption of serum would take place after the first
three of such injections. However, after the fourth in-
jection, infiltration appeared which finally developed into
necroses, sequestration and abscess formation. This Ar-
thus described as local anaphalaxis and his observation
is universally referred to as the “Arthus phenomenon."
The phenomenon of Arthus has its counterpart in the
human being. Such reactions have been reported in the
literature since 1909, chiefly in association with the ad-
ministration of antitoxins. Illustrative cases demonstrate
that the Arthus phenomenon results invariably from re-
peated serum injections, particularly when local serum
reactions from a previous inoculation are still present.
Gerlach, in 1923, 1 made a complete microscopic study
of the Arthus phenomenon and concluded that the re-
actions were in no way specific and did not differ from
any other inflammatory reaction except in degree. It is
believed that the mechanism of the reaction is initiated
by an antibody — antigen reaction resulting in arteriolar
spasm. The endothelial damage due to the blocking of
the vessels by leukocytic and red blood cell thrombi in
turn leads to hemorrhage, necroses and slough.
Report of Case
Mrs. S. H. (U.H. No. 769636) was first admitted to
the University Hospitals on August 15, 1946, with a his-
tory of having noted a painless tumor in the left breast
three months prior to admission and a tumor mass in
the left axilla three weeks prior to admission. Physical
examination revealed an irregular, indurated tumor deep
in the inferior portion of the left breast, 10 by 8 by 6 cm.
in size and in the anterior part of the left axilla, a hard,
matted cluster of nodes, 5 by 3 by 3 cm. Neither tumor
was fixed to the skin or underlying structures. The re-
mainder of the physical examination was negative. Blood
and urine determinations were within normal limits.
X-ray of the chest showed ectasia and calcification of the
aorta.
A clinical diagnosis of carcinoma of the breast with
axillary metastasis was made and, August 16, 1946, a
radical mastectomy was performed under cyclopropane
anesthesia. Pathological examination of the 2800 gm.
specimen revealed a scirrhous carcinoma of the breast
with multiple metastasis to the axillary nodes. Post-
operatively the patient received 20,000 units of penicillin
sodium intramuscularly every three hours on a prophy-
lactic basis for the duration of her hospital stay; a total
of 1,120,000 units were given over a seven-day period.
Her course was uneventful and she was discharged from
the hospital on August 23, 1946 (Fig. 1).
From the Department of Surgery, University of Minnesota
Medical School, Minneapolis. Minnesota.
May, 1947
The wound was dressed on the patient’s first clinic
visit, August 26, her tenth postoperative day. At this
time the skin surrounding the incision in the middle
third of the wound over a distance of 6.5 cm. appeared
dark; this portion of the wound had been closed under
some tension at the time of surgery, though the remain-
ing length of the incision had been approximated with
ease. On this date, the patient was started on penicillin
in wax and oil, 300,000 units of which were taken in
daily intramuscular injections until August 29. At this
time, the wound edges of the middle third of the wound
were beginning to separate, and it was evident that a
slough would occur in this region. The patient was re-
admitted for debridement and early grafting of the re-
sultant defect.
On admission the involved area of the wound, meas-
uring 5 by 7 cm., was debrided and a wet dressing of
0.5 per cent acetic acid in sterile saline, containing 250
units of penicillin per c.c., applied; in addition the pa-
tient was given 50,000 units of penicillin intramuscularly
every three hours. The debrided area showed slight in-
fection though the rest of the wound appeared healing
and healthy.
On September 3, the patient developed a generalized
urticaria, and the edges of the open part of the wound
appeared red and angry ; there was no associated rise of
temperature or pulse. Benadryl, 50 mg. every four hours,
was given with some recession of the urticaria; however,
the intense wound reaction, in the form of a nonpurulent,
necrotizing, intense inflammatory process, spread rapidly
to involve three-fourths of the wound. During this pe-
riod, there was redness and increased heat at the site of
the intramuscular injections of the penicillin, though no
slough appeared here. On September 5, all penicillin
therapy was discontinued and, within the next three days,
the inflammatory and necrotizing process in the wound
had completely subsided. By September 8, with debride-
ment, the wound presented as a clean, granulating sur-
face.
Comment
Rostenberg and Welch,2 in studying the types of hy-
persensitivity induced following the intradermal injec-
tions of penicillin in human subjects, noted that in origi-
nally nonsensitive individuals who became hypersensitive
following repeated injections, the reactions, although
eventually developing into a tuberculin type of hyper-
sensitivity, may show transient characteristics simulating
the type of reaction seen in the Arthus phenomenon.
They postulate that penicillin sodium, injected intrader-
mally, remains in situ for a sufficient time to combine
with body proteins, thus forming a heterologous antigen
in which the penicillin molecule acts as a hapten. When
subcutaneous injections of penicillin were made, no re-
actions were obtained, and they thought it possible that
517
CASE REPORT
PENICILLIN
(Daily dose)
400,000
300,000
200,000
100,000
ALL PENICILLIN
DISCONTINUED
50,000 U every 3 hours ▼
• Local penicillin 250 U
1 in sterile normal saline
300,000 '
T 0 .... *
20,000 U every 3 hours
ally
in wax
Generalized urticaria
Arthus phenomenon
. o I
E <»
-o Q-
< O
— CD
o >-
.t: o
8- -5
0 2
1 Q
Process
subsiding
DAY 1 5 16 1 7 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9
AUGUST SEPTEMBER ►
Fig. 1. Record of penicillin therapy in a patient who experienced an Arthus phenomenon.
rapid excretion did not permit sufficient time for the for-
mation of an antigen.
The case presented is believed to represent an Arthus
phenomenon induced by the local application of penicillin.
It is possible that the penicillin in oil and wax, given five
to eight days prior to the reaction was, by virtue of its
slow absorption, the factor concerned in the formation of
the antigen. It is also conceivable that the antigen was
formed by the continued exposure of the wound to the
penicillin solution. In either case, the formation of anti-
gen, stimulating the production of antibodies, resulted in
a hypersensitive state; the local application of antigen
then initiated an antibody-antigen reaction of the type
described as local anaphylaxis.
Conclusion
A case is presented in which the local use of a peni-
cillin solution in an open wound in a patient hypersensi-
tive to penicillin resulted in a rapid inflammatory and
necrotizing process characteristic of the Arthus phenom-
enon.
References
1. Ratner, B.: Allergy, Anaphylaxis and Immunotherapy. Bal-
timore: Williams and Wilkins, 1943.
2. Rostenberg, A., and Welch, H. : Am. J. M. Sc., 210-158,
1945.
DANGER OF TRANSMITTING MALARIA BY TRANSFUSION
To the Editor: — I believe it would be desirable to re-
new a warning to medical practitioners that a danger
exists in transfusing recipients from donors who have
had a past malarial history.
Although I have no extensive data, the transfer of
infection has occurred on numerous occasions all over
the country. A case reported by Sharnoff, Geiger and
Selzer (Am. J. Clin. Path. 15:494 [Nov.| 1945) was of
particular interest because blood had been stored in a
bank for eight days, yet a malarial infection was trans-
ferred. When blood is stored at low temperatures,
the parasites seem to exist for a long period. The
actual limits of time have not been established, but
eight days would seem to be quite an interval for an
active blood) bank.
I have been told of a soldier who had been overseas
under suppressive medication and never had had ex-
perience with malaria; yet, when his blood was used
in this country many months later, a malarial infection
occurred in the recipient. Such an occurrence is rather
unusual now, although during the war it was seen quite
frequently. Most of the men are now out of the malar-
ious areas ; hence that danger is minimized. In several
thousand cases seen personally no less than a hundred
men first had malaria in this country after withdrawal
of the suppressive drug used overseas. One man had
been off the drug thirteen months before his first attack
occurred.
As a routine procedure I believe physicians should be
advised never to use blood from any person who has
had a past history of malaria. There is an instance in
Denver where a Greek’s blood was used and malaria re-
sulted although the man had been away from Greece,
where he acquired his original infection, for thirty-
seven years.
All returning servicemen should be questioned closely
about a postmalarial infection. One instance occurred
here in which a man was asked specifically whether he
had had malaria and he replied in the negative. How-
ever, his blood was infectious for the recipient and, on
requestioning, he stated that he was afraid that the
patient would be denied blood needed very badly and
he thought it was of no importance.
It would seem that a safe time limit for a serviceman
in this country after withdrawal from the endemic ma-
laria areas and without a past history of malaria
would be two years, provided he had not used suppres-
sive drugs in the interim.
L. T. CoGGESHALL, M.D.
Chairman, Department of Medicine,
University of Chicago.
(Reprinted from JAMA, April 19, 1947.)
518
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HISTORY OF MEDICINE IN MINNESOTA
♦
♦
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester, Minnesota
(Continued from April issue)
Jacob Wright Magelssen, a son of Hans Gynther Magelssen, who was a
Lutheran minister and “provst,” and Drude Catherine Haar Daae Magelssen
was born on August 11, 1843, at Aafjorden, a town about seventy miles north
of Trondhjem, Norway. His parents were worthy representatives of two dis-
tinguished families.
The Magelssen family, dating back to 1350, was originally Hanoverian.
In 1756 one of the Magelssen men, the grandfather of Jacob Wright Magels-
sen, immigrated to Norway and there established the family name which is
well known and well represented in all the professions. The Daae family
were of an illustrious line that traces back to the old nobility of Denmark.
Catharine Haar Daae was born at Saltdalen, Norway, in the district where
her father was the provost ; her brothers, one of whom was Professor Ludvig
Kristensen Daae, were brilliant and distinguished historians^ economists and
scientists. A provst, it may be said, is an official of the church whose responsi-
bilities are comparable to those of a bishop in that he has supervision over
other ministers in a large district.
Hans Gynther Magelssen was remarkable for vision, for ardent work on
behalf of his church and his people, and for public spirit, especially in labor-
ing for post roads and public schools, and these qualities descended to his
children. To Mr. and Mrs. Magelssen were born nine children, six boys and
three girls. Johan, the eldest son, was for many years editor of Oslo’s famous
Aftenposten. Kristian, one of the two sons who came to America, was a Lutheran
minister at Highland Prairie, Minnesota, near Rushford. Kristen was a
noted sculptor. Next came Jacob Wright, the subject of this sketch. Ludvig,
the possessor of remarkable dramatic talent and beautiful singing voice, be-
came, not an artist, as he might well have done, but a wholesale importer.
Anton, the youngest son, had marked talent as a painter but, believing that
one artist in the family was enough, he followed Jacob’s example and became
a physician. Of the three daughters, Elizabeth, the eldest, a beautiful and
talented woman, was married to Peter Voss, head of a distinguished Latin
school which bears his name; Valentine, the son of this marriage, became an
eminent jurist. The second daughter, Gyda, ahead of her times, was one of
the first women in Norway to go into business for herself, establishing a
secretarial bureau. The youngest, Sofie, a linguist, newspaper correspondent
May, 1947
519
HISTORY OF MEDICINE IN MINNESOTA
and writer of books, was married to a Frenchman, P. Groth, and spent most
of her adult life in Paris. Her husband and her daughter shared her literary
interests and occupations. In 1940, because of the war, Madame Groth came
to America, to take up residence in New York. In 1943 she was the only
member living of the original family group, unless perhaps Ludvig survived.
When Jacob Wright Magelssen was small, he and the other children had
a private tutor because the family lived far from a good school. Before he
was four years old he learned to read and write and at the ripe age of eight
he was sent with his brothers to a large Latin school for boys at Arendanl.
Here he began the study of Latin and German ; English was not taught in
the school at that time. When, at thirteen, he began the study of English, his
textbook was Macauley’s History of England. After three years at the Latin
school, the brothers again had a private tutor for two years. Next, Jacob
was sent to Nissen’s Latin school for boys, in Oslo, and then to the LTniver-
sitv of Oslo, from which he was graduated in 1861, at the age of eighteen,
with the degree of bachelor of arts. In 1863 he passed the examination for
the degree of doctor of philosophy.
Shortly after completion of his university work, Jacob Magelssen came to
Aimerica, landing in New York during the famous wbek of July 13 to 16,
1863, when the Draft Riots of the Civil War were in progress in that city.
Long afterward, in Rushford, Fillmore County, Minnesota, he learned that his
colleague and close friend in the village. Dr. H. C. Grover, who served as
an army surgeon in the Civil War, had been in New York City with his regi-
ment, part of the troops that put down the riots. In coming to America
Jacob Magelssen had hoped for admission to service in an army hospital in
some capacity that would fit him to enter a medical school later, but finding
this plan infeasible, he decided to spend the months before college opened in
the fall in visiting the new Norwegian settlements in Wisconsin near Kosh-
konong and Stoughton. It was in this Wisconsin community that he met
his future wife, Karen Elizabeth Newberg, who was a native of Norway.
In January, 1886, Dr. Magelssen, aged twenty-two and a half years, was
graduated from Rush Medical College in Chicago ; he had earned his way
through by serving as assistant editor of a Norwegian paper, Emigranten. For
the next few years after his graduation Dr. Magelssen practiced medicine in
Koshkonong; the resident physician of the settlement, Dr. Hanson, wanting
to return to Norway, persuaded the young graduate, who was urged by his
local friends to accept the place, to take over the practice. For a time sub-
sequently in this general period of his life, Dr. Magelssen was ship’s physi-
cian on one of the boats of the newly established Norwegian-American line,
and during this time his wife (he had been married in 1866 at the age of
twenty-three) and children lived in Bergen with Mrs. Magelssen’s father.
When the shipping company had financial difficulty and the young physician
was out of a job, he left his family in Norway and returned to Wisconsin, to
the scene of his early medical practice. He was lonely, and impulsively on
one fine day of that autumn of 1873 he hitched up his horses and started on
the drive of five days to Minnesota to visit his brother, The Reverened Mr.
Kristen Magelssen, of Highland Prairie, seven miles from Rushford. Winter
set in early that year, Dr. Magelssen contracted inflammatory rheumatism,
which affected his heart, and for months at his brother’s home he was very
ill. It happened that soon after his arrival in Highland Prairie, Dr. Karl O.
Bendeke, of Rushford, who was planning to make a trip to Norway, heard of
520
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HISTORY OF MEDICINE IN MINNESOTA
the visiting physician and drove over to ask him to serve in Rushford as
locum tenens. By an unforeseen set of circumstances Dr. Bendeke moved
permanently to Minneapolis instead of making his visit to Norway, and in
the spring of 1874 Dr. Magelssen, pleased with Rushford and the beautiful
surrounding country, settled in the village. His wife and children joined him
in May. For three years the family lived in rented houses, and then Dr.
Magelssen bought the house on the hill which was to be his home for the
remainder of his long and useful life.
Under the Medical Practice Act of 1883 Dr. Magelssen received state
certificate No. 530 (R). His impress on professional life, as on civic and cul-
tural life in the community and county, was strong. He served his people
well and co-operated with the State Board of Health in promoting general
welfare. Excerpts from his memoirs concerning the early roads and particu-
larly concerning the epidemic of diphtheria of 1881 and 1882 were quoted
in the narrative which preceded the present series of biographical sketches
of physicians of Fillmore County.
This man, like his father, was progressive, possessed vision and acumen,
and was a tireless worker. Honest and fearless, loyal and dependable, of
magnetic personality, a humanitarian and a natural leader, he was a vital factor
in accomplishment of measures for the public good. He served a great many
terms as mayor of Rushford and, keenly interested in education, was long
the president of the school board. The schools of Rushford were among the
first in the county to have courses in manual training, home economics and
agriculture. Dr. Magelssen was a keen judge of men and, it is said, it was
largely through his influence that the local schools were headed by outstand-
ing superintendents, men who justified his opinion of them by going far in
their professional field.
Dr. Magelssen’s daughters, the Misses Thora and Gyda Magelssen, fur-
nished most of the material on which this sketch is based. In the next few
pages appear various verbatim excerpts from their contribution which give
vivid highlights on the character and personality of the man :
He was far ahead of his times in many ways. One of his pet projects was good roads.
At every opportunity he preached and pleaded. Much of his argument fell on deaf ears
because the people thought that he was considering only his own welfare. Sometimes they
would say to him, “We would like you to talk on such an occasion, but don’t talk about
roads.” When he said that every small town was dependent on the farmers ’round about,
they laughed at him. . . . Another of his ideas which was ridiculed was that of a community
hall.
Dr. Magelssen never lent his time and energies to politics although his abilities
and his influence were recognized by many of the political leaders of the state
who often tried to enlist him as a party worker. He always refused, saying that
he wanted to feel perfectly free to change his opinions and to ‘cuss’ politicians
when they needed it, and also that he could not guarantee not to lose his temper
over some clever chicanery. His influence was felt, nevertheless. It was not
an uncommon thing to hear a man say, “Well, if a smart man like the doctor
is going to vote for so-and-so, that’s what I’ll do, too.” On one occasion, when
an important issue was before the town and the citizens were gathered in a mass
meeting, discussion was dull and prolix, with much citation. of law and precedent.
Dr. Magelssen got up, big, forceful and genial : “Fellow citizens, you know what’s
for the best of this community. Never mind the law. Let’s do this thing right.'’
And the thing was settled in a few minutes.
May, 1947
521
HISTORY OF MEDICINE IN MINNESOTA
In the sense that the term “hobby” means an engrossing and excluding interest
in a particular occupation or subject, Dr. Magelssen had no hobbies, for he was
interested in everything, although especially in all aspects of nature and particu-
larly in weather, birds, and horses.
He knew every bird so well that he could recognize many birds by their flight and even
by the shadow of their flight cast upon the road ahead of him as he drove. As a part of
his daily record he set down the date of arrival of each kind or bird in the spring. He
always maintained that birds came north at certain dates, regardless of wind and weather.
The robin, for instance, was due between the tenth and the fourteenth of March and
arrived even when there was snow on the ground. . . . To the doctor a tree was one of
God’s most wonderful creations. He would cheerfully have imprisoned anyone who wan-
tonly destroyed one. He often paid out his own hard-earned money to buy a load of wood
for a poor man who wanted to chop down a lovely tree for firewood. And Heaven
help the chopper who wasn’t poor ! . . . He was always trying to have a city park board,
but there again he was ahead of his time.
In his memoirs more pages are devoted to horses than to anything else. He always owned
more than he needed or could really afford. He would drive any kind of a horse, even
one so crazy that it took two men to hold it while he climbed into the sulky. He would
never knowingly sell one to an unkind master, and many times he bought a horse just to
rescue it from a cruel owner. When he was the mayor, it was his rule that no team could
be left tied outside more than a short time. After that, the police put the team into a livery
stable, and the man had to pay the charges to get it out again. If the man put up a fight,
the doctor would call round and settle it in person.
He had a brilliant mind, was an omniverous reader and had a wonderful memory, and
all this made him an unusual conversationalist. He liked people and liked to talk with
them. It mattered little whether the other fellow was an archbishop or an atheist, a banker
or an Indian horse trader, the doctor could always contribute something and make the
other do the same. . . . He loved poetry and drama. To read a poem was to remember it
for life. . . . His courage was unfailing. Hard work and self-denial, responsibility and
worry, sorrow and sacrifice were all in the day’s work. . . . His compassion for the poor
colored all his life. He could never bring himself to charge what his trips were really worth
or to press for payment. “No,” he would say, “I can’t. There is too much sweat and blood
on those dollars.” . . . He was generous to a fault. His economies were practiced at his
own expense, so that he might give to some one else.
No one is perfect, and the doctor had his faults. He had a hair-trigger temper, and very
little patience, except with the sick. When he was really angry, he didn’t care what he said
or did. With his great size and strength he was not a man to meddle with when he was
angry. But he never bore a grudge, and when he offended any one he was quick to make
amends. . . .
Nationality and creed meant nothing to him, not just because it is a doctor’s business to
serve all, but because he respected every man’s right to his own faith and remembered the
religion of his patients. Often, when he was going to a Catholic home, he would look up
the priest and take him along.
In his memoirs, in writing in detail of the researches on leprosy of Armour-
Hansen and of Boeck, both of Norway but of different schools of thought as to
the origin and method of dissemination of the disease, he stated : “Some years
later I had the honor of meeting Dr. Armour-Hansen, whose contention was the
opposite of Dr. Roeck’s. He presented just as many logical arguments, and
plenty of proofs in support of his theory. This has always remained in my
mind as an instance of the fact that no man’s judgment is infallible and that
every proposition is open to argument.”
In 1897 the telephone first reached Rushford. The only instrument in town
was installed in a small central office and the girl at central sent out a messenger
for any one who was called. This limited arrangement led to comic inci-
dents and not infrequently to occurrences of potential tragedy. During a winter
storm when the wind was high and the roads drifting full of snow, Dr. Magelssen
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Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
was obliged to tell one family in which a death was imminent that he probably
would not be able to make his usual visit on the following day, but on the plead-
ing of the family he promised to go, making the one condition that if in the mean-
time the patient, an old man, died, some one was to go to the Hart Exchange and
telephone Rushford, to save Dr. Magelssen the trip. On the following day, one
of the most terrible in the history of the community, the temperature SO degrees
below zero, the doctor waited until the time that had been specified and then set
out. After hours of desperate struggle for himself and his horses he arrived,
to find that the old man had died in the previous night and that one of the family
duly had telephoned. The message never was delivered; it would be safe to say
that the telephone girl did not soon forget Dr. Magelssen’s comments when he
returned to the village.
His friends were in many places, in all walks of life. Among them were
Ibsen, who was also a relative; Bjornson, the novelist, who visited him in Rush-
ford, as Rolvaag also often did ; Prestgaard of the Decorah Posten; Bishop Lunde,
Primate of Norway ; Harold Stormoen, the actor ; Skovaard, the violinist ; Hugh
Cooper, the engineer; Governor Nestos ; Governor J. A. O. Preus (grandson of
the C. K. Preus of Koshkonong) ; Senators Knut Nelson and Henrik Shipstead.
A friendship which all who knew the men like to remember was that of Dr.
Magelssen, Dr. Henry C. Grover, and Dr. H. W. Eldred, the surgeon-dentist,
all of Rushford, for each other. Dr. Magelssen was handsome, very tall, large
and heavy, but not fat, with unusually broad shoulders and deep chest. He had
a broad forehead, a large Roman nose, and heavy dark hair. He always wore a
beard. His eyes, intensely blue, held a bright and delighted twinkle, as though
the world were a comical and entertaining place, as it was to him. Dr. Eldred was
a small wiry man, who also had very bright blue eyes. Dr. Grover was a tall,
lean Hoosier, who had a friendly smile and spoke with a slow drawl. Dr.
Eldred enjoyed the contrast in size between himself and Dr. Magelssen, who
towered above him, and made a point of dancing around the handsome giant,
sparring at him in pretended battle.
When any one of these three men came out on the street, any one passing stopped to
talk with him, sure of a lively conversation. When two of them came out at the same
time, every one around them stopped to listen. When all three of them came out on the
street together, a crowd would gather as promptly as for a circus, for it was certain that
there would be a most entertaining scene within a few minutes. They were all very funny
men, with keen sense of the comic, quick wits and even quicker tongues, and they kept the
crowd roaring with laughter. At public gatherings they could hold up all proceedings if
they decided to exchange a little lively repartee.
Dr. Grover had been in Rushford about five years when Dr. Magelssen came, and he
was kindness itself to the newcomer. They made many hard, long trips together and helped
each other in time of need. They spent long hours together in the office of one or the
other, to their mutual profit and pleasure ; and if there ever was any discord between them,
it was never enough for it to have been mentioned at home. There are many instances cited
in his memoirs by Dr. Magelssen and cherished by his children of the strong, sweet, lasting
friendship among the three men.
In Rushford, in February, 1881, the death of Mrs. Magelssen occurred. Karen
Elizabeth Newberg, mentioned earlier in this account, had been born in Bergen,
Norway, on September 24, 1844, and she was married in 1866 to Dr. Magelssen.
The seven children of the marriage were: Hans Gynther (1867-1902); Drude
Catharine (1869-1871); Karen Henriette (Mrs. S. Rue, 1871 ■) ; Mathias
Peter (1873-1920); Jacob A. O. (1876 — — ), a rancher in Montana; another
Drude Catharine (Mrs. Boyd of Minneapolis); and Kristian (1879 ),like
Jacob, a rancher in Montana.
May, 1947
523
HISTORY OF MEDICINE IN MINNESOTA
Dr. Magelssen was married, a second time, to Thora Larsen, who was born
on July 16, 1857, the daughter of Dr. Lauritz Larsen, founder and first president
of Luther College, Decorah, Iowa. Mrs. Magelssen died in Rushford on July 3,
1908. To this marriage there were born five children: Karen Elizabeth (Mrs.
N. M. Ylvisaker, of Minneapolis); Thora, a schoolteacher, of Rushford; Elsie
(Mrs. Einar Jenson, of Newell, Iowa); Gyda, of Rushford; Agnes Margot
(Mrs. M. C. Hoppin, in Anchorage, Alaska, in 1941).
Jacob Wright Magelssen died at his home in Rushford on January 9, 1931,
from the infirmities of old age, in his eighty-eighth year. He had been a prac-
ticing physician, ethical, honored and loved, for sixty-five years, of which fifty-
seven years were spent in Rushford, where he settled in 1874. Even after he
retired from active practice and had given up his office, Dr. Magelssen continued,
until a few months before his death, to see his old patients. Fifty-seven years
is a long time, in which a physician may be the friend of many generations;
and the knowledge in his community that father or grandfather knew “the doc-
tor” when one or both were young, engenders confidence.
His magnetism touched every one he met. When he came into a house of illness, so big
and full of life, so jolly and yet so wise and capable and sympathetic, the whole atmosphere
changed. The doctor radiated . . . the hope and strength and cheer of a vital person who
loved life and loved his fellow men. “Why,” he would say to some sick child, “when your
father was as small as you, and was sick . . .” The little patient would smile and the family
would relax.
About Dr. Masse of Chatfield, Timothy Halloran, a pioneer settler of the
village stated in his History of Chatfield (1897) written from memory: “Among
the practicing physicians of the early days were Dr. Allen . . . and Dr. Masse,
who practiced here for a number of years.” Other mention of Dr. Masse has not
appeared. Dr. Nelson W. Allen was in Chatfield from 1854 until his death in 1876.
It is possible that the name “Masse” was confused with that of Dr. D. N. Morse,
in Chatfield as early as 1856, who will be mentioned further.
— Mecklenberg, of Wykoff, mentioned in the official directory of physicians
licensed in Minnesota in the period from 1883 to 1890, inclusive, as a holder
of an exemption certificate under the “Diploma Law” of 1883, was Dr.
Frans Josef (Francis Joseph) Van Mackelenbergh, who came to America
from Holland in 1866, to Fillmore County in 1872, and who practiced medi-
cine in Fillmore County successively in Forestville, Spring Valley and Wykoff.
His death occurred in Wykoff on March 18, 1892. An account of the life of
Dr. Van Mackelenbergh follows in alphabetical place.
Roy A. O. Meidell, a graduate of the University of Christiania, Norway,
in 1895, was licensed on January 12, 1897, to practice medicine in Minnesota,
and on the following January 27 he filed his state certificate, No. 745, in
Fillmore County. Further record in Minnesota has been lacking. On
July 3, 1899, R. Meidell, aged thirty years, a graduate of the University of
Christiania in 1896 [sic], was licensed to practice in North Dakota. He was
a resident of Grank Forks County. In 1907 Dr. R. H. Meidell was in Aneta,
Nelson County, North Dakota, the only Meidell in the directory of the
American Medical Association. In 1912 Rolf Meidell was in Glendive, Mon-
tana, in 1914 in Havre; in 1916 he was in Aneta, North Dakota.
Simeon Paul Meredith was born on January 27, 1852, at Middleton, Wis-
consin, the son of a farmer who was a native of Wales. After receiving his
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HISTORY OF MEDICINE IN MINNESOTA
early education in the country school near his home, he enrolled as a student
at the University of Iowa, in Iowa City, and subsequently for a time he
taught the rural school near Middleton. In the next period of his life he
qualified as a medical practitioner, and in the middle seventies began his
professional career in Jefferson, Wisconsin, and later practiced in Spring
Green.
It was probably in 1880 that Dr. Meredith enrolled at the Hahnemann
Medical College and Hospital, in Chicago, from which he was graduated in
1882. Shortly after his graduation he came to Minnesota because of ill health,
and it has been said that in 1882 he was practicing medicine in Austin, Mower
County. In 1887 when, under the Affidavit Law of that year, he received a
license to practice in the state, he was living in Plain Prairie. By 1888 he
had brought his family to Spring Valley, Fillmore County, and there he re-
mained in successful practice for nearly ten years. (An unverified statement
has been noted that in 1897 he was in Owatonna, Steele County.) In Febru-
ary, 1899, he moved from Spring Valley to Pleasant Grove, Olmsted County,
where he assumed the practice of the late Dr. Marshall T. Bascomb, who
had died on January 28 of that year. A few weeks later, succeeding Dr. Bas-
comb, he was appointed county physician for the village and township of
Pleasant Grove. According to notes from the Minneapolis Homoeopathic
Magazine, in the spring of 1902 he settled in Grand Meadow, Mower County,
near his former location, Spring Valley. By October, 1902, however, he had
moved to Windom, Cottonwood County, in the southwestern part of the
state, and there he lived for several years before moving to Garden City,
southwest of Mankato, in Blue Earth County. From sparse record it would
appear that he was in Garden City through 1907 and into 1908; in this period
he retired from active medical practice, and in the spring of 1908 established
his permanent home in Mankato.
Before leaving Wisconsin, Simeon P. Meredith was married to Fannie
E. Glasier, of Bedford, Ohio, the sister of six brothers, most of whom were
physicians or dentists. One brother, Gilson Glasier, for more than thirty
years, in 1942, had been the librarian of the state law library of Wisconsin.
Dr. and Mrs. Meredith were the parents of two children, a daughter and a
son. Eva L„ Meredith, a graduate of the Windom High School, and a musi-
cian, died in 1934. Harlan M. Meredith, who was born on August 22, 1889,
at Spring Valley, in 1943 (since 1941) was an employe of the New York
Central Railway, in Cleveland, Ohio. In 1942 there were living also Dr.
Meredith’s brother, George Meredith, in Omaha, and one sister, Mrs. J. F.
Fargo, in Los Angeles, California.
Dr. Meredith died in Mankato on September 1, 1930, having suffered many
years from bronchitis and asthma. Never in good health, he was not able
to enter actively into civic life or to hold public office but applied his limited
strength to the practice of his profession. He held respect and liking in the
communities of his residence, in all of which he was a home-owning citizen,
and left a record of able service to the sick.
Dr. Miller, of Waukokee, Carimona Township, Fillmore County, was men-
tioned in a county newspaper of January, 1887. The well-known Dr. Luke
Miller, of Chatfield and Lanesboro, died in 1881.
(To be contiimed in June issue)
Ptesid ent s fetlel
MEDICAL SERVICE AREA IS KEY TO PHYSICIAN DISTRIBUTION
THOSE of us who were present at the meeting of the officials of the county medical
societies of the state on Saturday, March 1, 1947, in Saint Paul, were impressed by a
talk which was given by Frank G. Dickinson, Ph.D., director of the Bureau of Medical
Economic Research of the American Medical Association. In his discussion he proved that
the old method of determining the physician-patient ratio provides an incorrect idea of the
efficiency with which physicians are rendering medical service, and he showed further that the
key to the question of the availability of medical care and the distribution of physicians may
be found in the development of his new concept of medical service areas. Also, he demon-
strated in a convincing manner that this method will show, far more accurately than pre-
viously used methods, the areas in which physicians practice aS well as the availability of
medical services.
According to Dr. Dickinson’s scheme, the old method of determining the number of people
per physician in counties, townships and other political areas is abandoned, and an entirely
new concept, based on established marketing principles, is adopted. According to the old
concept, it is customary to consider the population in relation to the number of physicians in
a political area. One county may have one physician to 1,000 of population, and another
county may have one physician to 2,000 of population. Such statistics may be accurate but
what significance do they possess? Obviously, very little, because medical care is an econom-
ic service which bears no relationship to political boundary lines. Most physicians have
patients who come from areas outside the county in which their offices are situated.
Recently, a map of the state of Minnesota has been circulated, in which each county is
shaded according to the number of physicians there are per thousand of population. Ac-
cording to this map, white counties have one physician to 1,000 of population or less; black
counties have one physician to 3,000 or more persons, and various other shadings are in-
cluded between the two extremes. With this as an example, Dr. Dickinson brought out the
significance of his theory most forcefully. He called attention to the fact that Hennepin
and Ramsey counties appeared on the map in white, and Anoka County, which borders these
two counties, appeared in black, indicating a ratio of one physician to 3,000 or more people
in Anoka County. Obviously, it would be incorrect to assume that people living in Anoka
County could not obtain adequate medical care because of the small number of physicians
residing in that county. Actually, the people of Anoka County secure much of their medical
care in Minneapolis and Saint Paul.
Physicians render service to people who reside in communities which are closely related to
the retail trading area, very much as stores draw their customers from small or large areas.
A small store may draw customers from an area which covers only a few blocks whereas
a large department store may attract customers from a distance of many miles.
The Bureau of Medical Economic Research is attempting to designate medical service
areas for the United States. Maps have been sent to all county medical societies. The
secretaries of these societies have been asked to indicate on the maps the areas wherein
medical care is provided by physicians who reside in primary medical centers within the
counties. Not every county includes a primary medical center. A county which is lacking in
this respect will be included in one or more of the medical service areas, the primary center or
centers of which will lie outside the inadequately supplied county. Much overlapping will come
to light. Secretaries in two well-supplied counties, separated by a rural county which does
not have a medical center, may each claim that more than half of this rural county is
served from a medical center of his county. The secretary of the state medical association
will assist the secretaries of the county societies in allocating the disputed territory. At the
state level also there will be overlapping, because people who live near the border of a
state may look to a large city just across the border for some of their medical service.
Elimination of these overlapping interstate areas will require conferences between the state
secretaries. Eventually, the border of every medical service area should be drawn so that,
in normal times, one or more physicians will reside within the area.
CL>& UJJ6^
President, Minnesota State Medical Association
526
Minnesota Medicine
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
SCHOOLS FOR PRACTICAL NURSES
f I 'HE dearth of nurses constitutes a complicated
problem. With only 31,000 young women
enrolled in nursing training schools in 1946, com-
pared with 39,000 in 1938, and with 33,000 hos-
pital beds unavailable because of the shortage of
nurses, the seriousness of the present situation
for the public and the hospitals is clearly indi-
cated.1 Among the reasons for the diminution of
enrollment in training schools for nurses, prob-
ably the main one, is the opportunity for greater
financial compensation in other vocations which
do not require such a long period of training,
and such a great expense, which recently, it might
be noted, has been increasing. The many open-
ings for trained nurses in activities outside the
field of private nursing have made the scarcity
even more acute.
In recent years the educational requirements
for certification as a registered nurse have been
on the increase. A few nursing schools, includ-
ing the University Hospital, have instituted a
five-year course. The report of the Committee of
the American Surgical Association2 undoubtedly
represents the opinion of the medical profession
at large on this trend in the nursing field. It is
generally believed that a year of training in nurs-
ing will qualify a young woman of average intelli-
gence to render valuable bedside nursing at home
or in the hospital. The one-year graduate, of
course, cannot take the place of the three-year
trained nurse in the care of the seriously ill. The
three-year course also is a requisite for further
study and training for a Master of Nursing de-
gree, qualifying for teaching and other responsi-
ble positions.
Through the co-operation of the nursing and
medical professions of Minnesota, a bill providing
for the certification of practical nurses after a
year of training was recently passed by the state
legislature, thus adding Minnesota to the list of
twenty other states that have passed such a law.
The next step will be the establishing of train-
ing schools for practical nurses. The National
League of Nursing Education and the American
Nursing Association have declared themselves
opposed to the establishment of training schools
for practical nurses in conjunction with training
schools for registered nurses. The shortage of
nursing school instructors may well be one rea-
son for such an attitude. On the other hand,
there are a number of nurses’ training schools in
the state which have been forced to close because
they could not meet the requirements established
by the national organization of nurses. These
schools might well be opened for the training of
practical nurses. It should not be unreasonable
to expect that the national nurses’ organizations
will aid rather than obstruct the steps proposed
to train practical nurses. While some of the mem-
bers of the State Board of Examiners of Nurses
have shown a spirit of co-operation, others have
followed the lead of the national organizations.
The training of practical nurses is of necessity
a function of the nursing profession. The medical
profession in the past has left the training of
nurses to that profession. However, the public,
the hospitals and the physicians are vitally con-
cerned and are now entering the picture. To meet
the situation a Minnesota Advisory Committee on
Nursing has been formed, composed of rep-
resentatives of the Minnesota State Medical As-
sociation, State Hospital Association, State Nurs-
ing Association, State Board of Health, State
Board of Nursing Examiners, Farm Bureau
Federation, State Institutions, State Department
of Education, and Catholic Hospitals. This com-
mittee has sent out a questionnaire to hospital
superintendents to obtain vital information in re-
gard to facilities for training more nurses.
The co-operation of individual physicians, as
well as the State Medical Association, in further-
ing the establishment of training schools for
practical nurses, is assured.
1. Editorial: The supply of nurses. J.A.M.A., 133:1156,
(April 12) 1947.
2. Resolutions of the American Surgical Association on
nursing problems. J.A.M.A., 133:1168, (April 12) 1947.
May. 1947
527
EDITORIAL
TRIMETHADIONE (TRIDIONE) IN PETIT MAL
* | ’ HE reports of two fatalities resulting from
the use of tridione for epilepsy constitute a
warning to the profession, since this drug is now
available on prescription. The previously re-
ported toxic effects of the drug were few and
apparently unimportant. The drug appears high-
ly effective in the prevention of petit mal attacks
in childhood, hut not of grand mal attacks.
In one of the cases reported,1 a sixteen-year-
old girl had received tridione and dilantin each in
doses of 0.1 gm. three times a day for six months.
The second case2 was that of a young woman
of twenty-three who had been taking tridione over
a period of ten months, usually 4 grains a day.
She also had taken phenobarbital for the past
nineteen years without ill effect. Both individ-
uals developed severe anemia, granulocytopenia,
and purpura, which failed to respond to treat-
ment. At autopsy the bone marrow showed a
marked reduction in hemopoietic tissue.
Apparently, tridione must be put in the same
category as amidopyrine (to which it is similar
in structural formula) in its effect on the bone
marrow and on leukocyte production. While
idiosyncrasy doubtless explains the effect of both
drugs on the bone marrow, and is comparatively
rare, yet the patient receiving tridione should have
periodic red and white cell counts, and any toxic
manifestations such as gastric irritation, nau-
sea, skin eruptions or blurring of vision, should
indicate the cessation of its use. It should not
be used in the presence of any blood dyscrasia.3
1. Harrison, Francis F., et at.: T.A.M.A., 132:11, (Sept. 7)
1946.
2. Mackav, R. P., and Gottstein, W. K. : T.A.M.A., 132:11.
(Sept. 7) 1946.
3. New and Nonofficial Remedies: J.A.M.A., 133:320, (Feb.
1) 1947.
DEMEROL
-pvEMEROL hydrochloride, a synthetic prep-
aration, has been accepted by the Council
on Pharmacy and Chemistry, according to the
report which appeared in the Journal of the
American Medical Association of September 21,
1946. The report indicated that the drug has
a morphine-like analgesic effect which lies be-
tween that of codeine and morphine. While its
action is in part due to depression of the para-
sympathetic endings, it is primarily the result
of direct papavarin-like depression of the mus-
528
cle fibers. Unlike morphine, demerol is not a
potent hypnotic.
In an editorial which appeared in our Mardi,
1946, issue, attention was called to the value of
demerol in obstetrics. Dispensed in ampoule
form with 50 mg. in each c.c., a dose of 100 mg.
is given subcutaneously or intramuscularly at the
onset of labor, and one or two additional doses
are given as required. It is said that demerol
does not prolong labor and does not produce a
depression of respiration in the infant. Scopola-
mine is sometimes given with the first dose of
demerol because of the former’s amnesia effect,
but this often makes the patient uncontrollable.
The addition of a barbiturate adds a desirable
sedative effect.
Demerol may be used to prevent the withdrawal
effects in morphine addicts. It should be em-
phasized, however, that experience has shown
that addiction to demerol is not uncommon. In
accepting demerol, the Council has required man-
ufacturers to mention the possibility of addiction,
and will issue a report in the future on this
phase of the use of demerol.
CARE
r ■ ’HERE is something big and fine about this
philanthropic organization known as CARE
(Cooperative for American Remittances to Eu-
rope, Inc.) which is composed of twenty-seven
major American welfare agencies, and is operat-
ing on a nonprofit government-approved basis.
Among the agencies concerned are the American
Christian Committee for Refugees, American
Friends Service Committee, American Jewish
Joint Distribution Committee, CTkranian, Lithu-
anian, and Yugoslav Relief Committees.
Packages of food, weighing 21 pounds and
containing meat, fats, sugar, milk, flour, choco-
late, coffee and other essential foods, are already
packed and shipped and awaiting orders to be
sent to a designated needy person anywhere in
Europe except Russia and the Russian zone of
Germany (shame on you, Russia). Ten dollars
sent to CARE, 50 Broad Street, New York 4, New
York, will start a package on its way. Or for
the same amount, a Blanket Package containing
among other things two army surplus blankets,
or a Woolen Package containing woolen cloth,
cotton lining, thread, et cetera, can be similarly
sent to an address in Europe.
Minnesota Medicine
/
THE STATE MEETING
The ninety-fourth annual meeting of the Minnesota
State Medical Association will be held Monday, Tuesday
and Wednesday, Tune 30, July 1 and 2, with head-
quarters at the Duluth Hotel, Duluth, Minnesota.
This meeting brings together medical men from five
states and two provinces of Canada, men in all branches
of medicine — general practitioners and specialists.
Duluth, at the head of the Great Lakes, with its re-
freshing climate, its superb recreational facilities, its
central location and its accessibility, is situated in the
heart of the Upper Midwest vacation land and is an
ideal location for the 1947 convention.
The dates have been selected especially to provide
bus}- Midwest physicians with an inviting opportunity
to combine participation in one of the top medical
meetings of the year with a vacation over the Fourth
of July in Minnesota’s scenic Arrowhead Country.
Out-of-State Speakers
Nationally prominent medical men from out-of-state
will appear on the program, both for the general meet-
ing and for the special sectional meetings being held by
the Minnesota Academy of Ophthalmology and Oto-
laryngology, the Northwest Pediatric Society, the Min-
nesota Orthopedic Club, the American College of
Chest Physicians, the Minnesota Radiological Society
and the Minnesota Society of Clinical Pathologists.
Noted out-of-state speakers include :
Dr. Robert E. Gross, Children’s Hospital, Boston,
Massachusetts, specialist in heart surgery.
Dr. George E. Shambaugh, Jr., of Chicago, Illinois,
Professor of Otolaryngology at Northwestern Univer-
sity.
Dr. M. L. Sussman of New York City, who will
deliver the annual Russell D. Carman Lecture in
Radiology.
Dr. Benedict Frank Massed of Boston, specialists in
rheumatic fever.
Dr. John R. Neefe, a fellow of the National Research
Council, Philadelphia. (Dr. Neefe was formerly with
the University of Minnesota Medical School.)
Dr. Joseph Molner, Associate Professor of Preven-
tive Medicine and Public Health, Wayne University,
Detroit, Michigan, and Medical Consultant for the
National Foundation for Infantile Paralysis.
Mrs. Charles W. Sewell, Administrative Director of
the Woman's Division of the American Farm Bureau
Federation, Chicago, Illinois.
Dr. Haven Emerson, School of Public Health, Colum-
bia University, New York.
Drs. Dean Smiley and Fred V. Hein, Consultants in
Health and Physical Fitness of the American Medical
Association, Chicago, Illinois.
Mr. Tom Collins, Publicity Director, City Mutual
Bank and Trust Company, Kansas City, Missouri (Ban-
quet Speaker).
Program Features
A new lectureship has been added this year, with the
selection by the Minnesota Society of Clinical Pathol-
ogists of Dr. Elexious T. Bell of the Department of
Pathology, University of Minnesota, to give the first
annual A. H. Sanford Lecture, honoring the work of
Dr. Sanford, a pioneer clinical pathologist of this coun-
try, who is also a member of the Minnesota State Medi-
cal Association.
The A. H. Sanford lectureship was established and
dedicated to the Minnesota State Medical Association
by the Minnesota Society of Clinical Pathologists. Dr.
Bell will speak on the subject, “The Pathology of Dia-
betes Mellitus.”
Another feature will be a booth, where demon-
stration of interesting gross pathological specimens
by the members of the Minnesota Society of Clini-
cal Pathologists will be conducted during morning and
afternoon intermissions throughout the three-day session.
This year, as in years past, the last afternoon of the
annual meeting will be devoted to a program discussing
some important current problem. This meeting is
thrown open to the public, and special invitations are
sent to representatives of interested groups. This
year’s question for discussion is the problem of im-
proving health in rural areas, the title chosen for the
program being “Rural Health — A Joint Responsibility.”
In addition to MSMA members, invitations are going to
hospital administrators and hospital boards, nurses and
representatives of the AFL, CIO, the Farmers LInion,
the Railroad Brotherhood and the Minnesota Farm
Bureau Federation. The program is planned so as to
provide an exchange of ideas among farm people, hos-
pital authorities and physicians and a chance for each
group to present its views of the various phases of the
problem and its proposed solutions.
The Scientific and Non-Scientific Committees of the
Association will again hold their annual Committee
Breakfasts, preparatory to making their reports to the
House of Delegates.
Twenty Roundtable Luncheons — ten on Tuesday and
ten on Wednesday, both at 12:15 p.m., will also be held
again this year. Recent developments in scientific medi-
cine will be discussed.
The following Special Sectional Meetings are sched-
uled for this year’s program, each of them open to
all convention visitors :
Monday, June 30
9 a.m. — Minnesota Academy of Ophthalmology and
Otolaryngology.
Tuesday, July 1
9 a.m. — Minnesota Orthopedic Club.
2 p.m. — American College of Chest Physicians.
Wednesday, July 2
9 a.m. — A special meeting devoted to investigative
work, with speakers presenting latest infor-
mation on research developments. >
May, 1947
529
THE STATE MEETING
Social Events
The Annual Golf Tournament this year will be held
at the Northland Country Club on Sunday, June 29,
at 1 p.m. Attractive prizes are provided and arrange-
ments are being made by a committee of which Dr.
R. L. Nelson, 324 W. Superior St. Duluth, is chairman.
As a special feature, members are invited to partici-
pate in a deep-sea fishing excursion along the North
Shore of Lake Superior, where catches range up to 55
pounds. No fishing equipment or license is necessary;
just appropriate fishing togs. Arrangements are being
made through Dr. Karl E. Johnson, 2031 W. Superior
Street, Duluth.
“Variety Night” will be held in the Ballroom of the
Hotel Duluth at 7 :30 p.m. Monday, June 30. Special
music and entertainment with refreshments are planned.
All convention visitors and wives are invited.
The Annual Banquet, at which the presentation of
the Fifty Club certificates and pin and the presentation
of the Southern Minnesota Medical Association Medal
for the best individual scientific exhibit will be made,
is scheduled for 7:00 p.m. Tuesday, July 1. The Presi-
dential Address will be given by Dr. Louis A. Buie of
Rochester. Guest speaker is Mr. Tom Collins, Pub-
licity Director, City Mutual Bank and Trust Com-
pany, Kansas City, Missouri.
The American College of Chest Physicians will have
a luncheon at 12:30 p.m., Tuesday, July 1, in the Tally-
ho Room of the Holland Hotel. Reservations are being
taken care of by Dr. G. A. Hedberg, Nopeming Sana-
torium, Nopeming.
Alumni of Nu Sigma Nu, medical fraternity, will
get together Monday evening at 5 :30 for a social eve-
ning and dinner at the Duluth Athletic Club. This is the
first reunion since the meeting before the war.
The Minnesota Academy of Ophthalmology and
Otolaryngology is planning a 12:30 p.m. luncheon at
The Flame on Monday, June 30. Reservations are being
handled by Dr. Archie Olson, 815 Medical Arts Build-
ing, Duluth.
A Medical Women’s Luncheon will be held at 12:15
p.m. at the Kitchi Gammi Club, reservations being made
through Dr. Marie K. Bepko, Cloquet.
All physicians who served in World War II are in-
vited to a luncheon meeting at 12 :30 p.m., Monday,
June 30, in the Tally-ho Room of the Holland Hotel,
sponsored by the Society of Medical Veterans in Du-
luth. Purpose of the meeting is to give returned medical
officers a chance to air their grievances with regard to
the manner in which medical departments of the Army
and Navy were administered during the war. All for-
mer medical officers are invited to come prepared to
offer constructive criticism. Reservations are in charge
of Dr. Karl E. Johnson, 2031 West Superior Street,
Duluth.
A Minnesota Surgical Society luncheon will be held
at 12:30 p.m., Tuesday, July 1, at The Flame. Make
reservations through Dr. M. G. Gillespie, 205 West Sec-
ond Street, Duluth.
Exhibits
One of the largest technical exhibits in the history
of the Association will be on display in the Duluth
Armory. These exhibits will be open for inspection each
day beginning at 8 a.m. Arrangements have been made
so that both the General Sessions and the Special Sec-
tional Meetings will be recessed both in the morning
and in the afternoon for 45-minute periods to permit
convention visitors to view the exhibits, demonstrations
and the scientific cinema.
There will be a series of five obstetric manikin dem-
onstrations, arranged by the Committee on Maternal
Health and sponsored by the Minnesota Department of
Health. Three of these will be given in the Duluth
Armory. The first at 1 p.m., Monday, June 30, by
Dr. Willis E. Brown, Associate Professor of Obstetrics
and Gynecology, University of Iowa Medical School,
will be repeated at 5 p.m. the same day.
On Tuesday, July 1, Dr. Ralph E. Campbell, Asso-
ciate Professor of Obstetrics and Gynecology of the
University of Wisconsin Medical School, will give two
demonstrations, one in the Arrowhead Room of the
Hotel Duluth at 12 :15 p.m., and the second at the Duluth
Armory at 5 p.m.
On Wednesday, July 2, at 12:15 p.m., the final obstetric
demonstration will be given by Dr. Mancel T. Mitchell,
Clinical Assistant Professor of Obstetrics and Gynecol-
ogy. University of Minnesota Medical School. This
will be held in the Arrowhead Room of Hotel Duluth.
Radiological and Pathological Demonstrations will also
be given. Among the scientific exhibitors this year are
such organizations as the Minnesota Safety Council, the
Minnesota Nurses Association, the Minnesota Public
Health Association, the American College of Physicians
and Surgeons, the Minnesota Department of Health, the
Minnesota Society for the Prevention of Blindness,
collaborating with the Department of Ophthalmology
of the University of Minnesota, the Division of Voca-
tional Rehabilitation of the State Department of Educa-
tion, the American Medical Association, the Minnesota
State Pharmaceutical Association, and the Minnesota
Cancer Society. The Minnesota Society of Clinical
Pathologists and the Minnesota Radiological Society are
also sponsoring exhibits, as the State Committee on
Tuberculosis.
Business Sessions
The usual business sessions will, of course, be
held. The Council will have meetings on Saturday,
June 28, and all during the convention. The House of
Delegates will meet on Sunday, June 29, the day before
the convention officially opens, and also on Monday,
June 30, the first day of the convention.
Hotel Reservations
It is important that hotel reservations be made at once
at the Association office, 496 Lowry Medical Arts Build-
ing, Saint Paul 2, Minnesota.
530
Minnesota Medicine
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
COUNTY OFFICERS HEAR PROGRESS
REPORTS OF MSMA PROGRAMS
(Continued from previous issue)
Viewpoint of Farm Bureau
An able spokesman for the farm people, heard
at the County Officers meeting held March 1, was
Mr. J. S. Jones of Saint Paul, who is executive
secretary of the Minnesota Farm Bureau Federa-
tion and one of the members of the Board of Re-
gents of our State University.
His comments generally paralleled those of
Dr. Larson, indicating that the medical profession
and farm people see eye to eye on their common
medical problems, but that in their solution, farm
leaders feel there is much to be desired.
Speaking for the 60 thousand farm families
who are members of this organization, Mr. Jones
reported that prepayment medical service is up-
permost in the discussions of rural people these
days, and running a close second are demands for
adequate hospital facilities and medical and nurs-
ing personnel.
Nurse Shortage Plagues Rural Communities
The unfilled gap left in the ranks of registered
nurses by recruitment for military service and
subsequent attractive opportunities elsewhere were
lamented by Dr. W. H. Valentine of Tracy in
drawing the attention of the county officers to the
present plight of many rural hospitals. To relieve
this critical situation, the training of girls for
licensure as practical nurses was offered as a par-
tial solution by both Dr. Valentine and Miss
Thelma Dodds, R.N., president of the Minnesota
Nurses’ Association. Both speakers recognized
the need for a concerted recruitment drive for all
types of candidates for nurses training as the
present flow of student nurses into classrooms
is not keeping pace with the facilities that are
available.
Dr. Valentine charged that the doctors had a
May, 1947
bigger stake in a broad state nurse recruitment
program than their efforts in that direction to date
would indicate.
AMA Officials Describe Changing
Medical Order
Leading off the discussion at the evening ses-
sion, Dr. George F. Lull, secretary and general
manager of the American Medical Association,
dwelt at some length on the facilities which the
AMA stands ready to offer the county medical
societies to assist them in working out problems
which the changing order in medical practice has
produced.
The transition that is taking place, Dr. Lull
said, is the result of “extrinsic things that are
brought in from the outside, which has led to a
changed concept of what medical service im-
plies.” As an illustration, he pointed to the
United Mine Workers Health and Welfare fund,
which could very well set a pattern for other
industries.
Closer Liaison with County Medical Societies
An immediate objective of the AMA, Dr. Lull
told the county officers, is to establish a closer
liaison with the county medical societies to make
them more aware of the activities carried on by
the parent organization. As a means to that end,
the Secretary’s Letter was started recently to
carry information to the county and state units
about its deliberations and undertakings. In this
connection, also, he announced that at the time
of the centennial observance and annual meeting
in Atlantic City in June, the AMA has scheduled
a County Officers meeting for Sunday, June 8,
to which all county officials who attend the na-
tional meeting are invited. It is planned at that
meeting to have informal discussions on subjects
that seem to be of greatest interest to the people
who head up the grass roots of organized medi-
cine.
531
MEDICAL ECONOMICS
Noting the importance of prepayment plans
in the scheme of things medical, Dr. Lull described
the services being offered by the recently created
Division of Prepayment Plans within the Council
on Medical Service, through which the seal of
acceptance of the AMA is given to prepayment
plans that qualify by coming up to certain stand-
ards. As a related, though independent, organi-
zation, he drew attention to Associated Medical
Care Plans, Inc., working closely with the Coun-
cil on Medical Service for the purpose of devis-
ing methods to establish some degree of reciproc-
ity among the various prepayment plans in exist-
ence.
“It is when doctors step out of their role of
scientists to become businessmen that controversy
arises,” Dr. Lull said. This is particularly true,
he reflected, during this formative period when
such a variety of prepayment plans are being
launched.
The complete answer to the problem of pro-
viding prepayment medical service is not yet in
sight. Dr. Lull told the doctors. It may well em-
brace several types of insurance engendering
lively competition, which will keep the rates down,
and will, in all probability, give the public a bet-
ter service than if they were operated on a more
monopolistic basis.
Public Relations Responsibility of
Individual Doctor
The AMA has been accused of failure in its
public relations, Dr. Lull said. It was his convic-
tion, however, that the building up or breaking
down of public relations for the medical profes-
sion is actually almost entirely in the hands of
the individual doctor and his personal relation-
ship with his patients — a relationship that deter-
mines whether the public is going to think ill or
well of the profession as a whole. No amount of
newspaper or other publicity, however striking,
is likely to alter the judgment of the public, form-
ed on the basis of personal experience with the
family doctor, in Dr. Lull’s opinion.
As an excellent health education medium, he
urged the county societies to avail themselves of
the transcribed health platters, which may be bor-
rowed from the AMA headquarters for local
station rebroadcasts. Many stations, Dr. Lull
said, donate a certain amount of time for pub-
lic interest programs and would be glad to make
use of these transcriptions.
532
The county officers heard that eleven publica-
tions, including the Journal AMA, with a week-
ly circulation of over 130,000 are all a part of
the routine of the headquarters staff, along with
the keeping of a watchful eye on legislation
thrown into both national and state hoppers.
Supply of Medical Service
Speaking as a statistician and economist, Dr.
Frank G. Dickinson, director of the American
Medical Association’s Bureau of Medical Eco-
nomic Research, presented a different approach
in his discussion of the supply of medical serv-
ice from what is ordinarily heard.
With considerable emphasis, he declared that
the supply of medical service cannot be even
faintly indicated by the physician-population ra-
tio of a county, although this is the common yard-
stick used in all current surveys to measure the
adequateness of medical service.
“The traditional physician-population ratio by
county has no economic meaning whatsoever,”
he contended. He queried the doctors about the
number of patients from towns outside of the
county in which their offices are located as proof
of his contention that trading areas — not county
boundary lines — more properly determine the out-
line of medical service areas.
The second stage of a study of supply, he said,
involves a definition of a “unit of supply of medi-
cal service.” To quote Dr. Dickinson:
“Every definition I have discussed with my associates
has failed to get general approval. Shall one hour of
a doctor’s time be the unit of supply?
“ ‘No,’ my colleagues say, ‘it is the amount of work
that a doctor can do in one hour which is the unit of
supply.’
“Or shall one patient visit be considered a unit of
supply? This, too, my colleagues reject because what the
doctor does while he is visiting the patient is the real
unit of supply.”
He concluded, therefore, that until a practical
and efficient unit has been agreed upon, one can-
not know very much about the functional aspects
of supply. One cannot say that a ratio of 800
persons per physician, or 500 persons per physi-
cian, or 1,000 persons per physician is adequate
unless one can measure in fixed, unchanging
units the amount of medical service which one
physician can supply, according to Dr. Dickin-
son. A doctor seeing most of his patients in the
hospital, supplies a greater number of units of
medical service than a doctor who has to spend
Minnesota Medicine
MEDICAL ECONOMICS
one-third or one-half of his time in his automo-
bile en route to visit patients.
Minnesota "Medical Service Area" Map
Studied
A map of medical service areas in Minnesota,
marked off by county medical society secretaries,
co-operating in a joint project sponsored by the
State Association and the AM A, furnished an
interesting study and was the subject of Dr.
Dickinson’s concluding remarks.
Typical of chartered maps prepared by other
state medical associations, Dr. Dickinson said,
was the general overlapping of medical service
areas throughout the state as shown on the map,
which reflected, also, an overlapping in trade
areas.
These areas, he explained, were determined by
the relative attractiveness of the retail stores in
different towns — upon the transportation facili-
ties available, especially automobile highways, and
upon other attractions such as amusement and
service facilities represented by doctors, dentists,
hospitals, lawyers, repair shops, beauty parlors
and various agencies. Obstacles such as toll
bridges, poor roads and congested highways re-
duce the size of trade areas, Dr. Dickinson said.
In like manner, they cut down the medical serv-
ice areas which normally include one primary
trading center, which draws a considerable
amount of trade from surrounding territory, and
a number of secondary trading centers represent-
ing small towns having one or more physicians.
BORDER STATE DOCTORS MUST
HEED NARCOTIC REGULATIONS
Because Minnesota is one of the states border-
ing on Canada, doctors in this state are sometimes
caused considerable embarrassment and inconven-
ience by the enforcement of certain federal nar-
cotic regulations, about which they have not
been informed.
The specific law that they unwittingly break is
the Narcotic Drugs Import and Export Act which
makes it UNLAWFUL FOR A PHYSICIAN
TO CARRY NARCOTIC DRUGS IN HIS
MEDICAL BAG BACK AND FORTH BE-
TWEEN THE UNITED STATES AND
MEXICO AND THE UNITED STATES
AND CANADA.
Narcotic drugs found in the possession of a
physician when he re-enters the United States are
seized and forfeited in compliance with this reg-
ulation. This information is being brought to
the attention of state physicians in order that they
may be correctly informed with reference to this
provision of the federal law and saved the unnec-
essary embarrassment.
MINNESOTA STATE BOARD OF
MEDICAL EXAMINERS
230 Lowry Medical Arts Building, Saint Paul,
Minnesota
Julian F. DuBois, M.D., Secretary
David V. Bush, "Health Lecturer,'' pays $1,000 Fine
After Conviction by Jury in Minneapolis
Re State of Minnesota vs. David V. ! Bush
On April 17, 1947, David V. Bush, sixty-five, Me-
hoopany, Pennsylvania, was convicted by a jury of
seven men and five women in the District Court at Min-
neapolis, Minnesota, of the crime of practicing healing
without a basic science certificate, following a trial
lasting eight days. The jury, after listening to the evi-
dence presented by the State of Minnesota, and the
testimony offered by Bush and eleven of his followers,
needed less than forty-five minutes to find Bush guilty
as charged.
Bush, an itinerant health lecturer, who gives his
home address as Mehoopany, Pennsylvania, but whose
pills, vitamins and other concoctions bear the address
of 17234 South Main St., Gardena, California, came to
Minneapolis about February 15, and advertised that he
would give a health lecture at the Wesley Temple
Gymnasium on February 19. The advertisement stated
that a collection would be taken up. Knowing in ad-
vance Bush’s method of doing business, the Minnesota
State Board of Medical Examiners immediately ordered
an investigation made of his activities. This resulted
in a conference with Inspector Eugene Bemath of the
Minneapolis Police Department, and police officers were
assigned to co-operate with representatives of the Med-
ical Board in following Bush’s activities. During Bush’s
health lecture he announced that he would conduct a
so-called health class at the Dyckman Elotel, Minneapo-
lis, commencing the next evening, February 20, and
continuing until March 21: Bush also announced that
a fee of $3.00 would be charged each person attending
the health class. Police officers and a representative of
the Medical Board registered for the class. During the
next four weeks Bush, under his claim of “free speech,”
berated the medical profession, law-enforcement officers
and others. He would also describe the symptoms of
various ailments and would attribute the ailment to the
lack or deficiency of the body in certain vitamins and
minerals. At the conclusion of this build-up, Bush then
offered for sale various pills, powders and other con-
coctions for which he charged sums ranging from 75
cents to $2. His first lecture was attended by ap-
proximately 600 persons and his paid health class was
attended by approximately 200 persons, about half of
whom purchased some of Bush’s preparations each
night. When the State of Minnesota was in possession
of the facts, the police stepped in and Bush was arrested
on March 19, 1947. He fought the case all the way,
demanding a preliminary hearing in Municipal Court
which was given him, and at the conclusion of which
he was held to the District Court for trial by Judge
Paid T. Jaroscak under cash bail of $2,000, which was
furnished. Bush then demurred to the information and
May, 1947
533
MEDICAL ECONOMICS
this was overruled by the Hon. John A. Weeks of the
District Court of Hennepin County. At the trial, among
other things, Bush stated that he had written thirty-
two books, had an honorary Ph.D. Degree conferred
upon him, and that he was a regularly ordained min-
ister. He also stated that he had been a peanut butter
salesman, an actor, and a health lecturer. Following the
verdict of guilty in the District Court, the Hon. Levi
M. Hall sentenced Bush to pay a fine of $1,000 or to
serve nine months in the Minneapolis Workhouse. The
Court granted Bush a stay until May 5, 1947, so that
he could appeal the case to the Supreme Court of Min-
nesota if he so desired. However, on April 23, 1947,
Bush decided to pay his fine and so far as is known
has left the State of Minnesota.
The Minnesota State Board of Medical Examiners
desires to express its appreciation for the very fine co-
operation received from the Minneapolis Police De-
partment and, particularly, from Inspector Eugene Ber-
nath, police-woman Gladys Cook and the other officers
who were assigned to the case. The Medical Board also
believes that the splendid results achieved in this case
would not have been possible had it not been for the
excellent manner in which the trial was conducted for
the State of Minnesota by County Attorney Michael J.
Dillon, Otto Morck, first assistant county attorney, and
Per M. Larson, assistant county attorney.
Saint Paul Painter and Machinist Convicted
of Criminal Abortion
Re State of Minnesota vs. Thomas F. Jack amor e
On March 27, 1947, Thomas F. Jackamore, fifty-six,
461 Holly Avenue, Saint Paul, Minnesota, was sentenced
by the Hon. Royden S. Dane, Judge of the District
Court of Ramsey County, to a term of two to eight
years at hard labor in the State Prison at Stillwater,
following1 Jackamore’s plea of guilty to an information
charging him with the crime of abortion. On March 28,
1947, Jackamore was taken before the Hon. Robert V.
Rensch, Judge of the District Court of Ramsey County,
who had previously, on September 17, 1946, placed Jack-
amore on probation at the time of his conviction for
a similar offense. Judge Rensch made an order on
March 31, 1947, revoking the stay of sentence in the
previous case and ordered Jackamore to serve two to
eight years at hard labor in the State Prison in addition
to the sentence imposed by Judge Dane. This means that
Jackamore will have to serve four to sixteen years be-
cause of his two convictions of the crime of abortion.
In the present case, Jackamore was arrested and
charged on March 19, 1947, with the crime of abortion.
It was learned that Jackamore had performed ten or
twelve criminal abortions during the six months that
he was on probation. When arraigned in Court, Jacka-
more denied his guilt, but subsequently withdrew his
plea of not guilty and entered a plea of guilty. Jacka-
more admitted receiving $150 for each of his criminal
abortions which were performed by means of a catheter,
fackamore stated to the Court that he had previously
earned his living as a painter and machinist. He has
no medical education and holds no license to practice
any form of healing in the State of Minnesota. Jacka-
more was previously convicted in September, 1934, at
which time he pleaded guilty to grand larceny in the
second degree for participating in the theft of a type-
writer from the State of Minnesota. Jackamore served
sixty days for that offense.
The Minnesota State Board of Medical Examiners
wishes to acknowledge the very fine work done in this
case by the Saint Paul Police Department under Chief
Charles J. Tierney, and also the splendid work done
by Mr. James F. Lynch, County Attorney of Ramsey
County. Jackamore has been taken to the State Prison
to commence his sentence and it will, undoubtedly, be
several years before he is released.
CRUVEILHIER-BAUMGARTEN SYNDROME
(Continued from Page 508)
Other cases will appear, however, which clinic-
ally will seem to fall into the group with Cruveil-
hier-Baumgarten disease, but in which the true
anatomic and pathologic condition may not be ap-
parent without necropsy. Unfortunately there is
no accurate method of classifying these cases with-
out necropsy.
The case which was just reported falls, I be-
lieve, into the group of cases of Cruveilhier-Baum-
garten syndrome. This syndrome as was indi-
cated by the review of the literature is character-
ized by portal hypertension plus evidence of ex-
cessive umbilical circulation in the form of an
abdominal venous murmur or thrill. In a small
group of cases in which this syndrome is present,
the necropsy findings may reveal a small liver
with little or no fibrosis, a patent umbilical vein
and usually splenomegaly. In this small group
of cases a distinct etiologic and clinicopathologic
disease entity may be present which has been
designated Cruveilhier-Baumgarten disease.
References
1. Armstrong, E. L. ; Adams, W. L., Jr.; Tragerman, L. J.,
and Townsend, E. W. : The Cruveilhier-Baumgarten syn-
drome; review of the literature and report of two additional
cases. Ann. Int. Med., 16:113-151, 1942.
2. Blain, Alexander, III, and Clapper, Muir: The Cruveilhier-
Baumgarten syndrome; report of a case. New England J.
Med., 232:647-649. 1945.
3. Bruno, F. E. : The Cruveilhier-Baumgarten syndrome. New
Orleans M. & S. J., 95:339-343, 1943.
4. Cruveilhier, T. : Maladies des veines. In: Anatomie patho-
logique du corps humain. Vol. 1, pt. 16. Paris: J. B.
Bailliere, 1829-1835.
5. Gray, Henry: Anatomy of the Human Body. Ed. 21, p.
686. Philadelphia: Lea & Febiger, 1924.
6. Pegot, M. : Tumeur variqueuse avec anomalie du systeme
veineux et persistance de' la veine ombilicale, developpement
des veines scus-cutanees abdominales. Bull. Soc. anat. de
Paris, 8:49-57, 1833.
7. Valk, H. L., and Horne, S. F. : Cruveilhier-Baumgarten
syndrome (splenomegaly, portal hypertension and patent
umbilical vein); case report. Ann. Surg., 116:860-863, 1942.
8. von Baumgarten, P. : Ueber vollstandiges Offenbleiben der
Vena umbilicalis; zugleich ein Beitrag zur Frage des Morbus
Bantii. Arb. a. d. Geb. d. path. Anat. Inst, zu Tubingen,
6:93-110, 1907.
9. Wollaeger. E. E., and Shands, H. C. : Hepatolenticular de-
generation; report of two cases with predominantly hepato-
genic symptoms, one associated with the Cruveilhier-Baum-
garten syndrome. Arch. Int. Med., 75:151-154, 1945.
10. Yater, \V. M., and Kenrick, J. P. : Cruveilhier-Baumgarten
syndrome; report of two cases. M. Ann. District of Colum-
bia, 13:319-324, 1944.
534
Minnesota Medicine
Minnesota Academy of Medicine
Meeting of January 8, 1947
The regular monthly meeting of the Minnesota Acad-
emy of Medicine was held at the Town and Country
Club on Wednesday evening, January 8, 1947. Dinner
was served at 7 o’clock and the meeting was called
to order at 8:15 by the president, Dr. Ernest M.
Hammes.
There were fifty-six members and four guests present.
The first order of business was a discussion of at-
tendance which was discussed by Drs. Lepak and Hall.
Dr. Lepak made a motion that the rules in the Con-
stitution be adhered to, and his motion was carried on
vote of the membership.
Dean Harold Diehl of the University of Minnesota
Medical School was introduced as toastmaster by Dr.
Hammes, and made a few well-chosen remarks. Dr.
Diehl then introduced Dr. Sweitzer who read his ad-
dress as retiring president.
PENICILLIN IN THE TREATMENT OF SYPHILIS
S. E. SWEITZER, M.D.
Minneapolis, Minnesota
One of the most interesting subjects in the history
of medicine is that of the treatment of syphilis. This
has been recently covered in an admirable manner by
Moore.8 He reviewed the chemotherapy of syphilis
from 1493 to 1944 — a period of 451 years — and divided
this into three time periods. The first, lasting 410
years, ran from 1493 to 1903. In this period the treat-
ment of syphilis was entirely empirical and not of
much value until about the year 1500 when mercury
began to be used and was given in various ways : by
mouth, by inhalation, by inunction, and later by injec-
tion either intramuscular or intravenous.
The second period ran from 1903 to 1943, or forty
years, and saw many changes and much new information
about the disease. In 1903, syphilis was for the first
time transmitted to experimental animals by Metschni-
koff and Roux. In 1905 the treponema pallidum was
discovered by Schaudinn, and in 1907 the blood test for
syphilis was developed by Wassermann, Neisser and
Bruck. These two epoch-making advances were of im-
mense help in the study of the biology of syphilitic
infection, and a help in the diagnosis and for deter-
mining the effects of treatment.
In 1909 the modern chemotherapy of syphilis began
with the discovery of salvarsan “606” by Ehrlich and
Hata. This was accomplished after an enormous amount
of experimental work by these co-workers. Through
the years since 1909 a very good method of treatment
was worked out with the use of arsenicals and bismuth,
which had taken the place of mercury. This required
a continuous treatment of from two to three years,
which, besides being an expensive method, left much to
be desired from a clinical standpoint, as a treatment
of such long duration caused many of the patients to let
the treatment lapse before they were cured.
Later an effort was made to give the arsenicals by
a continuous drip method over a period of five days.
This was later modified by the syringe method. Neo-
salvarsan was used first and soon replaced by maphar-
sen. This method was found to be risky, and many
deaths occurred from encephalitis, so its use was dis-
carded in many clinics.
The last period in the chemotherapy of syphilis runs
from June, 1943, to the present, and marks a real revo-
lutionary change in our concept of what drug or drugs
to use and how long to use them. The effort to find
a safe and lasting cure is not ended, and changes will
and are being made as various methods are tried and
evaluated in clinics all over the country.
It all began in June, 1943, when Mahoney, Arnold
and Harris7 demonstrated that penicillin was effective
in early syphilis in the rabbit and in man. Because of
the importance of the control of the disease, and also
of conserving manpower in wartime, an organized in-
vestigation of the uses of the drug was begun with the
co-operation of the military and governmental agencies
and civilian clinics and laboratories.
With the use of penicillin by the army and navy and
in many intensive treatment centers, a vast number of
cases have been treated by this drug, and many methods
have been tried. One of the most important treatment
centers was the one set up in Chicago, and much fine
work was done there with the very large service that
they enjoyed.
The early reports on the results in penicillin-treated
cases were glowing and every syphilis clinic in the coun-
try started its use as soon as the drug was available.
It was found to be a great advance in the therapy of
syphilis and to have no mortality attending its use.
This happy state of affairs went on until early in 1946
when reports of frequent relapses and slow response
to treatment began to appear in the literature, and it
became obvious that something had happened to the
penicillin.
Because different strains of Penicillin notatum and
Penicillin chrysogienum are used in the manufacture of
penicillin, and because different techniques are used in
production, five different fractions have been identified.
They are F, G, X, K, and dihydro F. Penicillin K
is apparently rapidly destroyed or eliminated in the
body, and therapeutic levels are not achieved or main-
tained in the body fluids following ordinary doses.
The early penicillin used was predominately G and was
very efficacious. For some months in 1945 all penicillin
began to contain increasingly larger amounts of the K
factor, and this accounted for the poorer results. The
present penicillin is again up to the early qualities and
May, 1947
535
MINNESOTA ACADEMY OF MEDICINE
there is an ever-growing possibility that an even better
synthetic penicillin will be forthcoming. However, none
better than penicillin G is now available.
On February 7 and 8, 1946, there was a meeting of
the National Research Council of the United States
Public Health Service in Washington, D. C., at which
reports were made of studies in forty-three clinics. Some
of these papers were later published in the Journal of
the American Medical Association and give us a sum-
mary of what conclusions can be drawn as to the value
of penicillin therapy up to that time.
Generally speaking, the earlier in the course of the
disease treatment is begun, the better the clinical result.
Best results are obtained in the primary sero-negative
and early sero-positive cases. Much as with the older
form of treatment, there is a distinct drop in the per-
centage of good results in the cases of secondary
syphilis, and more or less indifferent results in late and
latent cases of the disease.
It has been found that the administration of maphar-
sen and [>enicillin, or penicillin and bismuth, or all three
together, give better results than penicillin alone.
The Committee on Medical Research and the United
States Public Health Service in a recent report given
out show that 6,558 syphilitic patients have been treated
with twelve different treatment schedules.2 The per-
centage of failure eleven months after treatment was
15 per cent in patients that had received 2,400,000 units
of penicillin. By combining 1,200,000 units of penicillin
with bismuth, 0.6 to 1 gm., the percentage of failures
was cut one-half, as was the case when 300,000 units of
penicillin were combined with 320 mg. of mapharsen.
Ingraham and his associates5 treated forty-nine preg-
nant women. The women received 2,400,000 units of
penicillin only, and of the thirty-seven infants born
during the course of this study only one was syphilitic.
Goodwin and Moore3 treated fifty-seven pregnant
women with early syphilis with penicillin. Their recom-
mended dose was 2,400,000. These women gave birth
to sixty children, only one of which developed syphilis.
Of the remaining fifty-nine, forty-two were followed up
long enough to justify a negative diagnosis as regards
congenital syphilis. These workers conclude that these
results in the prevention of prenatal syphilis are su-
perior to any heretofore attainable with any treatment,
and recommend the abandonment of all other methods
of treatment.
Platou11 reported on penicillin in congenital syphilis at
the Washington Penicillin Conference in Feruary, 1946.
He analyzed the treatment of 191 cases and considered
penicillin to be the best agent yet employed in the treat-
ment of congenital syphilis. In his series, serological
relapse was 3.6 per cent, and both clinical and serologi-
cal relapse was 2.6 per cent. The dosage of penicillin
for infants should range between a total of 100,000
to 400,000 units per kilogram of body weight. The
larger dosage is favored.
Schoch and Alexander13 in their report on the treat-
ment of early syphilis with penicillin recommended a
dosage of at least 2,400,000 units of penicillin and
either 40 mg. of mapharsen daily for eight doses, or
five injections of bismuth, 0.2 gm. each, on alternate
days, or both. For reasons of safety they prefer the
bismuth-penicillin combination.
In the reports on the treatment of neurosyphilis with
penicillin, Stokes14 recently came out with a very favor-
able report. He recommended a dose of at least 4,-
800.000 units.
O’Leary,9 on the other hand, was not favorably im-
pressed. He noted some good results in patients with
the meningeal forms of the disease but stated that
penicillin alone was not capable of controlling the
parenchymatous forms of neurosyphilis.
Heller4 in a recent article reported his conclusions in
the evaluation of the treatment of 8,000 cases with vari-
ous treatment schedules such as the five-day intra-
venous drip or the syringe method of multiple injec-
tions of mapharsen, and the use of penicillin in various
doses either alone or with an arsenical or bismuth
preparation, or both. He concluded that penicillin with
bismuth gave the best results. No deaths were ob-
served when penicillin was used alone. When penicillin
was combined with mapharsen and bismuth, there was
a mortality of one in 4,312 cases, and with intensive
arsenotherapy the mortality ranged from one per 149
cases with the five-day intravenous drip to one in 1,873
cases in those treated by multiple injections.
These mortality figures easily explain why penicillin
alone, or with small doses of mapharsen and bismuth,
has replaced all previous rapid treatment methods.
Cole1 recently reported his experience in the treatment
of syphilis in pregnancy and recommended a dose of
2.400.000 units or more.
Two of the most recent articles are those of Yam-
polsky and Heyman15 and that of O’Leary.10 Yampol-
sky and Heyman had good results with penicillin in
infantile congenital and acquired syphilis. Their results
were poor in interstitial keratitis as well as in juvenile
paresis.
O’Leary gave a good review of present-day treat-
ment with penicillin and concluded that it was very
good in recent cases and in pregnancy. In latent syphilis
it was not so brilliant, and in central nervous system
syphilis it gave variable results. O’Leary prefers a
schedule of mapharsen, penicillin (2,400,000 units) fol-
lowed by ten bismuth injections.
The usual method of giving penicillin is an aqueous
solution given intramuscularly every three hours for
from seven and one-half to ten days. This is done to
maintain a constant penicillin level in the blood. Vari-
ous methods have been tried to give penicillin in a form
that would allow slower absorption and less frequent
injections. Romansky12 offered a method using peanut
oil and beeswax. He gave a single daily injection of
300.000 units of calcium penicillin in a mixture of peanut
oil and beeswax for eight days. These cases were
followed from three to six months, and satisfactory
results were reported in fifty-eight of the sixty cases.
In a special Venereal Disease Bulletin of the City
and County of San Francisco, a report was made of
the daily injection of 300,000 units of penicillin in pea-
nut oil and beeswax for a period of ten days. Ninety-
eight cases were treated and observed for a period of
from three to nine months. The failure rate was 4 per
536
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
cent. They recommend combining the use of penicillin
in oil and wax with the use of the arsenicals and
bismuth.
Leifer6 treated 200 cases of syphilis in various stages
with penicillin, 300,000 units in peanut oil and wax
daily for eight days. One hundred sixty-five cases were
followed. In seventy-three cases of sero-negative pri-
mary syphilis he had two clinical relapses, and the
final YVassermann tests showed fifty negative, four doubt-
ful and two positive reactions. In sixty-nine cases of
sero-positive primary syphilis he had three clinical re-
lapses, and the final Wassermann tests showed thirty-
one negative, four doubtful, and eighteen positive. In
fifty-eight cases of secondary syphilis he had one clini-
cal relapse, and the final Wassermann tests showed
sixteen negative, six doubtful, and twenty-eight positive.
He followed them for from two to nine months.
These conflicting reports on the oil and wax method
show that this method is still in the experimental
stage and is not as yet to be recommended for general
use. The combined method of mapharsen, penicillin in
oil and wax, and bismuth, may give much better results.
This peanut oil and wax method has caused frequent
reactions both local and general. Generalized reactions
such as urticaria or Herxheimer reactions are not in-
frequent, while local lesions such as herpes simplex and
painful nodules are quite common.
As soon as penicillin became available we began its
use in the treatment of syphilis at the Minneapolis
General Hospital. We started with a dose of 1,200,000
and soon after increased the dose to 2,400,000. Later,
when reports of lessened activity of the penicillin began
to come in, we increased the dose to 4,800,000 units.
This small series, therefore, is a report of the treat-
ment of syphilis with penicillin alone.
At present we are running another series of cases
using mapharsen, penicillin and bismuth. This second
series shows promise of giving better results and is the
generally accepted method at present. As time goes on,
and as reports from the various treatment centers come
in, a method will be devised for a safe, rapid and sat-
isfactory treatment of this disease.
Out of a total of 191 cases of syphilis treated with
penicillin alone, 119 cases have been observed for at
least three months minimum, and for as long as twenty-
seven months maximum.
Of these there were twelve sero-negative primary
cases. This particular group was observed for from
three to sixteen months. Eight cases were followed
six months or longer, and all twelve received a dosage
of from 1,200,000 units in the first case, 2,400,000 in six
cases, up to 5,000,000 in the others. All twelve cases
have remained entirely free of any signs or symptoms,
and all serologic tests have been negative during the
period of observation.
Twenty-two cases of sero-positive primary syphilis
were observed at least three months, and eleven cases in
this group have been followed twelve months or longer.
Fifteen, or 68.2 per cent were negative to all serologic
tests at the time of their last examinations. Nine cases
of the latter group were females, one of whom de-
livered a normal child twelve months following her
treatment. Seven of the twenty-two cases, including the
latter, received 1,200,000 units, seven received 2,400,-
000 units, and eight received 4,800,000 units total dosage.
The six cases (27 per cent-) showing strongly positive
serologic tests at the time of their last visit were equal-
ly distributed between the above total dosages, so there
did not seem to be any increased benefits or results
derived from increasing the total dosage. One case
showed only weakly positive serologic reactions to the
more sensitive precipitation tests, and a negative reaction
to the Kolmer Wassermann test after four months.
Thirty-one cases with secondary manifestations were
followed for periods ranging from four to twenty-nine
months. Eleven cases (35.5 per cent) at the time of
their last visit still showed strongly positive serologic
tests and were considered failures. Two of these were
followed for four months, and the other four for sixteen
months. Twenty cases (64.5 per cent) reversed to
complete negativity and were considered cured.
Nine cases of early latent type of infection wrere fol-
lowed for periods ranging from three to eighteen months.
Four of these cases (44 per cent) showed negative
serologic tests within three months of the -time of treat-
ment; five (55 per cent) remained positive and were
considered failures.
Thirty-two cases of the late latent type were fol-
lowed for periods ranging from six months to seven-
teen months. Only three cases in this group (9 per
cent) showed completely negative reactions following
treatment and were considered cures. Twenty-nine (91
per cent) remained positive and were considered fail-
ures. All of the twenty-nine cases received at least 2,-
400,000 units, nine cases getting a total of 4,800,000
units.
Twenty-two cases with central nervous system involve-
ment, as evidenced by positive spinal fluid findings, were
treated. Nine cases were followed for periods ranging
from five to seventeen months. Of these nine cases,
two became entirely free of any positive findings. In
the other seven there was some decrease in the protein
content, and the number of cells found on examination
of the spinal fluid. The serologic tests remained positive,
however, and in spite of the fact that they showed gen-
eral improvement physically and an increased feeling
of well-being they were considered failures.
There were only two cases of congenital syphilis treat-
ed. One infant was first seen at four and one-half
months and was given 2,400,000 units of penicillin.
This child’s blood was completely negative two and one-
half months later. The second case, a male infant one
year old, was given 1,400,000 units of penicillin and
was lost after two months follow-up, at which time
the blood serologic tests were still strongly positive.
Two cases of aneurism were treated with penicillin,
beginning with 10,000 units every three hours for one
day, then 20,000, and slowly up to 50,000 units every
three hours. A total of 5,000,000 units was given. One
patient did very well and is greatly improved, but the
second man died in about three weeks from laryngeal
compression after the aneurism increased greatly in
size. This unhappy ending should cause us to be very
careful in the treatment of cardiovascular syphilis. A
May, 1947
537
MINNESOTA ACADEMY OF MEDICINE
preliminary course of bismuth should be given in such
cases.
Summary of Cases Treated with Penicillin Alone
In sero-negative primary syphilis all of our cases have
remained negative.
In sero-positive primary syphilis only 68.2 per cent
became negative, 27 per cent were still positive, and
4.4 per cent were weakly positive.
In secondary syphilis 64.5 per cent became negative
and 35.5 per cent were positive.
In early latent syphilis 45 per cent became negative
and 55 per cent were positive.
In late latent syphilis only 9 per cent became negative
and 91 per cent remained positive.
In a small series of central nervous system syphilis,
22 per cent became negative and the other cases had
some changes for the better in the spinal findings and
in physical well-being.
Comment
1. Penicillin is a valuable addition to our therapy of
syphilis.
2. The earlier it is given the better are the results.
3. A schedule of mapharsen, penicillin and bismuth
has replaced all other rapid treatment methods for early
syphilis.
4. In the treatment of latent syphilis the same sched-
ule can be used, and it is possible that the results may
be as good as the older method of continuous arsenicals
and bismuth given over many months.
5. Malaria plus penicillin is the treatment of choice
in central nervous system syphilis.
6. In the treatment of cardiovascular or visceral
syphilis, a course of bismuth and potassium iodide
should precede the administration of penicillin.
7. The results of penicillin therapy in sero-negative
primary syphilis and in syphilis in pregnancy are espe-
cially brilliant, and these results alone are enough to
give penicillin a high place in the treatment of this dis-
ease.
References
1. Cole, H. N., et al. : Use of penicillin in the treatment of
syphilis in pregnancy. Arch. Dermat. & Syph., 54:255,
(Sept.) 1946.
2. Committee on Medical Research and the U. S. Public Health
Service: The treatment of early syphilis with penicillin.
J.A.M.A., 131:265, (May 25) 1946.
3. Goodwin, M. S., and Moore, T. E. : Penicillin in the pre-
vention of prenatal syphilis. J.A.M.A., 130:688, (March 16)
1946.
4. Heller, J. R., Jr.: Results of rapid treatment of early
syphilis. J.A.M.A., 132:258, (Oct. 5) 1946.
5. Ingraham, et al.: Penicillin in the syphilitic pregnant wom-
an. J.A.M.A., 130:683, (March 16) 1946.
6. Leifer, William: Report on Meeting of Penicillin Investi-
gators, (Feb. 7-8) 1946, Washington. P. 118.
7. Mahoney, J. F. ; Arnold. R. C., and Harris, A.: Penicillin
treatment of early syphilis; preliminary report. Am. J.
Pub. Health, 33:1387, (Dec.) 1943.
8. Moore, J. E. : The chemotherapy of syphilis. Bull. New York
Acad. Med., 21:17, (Jan.) 1945.
9. O’Leary, Paul A.; Brunsting, L. A., and Ockuly, O.: Pen-
icillin in neurosyphilis. J.A.M.A., 130:698, (March 16)
1946.
10. O’Leary, Paul A.: Today’s treatment of syphilis. J.A.M.A.,
132:430, (Oct. 26) 1946.
11. Platou, R. V.: Report on Meeting of Penicillin Investigators,
(Feb. 7-8) 1946, Washing. P. 24.
12. Romansky, M. T., and Rein, Charles R.: Treatment of early
syphilis. J.A.M.A., 132:847, (Dec. 7) 1946.
13. Schoch, A. G., and Alexander, L. J. : Treatment of early
syphilis. J.A.M.A., 130:696, (March 16) 1946.
14. Stokes, John H., and Steiger, H. P. : Penicillin in neuro-
syphilis. J.A.M.A., 131:1, (May 4) 1946.
15. Yampolsky, Joseph, and Heyman, Albert: Penicillin in syph-
ilis in children. J.A.M.A., 132:368, (Oct. 19) 1946.
Discussion
Dr. P. A. O’Leary, Rochester, Minn.: I enjoyed Doc-
tor Sweitzer’s conservatism in regard to penicillin in
the treatment of syphilis, because I, too, have that same
attitude. During the early period of our experience with
penicillin I had the opportunity of observing a large
group of patients with acute syphilis at the Chicago In-
tensive Treatment Center, and it was apparent early in
our experience that penicillin, in small doses or in very
large doses, would not cure all patients with acute syphi-
lis. It was likewise evident that the earlier treatment was
started in the course of the disease, the better were the
results; in other words, in the sero-negative chancre
phase of syphilis, before the Wassermann had become
positive, successful results approximated 95 per cent,
whereas in the individual with the late recurrent lesions
of the skin and mucous membranes who had had his
disease for fifteen or eighteen months, the incidence
of failure approximated 40 per cent. When all of the
good systems for the treatment of early syphilis are
surveyed, it is apparent that the “cure rate” approxi-
mates some 80 per cent under all of the various pro-
grams. In other words, it would appear that approxi-
mately 80 per cent of the patients with early syphilis
respond satisfactorily to most any good system of treat-
ment for syphilis, while the remaining 20 per cent are
those who have been resistant heretofore to all forms
of treatment and are, in all probability, the individuals
who eventually develop the late and serious complica-
tions of the disease. It has been my experience that
.many million units of penicillin do not control the dis-
ease in individuals who are in this 20 per cent group, so
that I felt it necessary to supplement the penicillin with
the addition of mapharsen and bismuth. Likewise, it
does not seem advisable to regiment the treatment of
patients with early syphilis. One should not treat all
patients by the same procedure and expect to derive
100 per cent cure any more than one expects that pati-
ents with other infectious diseases will all respond to the
same doses of any given drug. It has been my practice
to give a second and occasionally a third course of
mapharsen-penicillin-bismuth when it is evident that the
first course is failing to produce satisfactory results.
Our practice is to give four injections of mapharsen
on four successive days, 0.05 gm. each, followed by 3,-
000,000 units of penicillin, in turn followed by fifteen
injections of bismuth. If the results are not satisfactory
after a period of four to six months, the course is re-
peated.
One of the many striking values of penicillin has
been the reduction in the incidence of asymptomatic
neurosyphilis. Under the old chemotherapeutic pro-
cedures, approximately 15 per cent of the patients with
the early forms of the disease are found to have posi-
tive spinal fluid tests. Under the pencillin regime, we
are finding that approximately 2 per cent have evidence
of activity in the spinal fluid. In a decade or two from
now, this finding might well be substantiated by a re-
duction in the incidence of clinical neurosyphilis. Al-
though the cure rate at the present time is cpiite com-
parable to that of the chemotherapeutic procedures,
penicillin does offer the opportunity of permitting more
patients to complete the course of treatment, so that
the future likewise suggests that although the per-
centage of cure rate is similar to the arsenic-bismuth
combinations, the all-over picture will show, however, a
higher incidence of cure because more patients will
finish the prescribed treatment.
Penicillin in a combination of beeswax and peanut
oil permits of giving one injection a day instead of one
every three hours, and in a year from now jnav further
simplify the treatment schemes of early syhpilis. The
course of treatment of early syphilis with mapharsen-
penicillin-bismuth is shorter, is less expensive, offers
decidedly fewer complications and gives a satisfactory
result in about 60 per cent of the patients. When taken
(Continued on Page 540)
538
Minnesota Medicine
Minneapolis Surgical Society
Stated Meeting Held March 6, 1947
LUMBAR RETROPERITONEAL CONGENITAL DIAPHRAGM OF THE
GANGLIONEUROMA
Review of Literature and Report of Case in
Which the Tumor was Removed Surgically
LAWRENCE M. LARSON, M.D., Ph.D. (Surg.)
Summary*
A case of retroperitoneal ganglioneuroma of the left
lumbar sympathetic system is reported in a twenty-
eighty-year-old white woman. This tumor had produced
definite severe pain locally on the left side and pos-
sibly on the right side of the abdomen and lower ex-
tremity. Complete relief of these symptoms followed its
surgical removal. An interesting postoperative sequela
of permanent increase in temperature of the lower
extremity on the same side is noted, similar to that oc-
curring with sympathectomy for hypertension.
A review of the literature has been made, and a de-
scription of the symptoms, findings and pathologic na-
ture of this tumor are recorded.
Microscopically, these tumors are composed of nerve
and connective tissue elements with bundles of nerve
fibers in longtitudinal and transverse sections surround-
ed by a connective tissue stroma. Ganglion cells in vari-
ous degrees of maturity may be present singly or in
groups, and are usually associated with nerve processes.
The cytoplasm of these cells is granular, their nuclei
may be single or multiple, and the stroma may be of
varying degrees of denseness.
Clinically and grossly, these tumors are indistinguish-
able from, neuroma, fibroma, sarcoma, and so forth,
and it is only by microscopic examination that the true
nature of the tumor can be made out. They are no
doubt congenital in origin and probably arise from cell
nests displaced in embryonic life. They rarely recur
when completely removed and practically never metas-
tasize.
The rarity of this lesion is indicated by the fact
that there are probably less than fifty similar cases
recorded in the literature and there are no similar tu-
mors recorded in the files of the Department of Pa-
thology, University of Minnesota.
^Complete paper will appear in a later issue.
TUBERCULOSIS
So much emphasis has been placed on tuberculosis as
a serious disease of girls and young women that its
greater havoc among men has not received the attention
that it deserves. As a result of the more rapid decline
of tuberculosis in females in this country there are today
156 deaths among males to every 100 deaths in females
May, 1947
DUODENUM
With Case Report and Preoperative
X-Ray Studies
WALLACE I. NELSON, M.D., F.A.C.S.
Summary*
Congenital diaphragm of the duodenum is a develop-
mental anomaly in which a membrane, formed by
an infolding of the mucosa and submucosa, extends
across the lumen of the duodenum. The diaphragm may
be complete or it may present an- aperture.
A review of the literature reveals thirty-five report-
ed cases of congenital duodenal diaphragm. Of the
thirty-five cases reported in the literature, twelve pa-
tients were operated upon. In only six cases of the
mtire series mas the true nature of the lesion discov-
ered during' life.
The author discusses the embryology, and anatomy,
including the relationship to the bile and pancreatic
ducts and clinical manifestations of this anomaly. The
most important factor in the diagnosis is the ability to
recognize the presence of the obstruction when it exists.
The differential diagnosis between pyloric stenosis and
various extrinsic and intrinsic causes of obstruction
is discussed.
A case is presented of a twenty-six-year-old woman
in whom preoperative x-rays demonstrated such anom-
aly ; this was proved by operation. No other cases
have been found in the literature in which the diagnosis
was made by x-ray before operation.
Dilatation of the duodenum proximal to the lesion
and the presence of a ring of constriction visible at
operation at the level of the diphragm are two signs
which should lead the surgeon to search for a dia-
phragm. Mobilization of the duodenum, duodenotomy,
and direct removal of the diaphragm are the surgical
procedures advocated in preference to short-circuiting
operations.
*Complete paper, fully illustrated, will appear in a later issue.
IN OLDER MEN
and only at ages ten to thirty is the mortality higher in
females. Tuberculosis is increasingly becoming a disease
of older, occupied men. — Henry D. Chadwick, M.D.,
and Alton S. Pope, M.D., The Modern Attack on Tu-
berculosis, The Commonwealth Fund, Revised, 1946.
539
MINNESOTA ACADEMY OF MEDICINE
(Continued from Page 538)
all together it is economically and therapeutically a great
improvement over the older systems of treatment.
Dr. George Fahr, Minneapolis: I shall confine myself
to a discussion of the treatment of syphilitic aortitis
with penicillin. This discussion will be based upon my
observations of the two cases of luetic aortitis treated
by Dr. Sweitzer’s staff at the Minneapolis General Hos-
pital, as well as on my experience in treating luetic
aortitis, including autopsy observations of patients who
have died following treatment with salvarsan and neo-
salvarsan. My experience in this field goes back to the
pre-salvarsan days and for this very reason is of some
value, because experience gleaned in treating luetic
aortitis and syhilitic gummas in pre-salvarsan days is
very helpful in developing a rational therapy with the
more effective drugs available since the invention of
“606.”
The preceding speakers have indicated that penicillin
is a very powerful anti-spirocheticidal drug. The use of
strong anti-spirocheticidal drugs can lead to the so-
called Herxheimer reaction. In luetic aortitis with a
moderately large to large aneurysm, the giving of a
strong anti-spirocheticidal agent without the necessary
preparation may lead to hemorrhage. This has been
demonstrated many times in the experience of the past
years, especially when salvarsan was given without
proper preparation in the early years of salvarsan and
neo-salvarsan use in the treatment of luetic aortitis.
When there is swelling about the mouths of the coro-
nary arteries in luetic aortitis, the giving of a strong
anti-spirocheticidal agent without previous preparation
may lead to swelling and edema in this area, leading to
partial or almost complete closure of the mouth of the
coronary artery with angina pectoris-like pains and fre-
quently sudden death. Where there is aortic insuffici-
ency in luetic aortitis, the exhibition of a strong anti-
syphilitic drug may lead to swelling of the commis-
sures of the aortic valves and increased degree of aortic
insufficiency and, if left heart failure is already present
to some degree, it may lead to an increased degree of
left heart failure with congestion and edema of the
lungs, and sometimes to heart failure and death.
The first case of luetic aortitis treated by Dr. Sweit-
zer’s assistants was given penicillin without previous
preparation. The patient had a large aneurysm of the
ascending and innominate arteries. Within ten days after
starting the penicillin, at which time 3,400,000 units had
been given, the patient developed a marked enlargement
of the aneurysm with hemorrhage into the surrounding
tissues and was dead within twelve days. The second
case of luetic aortitis treated with penicillin developed
severe angina pectoris twenty-four hours after being
given the first dose of penicillin. This patient luckily
did not die but recovered in a few days and is living
at the present time.
When one has a patient with luetic aortitis and wishes
to treat him with a strong anti-spirocheticidal drug, it
is necessary to begin treatment, in my estimation, with
the giving of potassium iodide in large doses for about
three weeks. Then a course of bismuth injections should
be given bi-weekly, extending over a period of six or
eight weeks. After this one can begin cautiously with
neo-salvarsan, starting in with 0.15 gm. per injection
the first week and reaching 0.45 gm. in four weeks.
After giving 0.45 gm. for two weeks, the danger of a
Herxheimer reaction is over with, and I can see no
objection then to giving neo-salvarsan in large doses
(at the rate of 0.45 gm. a week). I am inclined to be-
lieve that in the future we will use penicillin in the
treatment of luetic aortitis with good results and a great
deal of gratification to the internist. In my opinion,
the internist who is at the same time a competent cardi-
ologist should treat luetic aortitis, because one must not
only treat the syphilis but one must also treat the heart.
The meeting adjourned.
A. E. Carole, M.D., Secretary
CLINICAL-PATHOLOGICAL CONFERENCE
(Continued from Page 516)
basis of pulmonary emphysema although it is possible
that mechanical factors associated with the deformity
may be contributing factors. In all these cases of
kyphoscoliosis, there is usually a rather advanced degree
of emphysema.
There is little literature on the subject of cor pul-
monale following thoracoplasties for tuberculosis. In
the few cases reported, it would again appear that the
emphysema of the opposite lung would be the main
underlying factor in the development of the cor pul-
monale. The fibrosis associated with the tuberculosis
would be a contributing one. Dr. Kinsella7 states that
in twenty-five pneumonectomies performed by him, none
of these so far shows any signs of right ventricular
hypertrophy or dilatation. Two of the twenty-five cases
have been followed as long as ten years. Parker8 in
a study of thirty-two cases of essential pulmonary em-
physema found enlargement of the right ventricle in 71
per cent of the cases and congestive right heart failure
in 44 per cent of the cases. He concluded that the
arteriosclerotic changes found in the pulmonary vessels
in these cases were secondary to the pulmonary hyper-
tension produced by the emphysema. In pulmonary
tuberculosis, silicosis, chronic bronchiectasis, bronchial
asthma, and idiopathic pulmonary fibrosis, pulmonary
emphysema is almost universally present. When cor
pulmonale develops in these cases, it is generally
believed that the pulmonary hypertension is the result of
the emphysema.
References
1. Brenner, O. : Pathology of vessels of pulmonary circulation.
Arch. Int. Med., 56:211-237, 457-497, 724-752, 976-1014, 1935.
2. Brill, I. C., and Krygier, J. J. : Primary pulmonary vascular
sclerosis. Arch. Int. Med., 68: 560-577, 1941.
3. Clawson, B. J. : Personal communication.
4. Cross, K. R., and Kobayaski, C. K.: Primary pulmonary
vascular sclerosis. Am. J. Clin. Path., 17:155-162, 1947.
5. Hertzog, A. J., and Manz, W. R.: Right sided heart failure
caused by chest deformity. Am. Heart J., 25:399-403, 1943.
6. Higgins, G. K. : Effect of pulmonary tuberculosis upon
weight of heart. Am. Rev. Tuberc., 49:255-275, 1944.
7. Kinsella, Tliomas: Personal communication.
8. Parker, R. L. : Pulmonary emphysema: relation to heart
and pulmonary arterial system. Ann. Int. Med., 14:795-809,
(Nov.) 1940.
9. Spain. D. M., and Handler, B. J.: Chronic cor pulmonale.
Arch. Int. Med., 77:37-6S, 1946.
DEARTH OF NURSES
The American Hospital Association has launched an
intensified student nurse enrollment program on a nation-
wide scale. The campaign will involve the expenditure
of thousands of dollars and will utilize newspaper ad-
vertisements, magazine articles, the radio, and cards in
street cars, buses and office windows. The various na-
tional organizations are invited to co-operate.
Minnesota schools of nursing will offer opportunities
for the training of a thousand young women, next fall,
according to Miss Thelma Dodds, president of the Min-
nesota Nurses Association.
540
Minnesota Medicine
Minnesota State Medical Association
Roster, 1947
OFFICERS
Louis A. Buie, M.D. .
C. B. Drake, M.D. . . .
L. R. Gowan, M.D. . . .
B. B. Souster, M.D. .
W. H. Condit, M.D. .
E. J. Simons, M.D. . . .
W. A. Coventry, M.D
C. G. Sheppard, M.D. .
R. R. Rosell
President Rochester
First Vice President St. Paul
. . . Second Vice President Duluth
Secretary St. Paul
Treasurer Minneapolis
Past President Swanville
. Speaker, Plouse of Delegates Duluth
Vice Speaker, House of Delegates Hutchinson
Executive Secretary St. Paul
COUNCILORS*
First District
R. L. J. Kennedy, M.D. (1947) Rochester
Second District
L. L. Sogc.e, M.D. (1947) \\ indorn
Third District
tC. M. Johnson, M.D. (1949) Dawson
Fourth District
A. E. Sohmer, M.D. (1948) Mankato
Fifth District
E. M. Hammes, M.D. (1949) St. Paul
Sixth District
A. E. Cardle, M.D. (1948) Minneapolis
Seventh District
W. W. Will, M.D. (1949) Bertha
Eighth District
W. L. Burnap, M.D. (1948) Fergus Falls
Ninth District
F. J. Elias, M.D. (1947) (Chairman) Duluth
HOUSE OF DELEGATES, AMERICAN MEDICAL
ASSOCIATION*
Members Alternates
A. W. Adson, M.D. (1948) Rochester
W. A. Coventry, M.D. (1948) Duluth
E. W. Hansen, M.D. (1947) Minneapolis
F. J. Savage, M.D. (1947) St. Paul
SCIENTIFIC
COMMITTEE ON SCIENTIFIC ASSEMBLY
Louis A. Buie, M.D., General Chairman Rochester
E. J. Simons, M. D Swanville
R. R. Rosell Saint Paul
Section on Medicine
W. W. Spink, M.D Minneapolis
S. H. Boyer, Jr., M.D .Duluth
Section on Specialties
Paul F. Dwan, M.D Minneapolis
F. W. Lynch, M.D Saint Paul
Section on Surgery
O. J. Campbell, M.D Minneapolis
J. T. Priestley, M.D Rochester
Local Arrangements
R. P. Buckley, M.D Duluth
COMMITTEE ON ANESTHESIOLOGY
R. C. Adams, M.D Rochester
J. W. Baird, M.D Minneapolis
Frank Cole, M.D Duluth
F. iCc Jacobson, M.D Duluth
R: T. Knight, M.D . , . . „ .Minneapolis
T. JJ. Seldon, M.D , • • • ... Rochester
*Terms expire December 31 of year indicated.
’(Deceased.
May, ,4947
J. C. Hultkrans. M.D. (1948) Minneapolis
W. L. Burnap, M.D1. (1948) Fergus Falls
W. W. Will, M.D. (1947) Bertha
George Earl, M.D. (1947) St. P'aul
COMMITTEES
COMMITTEE ON CANCER*
A. H. Wells, M.D. (1947) Duluth
D. P. Anderson, Jr., M.D. (1949) Austin
Herbert Boysen, M.D. (1949) Madelia
E. C. Hartley, M.D. (1949) Saint Paul
J. A. Johnson, M.D. (1948) Minneapolis
J. F. Karn, M.D. (1949) Ortonville
F. H. Magney, M.D. (1948) Duluth
W. C. McCarty, Sr., M.D. (1947) Rochester
Martin Nordland, M.D. (1948) Minneapolis
Wm. A. O’Brien, M.D. (1947) Minneapolis
W. T. Peyton, M.D. (1947) Minneapolis
COMMITTEE ON CHILD HEALTH
G. B. Logan, M.D Rochester
S. L. Arey, M.D Minneapolis
F. G. Hedenstrom, M.D Saint Paul
R. J. Josewski, M.D Stillwater
R. L. J. Kennedy, M.D Rochester
E. E. Novak, M.D New Prague
R. E. Nutting, M.D Duluth
E. S. Platou, M.D Minneapolis
W. B. Richards, M.D Saint Cloud
L. F. Richdorf, M.D Minneapolis
C. H. Schroeder, M.D Duluth
V. O. Wilson, M.D ....Minneapolis
Irvine McQuarrie, M.D. (ex officio) Minneapolis
*Terms expire December 31 of year indicated.
541
ROSTER 1947
< <<MMITTEK OX CONSERVATION OK
L. R. Boies, M.D
A. G. Athens, M.D
W. L. Burnap, M.D
C. E. Connor, M.D
J. B. Gaida, M.D
A. V. Garlock, M.D
B. E. Hempstead, M.D
Anderson Hilding, M.D
H. \Y. Lee, M.D
E. A. Loomis, M.D
H. A. Roust, M.D
J. T. SCHLESSELMAN, M.D
Andrew Sinamark, M.D
G. E. Strate, M.D
HEARING
. . . Minneapolis
Duluth
. . Fergus Falls
. . . . Saint Paul
. . . Saint Cloud
Bemidji
Rochester
Duluth
Brainerd
. . . Minneapolis
. . . . Montevideo
Mankato
Hibbing
. . . . Saint Paul
COMMITTEE ON DIABETES
T. R. Meade, M.D Saint Paul
C. N. Harris, M.D Hibbing
J. K. Moen, Jr., M.D Minneapolis
W. S. Neff, M.D Virginia
Harry Oerting, M.D Saint Paul
B. F. Pearson, M.D Shakopee
R. H. Puumala, M.D Cloquet
E. H. Rynearson, M.D Rochester
R. V. Sherman, M.D Red" Wing
C. J. Watson, M.D Minneapolis
COMMITTEE ON FIRST AID AND RED CROSS
J. S. Lundy, M.D Rochester
G. 1. BadEaux, M.D Brainerd
Charles Bagley, M.D Duluth
Frank Cole, M.D Duluth
Paul F. Dwan, M.D Minneapolis
J. W. Edwards, M.D Saint Paul
B. A. F'lesche, M.D Lake City
A. F. Giesen, M.D Starbuck
G. H. Goehrs, M.D Saint Cloud
W. W. Rieke, M.D Wayzata
COMMITTEE ON FRACTURES
V. P. Hauser, M.D Saint Paul
N. H. Baker, M.D Fergus Falls
W. H. Cole, M.D Saint Paul
E. T. Evans, M.D Minneapolis
B. C. Ford, M.D Marshall
R. K. Ghormley, M.D Rochester
J. H. Moe, M.D Minneapolis
M. J. Nydahl, M.D Minneapolis
L. J. Rigler, M.D Minneapolis
J. A. Thabes, Jr., M.D Duluth
M. H. Tibbetts, M.D Duluth
Nei.s Westby, M.D Madison
COMMITTEE ON GENERAL PRACTICE
Ralph H. Creighton, M.D Minneapolis
E. C. Bayley, M.D Lake City
R. M. Burns, M.D Saint Paul
C. S. Donaldson, M.D Foley
R. J. Ecicman, M.D Duluth
HEART COMMITTEE*
F. J. Hirschboeck, M.D. (1948) Duluth
O. K. Behr, M.D. (1947) Crookston
H. E. Binet, M.D. (1949) Grand Rapids
C. A. Boline, M.D. (1949) Battle Lake
P. G. Boman, M.D. (1948) Duluth
J. F. Borg, M.D. (1948) Saint Paul
C. X. Hf.nsel, M.D. (1949) Saint Paul
Charles Koenigsberger, M.D. (1947) Mankato
M. j. Shapiro, M.D. (1947) Minneapolis
H. L. Smith, M.D. (1948) Rochester
S. M. White, M.D. (1949) Minneapolis
Arlie R. Barnes, M.D. (ex officio) Rochester
HISTORICAL COMMITTEE
M. C. Piper, M.D Rochester
Richard Bardon, M.D Duluth
Olga Hansen, M.D Minneapolis
F. R. Huxley, M.D Faribault
A. G. Liedloff, M.D Mankato
Robert Rosenthal, M.D Saint Paul
C. L. Scofield, M.D Benson
G. E. Sherwood, M.D Kimball
F. P. Strathern, M.D Saint Peter
J. A. Thabes, Sr., M.D Brainerd
W. F. Wilson, M.D Lake City
<<<MMITTEE ON HOSPITALS ANI) MEDICAL
EDUCATION
H. S. Diehl, M.D
A. R. Barnes, M.D
T. E. BroadiE, M.D
E. W. Humphrey, M.D. .
R. C. Hunt, M.D
C. C. Kennedy, M.D. ...
W. A. O’Brien, M.D. . . .
P. S. Rudie, M.D
H. L. Ulrich, M.D. . . .
W. H. Valentine, M.D.
H. B. ZlMMERMANN, M.D.
.Minneapolis
. . . Rochester
. Saint Paul
. .Moorhead
. . .Fairmont
Minneapolis
Minneapolis
Duluth
. Minneapolis
Tracy
.Saint Paul
Terms expire December 31 of year indicated.
COMMITTEE ON INDUSTR1 VL HEALTH
A. E. Wilcox, M.D Minneapolis
H. B. Allen, M.D Austin
L. S. Arling, M.D Minneapolis
Martin, Aune, M.D Minneapolis
N. W. Barker, M.D Rochester
C. C. Bell, M.D Saint Paul
T. H. Dickson, M.D Saint Paul
L. W. Foker, M.D Minneapolis
Clarence Jacobson, M.D Chisholm
O. L. McHaffie, M.D Duluth
J. L. McLeod, M.D Grand Rapids
J. R. McNutt, M.D Duluth
J. A. Thabes, Sr., M.D Brainerd
COMMITTEE ON MATERNAL HEALTH
J. J. Swendson, M.D Saint Paul
R. N. Andrews, M.D Mankato
C. J. Ehrenberg, M.D Minneapolis
A. D. Hoidale, M.D Tracy
A. B. Hunt, M.D Rochester
J. C. Litzenberg, M.D Minneapolis
J. L. McKelvey, M.D Minneapolis
R. J. Moe, M.D Duluth
D. E. Morehead, M.D Owatonna
F. J. Schatz, M.D Saint Cloud
A. M. Watson, M.D Royalton
V. O. Wilson, M.D Minneapolis
W. W. Yaeger, M.D Marshall
COMMITTEE ON MEDICAL TESTIMONY
E. M. Hammes, M.D Saint Paul
B. S. Adams, M.D •. Hibbing
L. A. Barney, M.D Duluth
H. Z. Giffin, M.D Rochester
S. R. Maxeiner, M.D Minneapolis
J. F. Norman, M.D Crookston
W. G. Workman, M.D „ Tracy
COMMITTEE ON MILITARY AFFAIRS
R. B. Hullsiek, M.D Saint Paul
M. S. Belzer, M.D Minneapolis
E. G. Benjamin, M.D Minneapolis
J. J. Catlin, M.D Buffalo
R. V. Fait, M.D Little Falls
M. G. Gillespif, M.D Duluth
Karl Johnson, M.D Duluth
G. C. MacRae, M.D Duluth
W. P. Ritchie, M.D Saint Paul
A. K. Stratte, M.D Pine City
COMMITTEE ON NERVOUS AND MENTAL DISEASES
W. P. Gardner, M.D Saint Paul
S. A. Ch ai.lman, M.D Minneapolis
G. H. Freeman, M.D Saint Peter
L. R. Gowan, M.D Duluth
R. C. Gray, M.D Minneapolis
E. M. Hammes, M.D Saint Paul
P. H. Heersema, M.D Rochester
W. H. Hengstler, M.D Saint Paul
W. L. Patterson, M.D Fergus Falls
COMMITTEE ON OPHTHALMOLOGY
T. R. F'ritsche, M.D New Ulm
W. L. Benedict, M.D Rochester
L. J. Dack, M.D Saint Paul
F. P. Frisch, M.D Willmar
H. W. Grant, M.D Saint Paul
E. W. Hansen, M.D Minneapolis
F. N. Knapp, M.D Duluth
V. I. Mihler, M.D Mankato
L. W. Morsman, M.D Hibbing
C. L. Oppegaard, M.D Crookston
C. E. Stanford, M.D Minneapolis
W. T. Wenner, M.D Saint Cloud
COMMITTEE ON PUBLIC HEALTH Nl USING
M. McC. Fischer, M.D Duluth
I. . V. Berghs, M.D Owatonna
W. C. Chambers, M.D Blue Earth
L. F. Davis, M.D .Wadena
T. F. Ha.mmermeister, M.D New Ulm
E. J. Huenekens, M.D Minneapolis
J. N. Libert, M.D Saint Cloud
COMMITTEE ON TUBERCULOSIS
J. A. Myers, M.D Minneapolis
R. N. Barr, M.D Minneapolis
Rutii E. Boynton, M.D Minneapolis
John Briggs, M.D Saint Paul
H. A. Burns, M.D Saint Paul
F. F. Callahan, M.D Saint Paul
S. S. Cohen, M.D Oak Terrace
K. A. Danielson, M.D Litchfield
W. H. Feldman, Ph.D. (Ex-Officio) Rochester
E. K. Geer, M.D Saint Paul
G. A. Hedberg, M.D Nopeming
H. C. Hinshaw, M.D Rochester
T. J. Kinsella, M.D Minneapolis
L. S. Jordan, M.D Granite Falls
Hilbert Mark, M.D Minneapolis
E. A. Meyerding, M.D Saint Paul
K. H. Pfuetze, M.D Cannon Falls
C. G. Sheppard, M.D Hutchinson
S. A. Slater, M.D Worthington
W. H. Ude, M.D Minneapolis
542
Minnesota Medicine
ROSTER 1947
COMMITTEE ON SYPHILIS AND SOCIAL DISEASES
P. A. O’Leary, II. D Rochester
C. D. Freeman, M.D Saint Paul
W. E. Hatch, M.D Duluth
H. G. Irvine, M.D Minneapolis
P. E. Kierland, M.D Alexandria
F. W. Lynch, M.D Saint Paul
H. E. Michelson, M.D Minneapolis
H. J. Nilson, M.D North Mankato
S. E. Sweitzer, M.D Minneapolis
COMMITTEE ON VACCINATION AND
IMMUNIZATION
E. J. HuEnekens, M.D Minneapolis
R. N. Barr, M.D Minneapolis
E. E. Barrett, M.D Duluth
A. J. Chesley, M.D -. Saint Paul
F. M. Feldman, M.D Rochester
W. W. Higgs, M.D Park Rapids
C. O. Kohlbry, M.D Duluth
C. E. Merkert, M.D Minneapolis
R. B. J. Schoch, M.D Saint Paul
C. S. Strathern, M.D Saint Peter
NON-SCIENTIFIC
EDITING AND PUBLISHING COMMITTEE*
E. M. Hammes, M.D. (1951) Saint Paul
P F. Donohue, M.D. (1948) Saint Paul
H W. Meyerding, M.D. (1949) Rochester
B. O. More, M.D. (1951) Worthington
C. L Oppegaard, M.D. (1950) Crookston
T A. Peppard, M.D. (1947) Minneapolis
H A Roust, M.D. (1948) Montevideo
O. W. Rowe, M.D. (1947) Duluth
H. L. Ulrich, M.D. (1950) Minneapolis
A. H. Wells, M.D. (1949) Duluth
COMMITTEE ON INTERPROFESSIONAL RELATIONS
W. P. Gardner, M.D Saint Paul
M J. Anderson, M.D Rochester
J. J. Catlin, M.D Buffalo
E. E. Christenson, M.D Winona
K. A. Danielson, M.D Litchfield
P F. Eckman, M.D Duluth
C. O. Estrem, M.D Fergus Falls
T M. Hayes, M.D Minneapolis
R. F. IIedin, M.D Red Wing
F. J. Savage, M.D Saint Paul
J. T. Schlesselman, M.D Mankato
L. G. Smith, M.D Montevideo
W. H. Valentine, M.D Tracy
COMMITTEE ON PUBLIC HEALTH EDUCATION
Executive
S. H Baxter, M.D Minneapolis
R. M. Burns, M.D Saint Paul
R. M. Hewitt, M.D Rochester
F. J. Heck, M.D ; Rochester
(Chairmen of all Scientific Committees)
Editorial
R. M. Hewitt, M.D Rochester
R. P. Buckley, M.D Duluth
G. W. Clifford, M.D Alexandria
T. J. Edwards Saint Paul
W. W. Spink, M.D Minneapolis
Radio
R. M. Burns, M.D Saint Paul
J. K. Anderson, M.D Minneapolis
R. N. Andrews, M.D Mankato
Elizabeth C. Bagley, M.D Duluth
N. W. Barker, M.D Rochester
P. M. Gamble, M.D ..Albert Lea
C. N. Harris, M.D ...Hibbing
E. A. Heiberg, M.D Fergus Falls
R. N. Jones, M.D Saint Cloud
F. R. Kotchevar, M.D Eveleth
R. H. Wilson, M.D Winona
Speakers' Bureau
F. J. Heck, M.D Rochester
J. W. Duncan, M.D. Moorhead
P. J. Hiniker, M.D Lq Sueur
P. A. Lommen, M.D Austin
Gordon MacRae, M.D Duluth
J. L. McLeod, M.D Grand Rapids
J. F. Norman, M.D Crookston
Charles E. Rea, M.D Saint Paul
M. M. Weaver, M.D Minneapolis
COMMITTEE ON PUBLIC POLICY
L. L. Sogge, M.D Windom
G. I. Badeaux, M.D Brainerd
L. A. Barney, M.D Duluth
J. F. DuBois, M.D Sauk Center
E. A. Eberlin, M.D Glenwood
Reuben F. Erickson, M.D Minneapolis
W. A. Fansler, M.D. Minneapolis
R. C. Gray, M.D Minneapolis
H. C. Habein, M.D. Rochester
V. M. Johnson, M.D Dawson
B. O. Mork, Jr., M.D. Worthington
M. O. Oppegaard> M.D Crookston
W. C. Rutherford, M.D Nisswa
H. R. Tregilgas, M.D South Saint Paul
MINNESOTA STATE CERTIFICATION BOARD ON
PUBLIC HEALTH NURSING
F. J. Savage, M.D Saint Paul
"Terms expire December 31 of year indicated.
May, 1947
COMMITTEES
COMMITTEE ON MEDICAL ECONOMICS
George Earl, M.D., General Chairman Saint Paul
Executive
George Earl, M.D Saint Paul
A. YV. Adson, M.D Rochester
S. H. Baxter, M.D Minneapolis
W. H. Hengstler, M.D Saint Paul.
R. D. Mussey, M.D Rochester
L. L. Sogge, M.D Windom
T. H. Sweetser, M.D Minneapolis
Editorial
George Earl, M.D Saint Paul
L. R. Boies, M.D Minneapolis
W. F. Braasch, M.D Rochester
W. L. Patterson, M.D Fergus Falls
D. W. Wheeler, M.D Duluth
Medical Advisory
W. H. Hengstler, M.D Saint Paul
B. J. Branton, M.D Willmar
Ivar Sivertsen, M.D Minneapolis
Medical Ethics
R. D. Mussey, M.D Rochester
B. S. Adams, M.D Hibbing
H. S. Diehl, M.D Minneapolis
Medical Service
A. W. Adson, M.D Rochester
J. A. Bargen, M.D Rochester
J. F. Borg, M.D Saint Paul
R. R. Cranmer, M.D Minneapolis
J. A. Malmstrom, M.D Virginia
C. B. McKaig, M.D Pine Island
C. A. McKinlay, M.D Minneapolis
J. F. Norman, M.D Crookston
O. I. Sohlberg, M.D Saint Paul
A. O. Swenson, M.D Duluth
H. B. Troost, M.D Mankato
W. W. Will, M.D Bertha
State Health Relations
T. H. Sweetser, M.D Minneapolis
R. B. Bray, M.D Biwabik
J. N. Dunn, M.D Saint Paul
John Earl, M.D Saint Paul
R. R. Heim, M.D Minneapolis
fC. M. Johnson, M.D Dawson
Harry Klein, M.D Duluth
A. G. Liedloff, M.D Mankato
J. P. McDowell, M.D Saint Cloud
Carl Simison, M.D Barnesville
S. A. Slater, M.D Worthington
COMMITTEE ON RURAL MEDICAL SERVICE
First District
Paul Leck, M.D., Chairman Austin
Second District
V. W. Doman, M.D Lakefield
Third District
Magnus Westby, M.D Madison
Fourth District
J. F. Traxler, M.D Henderson
Fifth District
A. K. Stratte, M.D Pine City
Sixth District
W. E. Hart, M.D • Monticello
Seventh District
A. J. Lenarz, M.D Browerville
Eighth District
C. W. Jacobson, M.D Breckenridge
Ninth District
J. K. Butler, M.D Carlton
COMMITTEE ON UNIVERSITY RELATIONS
Edwin J. Simons, M.D Swanville
E. L. Tuohy, M.D Duluth
E. M. Jones, M.D Saint Paul
S. H. Baxter, M.D Minneapolis
H. Z. Giffin, M.D Rochester
COMMITTEE ON VETERANS MEDICAL SERVICE
R. H. Creighton, M.D Minneapolis
S. H. Boyer, Jr., M.D Duluth
C. J. Fritsche, M.D New Ulm
W. P. Ritchie, M.D Saint Paul
C. A. Wilmot, M.D Litchfield
tDeceased.
543
ROSTER 1947
COUNTY MEDICAL ADVISORY COMMITTEES
AITKIN COUNTY
J. J. Ratcliffe, M.D Aitkin
H. T. Petraborg, M.D Aitkin
ANOKA COUNTY
R. J. Spurzem, M.D Anoka
George Schlesselman, M.D Anoka
A. H. More, M.D Anoka
BECKER COUNTY
H. C. Otto, M.D Frazee
A. R. Ellingson, M.D Detroit Lakes
G. G. Haight, M.D Audubon
BELTRAMI COUNTY
D. H. Garlock, M.D Bemidji
T. I*. Groschupf, M.D. Bemidji
D. D. Whittemore, M.D Bemidji
BENTON COUNTY
William Friesleben, M.D Sauk Rapids
C. S. Donaldson, M.D. Foley
L. M. Evans, M.D Sauk Rapids
BIG STONE COUNTY
Otto Bergan. M.D Clinton
B. R. Karn, M.D Ortonville
BLUE EARTH COUNTY
R. X. Andrews, M.D Mankato
R. G. Hassett, M.D Mankato
BROWN COUNTY
Albert Fritsche, M.D New Ulm
C. A. Saffert, M.D New Ulm
W. G. Nuessle, M.D Springfield
O. B. Fesenmaier, M.D New Ulm
A. P. Goblirsch, M.D Sleepy Eye
CARLTON COUNTY
R. M. Eppard, M.D Cloquet
E. O. Hanson, M.D Cloquet
J. K. Butler, M.D Carlton
CARVER COUNTY
M. B. Hebeisen, M.D Chaska
H. D. Nagel, M.D Waconia
B. H. Simons, M.D Chaska
CASS COUNTY
O. F. Ringle, M.D Walker
G. H. Adkins, M.D Pine River
Z. E. House, M.D Cass Lake
CHIPPEWA COUNTY
L. G. Smith, M.D Montevideo
L. R. Lima, Jr., M.D Montevideo
CHISAGO COUNTY
J. E. Halpin, M.D Rush City
A. E. Holmes, M.D Rush City
R. G. SwEnsen, M.D North Branch
CLAY COUNTY
O. H. Johnson, M.D Moorhead
F. A. Thysell, M.D Moorhead
S. B. Seitz, M.D Barnesville
CLEARWATER COUNTY
L. T. Larson, M.D Bagley
R. D. Davis, M.D Clearbrook
COTTONWOOD COUNTY
H. C. Stratte, M.D Windom
E. S. Schutz, M.D Mountain Lake
J. V. Carlson, M.D Westbrook
CROW WING COUNTY
V. E. Quanstrom, M.D Brainerd
G. I. Badeaux, M.D Brainerd
DAKOTA COUNTY
J. A. Sanford, M.D Farmington
L. R. Peck, M.D Hastings
A. J. Emond, M.D Farmington
DODGE COUNTY
C. E. Bigelow, M.D Dodge Center
H. R. Baker, M.D Hayfield
D. E. Affeldt, M.D Kasson
DOUGLAS COUNTY
G. W. Clifford, M.D Alexandria
L. M. Boyd, M.D Alexandria
E. R. Sather, M.D Alexandria
FARIBAULT COUNTY
W. C. Chambers, M.D Blue Earth
M. D. Cooper, M.D Winnebago
W. H. Barr, M.D Wells
FILLMORE COUNTY
C. W. Woodruff, M.D Chatfield
J. E. Westrup, M.D Lanesboro
I. . W. Clark, M.D Spring Valley
FREEBORN COUNTY
W. P. Freligh, M.D Albert Lea
B. A. Leopard, M.D Albert Lea
F. G. Folken, M.D Albert Lea
D. L. Donovan, M.D Albert Lea
GOODHUE COUNTY
W. W. Liffrig, M.D Red Wing
L. A. Steffens, M.D Red Wing
R. V. Sherman, M.D Red Wing
GRANT COUNTY
L. R. Parson, M.D Elbow Lake
E. T. Reeve, M.D Elbow Lake
A. M. Randall, M.D Ashby
RURAL HENNEPIN COUNTY
T. J. Devereaux, M.D Wayzata
M. H. Seifert, M.D Excelsior
F. J. KuCera, M.D Hopkins
HOUSTON COUNTY
J. W. Helland, M.D Spring Grove
G. T. Norris, M.D Caledonia
L. K. Onsgard, M.D Houston
HUBBARD COUNTY
W. W. Higgs, M.D Park Rapids
ISANTI COUNTY
L. H. Hedenstrom, M.D Cambridge
W. T. Nygren, M.D Braham
ITASCA COUNTY
J. L. McLeod, M.D Grand Rapids
II. R. Anderson, M.D Deer River
E. K. Rowles, M.D Coleraine
JACKSON COUNTY
W. S. Hitchings,, M.D Lakefield
W. H. Halloran, M.D Jackson
J. T. Rose, M.D Lakefield
KANABEC COUNTY
C. S. Bossert, M.D Mora
W. F. Nordman, M.D Mora
KANDIYOHI COUNTY
J. C. Jacobs, M.D Willmar
B. J. Branton, M.D Willmar
R. J. Ripple, M.D New London
KITTSON COUNTY
F. F. Stocking, M.D Hallock
A. S. Berlin, M.D Hallock
KOOCHICHING COUNTY
R. D. Hanovan, M.D Littlefork
F. G. Chermak, M.D International Falls
LAC QUI PARLE COUNTY
*C. M. Johnson, M.D Dawson
W. N. Lee, M.D Madison
LAKE COUNTY
R. F. Mueller, M.D Two Harbors
LE SUEUR COUNTY
E. E. Novak, M.D New Prague
Swan Ericson, M.D Le Sueur
R. A. Curtis, M.D LeCenter
LINCOLN COUNTY
P. E. Hermanson, M.D Hendricks
LYON COUNTY
B. C. Ford, M.D Marshall
544
Minnesota Medicine
ROSTER 1947
MAHNOMEN COUNTY
K. W. Covey, M.D Mahnomen
J. J. Ederer, M.D Mahnomen
MARSHALL COUNTY
C. H. Holmstrom, M.D Warren
I. G. Wiltrout, M.D Oslo
A. E. Carlson, M.D Warren
MARTIN COUNTY
R. C. Hunt, M.D Fairmont
H. B. Bailey, M.D Fairmont
T. J. Heimark, M.D Fairmont
McLEOD COUNTY
H.'H. Holm, M.D Glencoe
O. W. Scholpp, M.D Hutchinson
E. W. Lippman, M.D Hutchinson
MEEKER COUNTY
K. A. Danielson, M.D Litchfield
D. C. O’Connor, M.D Eden Valley
MILLE LACS COUNTY
Melvin Vik, M.D Onamia
J. D. Ryan, M.D Milaca
MORRISON COUNTY
A. M. Watson, M.D .Royalton
A. E. Amundsen, M.D Little Falls
E. J. Simons, M.D Swanville
MOWER COUNTY
R. S. HeggE, M.D Austin
C. L. Sheedy, M.D Austin
L. G. Flanagan, M.D Austin
MURRAY COUNTY
L. A. Williams, M.D Slayton
B. M. Stevenson, M.D Fulda
R. F. Pierson, M.D } Slayton
NICOLLET COUNTY
F. P. Strathern, M.D St. Peter
H. J. Nilson, M.D North Mankato
NOBLES COUNTY
E. W. Arnold, M.D Adrian
B. O. More, Sr., M.D Worthington
E. A. Kilbride, M.D Worthington
NORMAN COUNTY
Eskil Erickson, M.D Halstad
Theodore Loken, M.D Ada
OLMSTED COUNTY
J. M. Berkman, M.D Rochester
F. D. Smith, M.D Rochester
C. B. McKaig, M.D Pine Island
OTTER TAIL COUNTY
A. J. Lewis, M.D Henning
W. L. Burnap, M.D Fergus Falls
G. C. Jacobs, M.D Fergus Falls
PENNINGTON COUNTY
O. F. Mellby, M.D Thief River Falls
O. G. Lynde, M.D Thief River Falls
H. H. Hedemark, M.D Thief River Falls
PINE COUNTY
C. G. Kelsey, M.D Hinckley
Manuel Brownstone, M.D Sandstone
PIPESTONE COUNTY
W. G. Benjamin, M.D Pipestone
H. DeBoer, M.D Edgerton
J. G. Lohmann, M.D Pipestone
POLK COUNTY
C. L. Oppegaard, M.D Crookston
J. F. Norman, M.D Crookston
Abraham Shedlov, M.D Fosston
POPE COUNTY
E. A. Eberlin, M.D Glenwood
B. I. McIver, M.D Lowry
RED LAKE COUNTY
F. M. Petkevich, M.D Silver Springs, Md.
REDWOOD COUNTY
T. E. Flinn, M.D Redwood Falls
W. A. Brand, M.D Redwood Falls
G. B. Eaves, M.D Wabasso
RENVILLE COUNTY
J. Dordal, M.D Sacred Heart
A. M. Fawcett, M.D Renville
R. E. Erickson, M.D Hector
J. A. Cosgriff, M.D Olivia
May, T947
RICE COUNTY
F. R. Huxley, M.D Faribault
D. W. Francis, M.D Morristown
Warren Wilson, M.D Northfield
ROCK ■ COUNTY
C. L. Sherman, M.D Luverne
O. W. Anderson, M.D Luverne
F. W. BofEnkamp, M.D Luverne
ROSEAU COUNTY
J. L. Delmore, M.D Roseau
N. M. Leitch, M.D Warroad
D. O. BergE, M.D Roseau
ST. LOUIS COUNTY
A. T. Laird, M.D Duluth
M. H. Tibbetts, M.D Duluth
P. S. Rudie, M.D Duluth
SCOTT COUNTY
H. M. Jurgens, M.D Belle Plaine
B. F. Pearson, M.D Shakopee
SHERBURNE COUNTY
A. B. Roehlke, M.D Elk River
E. F. Clothier, M.D Elk River
Gordon H. Tesch, M.D Elk River
SIBLEY COUNTY
Rolf Hovde, M.D Winthrop
Thomas Martin, M.D Arlington
D. C. Olson, M.D Gaylord
STEARNS COUNTY
A. H. Zachman, M.D Melrose
C. F. Brigham, M.D St. Cloud
VV. T. Wenner, M.D St. Cloud
STEELE COUNTY
D. E. MorehEad, M.D Owatonna
L. V. Berghs, M.D Owatonna
D. H. Dewey, M.D Owatonna
STEVENS COUNTY
E. T. Fitzgerald, M.D Morris
M. L. Ransom, M.D Hancock
SWIFT COUNTY
Hans Johnson, M.D Kerkhoven
C. L. Scofield, M.D Benson
E. J. Kaufman, M.D Appleton
TODD COUNTY
M. E. Mosby, M.D Long Prairie
J. M. Cook, M.D Staples
E. J. Simons, M.D Swanville
TRAVERSE COUNTY
tN. F. Doleman, M.D Tintah
A. L. Lindberg, M.D Wheaton
WABASHA COUNTY
T. G, Wellman, M.D Lake City
B. J. Bouquet, M.D Wabasha
E. W. Ellis, M.D Elgin
WADENA COUNTY
L. T. Davis, M.D Wadena
H. G. Bosland, M.D Verndale
C. H. Pierce, M.D Wadena
WASECA COUNTY
O. J. Swenson, M.D Waseca
H. M. McIntire, M.D Waseca
B. J. Gallagher, M.D Waseca
WASHINGTON COUNTY
J. W. Stuhr, M.D Stillwater
E. R. Samson, M.D Stillwater
WATONWAN COUNTY
O. B. Bergman, M.D St. James
F. L. Bregel, M.D St. James
WILKIN COUNTY
W. E. Wray, M.D Campbell
WINONA COUNTY
Herbert IIeise, M.D Winona
WRIGHT COUNTY
T. J. Catlin, M.D Buffalo
L. II. Bendix, M.D Annandale
R. D. Thielen, M.D St. Michael
YELLOW MEDICINE COUNTY
E. R. Hudec, M.D Echo
P. G. Schmidt, Jr., M.D Granite Falls
(No committees have been appointed in the following counties:
Cook and Lake of the Woods.)
fDeceased.
545
ROSTER 1947
Woman’s Auxiliary
to the
Minnesota State Medical Association
Mrs. Melvin Henderson . .
Mrs. J. A. Thabes, Sr
Mrs. Edward V. Goetz
Mrs. Harold F. \\ ahlquist
Mrs. M. G. Gillespie
Mrs. Mark E. Ryan
Mrs. E. J. Simons
Mrs. H. W. Satterlee
Mrs. Haddon M. Carryer
Mrs. George E. Penn
Mrs. R. N. Jones
Mrs. Ei.i E. Christensen
Mrs. S. S. Hessei.gr ave . .
OFFICERS
President
. . . President-Elect . . .
. . . . Past President ....
. First Vice President .
Second Vice President
. Third Vice President .
Fourth Vice President
. Recording Secretary .
Corresponding Secretary
Treasurer
Auditor
Historian
. . . Parliamentarian . . .
. . Rochesttr
. . Brainerd
St. Paul
Minneapolis
... Duluth
. . . St. Paul
. Swanville
. . Lewiston
Rochester
Mankato
. St. Cloud
. . . Winona
Center' City
CHAIRMEN OF COMMITTEES
Advisory — Mrs. E. V. Goltz St. Paul
Archives — Mrs. J. J. Catlin Buffalo
Auxiliary Posters — Mrs. Thomas O. Young ...Duluth
Bulletin — Mrs. C. L. Oppegaard Crookston
Cancer Board — Mrs. L. R. Boies Hopkins
Editor — Mrs. Walter K. Haven Minneapolis
Emergency Nursing — Mrs. Harlow Hanson
Minneapolis
Finance — Mrs. Charles W. Waas St. Paul
Health Education — Mrs. E. W. Miller Anoka
Hygeia — Mrs. John Dordal Sacred Heart
Legislation — Mrs. Neil Dungay Northfield
Organization — Mrs. J. A. Thabes, Sr Brainerd
Pledge of Allegiance and Auxiliary Pledge of
Loyalty — Mrs. W. W. Will Bertha
Postwar Planning — Mrs. Claude C. Kennedy
Minneapolis
Press and Publicity — Mrs. W. Von-Der-Weyer ....
St. Paul Park
Printing — Mrs. Henry W. Quest Minneapolis
Program — Mrs. C. A. Boline Battle Lake
Public Relations — Mrs. Arthur Thompson ....Cokato
Resolutions — Mrs. Harry Klein Duluth
Revisions — Mrs. C. C. Allen Austin
Social — Mrs. Harry Ghent St. Paul
In Memoriam Service — Mrs. J. W. Stuhr ..Stillwater
District Councilors
DISTRICT NO. 1
R. L. J. Kennedy, M.D Rochester
Counties — Dodge, Fillmore, Freeborn, Goodhue, Hous-
ton, Mower, Olmsted, Rice, Steele, Wabasha, Winona.
DISTRICT NO. 2
L. E. Sogge, M.D ' Windom
Counties — Cottonwood, Faribault, Jackson, Martin,
Murray, Nobles, Pipestone, Rock, Watonwan.
DISTRICT NO. 3
fC. M. Johnson, M.D Dawson
Counties — Big Stone, Brown, Chippewa, Kandiyohi,
Lac Qui Parle, Lincoln, Lyon, Meeker, Pope, Red-
wood, Stevens, Swift, Traverse, Yellow Medicine.
DISTRICT NO. 4
A. E. Sohmer M.D Mankato
Counties — Elue Earth, Carver, Le Sueur, McLeod,
Nicollet, Renville, Scott, Sibley, Waseca.
tDeceased.
DISTRICT NO. 5
E. M. Hammes, M.D, Saint Paul
Counties — Anoka, Chisago, Dakota, Isanti, Kanabec,
Mille Lacs, Pine, Ramsey, Sherburne, Washington
DISTRICT NO. 6
A. E. C a rule, M.D Minneapolis
Counties — Hennepin, Wright.
DISTRICT NO. 7
W. W. Will, M.D Bertha
Counties — Aitkin, Beltrami, Benton, Cass, Clearwater,
Crow Wing, Hubbard, Koochiching, Morrison,
Stearns, Todd, Wadena.
DISTRICT NO. 8
W. L. Burnap, M.D Fergus Falls
Counties — Becker, Clay, Douglas, Grant, Kittson,
Lake of the Woods, Mahnomen, Marshall, Norman,
Ottertail, Pennington, Polk, Red Lake, Roseau,
Wilkin.
DISTRICT NO. 9
F. J. Elias, M.D Duluth
Counties — Carlton, Cook, Itasca, Lake, St. Louis.
54b
Minnesota Medicine
ROSTER 1947
County Society Roster
Key to Symbols: ^Deceased; f Affiliate, Associate or Life Member; :j: In Service;
§Wife is Member of Woman’s Auxiliary.
BLUE EARTH COUNTY MEDICAL SOCIETY
President
IHoeper, P. G Mankato
Secretary
§Vezina, J. C Mapleton
iAndrews, R. N Mankato
Batdorf, B. N Good Thunder
§Butzer, J. A Mankato
ifDahl, G. A Mankato
§Denman, A. V Mankato
tEdwards, R. T Big Fork, Mont.
§Franchere, F. W Lake Crystal
§Fugina, G. R Mankato
§Haes, J. E Mankato
Regular meetings, last Monday of each month
Annual meeting in May
Number of Members: 37
Hankerson, R. G Minnesota Lake
§Hassett, R. G Mankato
JjHoeper, P. G Mankato
§Howard, E. G Mapleton
§Howard, M. I Mankato
§Huffington, H. L Mankato
§ Jones, O. H Mankato
ijuliar, R. O St. Clair
§Kaufman, W. B Mankato
§ Kearney, R. W Mankato
§Kemp, A. F Mankato
§Koenigsberger, Chas Mankato
Liedloff, A. G Mankato
Luck, Hilda Mankato
’Macbeth, J. L
§Mickelson, J. C....
§ Miller, V. I.
§Morgan, H. O
§Penn, G. E
ISatnuelson, L. G...
§Schlesselman, J. T,
Schmidt, P. A. . .
§Schmitz, A. A
§Sohmer, A. E
§Stillwell, W. C. ...
§Troost, H. B
§Vezina, J. C
§Wentworth, A. J. . .
Williams, H. O. . . .
St. Clair
Mankato
Mankato
Amboy
Mankato
Mankato
Mankato
Good Thunder
Mankato
Mankato
Mankato
Mankato
Mapleton
Mankato
. .Lake Crystal
BLUE EARTH VALLEY MEDICAL SOCIETY
Faribault and Martin Counties
Regular meetings, first Thursday of month
Annual meeting, first Thursday in November
Number of Members: 30
President
Thayer, E. A Fairmont
Secretary
Bovsen, Herbert Madelia
Armstrong, R. S Winnebago
Bailey, R. B Fairmont
Barr, W. H Wells
Boysen, Herbert Madelia
Burmeister, R. O Welcome
Chambers, W. C Blue Earth
Cooper, M.D Winnebago Medlin, C. F. ...
Drexler, G. W Blue Earth Mills, J. L
Gardner, V. H Fairmont Parsons, R. L. .
Grogan, J. M Ceylon Rowe, W. H...
Hanson, Lewis Frost Russ, H. H
Heimark, T. J. Fairmont Snyder, C. D...
f Holm, P. F Wells Sommer, A. W.
Hunt, R. C Fairmont Thayer, E. A...
Hunt, R. S Fairmont Vaughan, V. M,
Hunte, A. F California Virnig, M. P. ..
Krause, C. W Fairmont Wilson, C. E. .
McGroarty, J. J Easton §Zemke, E. E. ...
. . . .Truman
.Winnebago
. .Monterey
. . .Fairmont
.Blue Earth
... .Kiester
Elmore
. . .Fairmont
. . . .Truman
Wells
Blue Earth
. . . Fairmont
CAMP RELEASE MEDICAL SOCIETY
Chippewa, Lac Qui Parle and Yellow Medicine Counties
President
Owens, W. A Montevideo
Secretary
§Schmidt, P. G., Jr Granite Falls
§Bergh, L. N Montevideo
Boody, G. J., Jr Dawson
Burns, F. M Milan
Burns, M. A Milan
Guilbert, G. D Wood, Wis.
Regular meetings monthly
Annual meeting, December
Number of Members: 27
§Hauge, M. I Clarkfield
Holmberg, L. J Canby
Hudec, E. R Echo
* Johnson, C. M Dawson
§johnson, V. M Dawson
f Jordan, Kathleen Granite Falls
Jordan, L. S Granite Falls
§Kath, R. PI Wood Lake
Kaufman, W. C Appleton
Lee, W. N Madison
Lima, Ludvig Montevideo
Lima, L. R., Jr Montevideo
Lundell, C. L Granite Falls
§Nelson, (M. S Granite Falls
Owens, W. A Montevideo
Pertl, A. L. Canby
§Roust, H. A Montevideo
Schmidt, P. G., Jr Granite Falls
§ Smith, L. G. . . Montevideo
§Westby, Magnus Madison
Westby, Nels Madison
CLAY-BECKER COUNTY MEDICAL SOCIETY
Regular meetings quarterly
Annual meeting, December
Number of Members: 22
President
Rutledge, L. H Detroit Lakes
Secretary
Hendrickson, R. R Lake Park
tAborn. W. H Hawley
Bottolfson, B. T Moorhead
Carman, J. E. Detroit Lakes
Duncan, J. W Moorhead
Ellington, A. R Detroit Lakes §OHver, James
Hagen, O. J Moorhead Olsen, Gertrude E.
Haight, G. G Audubon Otto, H. C
Hendrickson, R. R Lake Park Rutledge, L. H
Humphrey, E. W Moorhead Seitz, S. B
Ingebrightson, E. K. G Moorhead Shaw, H. A
Johnson, Olga H.... Moorhead Simison, Carl
Larson, Arnold Detroit Lakes Thysell, F. A
§Moberg, C. W Detroit Lakes Thysell, V. D
. . . .Moorhead
. . Georgetown
Erazee
Detroit Lakes
. . . Barnesville
. .Minneapolis
. . . Barnesville
. . . .Moorhead
Hawley
President
Emond, A. J Farmington
Secretary
Peck, L. R Hastings
May, 1947
DAKOTA COUNTY MEDICAL SOCIETY
Number of Members : 8
Burns, L. S So. St. Paul
Emond, A. J Farmington
Emond, J. S Farmington
Field, A. H Farmington
Peck, L. D Hastings
Peck, L. R Hastings
Sanford, J. A Farmington
Walter, G. F Farmington
547
ROSTER 1947
EAST CENTRAL MINNESOTA MEDICAL SOCIETY
Anoka, Chisago, Isanti, Kanabec, Mille Lacs, Pine and Sherburne Counties
Regular meetings, February, April, June, August, October, December
Annual meeting, December
Number of Members: 37
President
Gully, R. J Cambridge
Secretary
Roehlke, A. B Elk River
Arends, A. L Jamestown, N-. D.
§Albrecht, H. H Lind'strom
§Blomberg, W. R Princeton
Bossert, C. S Mora
Brownstone, Manuel Sandstone
§Bunker, B. W Anoka
Clothier, E. F Elk River
Crabtree, J. C Princeton
fDedolph, T. H Minneapolis
Dredge, H. P Sandstone
§Gully, R. J Cambridge
§Halpin, J. E Rush City
§Hedenstrom, L. H Cambridge
Holmes, A. E Rush City
Kapsner, Carl Princeton
§Kelsey, C. G Hinckley
Larson, Ralph Anoka
§Miller, E. W Anoka
§Mork, A. H Anoka
§Mork, F. E Anoka
§Nordman, W. F Mora
Nygren, W. T Braham
§0’Hanlon, J. A Lindstrom
§Petersen, P. C Mora
§Peterson, C. A Chisago City
Riegel G. S Taylors Falls
§Roehlke, A. B Elk River
Sather, R. N Mora
Schlesselman, George Anoka
§Sherman, H. T * Cambridge
Spurzem, R. J Anoka
Stephan, E, L Hinckley
§Stratte, A. K Pine City
§Swensen, R. G North Branch
§Tesch, G. H Elk River
Vik, Melvin Onamia
§Whitney, R. A Cambridge
FREEBORN COUNTY MEDICAL SOCIETY
Regular meetings quarterly
Annual meeting, December
Number of Members : 26
President
§Gamble, P. M Albert Lea
Secretary
Person, J. P Alden
§Barr, L. C Albert Lea
§ Branham, D. S Albert Lea
§Butturff, C. R Freeborn
Calhoun, F. W Albert Lea
§Demo, Robert A Albert Lea
Donovan, D. L Albert Lea
§Folken, F. G Albert Lea
§Freligh, W. P Albert Lea
Gamble, J. W Albert Lea
§Gamble, P. M Albert Lea
Gullixson, A Albert Lea
Hansen, T. M Alden
Kamp, B. A Albert Lea
Leopard, B. A Albert Lea
§Neel, H. B Albert Lea
Nelson, Clayton E. J Albert Lea
§Nesheim, M. O Emmons
Palmer, C. F Albert Lea
Palmer, W. L Albert Lea
Palmerton, E. S Albert Lea
§Person, J. P Alden
§Prins, L. R Albert Lea
Schultz. J. A Albert Lea
§Swanson, R. R Albert Lea
Wenzel, R. E Albert Lea
§ Whitson, S. A Albert Lea
GOODHUE COUNTY MEDICAL SOCIETY
Regular meetings, none
Annual meeting, December
Number of Members: 24
§Hartnagel, G.
President
F
. . Red Wing
§Claydon, H. F
SK'laydon, L. E
Red Wing
Larson, Ralph H. .
§Liffng, W. W
Cannon Falls
§Brusegard, J.
Secretary
. . Red Wing
§Flom, M. G
§Graves, R. B
Zumbrota
Red Wing
Mack, J. J..
McGuigan, H. T...
• Little Rock, Ark.
Red Wing
F
§HartnageI, G. F
Odessky, Louis....
Aanes, A. M,
§Hedin, R. F
Johnson, A. E
Red Wing
Red Wing
§Sherman, R. V....
tSmith, M. W
Akins, W. M.
. . . Red Wing
fjones, A. W
SSteffens. L. A....
Anderson, S.
H
. . Red Wing
. . . Red Wing
§Tuers, i.. H
Red Wing
§Weir, I. R
Brusegard, J.
F
§Kimmel, G. C
Red Wing
Williams, M. R. . .
HENNEPIN COUNTY MEDICAL SOCIETY
Regular meetings, first Monday each month, October through May
Annual meeting, October
Number of Members: 771
President
Boies. L. R Minneapolis
Secretary
Jones, W. R Minneapolis
Executive Secretary
Mr. J. H. Baker Minneapolis
Aagaard, G. N., Jr Minneapolis
§Abramson, Milton Minneapolis
Adkins, C. D ’.Minneapolis
Ahern, E. E Minneapolis
Alexander, H. A Minneapolis
Alger, E. W Minneapolis
§Aling, C. A Minneapolis
t§Aling, C. P Minneapolis
§t Allen, H. W Minneapolis
§Altnow, H. O.. Minneapolis
§ Andersen, A. G Minneapolis
§Andersen, S. C Minneapolis
§Anderson, D. D Minneapolis
Anderson, D. P Minneapolis
§Anderson, E. D Minneapolis
§Anderson, E. R Minneapolis
§Anderson, F. J Minneapolis
§Anderson, J. K Minneapolis
§Anderson, K. W Minneapolis
§Anderson, U. S Minneapolis
Anderson, W. T Minneapolis
Andreassen, E. C Minneapolis
Andresen, K. D Minneapolis
§Andrews, R. S Minneapolis
§Arey, S. L. Minneapolis
§Arlander, C. E Minneapolis
§Arling, L. S Minneapolis
Arnold, Ann W Minneapolis
Arnold, D. C Minneapolis
§Arvidson, C. G Minneapolis
§Aune, Martin Minneapolis
tAurand, W. II Minneapolis
Baird, J. W Minneapolis
§Baken, M. P Minneapolis
Baker, A. B Minneapolis
Baker, A. T Minneapolis
§Baker, E. L Minneapolis
Baker, Looe Minneapolis
§Balkin, S. G Minneapolis
Bank, H. E Minneapolis
f Barber, J. P Minneapolis
Barr, R. N Minneapolis
§Barron, Moses Minneapolis
Bateman, Olive A. I. Rochester
§Baxter, S. H Minneapolis
§ Bayard, H. F Minneapolis
§Beach, Northrop Minneapolis
fBeard, A. H Minneapolis
§fBeckman, W. G
San Francisco, Calif.
§Bedford, E. W Minneapolis
Beiswanger, R. H Minneapolis
tBell, E. T Minneapolis
Belzer, M. S Minneapolis
Benesh, L. A Minneapolis
Benesh, N. G Minneapolis
§Benjamin, A. E Minneapolis
^Benjamin, E. G Minneapolis
^Benjamin, H. G Minneapolis
§Benn, F. G Minneapolis
Berger, A. G Minneapolis
Bergh, G. S Minneapolis
Bergh, Solveig M Minneapolis
§Berkwitz, N. J Minneapolis
Berman, Reuben Minneapolis
SBessesen, A. N., Jr Minneapolis
§Bessesen, D. II Minneapolis
Bessesen, W. A Minneapolis
Bieter, R. N Minneapolis
tBlake, Alan Hopkins
§Blake, T. A Hopkins
§Blake, James Hopkins
f Blake, P. S Minneapolis
Bloedel, T. J Osseo
Blumenthal, J. S Minneapolis
Bockman, M. W. H Minneapolis
§Boehrer, J. J Minneapolis
§Boies, L. R Minneapolis
t Booth, A. E Minneapolis
§Boreen, C. A Minneapolis
Borgeson, E. J Minneapolis
§Borman, C. N Minneapolis
Borowicz, L. A Minneapolis
§Bowers, G. G Minneapolis
Boynton, Ruth E Minneapolis
§Bratrud, A. F Minneapolis
§Brekke, H. J Minneapolis
Brill, Alice K Minneapolis
Brooks, C. N Minneapolis
tBrown, E. D Paynesville
Brown, F. J Minneapolis
Brown, J. R Minneapilis
tBrown, S. P Minneapolis
Brown, W. D Minneapolis
Brutsch, G. C Minneapolis
§Buchstein, H. F Minneapolis
Buirge, Raymond Minneapolis
Bulkley, Kenneth Minneapolis
Bushard, W. J Minneapolis
§Buzzelle, L. K Minneapolis
§Cable, M. L Minneapolis
§Cabot, C. M Minneapolis
§Cabot, V. S Minneapolis
Cady, L. H Minneapolis
Callerstrom, G. W Minneapolis
Cameron, Isabell L Minneapolis
Camp, W. E Minneapolis
Campbell, L. M Minneapolis
§Campbell, O. J Minneapolis
§Cardle, A. E Minneapolis
§Carey, J. B Minneapolis
§Carlson, Lawrence. Minneapolis
§Carlson, L. T Minneapolis
548
Minnesota Medicine
ROSTER 1947
§Caron, R. P Minneapolis
Caspers, C. G Minneapolis
§Cavanor, F. T Minneapolis
Ceder, E. T Minneapolis
Challman, S. A Minneapolis
Chesley, A. J Minneapolis
§Christenson, G. R Minneapolis
IChristianson, H. W Minneapolis
*tClark, H. S Minneapolis
Clarke, E. K Minneapolis
§Clay, L. B Minneapolis
Cochrane, R. F Minneapolis
Cohen, B. A Minneapolis
SCohen, S. S Oak Terrace
Colp. E. A Robbinsdale
Cooper, J. P Wayzata
Condit, W. H Minneapolis
§Corbett, J. F Minneapolis
Corniea, A. D Minneapolis
ICorrea, D. H Minneapolis
ICoulter, E. B Minneapolis
Cowan, D. W Minneapolis
§Cranmer, R. R. Minneapolis
tCranston, R. W Minneapolis
§Creevy, C. D Minneapolis
SCreighton, R, H Minneapolis
JjCulligan, L. C Minneapolis'
Cumming, H. A Minneapolis
Cutts, George Minneapolis
§Dady, E, E Minneapolis
Dahl, E. O Minneapolis
JDahl, J. A Minneapolis
fDaniel, D. H Minneapolis
§Davis, J. C. Minneapolis
Davis, W. I Mound
Jdel Plaine, C. W ..Minneapolis
Dennis, Clarence Minneapolis
§Dtvereaux, T. J Wayzata
§Diehl, H. S Minneapolis
Diessner, H. D Minneapolis
§Dorge, R. I Minneapolis
§Dornblaser, H. D Minneapolis
§Dorsey, G. C Minneapolis
Dowidat, R. W Minneapolis
Doxey, G. L Minneapolis
IDoyle, L. O Minneapolis
§Drake, C. R Minneapolis
§Drill, H. E Hopkins
§Duff. E. R Minneapolis
§DukeIow, D. A Minneapolis
tDumas, A. G Minneapolis
jDunlap, E. H Minneapolis
§Dunn, G. R Minneapolis
§Dupont, J. A Excelsior
§Durvea, W. M Minneapolis
tDutton, C. E Minneapolis
^Dvorak, B. A Minneapolis
iDwan, P. F Minneapolis
iDworsky, S. D Minneapolis
Ebert, R. V Minneapolis
§*Ederer, J. J Minneapolis
iEhrenberg, C. J Minneapolis
§Eich, Matthew Minneapolis
Eisenstadt, D. H Minneapolis
Eisenstadt, W. S Minneapolis
§Eitel. G. D Minneapolis
lEllison, D. E Minneapolis
SEngelhart, P. C Minneapolis
Englund, E. F Minneapolis
§Engstrand, O. J Minneapolis
Erickson, C. O Minneapolis
Erickson, D. J Minneapolis
SErickson, R. F Minneapolis
lEricson, R. M Minneapolis
lErlich, S. P Minneapolis
JEvans, E. T Minneapolis
Evans, R. D Minneapolis
Fahr, G. E Minneapolis
§Fansler, W. A Minneapolis
tFarsht, I. J Minneapolis
tFarkas, J. V Minneapolis
Feeney, J. M Minneapolis
IFeinstein, J. Y Minneapolis
Fenger, E. P. K Oak Terrace
SFetterly, Warren Minneapolis
jjFink, L. W Minneapolis
§Fink, W. H Minneapolis
tFitzgerald, D. F Minneapolis
IFjelstad, C. A Minneapolis
Fleeson, W. H Minneapolis
§Foker, L. W Minneapolis
IFord. W. H Minneapolis
Foster, W. K Minneapolis
SFowler, L. H Minneapolis
Fox, J, R Minneapolis
Frane, D. B Minneapolis
Frank, W. L., Jr Minneapolis
Frear, Rosemary R Minneapolis
^Fredericks, G. M Minneapolis
JFredlund, M. L Minneapolis
§Fried, L. A * .... Minneapolis
JFriedell, Aaron Minneapolis
Friend, A. W Minneapolis
Frost, J. B Minneapolis
May, 1947
Frykman, H. M Minneapolis
Fuller, Alice H Minneapolis
§Funk, V. K Oak Terrace
Galligan, Margaret M. D
Minneapolis
§Galloway, J. B Minneapolis
iGammell, J. H Minneapolis
Garten, J." L '.Minneapolis
Gibbs, R. W Minneapolis
§Giebenhaan, J. N Minneapolis
§Giere, J. C Minneapolis
iGiere, R. W Minneapolis
tGiessler, P. W Minneapolis
Gilbert, M. G Minneapolis
*SGilles. F. L Minneapolis
Gingold, B. A Minneapolis
§Girvin, R. B Minneapolis
ItGoldberg, I. M Minneapolis
§Goldman, T. I Minneapolis
Goldner, M. Z Minneapolis
§Good, H. D Minneapolis
Gordon, P. E Minneapolis
Gratzek, F. R Minneapolis
§Grave, Floyd Minneapolis
Gray, R. C Minneapolis
Green, R. G Minneapolis
Grimes, Marian Minneapolis
§Gronvall, P. R Minneapolis
Groskloss, H. H Minneapolis
*Gunderson, N. A Minneapolis
§Gushurst, E. G Minneapolis
§Gustason, H. T Minneapolis
Haberer, Helen R Minneapolis
Hagen, P. S Minneapolis
fjtHagen, W. S Minneapolis
f Haggard, G. D Minneapolis
Hall, G. H., Jr ...Minneapolis
Hall, H. B Minneapolis
*Hall, J. M Minneapolis
Hall, W. H Minneapolis
Hallberg, C. A Minneapolis
*§Hamel, A. L Minneapolis
§Hamlin, G. B Minneapolis
ItHammerstad, L. M Minneapolis
Hammond, A. J Minneapolis
§Hannah, H. B Minneapolis
iHansen, C. O Minneapolis
§Hansen, E. W Minneapolis
Hansen, Olga S Minneapolis
§Hanson, H. J Minneapolis
Hanson, H. V Minneapolis
§Hanson, M. B Minneapolis
§Hanson, W. A Minneapolis
§Happe, L. J Minneapolis
§*Harrington, C. D Wayzata
’StHarrington, F. E Minneapolis
§Hart, V. L Minneapolis
§Hartig, Hermina Minneapolis
IfHartzell, T. B Minneapolis
§Hastings, D. R Minneapolis
Hastings, D. W Minneapolis
Hauge, E. T Minneapolis
Haugen, J. A Minneapolis
§Haven, W. K Minneapolis
§Hawkinson, R. P Minneapolis
§Hayes, J. M Minneapolis
tHays, A. T ...Minneapolis
§Head, D. P Minneapolis
§Head, G. D Minneapolis
Hedback, A. E Minneapolis
§Heim, R. R Minneapolis
tHendricksom J. F Minneapolis
§Henrikson, E. C Minneapolis
tHenry, C. E Kirksville, Mo.
Henry, M. O Minneapolis
Herbert, W. L Minneapolis
Hertzog, A. J Minneapolis
Higgins, J. H Minneapolis
*tHill, Eleanor J Minneapolis
IHillis, S. J Minneapolis
Hinckley, R. G Minneapolis
§Hirshfield, F. R Minneapolis
tHitchcock, C. R Minneapolis
tHoaglund, A. W
Santa Monica, Calif.
§Hodge, S. V Minneapolis
tHoffbauer, F. W Minneapolis
§Hoffert, H. E Minneapolis
isHoffman, R. A Minneapolis
§Hoffman, W. L Minneapolis
*fHoll, P. M Minneapolis
§Holmberg, C. J Minneapolis
Holzapfel, F. C Minneapolis
§Horns, R. C Minneapolis
Houkom, Bjarne Minneapolis
Hovland, M. L Minneapolis
Howard, S. E Minneapolis
Hudson, G. E Minneapolis
§Huenekens, E. J Minneapolis
§Hultkrans, J. C Minneapolis
Hultkrans, R. E Minneapolis
Hurd, Annah Minneapolis
§t Hutchinson, C. J Minneapolis
Hutchinson, D. W Oak Terrace
§Hymes, Charles Minneapolis
§Hynes, J. E Minneapolis
lams, A. M Minneapolis
Irvine, H. G Minneapolis
§Ivers9n, R. M Minneapolis
*t Jackson, G. M Minneapolis
t James, E. M Minneapolis
§Jensen, Harry Minneapolis
§t Jensen, M. J Minneapolis
Jensen, N. K Minneapolis
Jensen, R. A Minneapolis
t Jerome, Bourne Minneapolis
§Johnson, A. B Minneapolis
Johnson, A. E Minneapolis
Johnson, Evelyn V Minneapolis
Johnson, E. W Minneapolis
§Johnson, H. A Minneapolis
Ijohnson, J. A Minneapolis
tjohnson, J. W Minneapolis
§Johnson, Julius Minneapolis
§ Johnson, M. R Minneapolis
tjohnson, N. A. ..Santa Monica, Calif.
Johnson, Norman Minneapolis
Johnson, N. T Minneapolis
Johnson, R. A Minneapolis
tjohnson, Raymond A Minneapolis
Johnson, R. E Minneapolis
Johnson, Y. T Minneapolis
Jones, H. W., Jr Minneapolis
§Jones, W. R Minneapolis
Josewich, Alexander Minneapolis
§Judd, W. H. Washington, D. C.
§Jurdy, M. J Minneapolis
Kabler, P. W Minneapolis
Kalin, O. T Minneapolis
Kaplan, J. J Minneapolis
tKarleen, C. I Minneapolis
Karlstrom, A. E Minneapolis
§Kaufman, H. J Minneapolis
§Kelby, G. M ....Minneapolis
Kelly, J. P Minneapolis
§Kennedy, C. C Minneapolis
Kennedy, Jane F Minneapolis
§Kerkhof, A. C Minneapolis
Kertesz, G Minneapolis
tKing, E. A Minneapolis
King, F. W Oak Terrace
§Kinsella, T. J Minneapolis
§Kistler, A. J Minneapolis
§tKistler, C. M Minneapolis
§Knapp, M. E Minneapolis
§Knight, R. R Minneapolis
Knight, R. T Minneapolis
§Koepcke, G. M Minneapolis
Koller, H. M Minneapolis
Roller, L. R Minneapolis
Korchik, J. P Minneapolis
Koschnitzke, Herman Minneapolis
§Koucky, R. W. , Minneapolis
Kucera, F. J Hopkins
§Kucera, W. J Minneapolis
.Lagaard, S. M Minneapolis
Lajoie, J. M Minneapolis
§Lang, L. A Minneapolis
§Lapierre, A. P Minneapolis
§Lapierre, J. T Minneapolis
Larsen, F. W Minneapolis
§I,arson, C. M Minneapolis
Larson, E. A Minneapolis
§Larson, Lawrence M Minneapolis
§Larson, L. M. Oak Terrace
§Larson, P. N Minneapolis
§La yake, R. T Minneapolis
Law, S. G Minneapolis
§Laymon, C. W Minneapolis
tLeavitt, H. H Minneapolis
Lebowske, J. A Minneapolis
Lee, H. M Minneapolis
§Leland, H. R Minneapolis
§Lenz, O. A, Minneapolis
§Leonard, L. J Minneapolis
§Leonard, Sam Minneapolis
I^illehei, E. J Robbinsdale
tLind, C. J., Jr Minneapolis
Lind, C. J Minneapolis
Lindberg, A. C Minneapolis
§Lindberg, V. L Minneapolis
§Lindbloom, A. E Minneapolis
§Lindgren, R. C Minneapolis
§Lindquist, R. H Minneapolis
§Linner, H. P Minneapolis
Lippman, E. S Minneapolis
SLipschultz, Oscar Minneapolis
§Litchfield, J. T Minneapolis
Litman, A. B Minneapolis
§tLitzenberg, J. C Minneapolis
§Lofsness, S. V Minneapolis
SLogefeil, R. C Minneapolis
§Loomis, E. A Minneapolis
Lovett, Beatrice R Oak Terrace
Lowry, Elizabeth C Minneapolis
Lowry, Thomas Minneapolis
§Lufkin, N. H Minneapolis
Lund, C. J Minneapolis
549
ROSTER 1947
Lundberg, Ruth I Minneapolis
Lundblad, R. A Minneapolis
Lundblad, S. W Minneapolis
§Lundgren, A. C Minneapolis
§Lundquist, E. F Minneapolis
§Lynch, M. J Minneapolis
Lysne, Henry Minneapolis
§Lysne, Myron Minneapolis
tMacDonald, A. E Minneapolis
SMacDonald, D. A Minneapolis
§Mach, F. B Minneapolis
MacKinnon, D. C Minneapolis
§MacMillan, D. G Minneapolis
Macnie, J. S Minneapolis
§Maeder, ET. C Minneapolis
§Maland, C. O Minneapolis
§Mariette, E. S Oak Terrace
§Mark, D. B Minneapolis
SMarking, G. H Minneapolis
Martinson, C. J Wayzata
t Martinson, E. J Wayzata
tMatchan, G. R Minneapolis
Matthews, Justus Minneapolis
§Mattill, P. M Oak Terrace
§Mattson, Hamlin Minneapolis
§Maxeiner, S. R Minneapolis
§tMcCaffrey, F. J Minneapolis
McCarthy, Donald Minneapolis
McCartney, J. S Minneapolis
JMcCrimmon. H. P Minneapolis
tMcDaniel, Orianna Minneapolis
§McFarland, A. H Minneapolis
§McGandy, R. F Minneapolis
§McGeary, G. E Minneapolis
SMcInerny, M. W Minneapolis
McKelvey, J. L Minneapolis
§McKenzie, C. H Minneapolis
SMcKinlay, C. A Minneapolis
tMcKinlev, J. C Minneapolis
§McKinney, F. S Minneapolis
McMurtrie, W. B Minneapolis
§McPheeters, H. O Minneapolis
JMcQuarrie, Irvine Minneapolis
Meller, R. L Minneapolis
§Merkert, C. E Minneapolis
§Merkert, G. L Minneapolis
tMerrick, Charlotte T. ... Minneapolis
tMerrill, Elizabeth Minneapolis
§Mever, A. J Minneapolis
§Meyer, E. I, Minneapolis
Michael, J. C Minneapolis
Michel, H. H Minneapolis
§Michelson, H. E Minneapolis
tMickelsen, Emma F Minneapolis
§Miller, Harold E Minneapolis
Miller, Hugo E Minneapolis
§Miller, J. C Minneapolis
§Milton, J. S Minneapolis
§Minskv, A. A Minneapolis
Mitchell, B. D Minneapolis
Mitchell, E. C Mound
Mitchell. M. E Minneapolis
§Mitchell, M. T Minneapolis
§Moe, J. H Minneapolis
§Moen, J. K Minneapolis
Monahan, Elizabeth S Minneapolis
§Monson, E. M Minneapolis
Moos, D. J Minneapolis
Moren, Edward Minneapolis
Morrison, A. W Minneapolis
Morrison, Charlotte J Minneapolis
§Morse, R. W Minneapolis
§Murphy, E. P Minneapolis
§Murphy, I. J Minneapolis
fMusty, N. T Minneapolis
§Myers, J. A Minneapolis
§Naslund, A. W Minneapolis
§Neal, T. M Minneapolis
Neary, R. P Minneapolis
Nelson, E. N Minneapolis
tNelson, H. S Los Angeles, Calif.
§Nelson, M. C Minneapolis
SNelson, N. Harvey Minneapolis
§Nelson, O. L. N Minneapolis
StNelson, W. I Minneapolis
Nesbitt, Samuel Minneapolis
Nesset, L. B Marshall
Noonan, W. J Minneapoljs
iSNord, Robert E Minneapolis
§Noran, Harold H Minneapoljs
§Nordin, G. T Minneapolis
Nordland, Martin Minneapolis
§tNoth, H. W Minneapolis
§Nydahl, M. J Minneapolis
§Nylander, E. G Minneapolis
Nystrom, Ruth G Minneapolis
§Oberg, C. M Minneapolis
■fO’Brien, W. A Minneapolis
O’Donnell, J. E Minneapolis
Olsen, E. G Minneapolis
tjOlson, A. C Minneapolis
Olson, J. W Minneapolis
JOlson, O. A Minneapolis
§+01son, R. G Minneapolis
§Oppen, E. G Minneapolis
Otten, D. E Minneapolis
tOwre, Oscar Minneapolis
§ Paine, J. R Minneapolis
Palen, B. J Minneapolis
§*Patterson, W. E Minneapolis
§Peppard, T. A Minneapolis
Perlman, E. C Minneapolis
J Petersen, G. L Minneapolis
StPetersen, J. R Minneapolis
Peterson, Henry Minneapolis
Peterson, H. W Minneapolis
Peterson, L. J Minneapolis
Peterson, N. P Minneapolis
Peterson, O. H Minneapolis
§ Peterson, P. E Minneapolis
§Peterson, W. C Minneapolis
§Petit, J. V Minneapolis
§Petit, L. T Minneapolis
Pewters, j. T Minneapolis
Peyton, W. T Minneapolis
SPfunder, M. C Minneapolis
§Phelps, K. A Minneapolis
Plass, H. F. R Minneapolis
SPlatou, E. S Minneapolis
SPleissner, K. W St. Louis Park
Plimpton, N. C Minneapolis
§PohI, J. F Minneapolis
SPollard, D. W Minneapolis
SPollock, D. K Minneapolis
SPolzak, J. A Minneapolis
Poppe, F. H Minneapolis
§Potter, R. B Minneapolis
Pratt, F. J Minneapolis
§Preine, I. A Minneapolis
Preston, P. J Minneapolis
Priest, R. E Minneapolis
St Prim, J. A Minneapolis
Proffitt, W. E Minneapolis
SProshek, C. E Minneapolis
JtPumala, E. E Minneapolis
§Quello, R. O. 15 Minneapolis
§*tQuinby, T. F Minneapolis
SQuist, H. W Minneapolis
JQuist, H. W., Jr Minneapolis
§ Ransom, H. R Osseo
Reader, D. R Minneapolis
Regan, J. J Minneapolis
SRegnier, E. A Minneapolis
Reid, L. M Excelsior
§Reif, H. A Minneapolis
§Reilev, R. E Minneapolis
SReynolds, J. S Minneapolis
SRice, C. O Minneapolis
SRichdorf, L. F Minneapolis
§Rieke, W. W Wayzata
Rigler, L. G Minneapolis
Riordan, Elsie M Minneapolis
§Risch, R. E Minneapolis
Rizer, D. K Minneapolis
Rizer, R. I Minneapolis
§*Roan, C. M Minneapolis
Roan, O. M Minneapolis
Robb, E. F Minneapolis
tjRobbins, O. F Minneapolis
Roberts, I.. T Minneapolis
Roberts, S. W Minneapolis
^Roberts, W. B Minneapolis
Robitshek, E. C Minneapolis
SRodda, F. C Minneapolis
SRodgers, C. L Minneapolis
Rogers, G. E. B Minneapolis
Rosendahl, F. G Minneapolis
$ Rosen watd, R. M Minneapolis
Roskilly, G. C. P Minneapolis
§Ross, A. J Minneapolis
SRucker, W. H Minneapolis
Rud, N. E Minneapolis
Rudell, G. L Minneapolis
Russeth, A. N Minneapolis
JRusten, E. M Minneapolis
§Ryding, V. T Howard Lake
SSadler, W. P Minneapolis
§St. Cyr, K. J Robbinsdale
§Saliterman, B. I Minneapolis
§*Salt, C. G Minneapolis
Samut'lson, Samuel Minneapolis
SSandt, K. E Minneapolis
§Sawatzky, W. A Minneapolis
§Schaaf, F. II. K Minneapolis
^Schaefer, W. G Minneapolis
JScheldrup, N. H Minneapolis
§Scherer, L. R Minneapolis
Schiele, B. C Minneapolis
§Schmidt, G. F Minneapolis
tSchmitt, A. F Minneapolis
tSchmitt, S. C Los Angeles, Calif.
tSehneider, J. P Minneapolis
Schneider, R. A Minneapolis
tSchneidman, N. R Minneapolis
Schottler, M. E Minneapolis
§ Schultz, H. J Minneapolis
StSchultz, P. J Minneapolis
tSchussler, O. F Minneapolis
5 Schwartz, V. J Minneapolis
tSchwyzer, Gustav Minneapolis
tScott, F. H Minneapolis
§Scott, H. G Minneapolis
Seaberg, J. A Minneapolis
SfSeashore, Gilbert Minneapolis
Seham, Max Minneapolis
§Seifert, M. H Excelsior
SSelieskog, S. R Minneapolis
SShandorf, J.- F Minneapolis
Shaperman, Eva P Minneapolis
§Shapiro, M. J Minneapolis
Sharp, D. V Minneapolis
§Siegmann, W. C Minneapolis
Silver, J. D Minneapolis
§fSimons, J. H Minneapolis
Simonson, D. B Minneapolis
§ Simpson, E. D Minneapolis
Sinykin, M. B Minneapolis
Siperstein, D. M Minneapolis
T§Sivertsen, Andrew Nisswa
SSivertsen, Ivar Minneapolis
SSkjold, A. C Minneapolis
§tSmisek, F. M Minneapolis
§Smith, Adam M Minneapolis
ijSmith, Archie M Minneapolis
Smith, B. A., Jr Minneapolis
Smith, H. R Minneapolis
Smith, Margaret I Minneapolis
§Smith, N. M Minneapolis
Smith, N. R Minneapolis
Soderlind, R. T Minneapolis
§Solhaug, S. B Minneapolis
§Spano, J. P Minneapolis
SSpink, W. W Minneapolis
§Spratt, C. N Minneapolis
Stahr, A. C Hopkins
§Stanford, C. E Minneapolis
State, David Minneapolis
Stebbins, T. L Minneapolis
Stein, K. E Lakeville
§Stelter, L. A Minneapolis
Stennes, J. L Minneapolis
Stenstrom, Annette T Minneapolis
SStewart, R. I Minneapolis
Stoesser, A. V Minneapolis
fStomel, Joseph. .. .Los Angeles, Calif.
tStrachauer, A. C Minneapolis
Strom, G. W Minneapolis
Stromgren, D. T Minneapolis
§Stromme, W. B Minneapolis
Stone, S^ P Minneapolis
§Strout, G. E Minneapolis
SSturre, J. R Minneapolis
§Stuurmans, S. H Minneapolis
§Sukov, Marvin Minneapolis
Sullivan, R. M Minneapolis
Sullivan, R. R Minneapolis
§*Sundt, Mathias Minneapolis
Swanson, R. E Minneapolis
Swanson, V. F Minneapolis
SSweetser, FI. B., Jr Minneapolis
tSweetser, H. B., Sr Minneapolis
§Sweetser, T. H Minneapolis
Sweitzer, S. E Minneapolis
StSwendseen, C. G Minneapolis
STangen, G. M Minneapolis
Taylor, J. H Minneapolis
§Tenner, R. J Minneapolis
§Thomas, G. E Minneapolis
+' Thomas, G. H Minneapolis
^Thompson, W. H Minneapolis
SThysell, D. M Minneapolis
STingdale, A. C Minneapolis
Titrud, L. A Minneapolis
Todd, Romona L Minneapolis
§Trach, Benedict Minneapolis
STrow, T. E Minneapolis
JTrow, W. H Minneapolis
Troxil, Elizabeth B Minneapolis
Trueman, H. S Minneapolis
§Tudor, R. B Minneapolis
§Tunstead, II. J Minneapolis
§Turnacliff, D. D Minneapolis
§Ude, W. H Minneapolis
Ulrich, H. L Minneapolis
SUndine, C. A Minneapolis
Vik, A. E Minneapolis
§Wahlquist, H. F Minneapolis
isWalch, A. E Minneapolis
SWaldron, C. W Minneapolis
§ Wall, C. R Minneapolis
Walsh, F. M Minneapolis
Walsh, W. T Minneapolis
Wangensteen, O. H Minneapolis
Ward, P. A Minneapolis
SWatson, C. G Minneapolis
§Watson, C. J Minneapolis
Weaver, M. M Minneapolis
5 Webb, E. A Minneapolis
550
Minnesota Medicine
ROSTER 1947
§Webb, R. C Minneapolis
Werner, George Minneapolis
Werner, R. F. Minneapolis
tWest, Catharine C Minneapolis
tWestphal, K. F Minneapolis
§Wethall, A. G Minneapolis
Wetherby, Macnider Minneapolis
§Weum, T. W Minneapolis
White, A. A Minneapolis
§White, S. M Minneapolis
§White,W. D Minneapolis
§Whitesell, L. A Minneapolis
SWid'en, W. F Minneapolis
Wiechman, F. H Minneapolis
Wilcox, A. E Minneapolis
§tWillcutt, C. E Phoenix, Ariz.
JWildebush, F. F Minneapolis
Wilder, K. W Minneapolis
§ Wilder, R. E Minneapolis
Wilder, R. M., Jr .Minneapolis
§Wilken, P. A Minneapolis
tWilliams, Robert Carthage, 111.
Winther, Nora M. C Minneapolis
IWipperman, F. F Minneapolis
§Witham, C. A Minneapolis
Wittich, F. W Minneapolis
Wolf, A. H Minneapolis
*Wolf, W. W Minneapolis
iWohlrabe, A. A Minneapolis
tWright, C. D Minneapolis
§Wright, S. G Minneapolis
Wright, W. S Minneapolis
Wyatt, O. S Minneapolis
Wynne, H. M. N Minneapolis
§Ylvisaker, R. S Minneapolis
§YotTg, O. W Minneapolis
Zierold, A. A Minneapolis
§Zinter, F. A Minneapolis
Ziskin, Thomas Minneapolis
KANDIYOHI- SWIFT-MEEKER COUNTY MEDICAL SOCIETY
Regular meetings, second Wednesday of month
Annual meeting, November
Number of Members: 40
President
Lindley, S. B Willmar
Secretary
Wilmot, H. E Litchfield
Anderson, R. E Willmar
Arnson, J. M Benson
Bosland, H. G Willmar
§Branton, B. J Willmar
Daignault, Oscar .Benson
Danielson, K. A Litchfield
Danielson, Lennox Litchfield
Dille, D. E Litchfield
§Doswell, W. J Kerkhoven
Eberley, T, S Benson
Fisher, J. M Willmar
Frederickson, Alice C Willmar
Frederickson, G. U. Y Willmar
Frisch, F. P Willmar
§Frost, E. H Willmar
Giere, S. W Benson
Gilman, L. C Willmar
Hodapp, R. J Willmar
STacobs, D. L Willmar
§Jacobs, J. C Willmar
Johnson, Hans Kerkhoven
Kaufman, E. J Appleton
Lindley, S. B Willmar
Macklin, W. E Mankato
Mattson, Albert D Madison
Michels, R. P Willmar
O’Connor, D. C Eden Valley
Penhall, F. W Willmar
Peterson, Willard E Willmar
Porter, 0. M Willmar
Proeschel, R. K Willmar
Ripple, R. J New London
Rygh, Harold N Atwater
tScofield, C. L Benson
Sellers, G. K Dassel
Solsem, F. N Ah-Gwah-Ching
Telford, V. J Litchfield
Tyler, S. H Raymond
Wilmot, C. A Litchfield
Wilmot, H. E Litchfield
LYON-LINCOLN COUNTY MEDICAL SOCIETY
Regular meetings, first Tuesday of month
Annual meeting, last Tuesday in October
Number of Members: 26
President
Wolstan, S. D Minneota
Secretary
Workman, W. G Tracy
Akester, Ward Fergus Falls
Eckdale, J. E Marshall
Ferguson, W. C Walnut Grove
§Ford, B. C Marshall
Frank, J. E Marshall
Friedell, George Ivanhoe'
Gray, F. D Marshall
Helferty, J. K Minneapolis
Hermanson, P, E Hendricks
§Hoidale, A. D Tracy
Johnson, P. C Tyler
Kreuzer, T. C Marshall
Murphy, J. E Marshall
Patterson, R. B Marshall
Purves, G. H Hendricks
Remsberg, R. R Tracy
t Robertson, J. B. .
fSanderson, E. T.
Sether, A. F
Smith, L. A
Thompson, C. O,
Vadheim, A. L. ..
Vadheim, L. A.
§Valentine, W. H..
Wolstan, S. D. ..
Workman, W. G. .
Yaeger, W. W. .
McLEOD COUNTY MEDICAL SOCIETY
Regular meetings, second or third Wednesday of month
Annual meeting, January
Number of Members: 19
President
Truesdale, C. W Glencoe
Secretary
Gridley, J. W Glencoe
Brink, D. M Hutchinson
Clement, J. B Lester Prairie
Goss, H. C Glencoe
Goss, Martha D Glencoe
Gridley, J. W Glencoe
Holm, H. H Glencoe
Jensen, A. M Brownton
Kallestad, L. L Hutchinson
§Klima, W. W Stewart
Lippmann, E. W Hutchinson
McMahon, M. J Green Isle
Neumaier, Arthur..
Peterson, K. H. ...
Rempel, D. D
Sahr, W. G
Scholpp, O. W. ...
Selmo, J. D
§Sheppard, C. G....
Truesdale, C. W. . .
Trutna, T. J
Minneapolis
.Alexandria
. . . . Ruthton
. . . .Balaton
. .Hendricks
Tyler
Tyler
.Tracy
. . . Minneota
Tracy
. . . Marshall
Glencoe
.... Hutchinson
. Lester Prairie
. . . .Hutchinson
.... Hutchinson
Norwood
.... Hutchinson
........ Glencoe
. . . . Silver Lake
MOWER COUNTY MEDICAL SOCIETY
Regular meeting, last Thursday of each month
Annual meeting, December
Number of Members: 27
President
Leek. P. C Austin
Secretary
Rosenthal, F. H Austin
S*AUen, C. C Austin
§Allen, H. B Austin
SAnderson, D. P., Jr Austin
§Barber, Tracy £ Austin
SCronwell, B. J Austin
Fisch, H. M Austin
SFlanagan, L. G Austin
§Grise, W. B Austin
§Havens, J. G. W Austin
Hegge, O. H Austin
§Hegge, R. S Austin
Henslin, A. E Le Roy
Henslin, M. E Le Roy
§Hertel, G. E Austin
JLeck, P. C Austin
§Lommen, P. A Austin
SMcKenna, J. K.. . . .
Melzer, G. R
Morse, M. P
SRobertson, P. A...
§Rosenthal, F. H..
Schneider, P. J
§Schottler, G. J.. . .
SSheedy, C. L
Thomson, J. M. . .
§Wilson, F. C
§Wright, R. R
Austin
Lyle
. . . . Le Roy
. . . . .Austin
Austin
Adams
Dexter
. . . . .Austin
Minneapolis
Austin
Austin
President
Johnson, H. O
Secretary
Wohlrabe, C, F
tAitkens, H. B
Coveil, W. W
§Curtis, R. A.
fEricson, Swan
May, 1947
NICOLLET-LE SUEUR COUNTY MEDICAL SOCIETY
Regular meetings, every four months
Annual meeting, December
Number of Members : 24
Freeman, G. H... St. Peter
..Mankato §Giroux, A. A North Mankato
§Grimes, B. P St. Peter
,, , §Hiniker, P. J Le Sueur
•Mankato Holtan, Theodore Waterville
§Johnson, H. C North Mankato
.LeCenter Kolars, J. J Faribault
• St. Peter Lanhoff, A. H St. Peter
• LeCenter §Larson, M. H Nicollet
Le Sueur §Lenander, M. E St. Peter
SjNavratil, D. R..
§Nilson, H. j. . . . .
§01manson, E. G.
§01son, D. C
§Sonnesyn, N. N.
SSjostrom, L. E.
SStrathern, C. S. .
§Strathern, F. P. .
§Traxler, J. F. ...
§Wohrabe, C. F. .
Montgomery
...North Mankato
St. Peter
Gaylord
Le Sueur
St. Peter
St. Peter
St. Peter
....... Henderson
...North Mankato
551
ROSTER 1947
OLMSTED-HOUSTON-FILLMORE-DODGE COUNTY MEDICAL SOCIETY
Regular meetings, first Wednesday every odd month
Annual meeting, November
Number of Members: 6 62
President
Gray, H. K Rochester
Secretary
Carryer, H. M Rochester
Abbott, K. H Rochester
§Adams, R. C Rochester
§Adson, A. W Rochester
§Ahlfs, J. J Caledonia
§Aldrich, C. A Rochester
§Allen, E. V Rochester
§Alvarez, W. C Rochester
Amberg, Samuel Rochester
Ambrusko, T. S Rochester
Anderson, C. D Rochester
Anderson, M. E., Jr Rochester
§Anderson, M. J Rochester
§Anderson, M. W Rochester
*Anderson, N. E Harmony
§Anderson, R. E Rochester
Arling, P. A Rochester
{Ashburn, F. S Rochester
§Ashley, VV. F Rochester
§Askren, E. L., Jr Rochester
Babb, F. S Rochester
§Bacon, J. F Rochester
§Bailey, J. A Rochester
§Baggenstoss, A. H Rochester
§ Bailey, J. A Rochester
§Bair, H. L Rochester
§Baker, G. S Rochester
Baker, H. R Havfield
§Balfour, D. C Rochester
§{ Balfour, D. C, Jr Rochester
§Balfour, W. M Rochester
J Banner, E. A Rochester
§Bargen, J. A Rochester
§ Barger, J. D Rochester
§Barker, N. W Rochester
§Barnes, A. R Rochester
{Barr, M. M Rochester
Bayrd, E. D Rochester
Beahrs, O. H Rochester
§Beare, J. B Rochester
{Bearzy, H. T Rochester
§Belote, G. B Caledonia
^Benedict, W. I Rochester
{Bennett, J. G Rochester
Bennett, J. K Phoenix, Ariz.
{Bennett, VV. A Rochester
§Berkman, D. M Rochester
§ Berk man, D. S Rochester
SBerkman, J. M Rochester
§Bickel, W. H Rochester
§Bigelow, C. E Dodge Center
Biorn, C. L Rochester
Black, A. S., Jr Rochester
Black. B. M Rochester
Black, W. A Rochester
Blackburn, C. M Rochester
{Blaisdell, J. S Rochester
§Boothby, W. M Rochester
§ Bowing, H. H Rochester
Boylan, R. N Rochester
§Braasch, W. F Rochester
§Braastad, F. W Rochester
Bradley, VV. F Rochester
Braudes, R. W Rochester
{Breslow, Lester Rochester
Briggs, Natalie M. . .Wenatchee, Wash.
§Broders, A. C Rochester
Brooks. L. M Rochester
Brooksbv, W. A Rochester
§Brown, A. E Rochester
§Brown, H. A Rochester
§Brown, H. S Rochester
Brown, M. H Rochester
§Brown, P. W Rochester
Browning, W. H Rochester
Brownson, B. C Rochester
§Brunsting, L. A Rochester
Bryan, A. L Rochester
§Buie, Louis A Rochester
§Burchell, H. B Rochester
Bush, R. P Rochester
§Butt, H. R Rochester
§Cain, J. C Rochester
Cameron, J. M Rochester
§Camp, J. D Rochester
^Campbell, D. C Rochester
Cariker, Mildred Rochester
{Carmona, M. G Rochester
^Carpenter, R. E Rochester
Carr, D. T Rochester
§Carryer H. M Rochester
Carter, J. W., Jr Rochester
Chapman, J. P., Jr Rochester
Chesley, G. L Rochester
Christensen, N. A Rochester
Ciaramelli, Letizia C Rochester
§Clagett, O. T Rochester
Clark, F. H Rochester
SClark, L. W Spring Valley
{Clarkson, W. R Rochester
§Clifton, T. A Chatfield
{Cluxton, H. E., Jr Rochester
Collett, R. W Rochester
§Comfort, M. VV' Rochester
§ Conley, F. VV Rochester
Connery, D. B Rochester
§tConnor, H. M Rochester
§Cook, E. N Rochester
Cooper, Talbert Rochester
§Corbin, K. B Rochester
Costin, M. E., Jr Rochester
SCounseller, V. S Rochester
§Coventry, M. B Rochester
Cox, VV. B Rochester
*Cragg, R. VV Rochester
§Craig, M. S., Jr Rochester
§ Craig, VVT. McK Rochester
tCrewe, J. E Rochester
Cronkite, A. E Rochester
§Crowley, D. F., Jr Rochester
Cunningham, B. P. . Bridgeport, Conn.
Cunningham, E. S., Jr Rochester
Custer, M. D Rochester
{Dahleen, H. C Rochester
§Dahlin, D. C Rochester
§Daniels, B. T Rochester
Darling, J. P Rochester
t Daugherty, G. W Rochester
§Daut, R. V Rochester
{Davies, L. T Rochester
§Davis, A. C Rochester
Davis, I. G Rushford
{Davis, R. M Rochester
Day, Lois A Rochester
SDearing, VV. H., Jr Rochester
{DeForest, R. E Rochester
Demong, C. V Rochester
§Desjardins, A. IT Rochester
Deterling, R. A Rochester
Devine, K. D Rochester
DeVoe, R. VV Rochester
Devney, J. W Rochester
DeWeerd, J. H Rochester
§ Dickson, J. A.. Jr Rochester
Diessner. G. R Rochester
Dille, R. S Rochester
SDixon, C. F Rochester
§Dockerty, M. B Rochester
Doehring. P. C., Jr. ..Boston, Mass.
Dolder, F. C Eyota
{Donoghue, F. Rochester
§Dornberger, G. R Rochester
Douglas, J. M Rochester
1 Douglass. B. E Rochester
f Drake, F. A Lanesboro
Drips, Della G Rochester
{Drumheller, J. F Rochester
§Dry, T. J Rochester
DuMais. A. F Rochester
§Dunn, J. H Rochester
§Eaton, L. M Rochester
Edwards, J. E Rochester
Eckstam. E. E Rochester
Eger, Alban Rochester
§Elkins, E. C Rochester
Ellliott. R. B Rochester
J Ellis, F. H Rochester
Ellison, A. B. C Rochester
Emerson, G. F Rochester
§Emmett, J. L Rochester
§Erich, T. B Rochester
§ Estes, J. E Rochester
§Eusterman, G. B Rochester
fEvarts, A. B Rochester
§Faber, J. E Rochester
Faber, VV. M Rochester
Fair, E. E Rochester
§Farber, E. M Rochester
Faulconer, A.. Jr Rochester
Fawcett, R. M Rochester
§Feldman, F. M Rochester
Ferguson, W. J., Jr Rochester
J Ferguson, W. J Rochester
§Ferris, D. O Rochester
{Ferris, H. A., Jr Rochester
§Figi, F. A Rochester
Fisher, R. L Rochester
§Fitzgibbons, R. J Rochester
SFlasher, Jack Rochester
§Flashman, F. L Rochester
Fletcher, Mary E. H Rochester
Flickinger, F. M Lima, Ohio
§Flinn, J. H Rochester
{Foerster, J. M Rochester
{Fogarty, C. VV., Jr...
§Forney, R. A
Foss, E. L
{Freeman, J. G
§Fricke, R. E
Fryfogle, J. D
§Gaarde, F. W
§Gaarde, F. W., Jr....
§Gambill, E. E
Gastineau, C. F
Gentling, A. A
Gentry, R. VV'
§Ghormley, R. K
Gibson, R. H
{Giffin, H. M
§Giffin, PI. Z
Giffin, Mary E
§ Glenn, W. V
Glover, R. P
{Golden, P. B
Golden, R. F
§Good, C. A., Jr
Gordon, N. F
Gorsuch, M. T
§Graham, F. M
§Graham, R. B
Graham, R. J
Gramse, A. E
§Gray, H. K
Greene, L. F
Griess, D. F
Griffin, J. G
§Grindlay, J. H
§Groom, Dale
Gross, J. B
§Grotting, J. K
{Guernsey, D. E
§Habein, H. C
§Hagedorn, A. B
Haines, R. D
§Haines, S. F
§Hall, B. E
§Hallberg, O. E
§Hallenbeck, D. F. . . .
§Hallenbeck, G. A....
Hamilton, D. F
{Hamm, R. S
Hammes, E. M., Jr.
{Hanlon, G. H
Hansbro, G. L
Hanson, N. O
Hare, Helen J
§Hargraves, M. M....
^Harrington, S. VV. . . .
{Hart. G. M
SHartigan, J. D
§Hartman, H. R
Harvey, George’, Tr. ..
Hasskarl, W. F., Jr.. .
Hatcher, A. C
§Havens, F. Z
§Haynes, Allan
Headlev. N. E
§Heck, F. J
§Heersema, P. H
Heilman, F. R
Heinrich, VV'. A
tHelland, G. M
SHelland. T. VV
gHelmholz,’ H. F
§Hempstead, B. E. . . .
SHench, P. S
Henderson, E. D. . .
S Henderson, J. VV'
{Henderson, L. L
SHenderson, M. S. . . .
SHenegar, G. C
Henkel, H. B
SHerbst, R. F
SHerrell, VV. E
Hewitt, Edith S
{Hewitt, R. M
fHeyerdale, O. C
Heyerman, O. T
Higgins, R. S
Higginson, J. F
Hightower, N. C., Jr...
SHill, J. R
§ Hilton, PI. D
§Hines, E. A., Jr
§Hinshaw, H. C
§Hodgson, C. H
Hodgson, J. R
Hollenhorst, R. VV'....
§Holmes, C. L
§Holt, R. P
SHoon, J. R
§ Hoppes, E. E
SHoran, M. J
§Horton, B. T
. . .Rochester
. . . Rochester
... Rochester
. . . Rochester
. . .Rochester
... Rochester
... Rochester
... Rochester
. . .Rochester
. . . . Rochester
... Rochester
... Rochester
... Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . .Rochester
. . . . Rochester
. . . .Rochester
. . . Rochester
. . .Rochester
. . . .Rochester
. . . . Rochester
. . . .Rochester
... Rochester
... Rochester
. . .Rochester
. . . . Rochester
. . . . Rochester
. . . .Rochester
. . . .Rochester
. . . . Rochester
. . . .Rochester
. . . . Rochester
. .Minneapolis
. . . . Rochester
. . . . Rochester
. . . .Rochester
. . . . Rochester
. . . . Rochester
. . . .Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . .Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
Spring Grove
Spring Grove
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . .Rochester
. . . .Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
Wykofi
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . .Rochester
. . . . Rochester
. . . .Rochester
. . . .Rochester
. . . . Rochester
. . . .Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . .Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . . Rochester
. . . .Rochester
552
Minnesota Medicine
ROSTER 1947
Hosfeld. S. Marjorie Rochester
§Howell, L. P Rochester
Hughes, T. J Rochester
§Hunt, A. B Rochester
Hunt, V. W Rochester
J Hurley, J. P Rochester
Hutchins, S. P. R Rochester
Irmisch, G. W Rochester
Irons, W. E Rochester
♦ Iverson, H. A Rochester
Ivins, J. C Rochester
§Jackman, R. T Rochester
Sjjackson, H. S Rochester
lanes, J. M Rochester
t Jennings, D. T Rochester
Johns, Sylvia Rochester
§ Johnson, B. H., Jr Rochester
tTohnson, C. C Rochester
§ Johnson, C. R Rochester
Johnson, M. A Rochester
Johnson, R. B Lanesboro
Tondahl, W. H Rochester
§Jones, R. H., Jr Rochester
§Joss, C. S Rochester
ijjudd, E. S., Jr Rochester
Karstens, H. C Rochester
§Keating, F. R., Jr Rochester
§ Keating, J. U Rochester
Keeley, J. K Rochester
Keffer, W. H Rochester
§Keith, H. M Rochester
§Keith, N. M Rochester
Kelsey, M. P Rochester
Kemper, C. M Rochester
§Kennedv, R. L. J Rochester
Kennedy, T. J Rochester
§Kepler, E. J Rochester
Kern, C. E Rochester
§Kernohan, J. W Rochester
§Kierland, R. R. Rochester
§Kiernan, P. C Rochester
§Kirby, J. L Rochester
Kirkland, W. G Rochester
§Kirklin, B. R Rochester
§Kirklin, O. L Rochester
Klontz, C. E., Jr Rochester
tKnisely, R. M Rochester
j Knutson, J. R. B Rochester
§ Knutson, E. A Spring Grove
§Koelsche, G. A Rochester
Kreilkamp, B. L Rochester
§Krusen, F. H Rochester
Kurzweg, F. T Rochester
§Kvale, \V. F Rochester
§Lake, C. F Rochester
jjEampert, E. G Rochester
Lander, H. H Rochester
Landry, R. M Rochester
§Lannin, J. C Mabel
Large, H. R. Rochester
Larrabee, W. F., Jr Rochester
§Latterell, K. E Rochester
§ Leary, \V. V Rochester
Leavitt, M. D Rochester
LeBlttnc, L. J Rochester
§Leddy, E. T Rochester
§Lee, J. B Rochester
JLemon, W. E Rochester
§Lemon, W. S Rochester
Levin, Louis Rochester
Lightfoot, Grace K Rochester
iLillie, H. I Rochester
§Lillie, J. C Rochester
SLipscoinb, P. R Rochester
*|Lochead, D. C Rochester
Lofgren, K. A Rochester
§Logan, A. H Rochester
§Logan, G. B Rochester
Lombardi, A. A Rochester
Long, Mary Rochester
Loose, W. D Rochester
§Love, J. G Rochester
§Lovelady, S. B Rochester
SLovshin, L. L Rochester
§Lowe, G. H Rochester
§Loyd, E. L Rochester
§Ludden, T. E Rochester
Luellen, T. J Rochester
§Lundy, J. S Rochester
§Lyman, R. W Rochester
Lynch, J. L Rochester
Lynch, R. C New Orleans, La.
§MacCarty, C. S Rochester
StMacCarty, W. C Rochester
§Macdonald, I. D Rochester
§MacLean, A. R Rochester
JMacMurtrie, W. J., Jr
Bethesda, Md.
Macy, Dorothy Rochester
§Magath, T. B Rochester
SfMann, F. C Rochester
§Marek, F. H Rochester
Margulies, Harold Rochester
Marr, G. E Rochester
May, 1947
Martens, T. G Rochester
Marvin, C. P Rochester
§Masson, D. M Rochester
§Masson, J. C Rochester
§Mayfield, L. H Rochester
§Mayo, C. YV Rochester
§ May turn, C. K Rochester
McAnally, A. K Rochester
SMcBean, J. B Rochester
McClellan, J. T Rochester
§McConahey, W. M., Jr Rochester
McCreight, W. G Rochester
§ McDonald, J. R Rochester
§McElin, T. W Rochester
McEachern, C. G Rochester
§McGuff, P. E Rochester
McKaig, C. B Pine Island
McLaughlin, B. H Rochester
§McMahon, J. M Rochester
McMillan, J. T Rochester
§McQuarrie, H. B Rochester
McVicker, J. H Rochester
t Meadows, J. A Rochester
§Merritt, W. A Rochester
Messier, J. D Rochester
§ Meyer, A. C Rochester
Meyer, W. M Rochester
Meyerding, H. W Rochester
Meyers, W. C Rochester
Mezen, J. F Rochester
Millen, F. J Rochester
JMiller, Sidney Rochester
§Moersch, F. P Rochester
§Moersch, H. J Rochester
Montgomery, G. E Rochester
§Montgomery, Hamilton Rochester
Morgan, E. H Rochester
Morgan, J. L Rochester
§Morlock, C. G Rochester
§Morris, D. S Rochester
Morrow, J. R Rochester
Morton, R. J Rochester
Mulmed, E. I Rochester
tMurphy, J. T Rochester
Murphy, M. E Rochester
♦ Murray, R. A Rochester
Musgrove, J. E Rochester
Mussey, Mary E Rochester
§Mussey, R. D Rochester
Mussey, R. D., Jr Rochester
§Myers, T. T Rochester
tNay, R. M
§Nehring, J. P....
Neibling, H. A. . .
§New, G. B
§Nichols, D. R. . . .
tNickeson, R. W..
Nielsen, W. L
Nix, J. T
Nixon, R. R.
Nordland, M. A.
Norley, Theodore
Norris, N. T. . .
Norval, M. A
O’Brien, R. W...
§Odel, H. M
Olcott, E. D. . . .
§0’Leary, P. A...
lOlsen, A. M
§01son, E. A
§01son, G. E
Olson, O. C
Olson, S. W
O’Neal, Ruth
Onsgard, L. K. .
tOsborn, J. E
Owen, A. C. ...
Rochester
...!.. Preston
.... Rochester
. . . .Rochester
... .Rochester
.... Rochester
.... Rochester
.... Rochester
Rochester
Rochester
Rochester
Caledonia
. . . .Rochester
.... Rochester
Rochester
Rochester
.... Rochester
.... Rochester
. . . Pine Island
West Concord
... .Rochester
... .Rochester
.... Rochester
Houston
.... Rochester
Rochester
JPaalman, R. J Rochester
Palmer, J. K Rochester
Parke, F. F Rochester
§ Parker, H. L Rochester
jjParker, R. L Rochester
Parkhill, Edith M Rochester
Parkin, T. W Rochester
Paschall, Jack, Jr Rochester
Paulsony J. A Rochester
Pearson, C. C Rochester
Pearson, D. J. ..Battle Creek, Mich.
Pease, Gertrude L Rochester
§Peltzer, W. E Rochester
SPemberton, J. dej Rochester
§ Pender, J. W Rochester
Perkins, R. F Rochester
§ Perry, E. L Rochester
t Peters, G. A Rochester
§Petersen, M. C Rochester
§ Peterson, J. R Rochester
Pfuetze, M. E Rochester
Phillips, S. K Rochester
§Pierce, P. P Rochester
§Piper, M. C Rochester
§Plummer, W. A Rochester
SPolley, H. F Rochester
§*Pollock, L. W Rochester
§Pool, T. L
§ Poore, T. N
§Popp, W. C
§ Powers, F. H
§Prangen, A. D
§Pratt, 'J- H
Pratt, W. C
Preston, F. W
♦ Preston, L. F
§Prickman, L. E....
5 Priestley, J. T
§ Pruitt, R. D
§Pugh, D. G
Pugh, P. F. H
Pyle, Marjorie M..
§Ralston, D. E
Ramsey W. H. II..
§ Randall, L. M
Rang, R. H
§ Rasmussen, W. C. . .
Remington, J. H. . . .
Rice, Roberta G. . .
SRisser, A. F
SRivers, A. B
§*Robertson, H. E. ..
Robson, J. T
Rogers, J. D
SRogne, W. G
Rosenbaum, E. E. . . .
Rosenow, E. C
Rosenow, J. H
Rovelstad, R. A
§ Rucker, C. W
Ruff, C. C
Rulison, E. T., Jr...
tRushton, J. G
StRuss, F. H
Ryan, R. E
§Rynearson, E. H....
Salassa, R. M
§ Sanford, A. H
Sauer, W. G
§ Sayre, G. P
Scales, J. R
Scanlon, R. L
Schafer, L. A
Scheiflev, C. H
Schmidt, E. C
SiSchmidt, H. W
tSchmitt, G. F
JScholten, R. A
Seebach, Lydia M..
Seiler, H. H
§Seldon, T. H
tSengpiel, G. W
SSeybold’, W. D
SShellito, J. G
Sheridan, Viola E...
SShick, R. M
tShonyo, E. S
Short, C. A., Jr
Shullenberger, C. C.
Sicher, W. D
§Simonton, K. M
♦ Skillern, P. G„ Jr..
Skroch, E. E
Slaughter, O. L
§Slocumb, C. H
Smith, F. H
§Smith, F. L
SSmith, F. R
§ Smith, H. L
§Smith, L. A
jiSmith, N. D
§Smith, O. O., Jr....
Smith, R. S
§Snell, A. M
Snider, G. G
Spar, A. A
§ Sprague, R. G
ISpray, Paul
§Stark, D. B
t Stark, F. M
tStarks, W. O
Stein, B. R
§ Stevens, J. E., Jr...
§Stickney, J. M
§StiIwell, G. G
Stokes, G. D
Stout, H. A
Stover, Lee
SStroebel, C. F., Jr..
§ Strong, M. L
Stuart, R. L
fSutherland, C. G....
§Svien, H. J
tTaylor, J. C
Thomas, J. F
^Thompson, G. J
Thorson, S. B
Tice, G. I
tTice, W. A
§Tillisch, J. H
Tomlin, H. M
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Stewartville
Rochester
Rochester
Rochester
Rochester
...Spring Grove
Rochester
Cincinnati, Ohio
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
.Kingsville, Tex.
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
Rochester
553
ROSTER 1947
Tompkins, S. F Rochester
Tosseland, N. E Rochester
§Tuohy, E. B Rochester
Turner, J. L Rochester
Uhrich, E. C Rochester
§Uihlein, Alfred Rochester
§Underdahl, L. O Rochester
Upshaw, Bette Y Rochester
tUrban, D. A Rochester
§Van Cleve, H. P„ Jr Rochester
Van Herik, Martin Rochester
Varney, J. H Rochester
§ Vaughan, L. M Rochester
§Vaughn, L. D Rochester
Vigran, Myron Rochester
SjWagener, H. P Rochester
§ Wakefield, E. G Rochester
Walsh, A. C Rochester
§ Walsh, M. N Rochester
{(Walters, Waltman Rochester
+ Ward, B. H Rochester
Warren,, W. B Rochester
Washko, P. J Rochester
§Watkins, C. H Rochester
Watkins, D. H Rochester
§ Waugh, J. M Rochester
Webb, Margaret A Rochester
§ Weber, H. M Rochester
SWeed, L. A Rochester
SWeir, J. F Rochester
Weisman, S. J Rochester
Weismann, R. E Rochester
§Wellner, T. O Rochester
Wells, G. R Rochester
SWells, J. J Rochester
§ Westrup, J. E Rochester
White, E. F., Jr Rochester
White, N. K Rochester
Whitehouse, F. R Rochester
Whitesell, F. B Rochester
§Wilder, R. M .Rochester
SWilliams, H. L., Jr Rochester
§Williams, R. R., Jr Rochester
Williams, R. V Rushfoid
§Willius, F. A Rochester
SWilmer, H. A Rochester
Wilson, G. T Rochester
Wilson, J. M Rochester
Wilson, J. W Rochester
§ Wilson, R. V Rochester
S Winchester, W. W Rochester
§Wise, R. W. E Rochester
Wold, L. E Rochester
SWollaeger, E. E Rochester
§Woltman, H. W Rochester
8 Wood, H. G Rochester
tWood, W. D Rochester
Woodruff, C. W Chatfield
Wozencraft, J. P Rochester
§ Young, H. H Rochester
Zaslow, Jerry Rochester
PARK REGION DISTRICT AND COUNTY MEDICAL SOCIETY
Douglas, Grant, Otter Tail and Wilkin Counties
Regular meetings quarterly
Annual meeting, December
Number of Members : 58
President
Sather, E. R Alexandria
Secretary
Baker, C. E Herman
§Arndt, H. W Detroit Lakes
§ Baker, A. C Fergus Falls
Baker, C. E Herman
§Baker, N. H Fergus Falls
Baker, Jeannette L Fergus Falls
Bergquist, K. E Battle Lake
Bigler, I. E Perham
§Blakey, A. R Osakis
jiBoline, C. A Battle Lake
§Boyd, L. M Alexandria
SBurnap, W. L Fergus Falls
Cain, J. H Hoffman
Carlson, C. E Alexandria
Clifford, G. W Alexandria
§Combacker, L. C Fergus Falls
§ Drought, W. W Fergus Falls
Esser, John Perham
SEstrem, C. O Fergus Falls
SEstrem, R. D Fergus Falls
Hanson, E. C New York Mills
SHaske'll, A. D Alexandria
jiHeiberg, E. A Fergus Falls
§Helseth, H. K Fergus Falls
Jacobs, G. C F’ergus Falls
§ Jacobson, C. W Breckenridge
Johnson, O. V Fergus Falls
§Kierland, P. E Alexandria
Leibold, H. H Parkers Prairie
§Lewis, A. J Henning
Love, F. A Carlos
§Lund, C. J. T Fergus Falls
Miller, W. A New York Mills
8Mouritsen, G. J Fergus Falls
SNaegeli, F. A Fergus Falls
Nelson, R. A Fergus Falls
^Nelson, W. O. B Fergus Falls
O’Brien, Louis T Breckenridge
Ostergaard, Erling Fergus Falls
Parson, Lillian B Elbow Lake
Parson, L. R Elbow Lake
Patterson, W. L Fergus Falls
§ Paulson, E. C Elbow Lake
Paulson, G. S Evansville
Paulson, T. S Fergus Falls
Randall, A: M Ashby
Reeve, E. T Elbow Lake
§Satersmoen, Theodore. .Pelican Rapids
§ Sather, E. R Alexandria
SSchamber, W. F Parkers Prairie
SSchleinitz, F. B Battle Lake
§Serkland, J. C Rothsay
§Stemsrud, H. L Alexandria
Sutton, H. R Hoffman
STanquist, E. J Alexandria
§Thompson, H. B Fergus Falls
Warner, J. J Perham
§Wasson, I.. F {Alexandria
Wray, W. F. Campbell
RAMSEY COUNTY MEDICAL SOCIETY
Regular meetings, last Monday in every month excepting June, July, August
Annual meeting, last Monday in January
President
Secretary
8Ahrens, A. E.
‘tAlexander, F. H.
SArny, F. P..
§Arzt, P. K.
§Ausman C. F.
StBacon, L. C.
Barsness, Nellie O. N.
§ Barry, L. W
§Beek, H. O. .
Beer, J. J. . . .
Bennion, P. H.
Bernstein, W. C.
<,'E. T.
, R. A.
§Bock
Borg, J. F.
Bray, E. R.
§Brodie, W. D.
Brown, J. C...
Number of Members :
407
§Burch, E. P
.St. Paul
§Earl, G. A
St.
Paul
St.
t’aui
§ Burch, F. E
■ St. Paul
§Earl, 1. It
St.
Paul
Burlingame, David A
.St. Paul
Earl, Robert
St.
Paul
St
§ Burns, R. M
St. Paul
§Edlund, Gustaf
St.
Paul
Burton, C. G
.St. Paul
Edwards, J. W
St.
Paul
St.
Paul
SEusher. II. H
. St. Paul
§Edwards, T. T
St.
Paul
Paul
§Cain, ( . I
.St. Paul
Eginton. C. T
St.
Paul
St
Paul
Callahan, F. F
.St. Paul
Ely, (). S
. . . So. St.
Paul
St,
Paul
8Carley, W. A
St. Paul
§ Emerson, E. C
St.
Paul
.St.
Paul
5 Carroll, W. C
.St. Paul
SEndress, E. K
St.
Paul
St.
Paul
SChadbourn, C. R
St. Paul
Enroth, O. E
St.
Paul
St
Paul
§Chatterton, C. C
.St. Paul
Ernest, G. C. H
. . . So. St.
Paul
St.
Paul
§ Christiansen, A
. St. Paul
Ersfeld, Murray P. . .
St.
Paul
St,
Paul
'tChristison. 1. T
. St. Paul
JEshelby, E. C
St.
Paul
St
Paul
$Clark, H. B., Jr
.St. Paul
Evert, John A
St.
Paul
.St.
Paul
Cochrane, B. B
.St. Paul
tFahey, E. W
St.
Paul
. St,
Paul
Coddon, W. D
.St. Paul
§ Ferguson, T. C
St.
Paul
St
Paul
5 Colby, W. 1
.St. Paul
SFessler, H. II
St.
Paul
.St.
Paul
8 Cole, W. H
. St. Paul
Fink, It. L
St.
Paul
.St.
Paul
fCollte, H. G
.St. Paul
Fisher, Isadore
St.
Paul
Sr
Paul
Colvin, A. R
ijFlanagau, H. F
St.
Paul
St.
Paul
Connolly, C. I
-St. Paul
FTink, E. B
St.
Paul
St
Paul
§ Connor, ( . E
SF'ogarty, C. W
St.
Paul
St
Paul
SCook, C. K
§Fogelberg, E. T
St.
Paul
St
Paul
§ Cooper, C. C
.St. Paul
§ Foley, F. E. B
St.
Paul
.St.
Paul
SCountryman, R. S
St. Paul
Freeman, C. I)
St.
Paul
.St.
Paul
ICowern, E. VV No,
. St. Paul
Freidman, L. L
St.
Paul
St
Paul
§Critchfield, E. R
.St. Paul
Fritz, W. I
St.
Paul
.St.
Paul
Crombie, F. ] No,
. St. Paul
SFroats, C. W
St.
Paul
St
Paul
('rump, 1. VV
.St. Paul
Frost, Russell H
St.
Paul
.St.
Paul
SCulligan, 1 M
.St. Paul
SGarbrecht, A. W
St.
Paul
St
Paul
^Culver, L. < i
.St. Paul
Gardiner, D. G
St.
Paul
St
Paul
$Dack, L. G
.St. Paul
^Gardner, W. P
St.
Paul
St
Paul
t Daugherty, E. B.. .Marine-on
-St. Croix
Gar row, D. M
St.
Paul
St
Paul
8 Davis, F'. V
. St. Paul
Garthe, T. J
St.
Paul
St.
Paul
Davis, William
St. Paul
SGeer, E. K
St.
Paul
St.
Paul
Decker, C. H
.St. Paul
SGehlen, T. N
St.
Paul
.St.
Paul
8*DeCourcy, D. M
. St. Paul
§Geist, G. A
St.
Paul
St
Paul
8Dedolph, Karl
.St. Paul
§Ghent, Harry
St.
Paul
St
Paul
8Derauf, B. I
.St. Paul
Gibbs, E. C
St.
Paul
.St.
Paul
Deters, D. C
.St. Paul
Gilhllan, T. S
St.
Paul
.St.
Paul
§ Dickson, T. H
.St. Paul
Gilkey, S. E
St.
Paul
• St.
Paul
§*Dittman, G. C
. St. Paul
Gillespie, D. R
St.
Paul
St
Paul
Donohue, P. F
.St. Paul
tGinsberg, William....
St.
Paul
.St.
Paul
Dovre, C. M
.St. Paul
§Gjerde, W. P
St.
Paul
St
Paul
§ Drake, C. B
.St. Paul
Gleason, W. A
St.
Paul
.St.
Paul
§Dunn, T. N
St. Paul
§tGoltz, E. V
St.
Paul
554
Minnesota Medicine
ROSTER 1947
Grant, H. W St. Paul
§Gratzek, Thomas St. Paul
§Grau, R. K St. Paul
ijGruenhagen, A. P St. Paul
Gullingsrud, M. T. O Oregon
fHall, A. R ' St. Paul
Hall, H. H St. Paul
§Hammes, E. M St. Paul
Hammond, J. F St. Paul
§Hanson, H. B St. Paul
§Harmon, G. E St. Paul
gHartfiel, W. F St. Paul
Hartig, Marjorie St. Paul
^Hartley, E. C St. Paul
§Hassett, M. F St. Paul
§Hauser, V. P St. Paul
§Hayes, A. F St. Paul
§Heck, W. W St. Paul
Hedenstrom, F. G St. Paul
Henderson, A. J. G St. Paul
Hengstler, W. H St. Paul
§Hensel, C. N St. Paul
Herman, S. M St. Paul
§Heron, R. C St. Paul
§Herrmann, E. T St. Paul
Hertz, M. J St. Paul
§Hilger, A. W St. Paul
tHilger, D. D St. Paul
§Hilger, J. A St. Paul
§Hilger, L. D St. Paul
§Hilger, L. A St. Paul
Hiniker, L. P St. Paul
SHochfilzer, J. T St. Paul
§Hoff , Alfred...' St. Paul
Holcomb, O. W St. Paul
Hollinshead, W. H St. Paul
§Holmen, R. W St. Paul
§Holt, J. E St. Paul
Hopkins, G. W St. Paul
Howard, M. A St. Paul
Howard, W. S St. Paul
§HulIsiek, H. E St. Paul
§Hullsiek, R. B St. Paul
Hultgen, W. J St. Paul
Hurwitz, M. M St. Paul
§Ide, A. W St. Paul
Ikeda, Kano St. Paul
Ingerson, C. A St. Paul
Janssen, M. E St. Paul
Jesion, J. W St. Paul
§Johanson, W. G St. Paul
§ Johnson, A. M St. Paul
Johnson, C. E St. Paul
Johnson, J. A St. Paul
Jones, E. M St. Paul
§Kamman, G. R St. Paul
Kaplan, D. H St. Paul
Karon, I. M St. Paul
§Kasper, E. M St. Paul
Katzovitz, Hyman St. Paul
Keefe, R. E St. Paul
iKelly, T. V St. Paul
Kelly, P. H St. Paul
Kelsey, C. M St. Paul
Kendall, R. F St. Paul
§Kenefick, E. V St. Paul
§Kennedy, W. A St. Paul
Kenyon, T. J St. Paul
§Kesting, Herman St. Paul
King, G. L St. Paul
Kleifgen, G. V. H St. Paul
§Klein, H. N St. Paul
SfKnauff, M. K St. Paul
Knutson, G. E St. Paul
§Kugler, A. A St. Paul
Kuske, A. W St. Paul
Kvitrud, Gilbert St. Paul
§Lannin, B. G St. Paul
§Larsen, C. L St. Paul
Larson, Eva-Jane St. Paul
Larson, J. T St. Paul
Lauer, D. J Pittsburgh, Pa.
Lax, M. H St. Paul
§Leahy, Bartholomew St. Paul
§ Leavenworth, R. O St. Paul
Leick, R. M St. Paul
§Leitch, Archibald St. Paul
§Lepak, J. A St. Paul
tLerche, William Cable, Wis.
§Leven, N. L St. Paul
Leverenz, C. W St. Paul
Levin, Bert
St.
Paul
Levitt, G. X
St.
Paul
SLick, C. I
St.
Paul
Lien, R. J
St.
Paul
§Lightbourn, F.. L
St.
Paul
sJLilieberg, N. [
St.
Paul
Lippman, H. S
St.
Paul
‘tLittle, W. J
St.
Paul
§Loken, S. M
St.
Paul
Lowe, E. R
..So. St.
Paul
Lowe, T. A
. . So. St.
Paul
itLundholm, A. M
St.
Paul
§ Lynch. F. W
St.
Paul
McAdams, T. B
St.
Paul
McCain, D. L
St.
Paul
McCarthy, T. T
St.
Paul
McCarthv, W. R
St.
Paul
McClanahan, T. H
Bear
McClanahan, T. S
. . . White
Bear
McCloud, C. N
St.
Paul
SMcEwan, Alexander. . .
St.
Paul
tMcLaren, Jennette M..
. . . Minneapolis
S Madden, J. F
St.
Paul
§Madland, Robert S. . .
St.
Paul
Maertz, W. F
St.
Paul
Malerich, J. A
St.
Paul
Marks, R. W
St.
Paul
Martin, D. I
St.
Paul
§Martineau, J. 1
St.
Paul
SMeade, 1. R
St.
Paul
SMears, B. T
St.
Paul
§Medelman, T. P
St.
Paul
Melancon, j. F
St.
Paul
SMeyerding, E. A
St.
Paul
§Moga, J. A
St.
Paul
Molander, H. A
St.
Paul
Moquin, Marie A
St.
Paul
Moriartv, Berenice....
St.
Paul
Moriarty, Cecile R
St.
Paul
Muller, A. E
St.
Paul
§ Muller. R. T
St.
Paul
Naegeli, A. E
St.
Paul
§Nash, L. A
St.
Paul
§ Nelson, L. A
St.
Paul
§Nichols, A. E
St.
Paul
SNoble, T. F
St.
Paul
ijNoble, J. L
St.
Paul
Nuebel, C. 1
St.
Paul
Nye, Katherine A
St.
Paul
Nye, Lillian I
St.
Paul
O’Brien, W. M
St.
Paul
O'Connor, I.. f
St.
Paul
Oerting, Harry
St.
Paul
§ Ogden, Warner
St.
Paul
§Ohage, Justus Jr
St.
Paul
O'Kane, T. W
St.
Paul
Olsen, R. L
St.
Paul
Olson, C. A
St.
Paul
SO’Reilley, B. E
St.
Paul
ijOstergren, E. W
St.
Paul
^Ouellette, A. J
St.
Paul
§ Pearson, F. R
St.
Paul
Pearson, M. M
St.
Paul
Pedersen, A. H
St.
Paul
§ Perry, C. G
St.
Paul
Peterson, D. B
St.
Paul
^Peterson, H. O
St.
Paul
§ Peterson, T. L. E
St.
Paul
§Plondke, F. J
St.
Paul
§Prendergast, H. J
St.
Paul
Quattlebaum, F. W St Paul
Radabaugh, R. C Hastings
Ralph, J. R St. Paul
f Ramsey, W. R St. Paul
Rasmussen, R. C St. Paul
Rea, C. E St. Paul
^Richards, E. T. F. . .
St.
Paul
SRichardson, H. E. . . .
St.
Paul
Richardson, R. T. . . .
St.
Paul
Rick, P. F. W
St.
Paul
§Ritchie, W. P
St.
Paul
JjRitt, A. E
St.
Paul
SRogers, S. F
St.
Paul
Rolig, D. H
St.
Paul
ijRosenbladt, Louis...
. .Tacoma, Wash.
Rosenholtz, Burton. .
St.
Paul
§Rosenthal, Robert...
St.
Paul
§Roth, G. C
St.
Paul
Rothschild, H. J. . . .
St.
Paul
§Roy, P. C
St.
Paul
ijfRuhberg, G. XT
St.
Paul
Ruona, Martin A St. Paul
Rutherford, W. C Nisswa
Ryan, James D St. Paul
§Ryan, J. J St. Paul
§Ryan, J. M St. Paul
SRyan, M. E St. Paul
§Saruecki, M. M St. Paul
Satterlund, V. L St. Paul
§ Savage, F. J St. Paul
Schmidtke, R. L St. Paul
Schoch, R. B. J St. Paul
SSchons, Edward St. Paul
Schroeckenstein, H.F St. Paul
StSchuldt, F. C St. Paul
SSchulze, A. G St. Paul
itSchwyzer, H. C St. Paul
§Scott, E. E St Paul
Selvig, H S St. Paul
tSenkler, G. E St. Paul
§Setzer, H. J St. Paul
Shannon, W. R St. Paul
tShellman, J. L.. .Pacific Palisades, Cal.
sShimonek, S. W St. Paul
Short, Jacob St. Paul
Siegel, Clarence St. Paul
S Simons, L. T St. Paul
Singer, B. J St. Paul
STbkinner, H. O St. Paul
§Sm.isek, E. A \ St. Paul
SSmith, V. D. E St. Paul
it Snyder, G. W St. Paul
SSohlberg, O. I St. Paul
i! Sommers, Ben St. Paul
fSorem, M. B St. Paul
{iSouster, B. B St. Paul
SjSprafka, J. M St. Paul
§ Steinberg, C. L St. Paul
§Sterner, E. G St. Paul
§Sterner, E. R St. Paul
§Sterner, O. W St. Paul
Stewart, Alexander St. Paul
§*Stinnette, S. E St. Paul
SStolpestad, A. H St. Paul
SStolpestad', H. L St. Paul
SStrate, G. E St. Paul
Straus, M. L St. Paul
Strem, E. L St. Paul
Sturley, Rodney F St. Paul
Swanson, J. A St. Paul
SSwendson, J. J St. Paul
§Teisberg, C. B St. Paul
T eisberg, J. E St. Paul
Thompson, F. A St. Paul
Thoreson, M. C. Bernice.. So. St. Paul
Tifft, C. R St. Paul
Tracht, R. R St. Paul
Travis, J. S St. Paul
STregilgas, H. R So. St. Paul
Varco, R. L. St. Paul
Veirs, Dean St. Paul
Veirs, Ruby J. S St. Paul
§ Venables, A. E St. Paul
§Von der Weyer, W. H St. Paul
SWaas, C. W
§Walker, A. E
it Walter, C. W
tWard, P. D
Warren, C. A
Watz, C. E
§ Webber, F. L
iWeis, B. A
Weisberg, Maurice.
§Wenzel, G. P
Werner, O. S
tWheeler, M. W
Whitacre, J. C
*Whitemore, F. W. ..
Williams, A. B
§ Williams, C. K....
^Williams, J. A
SWilson, J. A
§ Wilson, J. V
Winnick, J. B
§Wold, K. C.
Wolff, H. J
Wolkoff, H. J
Word, H. L
Youngren, E. R. . . .
Zachman, L. L
§Zimmermann, H. B.
. .St. Paul
. . St. Paul
. .St. Paul
. . St. Paul
. .St. Paul
. . St. Paul
..St. Paul
. .St. Paul
..St. Paul
..St. Paul
Cambridge
. .St. Paul
. . St. Paul
. . St. Paul
. .St. Paul
. .St. Paul
. . St. Paul
. . . St. Paul
. . St. Paul
. . St. Paul
. . St. Paul
. . St. Paul
. . St. Paul
. . St. Paul
. .St. Paul
. . St. Paul
. . St. Paul
RED RIVER VALLEY MEDICAL SOCIETY
Kittson, Mahnomen, Marshall, Norman, Pennington, Polk, Red Lake and
Roseau Counties
Regular meetings quarterly
Annual meeting, December
Number of Members: 57
Uhley,
Sather,
President
C. G
Secretary
R. O
§Adkins, C. M. . . .
Anderson, J. T. .
Anderson, W. E.
Bechtel, M. J. . .
. . .Thief River Falls
Clearbrook
§Behr, O. K
Berge, D. O
Berlin, A. S
§Bertelsen, O. L
Roseau
Hallock
May. 1947
555
ROSTER 1947
Biedermann, Jacob.. Thief River Falls
§Bratrud, Edward. . . .Thief River Falls
§Bratrud, T. E Thief River Falls
Brink, A. A Baudette
§Brown, L. L Crookston
Carlson, A. E Warren
Covey, K. W Mahnomen
Delmore, John L. Jr Roseau
§Delmore, John L.. Sr Roseau
Delmore, R. J Roseau
Dodds, W. C Thief River Falls
§Erickson, Eskil Halstad
§Henney, W. H.e McIntosh
Hollands, W. H Fisher
Holmstrom, C. H Warren
Janecky, A. G Warroad
Johnson, H. C Thief River Falls
Johnson, R. E Crookston
Kirk, G. P East Grand Forks
Knutson, G. A Hallock
§Kostick, W. R Fertile
§Loken, Theodore Ada
§Lynde, O. G Thief River Falls
§Mellby, O. F Thief River Falls
§Mercil, W. F Crookston
Morley, G. A Crookston
Nelson, A. S Thief River Falls
Nelson, H. E Crookston
Nietfeld, A. D Warren
§Norman, J. F Crookston
SOppegaard, C. L Crookston
§Oppegaard, M. O Crookston
Parsons, J. G Crookston
Pearson, L. O Warroad
§RefT, A. R Crookston
Rydland, A. D Crookston
JSather, Allen Fosston
Sather, G. A Fosston
§Sather, R. O Crookston
§Shedlow, Abraham Fosston
Skoog-Smith, A. W Mahnomen
§Starekow, M. D. . .Thief River Falls
Stensgaard, K. L. ...Thief River Falls
Stevens, John Gonvick
§Torgerson, W. B Oklee
§Uhley, C. G Crookston
Van Rooy, G. T.... Thief River Falls
Watson, R. M Thief River Falls
§Wiltrout, I. G Oslo
Zorn, E. L Erskine
REDWOOD-BROWN COUNTY MEDICAL SOCIETY
Regular meetings quarterly
Annual meeting, May
Number of Members: 36
President
Fritsche, C. J New Ulm
Secretary
Fesenmaier, O. B New Ulm
Anderson, D. C Lamberton
§ Benton, P. C Gibbon
Bergman, O. B St. James
Bratrude, E. J St. Tames
Bregel, F. L St. James
§Cairns, R. J Redwood Falls
§Domeier. L. H New Ulm
§Dubbe, F. H New Ulm
§Dysterheft, A. F Gaylord
§Esser, O. J New Ulm
iSFesenmaier, O. B New Ulm
iiFritsche, Albert New Ulm
§ Fritsche, C. T New Ulm
§ Fritsche, T. R New Ulm
SGibbons, F. C Comfrey
§Goblirsch, A. P Sleepy Eye
§Hammermeister, T. F New Ulm
§Hovde, Rolf Winthrop
SKeithahn, E. E Sleepy Eye
SKruzick, S. J Sleepy Eye
§Kusske, A. L New Ulm
Mortensbak, H. E. .Great Falls, Mont.
§Nelson, Glen Fairfax
Nuessle, W. G Springfield
§Penk, E. L Springfield
Peterson, R. A Vesta
§Reineke, G. F New Ulm
§Saffert, C. A New Ulm
SSchroeppel, J. E Winthrop
§Seifert, O. J New Ulm
Senescall, C. R Enumclaw, Wash.
§ Vogel, H. A. L New Ulm
§ Vogel, J. H New Ulm
iiWeiser, G. B New Ulm
§Wohlrabe, E. J Springfield
RENVILLE COUNTY MEDICAL SOCIETY
Regular meetings, second Tuesday of month
Annual meeting, November
Number of Members: 21
President
Erickson, R. E Hector
Secretary
Johnson, H. E Bird Island
§Adams, R. C Bird Island
§Billings, R. E. Franklin
§Brand, W. A. Redwood Falls
Bushard, W. J Minneapolis
§Cosgriff, J. A Olivia
Ceplecha, S. F Redwood Falls
§Dordal, J Sacred Heart
§Erickson, R. E Hector
§Fawcett, A. M Renville
Flinn, T. E Redwood Falls
§Gaines, E. C Buffalo Lake
§Hinz, W. T Bird Island
§ Johnson, H. E Bird Island
Johnson, O. H Redwood Falls
§ Johnson, W. E Morgan
SLeitschuh, Henry Sanborn
Lenz, J. R Morton
§Mesker, G. H Cambridge
§ Passer, A. A Olivia
Potthoff, C. J Washington, D. C.
Priesinger, J. W Renville
President
Engberg, E. J Faribault
Secretary
Stevenson, F. W Faribault
§Dungay, N. S Northfield
§ Engberg, E. J Faribault
Francis, D. W Morristown
§Hanson, A. M Faribault
§Hanson, J. W Northfield
RICE COUNTY MEDICAL SOCIETY
Regular meetings, at call
Annual meeting, June
Number of Members: 27
Huxley, F. R Faribault
.Kennedy, G. L Faribault
§Lende, Norman Faribault
Lexa, F. J Lonsdale
McKeon, J. O Faribault
§Mears, R. F Northfield
Meyer, F. C Kenyon
Meyer, P. F Faribault
§ Moses, Joseph Jr Northfield
Moses, R. R Kenyon
Nielsen, A. M Northfield
LOUIS COUNTY MEDICAL SOCIETY
§Nuetzman, A. W Faribault
§Robilliard, C. M Faribault
Rohrer, C. A Waterville
Rumpf, C. W Faribault
tRumpf, W. H Faribault
§Stevenson, F. W Faribault
Street, Bernard Northfield
§Studer, D. J Faribault
Traeger, C. A Faribault
§ Weaver, P. H Faribault
§ Wilson, W. E Northfield
ST.
Carlton, Cook, Itasca, Lake and St. Louis Counties
Regular meetings, second Thursday every month except July and August
Annual meeting, December
Number of Members: 246
President
Wheeler, D. W Duluth
Secretary
Bagiev, Elizabeth C Duluth
§Abraham, A. L. . .
§Adams, B. S
Addy, E. R
Anderson, C. L. . .
Anderson, G. A...
Anderson, H. R. .
§Arhelger, S. W. .
§Arko, J. L
§Armstrong, E. L.
§Athens, A. G
JAyres, G. T
Bachnik, F. W...
§Backus, R. W. . . .
§Bagley, C. M
Bagley, Elizabeth
Bagley, W. R
Baich, V. M
SBakkila, H. E....
Duluth
Hibbing
Gilbert
Ely
Hibbing
Deer River
Duluth
Hibbing
Duluth
Duluth
Phoenix, Ariz.
Hibbing
Nopeming
Duluth
C Duluth
Duluth
Bovey
Duluth
§Bardon, Richard
SBarker, J. D
Barney, L. A
§ Barret t, E. E
§ Becker, F. T
Bepko, Marie K
Berdez, G. L
§ Bianco, A. J
fBinet, II. E
Blackmore, S. C
* Blakely, C. C
Bolz, J. A
Bowman, P. G
Booren, J. C
Bowen, R. L
§Boyer, S. H., Jr
Boyer, S. H., Sr
§*Braverman, N. J
Bray, K. E New
§Bray, P. N
Bray, R. B
§ Buckley, R. P
§ Butler, J. K
Duluth
Duluth
Duluth
Duluth
Duluth
Cloquet
Duluth
Duluth
Grand Rapids
Biwabik
Barnum
Grand Rapids
Duluth
Duluth
Hibbing
Duluth
Duluth
Duluth
Orleans, La.
Duluth
Biwabik
Duluth
Carlton
Cantwell, W. F. ... International Falls
Carstens, C. F Hibbing
Chapman, T. L Duluth
Cherniak, F. G. ... International Falls
SChristenson, C. H Duluth
§Clark, I. T Duluth
Clarke, E. T Buhl
§Cole, Frank Duluth
Collins, A. N Duluth
tCollins, H. C Duluth
^Coventry, W. A Duluth
§ Coventry, W. D Duluth
Cunningham, C. B Virginia
Dahlin, I. T Aurora
§Davies, R. J
Richland Highlands, Wash.
§Dickson, F. H., Jr Proctor
§Dittrich, R. J Duluth
liDoolittle, L. E Duluth
Doyle, G. C Duluth
§Eckman, P. F Duluth
SEckman, R. J Duluth
§Ekblad, J. W Duluth
556
Minnesota Medicine
ROSTER 1947
§Elias, F. J Duluth
§Emanual, K. W Duluth
Eppard, R. M Cloquet
Erskine, G. M Grand Rapids
§Estrem, T. A Hibbing
Ewens, H. B Virginia
§Fawcett, K. R Duluth
Fearing, J. E Virginia
§Fellows, M. F Duluth
Ferrell, C. R Grand Rapids
§Fischer, M. McC Duluth
Fisketti, Henry Duluth
Flynn, B. F Hibbing
§ Fredericks, M. G Duluth
Gendron, J. F Grand Rapids
§ Gillespie, M. G Duluth
§ Goldish, D. R Duluth
§Goodman, C. E Virginia
§Gowan, L. R Duluth
Graham, A. W Chisholm
§Grahek, J. P Ely
§ Graves, W. N Duluth
Grinley, A. V Grand Rapids
Haney, C. L Duluth
§Hanson, E. O Cloquet
§Harris, C. N Hibbing
Hartman, Jack Soudan
Hatch, W. E Duluth
Hathaway, S. J Tacoma, Wash.
Hayes, M. F Nashwauk
§Hedberg, G. A Nopeming
Heiam, W. C Cook
§Hilding, A. C Duluth
Hill, F. E Duluth
Hirschboeck, F. T Duluth
§Hoff, H. O Duluth
§Houkom, S. S Duluth
Hutchinson, Henry Moose Lake
Jacobson, Clarence Chisholm
§Jacobson, F. C Duluth
§ Jensen, T. J Duluth
SJeronimus, H. J Duluth
jtjessico, C. M Duluth
§ Joffe, H. H Duluth
§ Johnson, K. E Duluth
Johnsrud, L. W Chisholm
Jolin, F. M Bovey
Kelley, K. J Bigfork
Kemp, M. W Alton, 111.
^Kingsbury, E. M Moose Lake
§ Klein, Harry Duluth
§ Knapp, F. N Duluth
§ Knoll, W. V Duluth
§Kohlbry, C. O Duluth
Kotchevar, F. R Eveleth
tKozberg, Oscar Moose Lake
§ Krueger, V. R Nopeming
§La Bree, R. H Duluth
§ Laird, A. T Duluth
Lenont, C. B Virginia
Lepak, F. J
§Litman, S. N
Loofbourrow, E. H..
§Luth, D. V
tMcCoy, Mary K....
McDonald, A. L. . . .
§McHaffie, O. L
McKenna, M. J. . . .
McLane, W. O
McLeod, J. L
IMcNutt, J. R
§Macfarlane, P. H...
§ MacRae, G. C
§Magney, F. H
§Magraw, R. M
§Malmstrom, J. A...
§ Manley, J. R
fMarcley, W. T
Marshall, Helen S.
§Martin, W. C
§Mayne, R. M
Mead, C. H
§Merriman, L. L....
Meyer, J. O
Minckler, J. E
Miners, G. A
§ Minty, E. W
§Moe, R. J
Moe, Thomas
Mollers, T. P
Monroe, P. B
Monserud, N. O. . .
More, C. W
§Morsman, L. W. . . .
§Mueller, R. F
Mueller, Selma C. . .
Murray, R. A
Neff, W. S
Nelson, E. H
Nelson, L. S
§Nelson, R. L
§ Nicholson, M. A....
Norberg, C. E
§ Nutting, R. E
§ Olson, A. E
Olson, A. O
Palmer, H. A
f Parker, O. W
Parker, W. H
§ Parson, E. I
Pasek, A. W
§Patch, O. B
Pearsall, R. P
§ Pederson, R. C
Pennie, D. F
Peterson, E. N
Peterson, T. H
§ Pfuetze, K. H
Pollard, W. II., Jr.
§ Power, J. E
Duluth
Duluth
Keewatin
Duluth
Duluth
Duluth
Dpluth
...Grand Rapids
Duluth
, . . . Grand Rapids
Duluth
Chisholm
Duluth
Duluth
St. Paul
Virginia
Duluth
Minneapolis
. ..Statesan, Wis.
Duluth
Duluth
Duluth
Duluth
....Grand Rapids
St. Paul
Deer River
Duluth
Duluth
Moose Lake
..Mountain Iron
Cloquet
Cloquet
Eveleth
Hibbing
....Two Harbors
Duluth
Hibbing
Virginia
Chisholm
Hibbing
Duluth
Duluth
Cloquet
Duluth
Duluth
Duluth
Blackduck
Duluth
Chisholm
Duluth
Cloquet
Duluth
Virginia
Duluth
Duluth
Virginia
Minneapolis
....Cannon Falls
Duluth
Duluth
Puumala, R. H
Cloquet
Raadquist, C. S
Hibbing
Raihala, Tohn
§Raiter, R. F
Reed, Paul
Virginia
tRobinso'n, J. M
. . . Goshen, N. Y.
Rokala, H. E
§f Rood, D. C
Duluth
Rosenfield, A. B
Rowe, O. W
Duluth
SRowles, E. K
SRudie, P. S
§Ryan, W. J
Duluth
Sach-Rowitz, Alvin..
Moose Lake
§ Salter, R. A
Sand'ell, S. T
Sarff, O. E
Sax, M. II
Sax, S. G
§ Schneider, L. E. . . .
§Schroder, C. H
Schweiger, T. R. . . .
Seashore, R. T
*Shastid, T. PI
Duluth
Shaw, A. W
Sher, D. A
Siegel, J. S
§Sinamark, Andrew.
Sisler, C. F.
. . . . Grand Rapids
§Smith, C. M
Smith, W. R
. . . . Grand Marais
Snyker, O. E
Ely
§ Spang, A. J
Duluth
§ Spang, J. S
Duluth
Spicer, F. W
Spurbeck, R. G. . . .
Strathern, M. L. . . .
Gilbert
§Strauss, E. C
Duluth
§Strobel, W. G
Stuart, A. B
Cloquet
Sutherland, H. N. . .
Ely
Swedberg, W. A....
Duluth
§Swenson, A. O
§Taylor, C. W
Duluth
§Teich, K. W
1 luluth
§Terreil, B. J
§Tibbetts, M. H
Duluth
Tilderquist, D. I,. . . .
Tingdale, Carlyle...
Trytten, E. G
§Tuohy, E. I.
§Urberg, S. E
Duluth
Van Valkenberg, J.
D Floodwood
§t Walker, A. E
§ Wallace, M. O
§ Wells. A. H
i) Wheeler, D. W
Winter, T. A
§ Young, T. O
Duluth
tZlatovski, M. L
Duluth
SCOTT-CARVER COUNTY MEDICAL SOCIETY
Regular meetings, second Tuesday of the alternate months
Annual meeting, June
Number of Members: 29
President
Westerman, F. C Montgomery
Secretary
Schimelpfenig, G. T Chaska
Ahrens, C. F Prior Lake
Bodaski, A. A Montgomery
Bratholdt, J. W Watertown
§Buck, F. H Shakopee
Carlson, N. C Watertown
§Cervenka, C. F New Prague
§ Doherty, E. M New Prague
§Havel, H. W Jordan
Hebeisen, M. B Chaska
§Juergens, H. M Belle Plaine
Klein, J. C Shakopee
§Kortsch, F. P Prior Lake
§Kucera, S. T Lonsdale
Leibold, E. F New Prague
Martin, T. P Arlington
Nagel, H. D Waconia
Nelson, K. L Clara City
Ninneman, N. N Waconia
Novak, E. E New Prague
Olson, C. J Belle Plaine
§ Pearson, B. F. Shakopee
Pogue, R. E Watertown
§Ponterio, J. E Shakopee
t Reiter, H. W Shakopee
Schimelpfenig, G. T Chaska
§ Simons, B. H Chaska
§tWesterman, A. E Montgomery
§Westerman, F. C Montgomery
Wunder, H, E Shakopee
SOUTHWESTERN MINNESOTA MEDICAL SOCIETY
Cottonwood, Jackson, Murray, Nobles, Pipestone and Rock Counties
Regular meetings, at call
Annual meeting, October
Number of Members: 63
President
Halpern, D. J Brewster
Secretary
Mork, B. O., Jr Worthington
Anderson, O. W Luverne
§ Arnold, E. W Adrian
|Balmer, A. I Pipestone
Basinger, H. P Windom
Basinger, H. R Mountain Lake
Beckering, Gerrit Edgerton
§Benjamin, W. G Pipestone
Bofenkamp, F. W Luverne
t Brown, A. PI Pipestone
Burleigh, J. S Luverne
Carlson, J. V Westbrook
Christiansen, H. A Jackson
Chunn, S. S Pipestone
§ DeBoer, Hermanns Edgerton
Doman, V. W Lakefield
Doms, H. C. A Slayton
§Hallin, R. P Worthington
Halloran, W. H Jackson
§ Halpern, D. J Brewster
§Harrison, P. W Worthington
Hebbel, Robert Minneapolis
§ Heiberg, O. M Worthington
§Hitchings, W. S Lakefield
Hoyer, L. J Windom
Johnson, R. M Slayton
Kabrick, O. A Jackson
Karleen, B. N Jackson
§ Kilbride, E. A Worthington
tKilbride, J. S Worthington
Laikola, L. A. . .
§Lohmann, J. G. ..
Maitland, E. T..
fManson, F. M....
McElmeel, E. F. .
§Mork, B. O., Sr..
§Mork, B. O., Jr.
§Nealy, D. E
Nickerson, J. R. .
Pankratz, P. J...
Patterson, H. D.
Pierson, R. F. . . .
§ Piper, W. A
Rogers, C. W....
§Rose, J. T
§Schade, F. L
§Schmidt, W. R. .
.Adrian
Pipestone
Jackson
. . .Worthington
.Seattle, Wash.
. . . .Worthington
. . . . Worthington
Adrian
...Heron Lake
Mountain Lake
Slayton
Slayton
Mountain Lake
. . . .Minneapolis
Lakefield
. . .Worthington
. . .Worthington
May, 1947
557
ROSTER 1947
Schutz, E. S Mountain Lake
Sherman, C. L Luverne
§ Slater, S. A Worthington
§Sogge, L. L Windom
§Sorum, F. T Jasper
Stam, John Worthington
{(Stanley, C. R Worthington
Stevenson, B. M Fulda
Stratte, H. C Windom
Tofte, Josephine Minneapolis
Waller, J. D Pine City
§ Wells, W. B Jackson
§ Williams, C. A Pipestone
Williams, L. A Slayton
"Wright, C. O Luverne
STEARNS-BENTON COUNTY MEDICAL SOCIETY
President
Goehrs, G. G St. Cloud
Secretary
Libert, J. N St. Cloud
§ Baumgartner, F. H Albany
Beuning, J. B St. Cloud
Brigham, C. F St. Cloud
§Buscher, J. C St. Cloud
SjClark, H. B St. Cloud
Cleaves, W. D Sauk Center
§Donaldson, C. S Foley
Du Bois, J. F Sauk Center
§Emerson, E. E Osakis
Engstrom, G. F Belgrade
§ Evans, L. M Sauk Rapids
§ Fleming, T. N St. Cloud
§Friesleben, William Sauk Rapids
§Gaida, J. B St. Cloud
Goehrs, G. H St. Cloud'
President
Berghs, L. V Owatonna
Secretary
Stransky, T. W Owatonna
Berghs, L. V Owatonna
Regular meetings, third 1 hursday of month
Annual meeting, third Thursday of December
Number of Members: 56
Goehrs, H. W St. Cloud
Grant, J. C Sauk Center
Haberman, Emil Osakis
§Halenbeck, P. L St. Cloud
{(Hall, W. E Maple Lake
tHemstead, Werner Fergus Falls
Henry, C. J Milaca
§Jones, R. N St. Cloud
§ Kelly, J. F Cold Springs
Kettlewell, R. B Sauk Center
Kohler, D. W St. Joseph
§Koop, S. H Richmond
Kuhlman, L. B Melrose
Lewis, C. B St. Cloud
Libert, J. N St. Cloud
§Luckemeyer, C. J St. Cloud
§ McDowell, J. P St. Cloud
fjMahowald, A Albany
Meyer, A. A Melrose
§Milhaupt, E. N St. Cloud
STEELE COUNTY MEDICAL SOCIETY
Regular meetings, at call
Annual meeting, January
Number of Members: 15
Dewey, D. H Owatonna
Ertel, E. Q Ellendale
§Hartung, E. H Claremont
Kurtin, H. J Blooming Prairie
McEnaney, C. T Owatonna
McIntyre, J. A Owatonna
Melby, Benedik Blooming Prairie
§Murphy, James E St. Cloud
Musachio, N. F Foley
Myre, C. R Paynesville
§Nessa, C. B St. Cloud
SO’Keefe, J. P St. Cloud
§ Peterson, R. T St. Cloud
Raetz, S. J Maple Lake
§ Richards, W. B St. Cloud
{jReif, H. J St. Cloud
Sandven, N. O Paynesville
Schatz, F. J St. Cloud
§Schmitz, E. J Holdingford
Sherwood, G. E Kimball
Stangl, P. E St. Cloud
Stewart, N. E St. Petersburg, Fla.
VtTanth, L. A St. Cloud
§ Walfred, K. A St. Cloud
§Wenner, W. T St. Cloud
§ Wetzel, E. V St. Cloud
Wittrock, L. H Watkins
Zachman, A. H Melrose
Moorhead, D. E Owatonna
§Nelson, E. J Owatonna
Roberts, O. W Owatonna
Schaefer, J. F Owatonna
Senn, E. W Owatonna
Stransky, T. W Owatonna
SWilkowske, R. J Owatonna
UPPER MISSISSIPPI MEDICAL SOCIETY
Aitkin, Beltrami, Cass, Clearwater, Crow Wing, Hubbard, Koochiching,
Lake of the Woods, Morrison, Todd and Wadena Counties
Regular meetings, Spring, Summer, Fall, Winter
Annual meeting, February
Number of Members: 92
President
Ringle, O. J Walker
Secretary
Badeaux, G. I Brainerd
Adkins, G. H
Amundson, A. E. ..
Anderson, F. C. . . . .
Badeaux, G. I
§Beise, R. A
Bender, J. H
§Borgerson, A. H...
Cardie, G. E
"tChristie, G. R
Christie, R. L
Closuit, F. C
Cook, J. M
Coombs, C. H
tCorrigan, J. E
§Crow, E. R
§Dale, L. N
Davis, L. F
Davis, L. T
Davis, T. C
Eiler, John
{(Erickson, Alvin...,
Eyres, T. E
Fait, R. V
§ Fitzsimmons, W. E.
Friefeld, Saul
Garlock, A. V
Garlock, D. H
Pine River
. . . . Little Falls
. . . .Little Falls
Brainerd
Brainerd
Brainerd
. . . Long Prairie
.Brainerd
...Long Prairie
. . . Long Prairie
Aitken
Staples
Cass Lake
Spooner
Ah-Gwah-Ching
Crosby
Wadena
Wadena
Wadena
... Park Rapids
..Long Prairie
. . Pequot Lakes
....Little Falls
Brainerd
Wadena
Bemidji
Bemidji
Gerber, M. P Brainerd
Ghostley, Mary C Puposky
tGilmore, Rowland Bemidji
Grogan, J. S Wadena
Groschupf, T. P Bemidji
Grose, F. N Clarissa
§Halladay, G. J Brainerd
Hanover, R. D Little Fork
Healy, R. T. . . Pierz
Hendricks, E. J Verndale
tHouse, Z. E Cass Lake
Houston, D. M Park Rapids
§Hubbard, O. E Brainerd
Hubin, E. G Swanville
Jamieson, E. F Brainerd
tjohnson, C. E Pine River
Johnson, D. T Little Falls
Johnson, E. W Bemidji
Kinports, E. B. ... International Falls
Knight, E. G Swanville
Larson, Leroy Bagiev
Laughlin, J. T Grey Eagle
§Lee, H. W Brainerd
Leemhuis, G. IJ Aitken
§Lenarz, A. J Browerville
Longfellow, Helen B Brainerd
Lund, W. J Staples
Mark, Hilbert Minneapolis
McCann, D. F Bemidji
Mitby, I. L Aitkin
Monahon, R. H., Jr
International Falls
§Mosby, M. E Long Prairie
{(Mulligan, A. M Brainerd
Nelson, Bernette G Menahga
Nelson, Bernice A Northome
§ Nelson, N. P Brainerd
Nixon, James B Crosby
Nolan, D. E Dayton, Ohio
Parker, Warren E Sebeka
Petraborg, Harvey T Aitkin
Pierce, C. H Wadena
§Potek, D. M International Falls
§Quanstrom, V. E. Brainerd
§tRatcliffe, J. J Aitkin
Rice, H. G Aitkin
Ringle, O. F Walker
{(Sanderson, A. G Deerwood
§Simons, E. J Swanville
§ Smith, B. A Crosby
Stein, R. J Pierz
§Thabes, J. A., Sr Brainerd
§Thabes, J. A., Jr Brainerd
Trommald, Gladys Brainerd
Vandersluis, C. W Bemidji
§ Watson, A. M Royalton
tWatson, J. D Minneapolis
Watson, P. T Northfield
§ Watson, S. W Royalton
Whittemore, D. D Bemidji
Will, C. B Bertha
Will, W. W Bertha
{(Williams, M. M Ah-Gwah-Ching
Wilson, V. O Minneapolis
Wingquist, C. G Crosby
Withrow, M. E. . .International Falls
WABASHA COUNTY MEDICAL SOCIETY
Annual
President
Flesche, B. A Lake City
Secretary
Wilson, W. F Lake City
§Bayley, E. C Lake City
§Bouquet, B. J Wabasha
Regular meetings, Spring and Fall
meeting, first Thursday after first Monday
Number of Members : 14
§ Bowers, R. N Lake City
Collins, J. S Wabasha
"Dempsey, D. P Kellogg
{(Ekstrand, L. M Wabasha
§ Ellis, E. W Elgin
{jFlesche, B. A Lake City
in October
Glabe, R. A Plainview
§Mahle, D. G Plainview
§Ochsner, C. G Wabasha
Replogle, W. H Wabasha
§Wellman, T. G Lake City
§tWilson, W. F Lake City
558
Minnesota Medicine
ROSTER 1947
President
Olds, G. H New Richland
Secretary
Oeljen, S. C. G Waseca
WASECA COUNTY MEDICAL SOCIETY
Regular meetings, every six months
Annual meeting, January
Number of Members : 9
§ Davis, R. D Waseca
§Gallagher, B. J Waseca
§Hottinger, R. C Janesville
§McIntire, H. M Waseca
§ Oeljen, S. C. G Waseca
jjOlds, G. H New Richland
tSpittler, R. O New Richland
§Swenson, O. J Waseca
§Wadd, C. T Janesville
WASHINGTON COUNTY MEDICAL SOCIETY
Regular meetings, Second Tuesday in each month, except June, July, August
Annual meeting, second Tuesday in December
Number of Members: 16
President
McCarten, F. M Stillwater
Secretary
Boleyn, E. S Stillwater
§Boleyn, E. S Stillwater
§ Carlson, R. E Stillwater
§fHaines, J. H Stillwater
Holcomb, J. T. . . Marine-on-St. Croix
Humphrey, W. R Stillwater
§ Johnson, R. G ....Stillwater
fjjosewski, R. J Stillwater
§ McCarten, F. M Stillwater
Poirier, J. A Forest Lake
Ruggles, G. M Forest Lake
§Samson, E. R Stillwater
§ Sherman, C. H Bayport
§Stuhr, J. W Stillwater
Thompson, V. C. .. Marine-on-St. Croix
Van Meier, Henry Stillwater
Wilkinson, Stella Faribault
WATONWAN COUNTY MEDICAL SOCIETY
Pending approval of the 1947 House of Delegates of the dissolution of the' above society, the following
physicians have become members of the Redwood-Brown County Medical Society
Bergman, O. B St. James Bratrud, E. J St. James *Grimes, H. B Madelia
Bregel, F. L St. James
WEST CENTRAL MINNESOTA MEDICAL SOCIETY
Big Stone, Pope, Stevens, and Traverse Counties
Regular meetings, March, May, September and November
Annual Meeting, September
Number of Members: 28
President
Merrill, Robert Morris
Secretary
Rydburg, W. C Brooten
§Arneson, A. I Morris
§Behmler, F. W Morris
§Bergan, Otto Clinton
StBolsta, Charles Ortonville
§Dahle, M. B Glenwood
§Eberlm, E. A Glenwood
§Elsey, E. M Glenwood
Elsey, J. R Glenwood
Fitzgerald, E. T Morris
Gericke, J. T Glenwood
§Giesen, A. F Starbuck
Hedemark, H. H Ortonville
Hedemark, T. A Ortonville
§Karn, B. R Ortonville
§Karn, J. F Ortonville
Lindberg, A. L Wheaton
§Linde, Herman Cyrus
Magnuson, A. E Wheaton
§ Merrill, R. W Morris
Mclver, B. A Lowry
§ Mooney, L. P Graceville
Muir, W. F Browns Valley
§0’Donnell, D. M Ortonville
§ Oliver, I. L Graceville
Ransom, M. L Hancock
Rossberg, Raymond A Morris
§ Rydburg, W. C Brooten
Swedenberg, Paul A Glenwood
Wagner, N. W Graceville
President
Hamlon, John
Secretary
Heise, Paul
§Benoit, F. T
§Boardman, D. V
§ Canfield, W. W
IChristensen, E. E. . . .
§ Hamlon, J. S
§Heise, Herbert
WINONA COUNTY MEDICAL SOCIETY
Regular meetings, first Monday in January, April, July, October
Annual meeting, first Monday in January
St.
Charles
Number of Members
jjHeise, Paul
§tHeise, W. F. C
: 30
. . . Winona
§f Robbins, C. P. .
§Roemer, H. T. ..
.Winona
§ Heise, W. V
ijohnston, L. F
Keyes, J. D
§Roth, F. D. . . . . .
§Satterlee, H. W. .
§ Schaefer, Samuel
.Winona
§ Loomis, G. L
§Mattison, P. A
§ Steiner, I. W. . . ,
§T weedy, G. J. ...
Winona
McLaughlin, E. M
Tweedy, J. A. . .
Winona
§Meinert, A. E
. . .Winona
§Tweedy, R. B..
.Winona
Nauth, B. S.
Vollmer, F. J.
St.
Charles
Neumann, C. A.
§ Wilson, R. H...,
.Winona
§Page, R. L
St. Charles
§Younger, L. I...
. .Winona
. .Winona
Lewiston
Lewiston
. .Winona
. .Winona
. .Winona
. .Winona
. . Winona
. .Winona
. .Winona
, .Winona
WRIGHT COUNTY MEDICAL SOCIETY
Regular meetings quarterly
Annual meeting, October
Number of Members: 16
President
Greenfield, W. T Delano
Secretary
Catlin, J. J Buffalo
§Anderson, W. P Buffalo
§Bendix, L. M Annandale
§Catlin, J. J. Buffalo
§ Catlin, T. J Buffalo
§ Ellison, F. E Monticello
§ Greenfield, W. T Delano
Grundset, O. J Montrose
Guilfoile, P. J Delano
Harriman, Leonard Howard Lake
§Hart, W. E Monticello
Peterson, O. L Cokato
§Ridgway, A. M Annandale
§Roholt, C. L Waverly
§Swezey, B. F Buffalo
SThielen, R. D St. Michael
§Thompson, Arthur Cokato
May, 1947
559
ROSTER 1947
Alphabetic Roster
Key to Symbols: *Deceased; fAffiliate, Associate or Life Member; Jin Service;
§Wife is member of Woman’s Auxiliary
Aagaard, C>. N., Jr Minneapolis
Aanes, A. M Red Wing
Abbott, K. if Rochester
tAborn, W. H Hawley
§ Abraham, A. L Duluth
§ Abramson, Milton Minneapolis
Adair, A. F., Jr St. l’aul
§ Adams, B. S Hibbing
§ Adams, R. C Bird Island
{{Adams, Richard C Rochester
Addv, E. R Gilbert
Adkins, C. D Minneapolis
§ Adkins, C. M Thief River Falls
Adkins, G. H Pine River
§ Adson, A. W Rochester
Adler, B. C St. Paul
Ahern, E. E Minneapolis
§Ahlfs, J. J Caledonia
§Ahrens, A. E St. Paul
§Ahrens, A. H St. Paul
Ahrens, C. F Prior Lake
t§Aitkens, H. B LeCenter
Akester, Ward Fergus Falls
Akins, W. M Red Wing
§ Albrecht, H. H Lindstrom
§Alden, J. F St. Paul
{{Aldrich, C. A Rochester
‘fAlexander, F. H St. Paul
Alexander, H. A Minneapolis
Alger, E. W Minneapolis
§ Aling, C. A Minneapolis
ItAling, C. P Minneapolis
§ Allen, E. V. N Rochester
§ Allen, H. B Austin
§*Allen, H. W Minneapolis
§ Altnow, H. O Minneapolis
§ Alvarez, W. C Rochester
Amberg, Samuel Rochester
Ambrusko, J. S Rochester
Amundsen, A. E Little Falls
5 Andersen, A. G Minneapolis
§ Andersen, S. C Minneapolis
Anderson, C. D Rochester
Anderson, C. L Ely
Anderson, Donald Lamberton
§ Anderson, D. D Minneapolis
ijAnderson, D. P., Jr Austin
{{Anderson, E. D Minneapolis
{{Anderson, E. R Minneapolis
Anderson, F. C Little Falls
§ Anderson, F. J Minneapolis
Anderson, G. A Hibbing
Anderson, H. R Deer River
§ Anderson, J. K Minneapolis
Anderson, J. T Red Lake Falls
§ Anderson, K. W Minneapolis
Anderson, M. E., Jr Rochester
§ Anderson, M. J Rochester
j) Anderson, M. W Rochester
‘AndtTSon, N. E Harmony
Anderson, O. W Luverne
§ Anderson, R. E Willmar
Anderson, R. E Rochester
Anderson, S. H Red Wing
§ Anderson, U. S Minneapolis
§ Anderson, W. P Buffalo
Anderson, W. E Clearbrook
Anderson, W. T Minneapolis
Andreassen, E. C Minneapolis
Andresen, K. D Minneapolis
{(Andrews, R. N Mankato
§ Andrews, R. S Minneapolis
Arends, A. L Jamestown, N. D.
§Arey, S. L Minneapolis
{jArheiger, S. W Duluth
SArko, J. L Hibbing
§Arlander, C. E Minneapolis
{{Arling, L. S Minneapolis
Ailing, P. A Rochester
{(Armstrong, E. L Duluth
Armstrong, R. S Winnebago
§ Arndt, H. W Detroit Lakes
{jArneson, A. 1 ...Morris
Arnold, Anna W Minneapolis
Arnold, D. C Minneapolis
§ Arnold, E. W Adrian
SjArnquist, A. S St. Paul
Arnson, J. M Benson
§Arny, F. P St. Paul
{{Arvidson,. C. G Minneapolis
§Arzt, P. K St. Paul
tAshburn, F. S Rochester
§ Ashley, W. F Rochester
§Askren, E. L., Jr Rochester
{(Athens, A. G Duluth
SAune, Martin Minneapolis
tAurand, W. H Minneapolis
§ Aurelius, J. R St. Paul
§Ausman, C. F St. Paul
t Ayres, G. T Phoenix, Ariz.
Babb, F. S Rochester
Bachnik, F. W Hibbing
§ Backus, R. W Nopeming
§Bacon, D. K St. Paul
§ Bacon, J. F Rochester
ItBacon, L. C St. Paul
Badeaux, G. I Brainerd
§Baggenstoss, A. H Rochester
{{Bagley, C. M Duluth
Bagley, Elizabeth C Duluth
Bagley, W. R Duluth
Baich, V. M Bovey
§Bailey, J. A Rochester
{(Bailey, R. B Fairmont
§Bair, H. L Rochester
Baird, T. W Minneapolis
§Baken, M. P Minneapolis
Baker, A. B Minneapolis
§Baker, A. C Fergus Falls
Baker, A. T Minneapolis
Baker, C. E Herman
§Baker, E. L Minneapolis
{(Baker, G. S Rochester
{(Baker, H. R Hayfield
Baker, Jeannette L Fergus Falls
Baker, Looe Minneapolis
§ Baker, N. H Fergus Falls
Baker, R. L Hayfield
§ Bakkila, H. E Duluth
{(Balcome, M. M St. Paul
{(Balfour, D. C Rochester
§Balfour, D. C., Jr Rochester
{{Balfour, W. M Rochester
{{Balkin, S. G Minneapolis
§Balmer, A. I Pipestone
Bank, H. E Minneapolis
^Banner, E. A Rochester
§ Barber, T. E Austin
{(Bardon, Richard Duluth
SBargen, T. A Rochester
{(Barger, J. D Rochester
§ Barker, J. D Duluth
{(Barker, N. W Rochester
{(Barnes, A. R Rochester
Barnett, J. M St. Paul
Barney, L. A Duluth
§Barr, L. C Albert Lea
JBarr, M. M McCoy, Wis.
Barr, R. N Minneapolis
Barr, W. H Wells
§ Barrett, E. E Duluth
§ Barron, Moses Minneapolis
{{Barry, L. W St. Paul
Barsness. Nellie O. N St. Paul
Barton, J. C St. Paul
Basinger, H. P Windom
Basinger, II. R Mountain Lake
Batdorf, B. N Good Thunder
tBarber, J. P Minneapolis
§Baumgartner, F. H Albany
§ Baxter, S. H Minneapolis
{(Bayard, H. F Minneapolis
{(Bayley, E. C Lake City
Bayrd, E. D Rochester
{(Beach, Northrup Minneapolis
Beahrs, O. II Rochester
SitBeals, Hugh .St. Paul
fBeard, A. H Minneapolis
§Beare, J. B Rochester
tBearzy, H. J Rochester
Bechtel, M. J Warren
§Becker; F. T Duluth
Beckering, Gerrit Edgerton
{tfBeckman, W. G
San Francisco, Calif.
{(Bedford. E. W Minneapolis
§ Beech, R. H St. Paul
§ Beek, H. O St. Paul
Beer, J. J St. Paul
{(Behmler, F. W Morris
§Behr, O. K Crookston
§Beise, R. A Brainerd
Beiswanger, R. H Minneapolis
{{Bell, C. C St. Paul
fBell, E. T Minneapolis
§Belote, G. B Caledonia
Belzer, M. S Minneapolis
Bender, J. H Brainerd
SjBendix, L. H Annandale
§ Benedict, W. L Rochester
§Benepe, J. L St. Paul
Benesh, L. A Minneapolis
Benesh,. N. G Minneapolis
§ Benjamin, A. E Minneapolis
§ Benjamin, E. G Minneapolis
{{Benjamin, H. G Minneapolis
{{Benjamin, W. G Pipestone
§Benn, F. G Minneapolis
J Bennett, J. G Rochester
Bennett, J. K Phoenix, Ariz.
IBennett, W. A Rochester
Bennion, P. H St. Paul
{(Benoit, F. T Winona
{(Bentley, N. P St. Paul
{(Benton, P. C Gibbon
Bepko, Marie K Cloquet
Berdez, G. L Duluth
§Bergan, Otto Clinton
Berge, D. O Roseau
Berger, A. G Minneapolis
Bergh, G. S Minneapolis
§Bergh, L. N Montevideo
Bergh, Solveig, M Minneapolis
Berghs, L. V Owatonna
Bergman, O. B St. James
Bergquist, K. E Battle Lake
{{Berkman, D. M Rochester
§Berkman, D. S Rochester
§ Berkman, J. M Rochester
§Berkwitz, N. J Minneapolis
Berlin, A. S Hallock
Berman, Reuben Minneapolis
Bernstein, W. C St. Paul
{{Bertelson, O. L Crookston
§Bessesen, A. N., Jr Minneapolis
{{Bessessen, D. H Minneapolis
Bessessen, W. A Minneapolis
Beuning, J. B St. Cloud
{{Bianco, A. J Duluth
§ Bicek, J. F St. Paul
{{Bickel, W. H Rochester
Biedermann, Jacob. .Thief River Fallls
Bieter, R. N Minneapolis
§ Bigelow, C. E Dodge Center
Bigler, I. E Perham
{(Billings, R. E Franklin
tBinet, II. E Grand' Rapids
Binger, H. E St. Paul
Biorn, C. L Rochester
Black, A. S., Jr Rochester
Black, E. J St. Paul
§Black, II. M Rochester
Black. W. A Rochester
Blackburn, C. M Rochester
Blackmore, S. C Biwabik
JBlaisdell, J. S Rochester
Blake, A. J Hopkins
{{Blake, James Hopkins
{{Blake, James A Hopkins
tBlake P. S Minneapolis
‘Blakely, C. C Barnum
§Blakey. A. R Osakis
Bloedel, T. J. G Osseo
{{Blomberg, W. R.... Princeton
Blumenthal, J. S Minneapolis
fjBoardman, D. V Winona
§Bock, R. A St. Paul
Bockman, M. W. H Minneapolis
Bodaski, A. A Montgomery
Boeckmann, Egil St. Paul
{(Boehrer, J. J., Jr Minneapolis
Bofenkamp, F. W Luverne
SBoies, L. R Minneapolis
{{Bolender, H. L St. Paul
SiBoleyn, E. S Stillwater
§Boline, C. A Battle Lake
SitBolsta, Charles Ortonville
Bolz. J. A Grand Rapids
Boman, P. G Duluth
Boody, G. J., Jr Dawson
t Booth, A. E Minneapolis
§Boothby, W. M Rochester
§Boreen, C. A Minneapolis
Booren, J. C Duluth
Borg, J. F' St. Paul
§ Borgerson, A. H Long Prairie
Borgeson, E. J Minneapolis
§ Borman, C. N Minneapolis
Borowicz, I.. A Minneapolis
Bosland, H. G Willmar
560
Minnesota Medicine
ROSTER 1947
Bossert, C. S Mora
Bottolfson, B. T Moorhead
§Bouma, L. R St. Paul
§ Bouquet, B. J Wabasha
Bowen, R. L Hibbing
§Bowers, G. G Minneapolis
§Bowers, R. N Lake City
| Bowing, H. H Rochester
5j Boyd, L. M Alexandria
Boyer, S. H Duluth
§ Boyer, S. H.. Tr Duluth
Boylan, R. N Rochester
Boynton, Ruth E Minneapolis
Boysen, Herbert Madelia
§Boysen, Peter Pelican Rapids
§Braasch, W. F Rochester
SBraastad, F. W Rochester
Bradley, W. F Rochester
§Brand, G. D St. Paul
§Brand, W. A Redwood Falls
Brandes, R. W Rochester
§ Branham, D. S Albert Lea
§Branton, B. J Willmar
Bratholdt, J. W Watertown
§Bratrud, A. F Minneapolis
§Bratrud, Edward. . .Thief River Falls
fjBratrud, X. E Thief River Falls
Bratrude, E. J St. James
§*Braverman, N. T .Duluth
Bray, E. R St. Paul
Bray, K. E New Orleans, La.
§Bray, P. N Duluth
Bray, R. B Biwabik
Bregel, F. L St. James
§Brekke, H. J Minneapolis
fBreslow, Lester Rochester
§Briggs, J. F St. Paul
Briggs, Natalie M., Wenatche, Wash.
Brigham, C. F St. Cloud
^Brigham. F. T Watkins
Brill. Alice K Minneapolis
Brink, A. A Baudette
Brink, D. M Hutchinson
§Broadie, T. E St. Paul
§Broders, A. C Rochester
§Brodie, W. D St. Paul
Brooks, C. N Minneapolis
Brooks, L. M Rochester
Brooksby, W. A Rochester
§ Brown, A. E Rochester
fBrown, A. H Pipestone
fBrown, E. D Paynesville
Brown, F. J Minneapolis
§ Brown, H. A Rochester
§ Brown, H. S ..Rochester
Brown, J. C St. Paul
Brown, J. R Minneapolis
§Brown, L. L Crookston
Brown, M. H Rochester
§ Brown, P. W Rochester
fBrown, S. P Minneapolis
Brown, W. D Minneapolis
Browning, W. H Rochester
Brownson, B. C .Rochester
Brownstone, Manuel Sandstone
§Brunsting, L. A Rochester
§Brusegaard, J. F Red Wing
Brutsch. G. C Minneapolis
Bryan, A. L Rochester
§Buchstein, H. F Minneapolis
§ Buck, F. H Shakopee
§Buckley, R. P Duluth
§Buie, Louis A Rochester
Buirge, R. E Minneapolis
Bulinski, T. J St. Paul
Bulkley, Kenneth Minneapolis
§ Bunker, B. W Anoka
§Burch, E. P St. Paul
§Burch, F. E St. Paul
§Burchell, H. B Rochester
Burleigh, J. S Luverne
Burlingame, D. A St. Paul
Burmeister, R. O Welcome
§Burnap, W. L Fergus Falls
Burns, F. M Milan
Burns, L. S So. St. Paul
Burns, M. A Milan
§Buras, R. M St. Paul
Burton, C. G St. Paul
§Buscher, J. C St. Cloud
Bush, R. P Rochester
Bushard, W. J Minneapolis
SBusher, H. H St. Paul
§ Butler, J. K Carlton
§Butt, H. R Rochester
§Butturff, C. R Freeborn
§Butzer, J. A Mankato
§Buzzelle, L. K Minneapolis
SCable, M. L.
§Cabot, C. M.
§ Cabot, V. S..
Cady, L. IL.
§Cain, C. L. . .
May, 1947
Minneapolis
Minneapolis
Minneapolis
Minneapolis
. ... St. Paul
§Cain, J. C Rochester
Cain, J. H Hoffman
§Cairns, R. J Redwood Falls
Calhoun, F. W Albert Lea
Callahan, F. F .St. Paul
Callerstrom, G. W Minneapolis
Cameron, Isabell L Minneapolis
Cameron, J. H Erskine
Cameron, J. M Rochester
§ Camp, J. D Rochester
Camp, W. E Minneapolis
§ Campbell, D. C Rochester
‘Campbell, L. M Minneapolis
((Campbell, O. J Minneapolis
§ Canfield, W. W Winona
Cantwell, W. F. ... International Falls
§Cardle, A. E Minneapolis
Cardie, G. E Bramerd
§Carey, J. B Minneapolis
Cariker, Mildred Rochester
§Carley, W. A St. Paul
Carlson, A. E Warren
Carlson, C. E Alexandria
Carlson, J. V Westbrook
§Carlson, Lawrence Minneapolis
if Carlson, L. T Minneapolis
Carlson, N. C Watertown
§ Carlson, R. E Stillwater
Carman, J. E Detroit Lakes
tCarmona, M. G Rochester
((Caron, R. P Minneapolis
§ Carpenter, R. E Rochester
Carr, D. T Rochester
((Carroll, W. C St. Paul
§Carryer, H. M Rochester
Carter, J. W., Jr Rochester
Carstens, C. F Hibbing
Caspers, C. G Minneapolis
SCatlin, J. J Buffalo
§Catlin, T. J Buffalo
§Cavanor. F. T Minneapolis
Ceder, E. T Minneapolis
Ceplecha, S. F Redwood Falls
§Cervenka, C. F New Prague
§Chadbourn, C. R St. Paul
Challman, S. A Minneapolis
Chambers, W. C Blue Earth
Chapman, J. P., Jr Rochester
Chapman, T. L Duluth
§Chatterton, C. C St. Paul
Chermak, F. G International Falls
Chesley, A. J Minneapolis
Chesley, G. L Rochester
§Christensen, C. H Duluth
§ Christensen, E. E Winona
Christensen, N. A Rochester
§ Christenson, G. R Minneapolis
§Christiansen, Andrew St. Paul
Christiansen, H. A ..Jackson
((Christianson, H. W Minneapolis
*fChristie, G. R Long Prairie
Christie, R. I. Long Prairie
*f Christison. J. T St. Paul
Chunn, S. S..... Pipestone
Ciaramelli, Letizia C Rochester
§ Clagett, O. T Rochester
Clark, F. H Rochester
§ Clark, H. B St. Cloud
§Clark, PI. B., Jr St. Paul
*f Clark, H. S Minneapolis
§ Clark, I. T Duluth
§Clark, L. W Spring Valley
‘Clarke, E. K Minneapolis
Clarke, E. T Buhl
t Clarkson, W. R Rochester
§Clay, L. B Minneapolis
IClaydon, H. F Red Wing
§fClaydom L. E Red Wing
Cleaves, W. D Sauk Centre
Clement, J. P. Lester Prairie
Clifford, G. W Alexandria
§ Clifton, T. A Chatfield
Closuit, F. C Aitkin
Clothier, E. F Elk River
tCluxton, H. E., Jr Rochester
Cochrane, B. B St. Paul
Cochrane, R. F Minneapolis
Coddon, W. D St. Paul
Cohen, B. A Minneapolis
§ Cohen, S. S Minneapolis
§ Colby, W. L St. Paul
§Cole, Frank Duluth
§Cole, W. H St. Paul
Collet, R. W Rochester
f Collie, IL G St. Paul
Collins, A. N Duluth
fCollins, PI. C Duluth
Collins, J. S Wabasha
Colp, E. A Minneapolis
Colvin, A. R St. Paul
SCombacker, L. C Fergus Falls
§ Comfort, M. W Rochester
Condit, W. H Minneapolis
§Conley, F. W Rochester
§fConner, H. M
Connery, D. B.
Connolly, C. J
§ Connor, C. E
ijCook, C. K
§Cook, E. N
Cook, J. M
Coombs, C. H
§ Cooper, C. C
Cooper, J. P
Cooper, M. D
Cooper, Talbert
§ Corbett, J. F
§ Corbin, K. B
Corniea, A. D
§ Correa, D. H.
fCorrigan, J. E
§Cosgriff, J. A
Costin, M. E., Jr. . . .
§Coulter, E. B
§Counseller, V. S...
§ Countryman, R. S..
(jCovell, W. W
((Coventry, M. B....
§ Coventry, W. A
§ Coventry, W. D....
Covey, K. W
Cowan, D. W
fCowern, E. W
Cox, W. B
Crabtree, J. C. . .
*C'ragg, R. W
§Craig, M. S., Jr. . . .
§Craig, W. McK
§Cranmer, R. R
f Cranston, R. W....
§Creevy, C. D
§ Creighton, R. H...
fCrewe, J. E
ICritchfield, L. R. . . .
Crombie, F. J.
Cronkite, A. E
§Cronwell, B. J
ijCrow, E. R
§Crowley, D. F., Jr.
Crump, J. W
§Culligan, J. M
§Culligan, L. C
§ Culver, L. G
Cumming, H. A. . . .
Cunningham, B. P.,
Cunningham, C. B
Cunningham, E. S.,
§ Curtis, R. A
Custer, M. D
Cutts, George
Rochester
Rochester
St. Paul
St. Paul
St. Paul
Rochester
Staples
Cass Lake
St. Paul
Excelsior
Winnebago
Rochester
Minneapolis
Rochester
Minneapolis
Minneapolis
Spooner
Olivia
Rochester
Minneapolis
Rochester
St. Paul
St. Peter
Rochester
Duluth
Duluth
Mahnomen
Minneapolis
. . . .No. St. Paul
Rochester
Princeton
Rochester
Rochester
Rochester
Minneapolis
Minneapolis
Minneapolis
Minneapolis
Rochester
St. Paul
No. St. Paul
Rochester
Austin
. . Ah-Gwah-Ching
Rochester
St. Paul
St. Paul
Minneapolis
St. Paul
Minneapolis
Bridgeport, Conn.
Virginia
Jr., ..Rochester
LeCenter
Rochester
Minneapolis
§Dack, L. G St. Paul
Dady, E. E Minneapolis
§Dahl, E. O Minneapolis
SifDahl, G. A Mankato
§Dahl, J. A Minneapolis
§Dahle, M. B Glenwood
f Dahleen, 11. C Rochester
§Dahlin, D. C Rochester
Dahlin, I. T Aurora
Daignault, Oscar Benson
§Dale, L. N Crosby
((Daniel, D. H Minneapolis
§ Daniels, B. T. Rpchester
Danielson, K. A Litchfield
Danielson, Lennox Litchfield
Darlirig-, J. P Rochester
fDaugherty, E. B.. . Marine-on-St. Croix
t Daugherty, G. W Rochester
§Daut, R. V Rochester
t Davies, L. T Rochester
§Davis, A. C Rochester
§Davis, E. V St. Paul
‘Davis, I. G Rushford
§ Davis, J. C Minneapolis
‘Davis, L. T Wadena
Davis, L. F Wadena
§Davis, R. J ,
Richland' Highlands, Wash.
fDavis, R. M Rochester
SDavis, R. D .Waseca
Davis, T. C Wadena
*fDavis, William St. Paul
Davis, W. I Mound
Day, Lois A Rochester
§ Dearing, W. H., Jr Rochester
§ DeBoer, Hermanus Edgerton
Decker, C. H St. Paul
§*DeCourcey, D. M St. Paul
((Dedolph, Karl St. Paul
fDedolph, T. H Minneapolis
JDeForest, R. E Rochester
Delmoref J. L., Jr Roseau
§Delmore, J. L Roseau
Delmore, R. J Roseau
§del Plaine, C. W Minneapolis
§Demo, R. A Albert Lea
Demong, C. V Rochester
561
ROSTER 1947
*tDempsey, D. P
§Denman, A. V
Dennis, Clarence....
§Derauf, B. I
§ Desjardins, A. U. ..
Deterling, R. A....
Deters, D. C
§Devereaux, T. J. . . .
Devine, K. D
Devney, J. W. . . .
DeVoe, R. W
DeWeerd, J. H., Jr.
Dewey, L). H
§ Dickson, J. A., Jr.. .
§ Dickson, F. H., Jr. .
§ Dickson. T. H
§ Diehl, H. S
Diessner, G. R. . . .
Diessner, H. D
Dille, D. E
Dille, R. S
§*Dittman, G. C
§ Dittrich, R. J
§ Dixon, C. F
§Dockerty, M. B
Dodds. W. C
Doehring, P. C., Jr.
§ Doherty, E. M
Dolder, F. C. ..!... .
Dorn an, V. W
§Domeier, L. H
Doms, H. C. A
§Donaldson, C. S....
tDonoghue, F. E
Donohue, P. F
Donovan, D. I.
§ Doolittle, L. E
§Dordal, J
§Dorge, R. I
§Dornberger, G. R.
§Dornblaser, H. B...
§ Dorsey, G. C
Douglas, J. M. . . .
Douglass, B. E
Dovre, C. M
Dowidat, R. W
§Doswell, W. J
Doxey, G. L
Doyle, G. C
§ Doyle, L. O
§Drake, C. B
§Drake, C. R
tDrake, F. A
Dredge, H. P
Drexler, G. W. . . .
§ Drill, H. E
Drips, Della G
§ Drought, W. W
JDrumheller, J. F. . . .
§Dry, T. J
§Dubbe, F. H
DuBois. J. F
§Duff, E. R
§Dukelow, D. A
DuMais, A. F
tDumas. A. G
Duncan, J. W
§Dungay, N. S
§Dunlap, E. H
§Dunn, G. R
§Dunn, J. H
§Dunn, J. N
§DuPont, J. A
§Duryea, W. M
tDutton, C. E
^Dvorak, B. A
§Dwan, P. F
§Dworsky, S. D
$Dysterheft, A. F. . . .
Kellogg
Mankato
Minneapolis
St. Paul
Rochester
Rochester
St. Paul
VV ayzata
Rochester
Rochester
Rochester
Rochester
Owatonna
Rochester
Proctor
St. Paul
Minneapolis
Rochester
Minneapolis
Litchfield
Rochester
St. Paul
Duluth
Rochester
Rochester
Thief River Falls
..Boston, Mass.
New Prague
Eyota
Lakefield
New Ulm
Slayton
Foley
Rochester
St. Paul
Albert Lea
Duluth
....Sacred' Heart
Minneapolis
Rochester
Minneapolis
Minneapolis
Rochester
Rochester
St. Paul
Minneapolis
Kerkhoven
Minneapolis
Duluth
Minneapolis
St. Paul
Minneapolis
Lanesboro
Sandstone
Blue Earth
Hopkins
Rochester
Fergus Falls
Rochester
Rochester
New Ulm
Sauk Centre
Minneapolis
Minneapolis
Rochester
Minneapolis
Moorhead
Northfield
Minneapolis
Minneapolis
Rochester
St. Paul
Excelsior
Minneapolis
Minneapolis
Minneapolis
Minneapolis
Minneapolis
Gaylord
§Earl, G. A St. Paul
§Farl, T. R St. Paul
Earl, Robert St. Paul
§Faton, L. M Rochester
Eberley, T. S Benson
§Fberlin. E. A Glenwood
Ebert, R. V Minneapolis
Eckdale, J. E Marshall
§Eckman, P. F Duluth
§Eckman, R. J Duluth
Eckstam, E. E Rochester
§*Ederer, J. J Minneapolis
§Edlund. GustaJ St. Paul
Edwards, Jessie E Rochester
Edwards, J. W St. Paul
f Edwards, R. T Big Fork, Mont.
§Edwards, T. J St. Paul
Eger, Alban ....Rochester
Eginton, C. T St. Paul
§Ehrenberg, C. J Minneapolis
§ Ehrlich, S. P Minneapolis
§Eich, Matthew Minneapolis
Eiler, John Park Rapids
EisenstacTt, D. H Minneapolis
Eisenstadt, W. S...
§Eitel, G. D
§Ekblad, J. W
§Ekstrand, L. M. .
§ Elias, F. J
§Elkins, E. C
Ellingson, A. R. . .
Elliott, R. B. ...
§ Ellis, E. W
t Ellis, F. H
Ellison, A. B. C. .
§ Ellison, D. E
§ Ellison, F. E
§Elsey, E. M
T T>
Ely, O. S
§Emanuel, K. W....
§ Emerson, E. C....
§ Emerson, E. E. ..
Emerson, G. F. . . .
§Emmett, J. L
Emond, A. J
Emond, J. S
§Endress, E. K
§Engberg, E. J
§Engelhart, P. C...
Englund, E. F. .
§Engstrand, O. J...
Engstrom, G. F. ..
Enroth, O. E. . .
Eppard, R. M....
§ Erich, J. B
§Erickson, A. O....
Erickson, C. O. .
Erickson, D. J. .
§ Erickson, Eskil...
§ Erickson, R. E. . .
§ Erickson, R. F. ...
fjEricson, R. M. . . .
§Ericson, Swan....
Ernest, G. C. H. . .
Ersfeld, M. P. ..
Erskine. G. M
F.rtel. E. Q
tEshelby, E. C
Esser, John
§Esser, O. J
§ Estes, J. E
§Estrem, C. O
§Estrem, R. D
§F.strem, T. A
§Eusterman, G. B. .
§ Evans, E. T
§ Evans, L. M
Evans, R. D
JEvarts, A. B
Evert, J. A
Ewens, H. B
Eyres, T. E
Minneapolis
Minneapolis
Duluth
Wabasha
'. . Duluth
Rochester
. . . Detroit Lakes
Rochester
Elgin
Rochester
Rochester
Minneapolis
Monticello
Glenwood
Glenwood
... . . So. St. Paul
Duluth
St. Paul
Osakis
Rochester
Rochester
Farmington
Farmington
St. Paul
Faribault
M inneapolis
Minneapolis
Minneapolis
Belgrade
St. Paul
Cloquet
Rochester
. . . . Long Prairie
Minneapolis
Minneapolis
Halstad
Hector
Minneapolis
Minneapolis
Le Sueur
So. St. Paul
St. Paul
... Grand Rapids
Ellendale
St. Paul
Perham
New Ulm
Rochester
.... Fergus Falls
.... Fergus Falls
Hibbing
Rochester
Minneapolis
. . . . Sauk Rapids
Minneapolis
Rochester
St. Paul
Virginia
Pequot
§Faber, J. E Rochester
§Faber, W. M Rochester
tFahey, E. W St. Paul
Fahr, G. E Minneapolis
Fair, E. E Rochester
Fait, R. V Little Falls
§Fansler, W. A Minneapolis
Farber, E. M Rochester
tFarkas, J. V Minneapolis
tFarsht, I. J Minneapolis
Faulconer, Albert, Jr Rochester
§Fawcett, A. M Renville
§Fawcett, K. R Duluth
Fawcett, R. M Rochester
Fearing, J. E Virginia
Feeney, J. M Minneapolis
§Feinstein, J. Y Minneapolis
§ Feldman, F. M Rochester
^Fellows, M. F Duluth
Fenger, E. P. K Oak Terrace
§Ferguson, J. C St. Paul
Ferguson, W. C Walnut Grove
Ferguson, W. J., Jr Rochester
{Ferguson, W. J Rochester
Ferrell, C. R Grand Rapids
StFerris, D. O Rochester
{Ferris, H. A., Jr Rochester
§Fensenmaier, O. B New Ulm
§Fesler, H. H .St. Paul
§Fetterly, Warren Minneapolis
Field, A. H Farmington
§Figi, F. A Rochester
Fink, D. L St. Paul
§Fink, L. W Minneapolis
§Fink, W. H Minneapolis
Fisch, H. M Austin
JjFischer, M. McC Duluth
Fisher, Isadore St. Paul
Fisher, J. M Willmar
Fisher, R. L Rochester
Fisketti, Henry Duluth
{Fitzgerald, D. F Minneapolis
Fitzgerald, E. T Morris
§Fitzgibbons, R. J Rochester
§Fitzsimons, W. E Brainerd
§Fjeldstad, C. A Minneapolis
5 Flanagan, H. F St. Paul
§ Flanagan, L. G Austin
§ Flasher, Jack Rochester
§Flashman, F. L Rochester
Fleeson, W. H Minneapolis
§ Fleming, T. N St. Cloud
§Flesche, B. A Lake City
Fletcher, Mary E. H Rochester
Flickinger, F. M Lima, Ohio
Flink, E. B St. Paul
§Flinn, J. H Rochester
Flinn, T. E Redwood Falls
§Flom, M. G Zumbrota
Flynn, B. F Hibbing
{Foerster, J. M Rochester
{Fogarty, C. W., Jr Rochester
Fogarty, C. W St. Paul
§Fogelberg, E. J St. Paul
§Foker, L. W Minneapolis
§ Foley, F. E. B St. Paul
§Folken, F. G Albert Lea
jtFord, B. C Marshall
§Ford, W. II Minneapolis
§ Forney, R. A Rochester
*Foshager, H. T Clara City
Foss, E. L Rochester
Foster, W. K Minneapolis
fjFowler, L. H Minneapolis
Fox, James R Minneapolis
§Franchere. F. W Lake' Crystal
Francis, D. W Morristown
Frane, D. B Minneapolis
Frank, T. E Marshall
Frank, W. L., Jr Minneapolis
Frear, Rosemary R Minneapolis
§Fredericks, G. M Minneapolis
Frederickson, Alice C Wilmar
Frederickson, G. U. Y Willmar
§Fredlund, M. L Minneapolis
fjFredricks, M. G Duluth
Freeman, C. D St. Paul
Freeman, G. H St. Peter
Freidman, L. L St. Paul
§Freligh, W. P Albert Lea
§Fricke, R. E Rochester
SFried, I.. A Minneapolis
§Friedell, Aaron Minneapolis
Friedell, George Ivanhoe
Friefeld, Saul Wadena
Friend, A. W Minneapolis
§Friesleben, William Sauk Rapids
Frisch, F. P Wilmar
SFritsche, Albert New Ulm
§Fritsche, C. J New Ulm
§Fritsche, T. R New Ulm
Fritz, W. L St. Paul
§Froats, C. W St. Paul
§ Frost, E. H ' Willmar
* Frost, H. T Wadena
Frost, J. B Minneapolis
Frost, R. H St. Paul
Fryfogle, J. D Rochester
Frykman, H. M Minneapolis
Fugina, G. R Mankato
Fuller, Alice H Minneapolis
§Funk, V. K Oak Terrace
§Gaarde, F. W Rochester
§Gaarde, F. W., Jr Rochester
§Gaida, J. B St. Cloud
§Gaines, E. C Buffalo Lake
§Gallagher, B. J ..Waseca
Galligan, Margaret M. D. . Minneapolis
^Galloway, J. B Minneapolis
SGambill, E. E Rochester
Gamble, J. W Albert Lea
§ Gamble1, P. M Albert Lea
SiGammell, J. II Minneapolis
§Garbrecht, A. W St. Paul
Gardiner, D. G St. Paul
Gardner, V. II Fairmont
§ Gardner, W. P St. Paul
Garlock, A. V Bemtdu
Garlock, D. H . Bemidjt
Garrow, D. M St. Paul
Garten, T. L Minneapolis
Garthe, j. J St. Paul
Gastineau, C. F Rochester
5 Geer, E. K St. Paul
§Gehlen, J. N St. Pau
§Geist, G. A St. Paul
Gendron, J. F Grand Rapids
Gentling, A. A Rochester
Gentry, R. W Rochester
Gerber, M. P Brainerd
Gericke, J. T., Jr Glenwood
§Ghent, C. H St. Paul
§Ghormley, R. K Rochester
Ghostley, Mary C Puposky
5 Gibbons, F. C Comfrey
Gibbs, E. C St. Paul
562
Minnesota Medicine
ROSTER 1947
Gibbs, R. W Minneapolis
Gibson, R. H Rochester
§Giebenhain, J. N Minneapolis
§Giere, J. C Minneapolis
§Giere, R. W Minneapolis
Gierf, S. W Benson
§Giesen, A. F Starbuck
fGiessler, P. W Minneapolis
{Giffin, H. M Rochester
§Giffin, H. Z Rochester
Giffin, Mary E Rochester
Gilbert, M. G Minneapolis
tGilfillan, J. S St. Paul
Gilkey, S. E St. Paul
*§Gilles, F. L Minneapolis
Gillespie1, D. R St. Paul
§ Gillespie, M. G Duluth
Gilman, L. C Willmar
Gilmore, Rowland Bemidji
Gingold, B. A Minneanolis
tGinsberg, William St. Paul
§ Giroux, A. A No. Mankato
§Girvin, R. B Minneapolis
§Gjerde, W. P St. Paul
Glabe. R. A Plainview
Gleason, W. A St. Paul
§ Glenn, W. V Rochester
Glover, R. P Rochester
§Goblirsch, A. P Sleepy Eye
Goehrs, G. H St. Cloud
Goehrs, H. W St. Cloud
§ Goldberg. I. M Minneapolis
{Golden, P. B Rochester
Golden, R. F Rochester
§ Goldish, D. R Duluth
§Goldman, T. I Minneapolis
Goldner, M. Z Minneapolis
§tGoltz, E. V .St. Paul
§Good, C. A., Jr Rochester
§Good, H. D Minneapolis
SjGoodman, C. E Virginia
Gordon, N. F Rochester
Gordon, P. E Minneapolis
Gorsuch, M. T Rochester
Goss, H. C Glencoe
Goss, Martha D Glencoe
§Gowan, L. R Duluth
Graham, A. W Chisholm
§ Graham, F. M Rochester
Graham, R. B Rochester
Graham, R. J Rochester
§Grahek, J. P Ely
Gramse, A. E Rochester
Grant, H. W" St. Paul
Grant, J. C Sauk Center
Gratzek, F. R. E Minneapolis
SGratzek, Thomas St. Paul
§Grau, R. K St. Paul
§ Grave, Floyd Mmneapplis
§Graves, R. B Red Wing
§ Graves, W. N Duluth
Gray, F. D Marshall
§Gray, H. K Rochester
Grav, R. C Minneapolis
Green, R. G Minneapolis
Greene, L. F Rochester
§ Greenfield, W. T Delano
Gridley, J. W Glencoe
Griess, D. F Rochester
Griffin, J. G Rochester
§Grimes, B. P St. Peter
*Grimes, FI. B Madelia
Grimes, Marian Minneapolis
§Grindlay, J. FF Rochester
Grinley. A. V Grand Rapids
SGrise, W. B Austin
Grogan, J. M Ceylon
Grogan, J. S Wadena
§Gronvall, P. R Minneapolis
§Groom, Dale Rochester
Groschupf, T. P Bemidji
Grose, F. N Clarissa
Groskloss, FF. H Minneapolis
Gross, J. B Rochester
§Grotting, J. K Rochester
Grugenhagen, A. P St. Paul
Grundset, O. J Montrose
{Guernsey, D. E Rochester
Guilbert, G. D Wood, Wis.
Guilfoile, P. J FFelano
Gullingsrud, M. J. O Oregon
Gullixson, Andrew Albert Lea
§ Gully, R. J Cambridge
*Gunderson, N. A Minneapolis
§Gushurst, E. G Minneapolis
§Gustason, H. T Minneapolis
§Habein, H. C Rochester
Flaberer, Helen R Minneapolis
Haberman, Emil Osakis
§FFaes, J. E Mankato
§Hagedorn, A. B Rochester
Hagen, O. J Moorhead
Hagen, P. S Minneapolis
May, 1947
§ Hagen, W. S Minneapolis
{Haggard, G. D Minneapolis
Haight, G. G Audubon
§{Haines, J. H Stillwater
{Haines, R. D Rochester
§ Haines, S. F Rochester
Halenbeck, P. L St. Cloud
{Hall, A. R St. Paul
§Hall, B. FI Rochester
Hall, G. H., Jr Minneapolis
Hall, H B Minneapolis
Hall, H. H St. Paul
*Hall, J. M Minneapolis
§Hall, W. E Maple Lake
Hall, W. H Minneapolis
§Halladay, G. J Brainerd
Hallberg, C. A Minneapolis
§Hallberg, O. E Rochester
§Hallenbeck, D. F Rochester
§ Hallenbeck, G. A Rochester
ijHallin, R. P Worthington
Halme, W. B Cloquet
Halloran, W. H Jackson
fjHalpern, D. J Brewster
§Halpin, J. E Rush City
§*Hamel, A. L Minneapolis
Hamilton, C. F Rochester
§Hamlin, G. B Minneapolis
SHamlon, J. S St. Charles
{Hamm, R. S Rochester
§Hammermeister, T. F New Ulm
§{Hammerstad, L. M Minneapolis
§Hammes, E. M St. Paul
Hammes, E. M., Jr Rochester
Hammond, A. J. H Minneapolis
Hammond, J. F St. Paul
Haney, C. L Duluth
Hankerson, R. G Minnesota Lake
Hanlon, G. H Rochester
§Hannah, H. B Minneapolis
Hanover, R. D Littlefork
Hansbro, G. L Rochester
§Hansen, C. O Minneapolis
§Hansen, E. W Minneapolis
Hansen, Olga S Minneapolis
Hansen, T. M Alden
§ Hanson, A. M Faribault
§ Hanson, E. O Cloquet
Hanson, E. C New York Mills
§ Hanson, H. J Minneapolis
§Hanson, H. B St. Paul
Hanson, H. V Minneapolis
§Hanson, J. W Northfield
Hanson, Lewis Frost
§Hanson, M. B Minneapolis
Hanson, N. O , Rochester
§Hanson, W. A. H Minneapolis
§Happe, L. J Minneapolis
Hare, Helen J Rochester
§Hargraves, M. M Rochester
§ Harmon, G. E St. Paul
Harper. Harry P Rochester
Harriman, Leonard .... Howard Lake
§ Flarrington, C. D Minneapolis
*§{ Harrington, F. E Minneapolis
§ Harrington, S. WT Rochester
§Harris, C. N Hibbing
§Harrison, P. W Worthington
{Hart, G. M Rochester
ijHart, V. L Minneapolis
§Hart, W. E Monticello
§Hartfiel, W. F St. Paul
§Hartig, Hermina A Minneapolis
Hartig. Marjorie St. Paul
SHartigan, J. D Rochester
^Hartley, E. C St. Paul
§Hartman, H. R Rochester
Hartman, Jack Soudan
§Hartnagel, G. F Red Wing
§Hartung, E. H Claremont
§{Hartzell, T. B Minneapolis
Harvev, George, Jr Rochester
§ Haskell, A. D Alexandria
SjHassett, M. F St. Paul
§ Hassett, R. C. Mankato
FFasskarl, W. F Rochester
§Hastings, D. R Minneapolis
Hastings, D. W Minneapolis
Hatch, W. E Duluth
Hatcher, A. C Rochester
Hathaway, S. J Tacoma, Wash.
Hauge, E. T Minneapolis
§FIauge, M. F Clarkfield
Haugen, J. A Minneapolis
§Hauser, V. P St. Paul
§Havel, H. W Jordan
§ Haven, W. K Minneapolis
§Havens, F. Z Rochester
§Havens, J. G. W Austin
§Hawkinson, R. P Minneapolis
§ Hayes, A. F St. Paul
§Hayes, J. M Minneapolis
Hayes, M. F Nashwauk
§Haynes, A. L Rochester
Hays, A. T Minneapolis
§Head, D. P Minneapolis
§Head, G. D Minneapolis
Headley, N. E Rochester
Healy, R. T Pierz
Hebbel, Robert Minneapolis
Hebeisen, M. B Chaska
§Heck, F. J Rochester
§Heck, W. W St. Paul
Hedback, A. E Minneapolis
§Hedberg, G. A Nopeming
Hedemark, H. H Ortonville
Hedemark, T. A Ortonville
Hedenstrom, F. G St. Paul
§Hedenstrom, F^. H Cambridge
§Hedin, R. F Red Wing
§Heersema, P. H Rochester
Hegge, O. H Austin
§Hegge, R. S Austin
Heiam, W. C Cook
§Heiberg, E. A Fergus Falls
§ Heiberg, O. M Worthington
Heilman, F. R Rochester
§FIeim, R. R Minneapolis
Heimark, J. J Fairmont
Heinrich, W. A Rochester
§Heise, FFerbert Winona
§Heise, Paul Winona
StHeise, W. F. C Winona
§Heise, W. V Winona
Helferty, J. PC Minneapolis
tFIelland, G. M Spring Grove
SjHelland, T. W Spring Grove
§Helmholz, H. F Rochester
§Helseth, H. PC Fergus Falls
§ Hempstead, B. E Rochester
{Hemstead, Werner Fergus Falls
§Hench, P. S Rochester
§{Henderson, E. D Rochester
Henderson, A. J. G St. Paul
§ Henderson, J. W Rochester
{Henderson, L. L Rochester
§Henderson, M. S Rochester
Hendricks, E. J . Verndale
{Plendrickson, J. F Minneapolis
Hendrickson, R. R F-ake Park
§Henegar, G. C Rochester
Hengstler, W. H St. Paul
Henkel, H. B Rochester
§Henney., W. H McFntosh
ijHenrikson, E. C Minneapolis
Henry, C. J ; • Milaca
{Henry, C. E Kirksville, Mo.
Flenry, M. O Minneapolis
§Hensel, C. N St. Paul
Henslin, A. E Le Roy
Henslin, M. E Le Roy
Herbert, W. L Minneapolis
§Herbst, R. F .Wykoff
Herman, S. M St. Paul
5 Hermanson, P. E Hendricks
ijHeron, R. C St. Paul
jiHerrell, W. E Rochester
§ Herrmann, E. T St. Paul
jFFertel, G. E ..Austin
Hertz, M. J St. Paul
Hertzog, A. J Minneapolis
Hewitt, Edith S Rochester
{Hewitt, R. M Rochester
{Heyerdale, O. C Rochester
Heyerman, O. T Rochester
Higgins, J. H Minneapolis
Higgins, R. S Rochester
Higginson, J. F Rochester
Hightower, N. C., Jr Rochester
SHilding, A. C -Duluth
§Hilger, A. W St. Pau
{Hilger, D. D St. Paul
§Hilger, J. A St. Pau
§ Hilger, L. D St. Pau
tjHilger, L. A ■■•St.
4 {Hill, Eleanor T Minneapolis
Hill, F. E .Duluth
§ FF ill. J. R Rochester
§Hillis, S. T Minneapolis
SHilton, FF. D Rochester
FFincklev, R. G Minneapolis
SHines, E. A., Jr Rochester
Hiniker, L. P St. Paul
SHiniker, P. J -. . . .Le Sueur
SFFinshaw, FF. C Rochester
§Hinz, W. T Bird Island
Hirschboeck, F. J Duluth
§Hirshficid, F. R Minneapolis
^Hitchings, W. S Lakefield
{Hoaglund, A. W., Santa Monica, Calif.
gHocnfilzer, J. J St. Paul
Hodapp, R. J Willmar
§Hodge, S. V Minneapolis
§Hodgson, C. H Rochester
Hodgson, J. R Rochester
§Hoeper, P. G Mankato
§Hoff, Alfred St. Paul
§Hoff, H. O Duluth
563
ROSTER 1947
tHoffbauer, F. W Minneapolis
§Hoffert, H. E Minneapolis
§Hoffman, R. A Minneapolis
§ Hoffman, W. L Minneapolis
§Hoidale, A. D Tracy
Holcomb, J. T. . . . Marine-on-St. Croix
Holcomb, O. W St. Paul
*tHoll, P. M Minneapolis
Hollenhurst, R. W Rochester
Hollands, W. H Fisher
Hollinshead, W. H St. Paul
Holm, H. H Glencoe
tHolm, P. F § Wells
§Holmberg, C. J Minneapolis
Holmberg, L. J Canby
§Holmen, R. W St. Paul
Holmes, A. E Rush City
§ Holmes, C. L Rochester
Holmstrom, C. H Warren
§Holt, J. E.. . St. Paul
§Holt, R. P Rochester
Holtan, Theodore Waterville
Holzapfel, F. C Minneapolis
§Hoon, J. R Rochester
Hopkins, G. W St. Paul
§Hoppes, E. E Rochester
§ Horan, M. J Rochester
§ Horton, B. T Rochester
§ Horns, Richard . . Minneapolis
Hosfeld, S. Marjorie Rochester
ijHottinger, R. C Janesville
Houkom, Bjarne Minneapolis
§Houkom, S. S Duluth
t House, Z. E Cass Lake
Houston, D. M Park Rapids
§ Hovde, Rolf Winthrop
Hovland, M. L Minneapolis
§Howard, E. G Mapleton
§ Howard, M. 1 Mankato
Howard, M. A St. Paul
Howard, S. E Minneapolis
Howard, W. S St. Paul
§ Howell, L. P Rochester
Hoyer, L. J Windom
§Hubbard, O. E Brainerd
Hubin, E. G Swanville
lludec, E. R Echo
Hudson, G. E Minneapolis
§lluenekens, E. J Minneapolis
§Huffington, H. L Mankato
Hughes, T. J Rochester
§Hullsiek, II. E St. Paul
§Hullsiek, R. B St. Paul
Hultgen, W. J St. Paul
jjHultkrans, J. C Minneapolis
Hultkrans, R. E Minneapolis
Humphrey, E. W Moorhead
Humphrey, W. R Stillwater
§ Hunt, A. B Rochester
Hunt, R. C Fairmont
Hunt, R. S Fairmont
Hunt, V. W Rochester
Hunte, A. F Alhambra, Calif.
Hurd, Annah Minneapolis
Hurley, J. P Rochester
Hurwitz, M. M St. Paul
Hutchins, S. P Rochester
gtHutchinson, C. T Minneapolis
Hutchinson, D. W Oak Terrace
Hutchinson, Henry Moose Lake
Huxley, F. R Faribault
§Hymes, Charles Minneapolis
§Hynes, J. E Minneapolis
lams, A. M Minneapolis
§Ide, A. W St. Paul
Ikeda, Kano St. Paul
Ingebrigtson, E. K. G Moorhead
Ingerson, C. A St. Paul
Irmisch, G. W Rochester
Irons, W. E Rochester
Irvine, H. G Minneapolis
tlverson, H. A Rochester
§ Iverson, R. M Minneapolis
Ivins, J. C Rochester
jjjackman, R. J Rochester
*tJackson, C. M Minneapolis
§Jackson, H. S Rochester
^Jacobs, D. L Willmar
Jacobs, G. C Fergus Falls
Jacobs, J. C Willmar
Jacobson, Clarence Chisholm
§ Jacobson, C. W Breckenridge
§ Jacobson, F. C Duluth
James, E. M Washington, D. C.
Tamieson, E. F Brainerd
Janecky, A. G Warroad
Janes, J. M Rochester
Janssen, M. E St. Paul
t Jennings, D. T Rochester
Jensen, A. M Brownton
§ Jensen, H. C Minneapolis
§t Jensen, M. J Minneapolis
Jensen, N. K Minneapolis
Jensen, R. A Minneapolis
§ Jensen, T. J Duluth
Jesion, J. W .St. Paul
t Jerome, Bourne Minneapolis
§Jeronimus, H. J Duluth
ST.essico, C. M Duluth
§ joffe, H. PI. Duluth
jjjohanson, W. G St. Paul
Johns, Sylvia Rochester
§Johnson, A. B Minneapolis
Johnson, A. E Minneapolis
Johnson, A. F. Red Wing
§ Johnson, A. M St. Paul
§ Johnson, B. H Rochester
Johnson, C. C Rochester
tjohnson, C. . E Pine River
Johnson, C. E St. Paul
*Tohnson, C. M Dawson
Johnson, C. P Tyler
§Johnson, C. R Rochester
Johnson, D. L Little Falls
Johnson, E. W Bemidji
Johnson, E. W Minneapolis
Johnson, Evelyn V Minneapolis
Johnson, H. C Thief River Falls
Johnson, Hans Kerkhoven
§ Johnson, H. A Minneapolis
§ Johnson, PI. C North Mankato.
§ Johnson, H. E Bird Island
Johnson, J. A St. Paul
§ Johnson, J. A Minneapolis
J Johnson, J. W .St. Louis Park
§ Johnson, Julius Minneapolis
§Johnson, K. E Duluth
Johnson, M. A., Ill Rochester
STohnsoti, M. R Minneapolis
tjohnson, N. A. ..Santa Monica, Calif.
Johnson, N. P Minneapolis'
Johnson, N. T Minneapolis
Johnson, O. H Redwood Falls
Johnson, Olga H Moorhead
Johnson, O. V Fergus Falls
Johnson, R. B Lanesboro
Johnson, R. G Stillwater
Johnson, Reuben A Minneapolis
Johnson, R. F. Crookston
Johnson, R. E ..Minneapolis
Johnson, R. M Slayton
§ Johnson, V. M Dawson
Johnson, W. E Morgan
Johnson, Y. T Minneapolis
Johnsrud', L. W Chisholm
§ Johnston, L. F Winona
John, F. M Bovey
Jondahl, W. H Rochester
t Jones, A. W Red Wing
Jones, E. M St. Paul
Jones, H. W., Jr Minneapolis
§Tones, O. H Mankato
§Jones, R. H Rochester
§ Jones, R. N St. Cloud
i) Jones, W. R Minneapolis
t Jordan, Kathleen Granite Falls
Jordan, L. S Granite Falls'
Josewich, Alexander Minneapolis
§Josewski, R. J Stillwater
§Joss, C. S Rochester
§Judd, E. S., Tr Rochester
§ Judd, W. IT.' Washington, D. C.
STuergens, H. M Belle Plaine
§Tuers, F.. H Red Wing
§ Juliar, R. O St. Clair
Ijurdy, M. J Minneapolis
Kabler, P. W
Kabrick, O. A
Kalin, O. T
Kallestad, L. L. . .
§Kamman, G. R
Kamp, B. A
Kaplan, D. H
Kaplan, J. J
Kapsner, Carl . . . .
Karleen, B. N. . .
Karleen, C. I
Karlstrom, A. E. ...
§Karn, B. R
§Karn, J. F
Karon, I. M
Karstens, H. C. . .
§ Kasper, E. M
§Kath, R. H
Katzovitz, Hyman. .
Kaufman, F.. J
§Kaufman, H. J
§ Kaufman, W. B...
Kaufman, W. C. ..
iiKearney, R. W. . . .
§Keating, F. R., Jr..
§ Keating, J. U. ...
Keefe, R. E
Keeley, T. K
Keffer, W. H. ...
. . Minneapolis
Jackson
. . Minneapolis
.... Brownton
St. Paul
. . . Albert Lea
St. Paul
. . Minneapolis
.... Princeton
Jackson
. . Minneapolis
. . Minneapolis
. . . . Ortonville
. . . . Ortonville
St. Paul
.... Rochester
St. Paul
..Wood Lake
St. Paul
Appleton
. . Minneapolis
Mankato
Appleton
Mankato
.... Rochester
.... Rochester
St. Paul
.... Rochester
.... Rochester
§Keith, H. M Rochester
§Keith, N. M Rochester
§Keithahn, E. E ...Sleepy Eye
§Kelbv, G. M ..Minneapolis
Kelley, K. J Big Fork
§ Kelly, J. F Cold Springs
Kelly, J. P Minneapolis
§Kelly, J. V St. Paul
Kelly, P. H St. Paul
§Kelsey, C. G Hinckley
Kelsey, C. M St. Paul
Kelsey, M. P Rochester
jjKemp, A. F Mankato
Kemp, M. W Alton, 111.
Kemper, C. M Rochester
Kendall, R. F St. Paul
§Kenefick, E. V St. Paul
§Kennedy, C. C Minneapolis
Kennedy, G. L Faribault
Kennedy, Jane F Minneapolis
§ Kennedy, R. L. J Rochester
Kennedy, T. J Rochester
§ Kennedy, W. A St. Paul
Kenyon, T. J St. Paul
§Kepler, E. J Rochester
§Kerkhof, A. C Minneapolis
Kern, C. E Rochester
§Kernohan, J. W Rochester
Kertesz, G Minneapolis
§Kesting, Herman St. Paul
Kettlewell, R. B Sauk Centre
Keyes, J. D Winona
§Kierland, P. E Alexandria
§Kierland, R. R Rochester
§Kiernan, P. C Rochester
^Kilbride, E. A Worthington
t Kilbride, J. S Worthington
jjKimmel, G. C., Jr Red Wing
fKing, E. A Hennepin
King, F. W Oak Terrace
King, G. L St. Paul
*Kingsbury, E. M Moose Lake
§Kinsella, T. J Minneapolis
Kinsport, E. B. ..International Falls
§Kirby, J. L Rochester
Kirk, G. P East Grand Forks
Kirkland, W. G Rochester
§KirkIin, B. R Rochester
SKirklin, O. L Rochester
SKistler, A. J Minneapolis
§tKistler, C. M Minneapolis
Kleifgen, G. V. H St. Paul
Klein, A. D Chisholm
§Klein, Harry Duluth
§Klein, H. N St. Paul
Klein, J. C Shakopee
§Klima, W. W Stewart
Klontz, C. E., Jr Rochester
§ Knapp, F. N Duluth
§Knapp, M. E Minneapolis
iitKnauff, M. K St. Paul
Knight, E. G Swanville
Knight, R. R Minneapolis
§ Knight, R. T Minneapolis
tKnisely, R. M Rochester
§ Knoll, ’ W. V Duluth
Knutson, G. A Hallock
Knutson, G. E St. Paul
IKnutson, T. R. B Rochester
5 Knutson, L. A Spring Grove
§Koelsche, G. A. Rochester
§Koenigsberger, Charles Mankato
SKoepcke, G. M Minneapolis
i?Kohlbry, C. O ..Duluth
'Kohler, D. W St. Joseph
Kolars, J. J Faribault
Koller, H. M Minneapolis
Koller, L. R Minneapolis
§Koop, S. H Richmond
Korchik, T. P Minneapolis
fjKortsch, F. P Prior Lake
Koschnitzke, H. K Minneapolis
§Kostick, W. R Fertile
Kotchevar, F. R Eveleth
§Kouckv, R. W Minneapolis
Krause, C. W Fairmont
Kreilkamp, B. L Rochester
Kreuzer, T. C Marshall
§Krueger, V. R Nopeming
jSKruzick, S. J Sleepy Eye
§Krusen, F\ H Rochester
Kucera, F. J Hopkins
§Kucera, S. T Lonsdale
§ Kucera, W. J Minneapolis
§Kugler, A. A St. Paul
Kuhlman, L. B Melrose
Kurtin, H. J Blooming Prairie
Kurzweg, F. T Rochester
Kuske, A. W St. Paul
§Kusske, A. L New Ulm
§Kvale, W. F Rochester
Kvitrud, GiftJert St. Paul
564
Minnesota Medicine
ROSTER 1947
§LaBree, R. H Duluth
Lagaard, S. M Minneapolis
Laikola, L. A Adrian
§Laird, A. T Duluth
Lajoie, T. M Minneapolis
§Lake, C. F Rochester
§Lampert, E. G Rochester
Landry, R. M Rochester
SLang, L. A Minneapolis
Langhoff, A. H St. Peter
§Lannin, B. G St. Paul
§Lannin, J. C Mabel
§Lapierre, A. P Minneapolis
§Lapierre, J. T Minneapolis
Large, H. R Rochester
Larrabee, W. F., Jr Rochester
§Larsen, C. L St. Paul
Larsen, F. W Minneapolis
Larson, Arnold Detroit Lakes
§Larson, C. M Minneapolis
Larson, E. A Minneapolis
Larson, Eva- Jane St. Paul
Larson, J. T St. Paul
§ Larson, L. M Minneapolis
SjLarson, Leonard M Oak Terrace
Larson, Leroy Bagley
§Larson, M. H Nicollet
§Larson, P. N Minneapolis
Larson, R. H Anoka
fLatterell, K. E Rochester
Lauer, D. J Pittsburgh, Pa.
Laughlin, J. T Grey Eagle
§La Vake, R. T Minneapolis
Law S. G Minneapolis
Lax, M. H * St. Paul
§Laymon, C. W Minneapolis
SjLeahy, Bartholomew St. Paul
§Leary, W. V Rochester
^Leavenworth, R. O St. Paul
fLeavitt, H. H Minneapolis
Leavitt, M. D Rochester
LeBlanc, L. J Rochester
Lebowske, T. A Minneapolis
§Leck, P. C Austin
§Leddy, E. T Rochester
Lee, II. M Minneapolis
§Lee, H. W Bramerd
§Lee, J. B Rochester
Lee, W. N Madison
Leemhuis. G. H Aitkin
Leibold, E. F New Prague
Leibold, H. H Parkers Prairie
Leick, R. M St. Paul
fjLeitch, Archibald St. Paul
§Leitschuh, T. H Sanborn
Leitschuh, L. F Sleepy Eye
ILeland, H. R Minneapolis
Lemon, W. E Rochester
§Lemon, W. S Rochester
§Lenander, M. E. L St. Peter
iLenarz, A. J Browerville
§Lende, Norman Faribault
Lenont, C. B Virginia
Lenz, J. R Morton
§Lenz, O. A Minneapolis
§Leonard, L. J Minneapolis
ijLeonard, Samuel Minneapolis
Leopard, B. A Albert Lea
Lepak, F. J Duluth
§Lepak, J. A St. Paul
tLerche, William Cable, Wis.
§Leven, N. L St. Paul
Leverenz, C. W St. Paul
Levin, Bert St. Paul
Levin, Louis Rochester
Levitt, G. X St. Paul
§Lewis, A. J Henning
Lewis, C. B St. Cloud
Lexa, F. J Lonsdale
Libert, J. 'N St. Cloud
§Lick, C. L St. Paul
Liedloff. A. G Mankato
Lien, R. J St. Paul
§Liffrig, W. W Red Wing
§Lightbourn, E. L St. Paul
Lightfoot, Grace K Rochester
§Lilleberg, N. J St. Paul
Lillehei, E. J Robbinsdale
§ Lillie, H. X Rochester
§Lillie, J. C Rochester
Lima, L. R Montevideo
Lima, L. R., Jr Montevideo
Lind, C. J Minneapolis
JLind, C. J., Jo Minneapolis
Lindberg, A. L Wheaton
Lindberg, A. C. Minneapolis
§Lindberg, V. L Minneapolis
§Lindblom, A. E Minneapolis
§Linde, Herman Cyrus
§Lindgren, R. C Minneapolis
Lindley, S. B Willmar
§Lindquist, R. LI Minneapolis
§Linner, H. P Minneapolis
Lippman, E. S Minneapolis
May, 1947
Lippman, H. S St. Paul
Lippmann, E. W Hutchinson
§Lipschultz, Oscar Minneapolis
§Lipscomb, P. R Rochester
^Litchfield, J. T Minneapolis
Litman, A. B Minneapolis
§I,itman, S. N Duluth
^Little, W. J ..St. Paul
§fLitzenberg, J. C Minneapolis
*fLochead, D. C Rochester
Lofgren, K. A Rochester
§Lofsness, S. V Minneapolis
§Logan, A. H Rochester
§Logan, G. B Rochester
§Logefeil, R. C. Minneapolis
§Lohmann, J. G Pipestone
§Loken, Theodore Ada
§Loken, S. M St. Paul
Lombardi, A. A Rochester
§Lommen, P. A Austin
Long, Mary Rochester
Longfellow, Helen B. W. ..Brainerd
Loofbourrow, E. H Keewatin
§ Loomis, E. A Minneapolis
§ Loomis, G. L Winona
Loose, W. D Rochester
Love, F. A Carlos
§Love, J. G Rochester
§Lovelady, S. B Rochester
Ixivett, Beatrice R Oak Terrace
gtLovshin, L. L Rochester
Lowe, E. R So. St. Paul
§Lowe, G. H Rochester
Lowe, T. A So. St. Paul
Lowry, Elizabeth C Minneapolis
Lowrv, Thomas Minneapolis
§Lovd,' E. L Rochester
Luck, Hilda Mankato
§Luckemeyer, C. J St. Cloud
Ludden, T. F. Rochester
Luellen, T. J Rochester
§ Lufkin, N. XI Minneapolis
§Lund, C. J. T Fergus Falls
Lund, C. J Minneapolis
Lund, W. J ...Staples
Lindberg, Ruth I Minneapolis
Lundblad, R. A Minneapolis
Lundblad, S. W Minneapolis
Lundell, C. L Granite Falls
Lundgren, A. C Minneapolis
§Lundholm, A. M St. Paul
§Lundquist, E. F Minneapolis
§Lundy, J. S Rochester
§Luth, D. V Duluth
§Lyman, R. W Rochester
§Lynch, F. W St. Paul
Lynch, J. L Rochester
§ Lynch, M. J Minneapolis
Lynch, R. C New Orleans, La.
§Lynde, O. G Thief River Falls
Lysne, Henry Minneapolis
§Lysne, Myron Minneapolis
*Macbeth, J. L St. Clair
§MacCarty, C. S Rochester
SfMacCarty, W. C Rochester
fMacDonald, A. E Minneapolis
§MacDonald, D. A Minneapolis
§Macdonald, I. D Rochester
§MacFarlane, P. H Chisholm
§Mach, F. B Minneapolis
Mack, J. J Little Rock, Ark.
MacKinnon, D. C Minneapolis
Macklin, W. E., Jr Mankato
Macklin, W. E., Jr Litchfield
§MacLean, A. R Rochester
§MacMillan, D. G Minneapolis
MacMurtrie, W. J., Jr Rochester
Macnie, J. S Minneapolis
§ MacRae, G. C Duluth
Macy, Dorothy Rochester
§ Madden, J. F St. Paul
§Madland, R. S St. Paul
§Maeder, E. C Minneapolis
Maertz, W. F St. Paul
§Magath, T. B Rochester
§Magney, F. H Duluth
Magnuson, A. E Wheaton
§Magraw, R. M St. Paul
§Mahle, D. G Plainview
§Mahowald, A Albany
Maitland, E. T Jackson
§Maland, C. O Minneapolis
Malerich, J. A St. Paul
§Malmstrom, J. A Virginia
§Manley, J. R Duluth
§tMann, F. C Rochester
tManson, F. M Worthington
tMarcley, W. J Minneapolis
§Marek, F. H Rochester
Margulies, Harold' Rochester
§Mariette, E. S Oak Terrace
§Mark, D. B Minneapolis
Mark, Hilbert Minneapolis
§ Marking, G. H Minneapolis
Marks, R. W St. Paul
Marr, G. E Rochester
Marshall, Helen S Statesan, Wis.
Martens, T. G Rochester
Martin,' D. L St. Paul
Martin, T. P Arlington
§ Martin, W. C Duluth
§Martineau, J. L St. Paul
Martinson, C. J Wayzata
tMartinson, E. J Wayzata
Marvin, C. P Rochester
§Masson, D. M Rochester
§ Masson, J. C Rochester
JMatchan, G. R Minneapolis
Matthews, Justus Minneapolis
§Mattill, P. M Oak Terrace
§ Mattison, P. A Winona
Mattson, A. D Madison
§ Mattson, H. A. N Minneapolis
ijMaxeiner, S. R Minneapolis
§Mayfield, L. H Rochester
ItMayne, R. M Duluth
SMayo, C. W Rochester
ijMaytum, C. K Rochester
McAdams, T. B St. Paul
McAnally, A. K Rochester
§McBean, J. B Rochester
StMcCaffrey, F. J Minneapolis
McCain, D. L St. Paul
McCann, D. F Bemidji
§ McCarten, F. M Stillwater
McCarthy, Donald Minneapolis
McCarthy, J. J St. Paul
McCarthy, W. R St. Paul
McCartney, J. S Minneapolis
fMcCarty, P. D ....Ely
McClanahan, J. XT White Bear
McClanahan, T. S White Bear
McClellan, J. T Rochester
§ McCloud, C. N. St. Paul
§McConahey, W. M., Jr., .... Rochester
JMcCoy, Mary K Duluth
McCreight, W. G Rochester
JMcCrimmon, H. P Minneapolis
JMcDaniel, Orianna Minneapolis
McDonald, A. L Duluth
§McDonald, J. R Rochester
§ McDowell, J. P St. Cloud
McEachern, C. G Rochester
§McElin, T. W Rochester
McElmeel, E. F Seattle, Wash.
McEnaney, C. T Owatonna
§McEwan, Alexander St. Paul
§ McFarland, A. XI Minneapolis
§McGandy, R. F Minneapolis
§McGeary, G. E Minneapolis
McGroarty, J. J Easton
§McGuff, P. E Rochester
McGuigan, H. T Red Wing
SMcHaffie, O. L Duluth
§ Mclnerny, M. W Minneapolis
§McIntire, H. M Waseca
McIntyre, J. A Owatonna
Mclver, B. A Lowry
McKaig, C. B Pme Island
McKelvey, J. L Minneapolis
§McKenna, J. K Austin
McKenna, M. J Grand Rapids
§McKenzie, C. H Minneapolis
McKeon, J. O. Faribault
§McKinlay, C. A Minneapolis
f McKinley, J. C Minneapolis
§ McKinney. F. S Minneapolis
McLane, W. O ...Duluth
fMcLaren, Jennette M. ..Minneapolis
McLaughlin, B. H Rochester
McLaughlin, E. M Winona
McLeod, J. L Grand Rapids
§McMahon, J. M Rochester
McMahon, M. J Green Isle
McMillan, J. T Rochester
McMurtrie, W. B Minneapolis
^McNutt, J. R Duluth
§ McPheeters, H. O Minneapolis
McQuarrie, H. B Rochester
fMcpuarrie, Irvine Minneapolis
McV’icker, J. H Rochester
Mead, C. XI .Duluth
§Meade, J. R St. Paul
§Mears, B. J St. Paul
§Mears, R. F Northfield
ijMedelman, J. P St. Paul
Medlin, C. F Truman
§Meinert, A. E Winona
Melancon, J. F St. Paul
Melby, Benedik ..Blooming Prairie
§Mellby, O. F Thief River Falls
Meller, R. L Minneapolis
Melzer, G. R Lyle
§Mercil, W. F Crookston
§Merkert, C. E Minneapolis
§Merkert, G. L Minneapolis
JMerrick, Charlotte T Minneapolis
565
ROSTER 1947
tMerrill, Elisabeth Minneapolis
§Merrill, R. W Morris
§Merriman, L. L Duluth
§ Merritt, W. A Rochester
§Mesker, G. H Cambridge
Messier, J. D Rochester
Meyer, A. A Melrose
§Meyer, A. C Rochester
§Meyer, A. J Minneapolis
§Meyer, E. L Minneapolis
Meyer, F. C Kenyon
Meyer, J. O Grand Rapids
Meyer, P. F Faribault
Meyer, W. M Rochester
§Meyerding, E. A St. Paul
Meyerding, H. W Rochester
Meyers, W. C Rochester
Mezen, J. F Rochester
Michael, J. C Minneapolis
Michel, H. H Minneapolis
Michels, R. P Willmar
§Michelson, H. E Minneapolis
tMiekelsen, Emma F Minneapolis
§Mickelson, J. C Mankato
Milhaupt, E. N St. Cloud
Millen, F. J Rochester
§ Miller, E. W Anoka
§Miller, H. E Minneapolis
Miller, Hugo E Minneapolis
§Miller, J. C Minneapolis
tMiller, Sidney Rochester
§ Miller, V. I Mankato
Miller, VV. A New York Mills
Mills, J. L Winnebago
§Milton, J. S Minneapolis
Minckler, J. E St. Paul
Miners, G. A Deer River
§Minsky, A. A Minneapolis
§Minty, E. W Duluth
Mitbv, I. L Aitkin
Mitchell, B. D ...Minneapolis
Mitchell, E. C Minneapolis
Mitchell, M. T Minneapolis
§Moberg, C. W Detroit Lakes
§Moe, J. H Minneapolis
§Moe, R. J Duluth
Moe, Thomas Moose Lake
§Moen, J. K., Jr Minneapolis
§Moersch, F. P Rochester
§Moersch, H. J Rochester
§Moga, J. A St. Paul
Molander, H. A St. Paul
Mollers, T. P Mountain Iron
Monahan, Elizabeth S. ..Minneapolis
Monahan, R. H., Jr., ......
International Falls
Monroe, P. B Cloquet
Monserud. N. O Cloquet
§Monson, E. M Minneapolis
Montgomery, G. E Rochester
§ Montgomery, Hamilton . . . .Rochester
§Mooney, L. P Graceville
Moos, D. T Minneapolis
Moquin, Marie A St. Paul
More. C. W Eveleth
Morehead, D. E Owatonna
Moren. Edward Minneapolis
Morgan, E. H Rochester
§ Morgan, H. O Amboy
Morgan, J. L Rochester
Moriarty, Berenice St. Paul
Moriartv, Cecile R St. Paul
§Mork, A. H Anoka
§Mork, B. O., Tr Worthington
§Mork, B. O., Sr Worthington
§Mork, F. E Anoka
Morley. G. A Crookston
§Morlock, C. G Rochester
§ Morris, D. S Rochester
Morrison, A. W Minneapolis
Morrison, Charlotte J. ..Minneapolis
Morrow. T. R Rochester
Morse, M. P . Le Roy
§Morse, R. W Minneapolis
§Morseman L. W ...Hibbing
Morton, R .J Rochester
§Mosbv, M. E Long Prairie
§Moses, Toseph, Jr Northfield
Moses. R. R Ken von
§Mouritsen. G. J Fergus Falls
Mueller, R. F Lincoln, Nebr.
Mueller. Selma C Duluth
Muir, W. F Browns Valley
Muller, A. E North Saint Paul
§ Muller. R. T St. Paul
^Mulligan, A. M Brainerd
Mulmed, E. T Rochester
§Murphy, E. P Minneapolis
§ Murphy, I. J Minneapolis
Murphy, J. E Marshall
SMurphy, James E St. Cloud
jMurphy, J. T Rochester
Murphy, M. E Rochester
Murray, R. A Hibbing
Murray, R. A Rochester
Musachio, N. F Foley
Musgrove, J. E Rochester
Mussey, Mary E Rochester
§Mussey, R. D Rochester
Mussey, Robert D., Jr Rochester
fMusty, N. J Minneapolis
§Myers, J. A Minneapolis
§ Myers, T. T Rochester
Myre, C. R Paynesville
Naegeli, A. E St. Paul
§Naegeli, Frank Fergus Falls
Nagel, H. D Waconia
§Nash, L. A St. Paul
§Naslund, A. W Minneapolis
Nauth, B. S Winona
§Navratil, D. R Montgomery
tNay, R. M Rochester
§Neal, J. M Minneapolis
§Nealy, D. E Adrian
Neary, R. P Minneapolis
§Neel, H. B Albert Lea
Neff, W. S Virginia
§Nehring, J. P Preston
Neibling, H. A Rochester
Nelson, A. S Thief River Falls
Nelson, Bernette G Menagha
Nelson, Bernice A Northome
Nelson, C. E. J Albert Lea
Nelson, E. H Chisholm
§Nelson, E. J Owatonna
Nelson, E. N Minneapolis
Nelson, H. E Crookston
§Nelson, G. E Fairfax
fNelson, H. S Los Angeles, Calif.
Nelson, K. L Clara City
§Nelson, L. A St. Paul
Nelson, L. S Hibbing
§Nelson, M. C Minneapolis
§Nelson, M. S Granite Falls
§ Nelson, N. H Minneapolis
§Nelson, N. P Brainerd
§Nelson, O. L. N Minneapolis
Nelson, R. A Fergus Falls
§Nelson, R. L Duluth
§Nelson, W. I Minneapolis
§Nelson, W. O. B Fergus Falls
Nesbitt, Samuel Minneapolis
§Nesheim, M. O Emmons
§Nessa, C. B St. Cloud
Nesset, L. B Minneapolis
Neumaier, Arthur Glencoe
Neumann, C. A Winona
§New, G. B Rochester
§Nichols, A. E St. Paul
§ Nichols, D. R Rochester
§Nicholson, M. A Duluth
t Nickel, W. R Rochester
Nickerson, J. R Heron Lake
JNickeson, R. W Rochester
Nielsen, W. L Rochester
Nielson, A. M Northfield
Nietfeld, A. B Warren
§Nilson, H. J North Mankato
Ninneman, N. N Waconia
Nix, J. T Rochester
Nixon, J. B Crosby
Nixon, R. R Rochester
§Noble, T. F St. Paul
§ Noble, J. L St. Paul
Nolan, D. E Dayton, Ohio
Noonan, W. J Minneapolis
§Noran, H. H Minneapolis
Norberg, C. E Cloquet
§Nord, R. E Minneapolis
§Nordin, G. T Minneapolis
Nordland, M. A Rochester
§Nordland, Martin Minneapolis
Norley, Theodore Rochester
§Nordman, W. F Mora
§ Norman, J. F Crookston
§Norris, N. T Caledonia
§fNoth, H. W Minneapolis
Novak, E. E New Prague
Norval, M. A Rochester
Nuebel, C. J St. Paul
Nuessle, W. G Springfield
§Nuetzman, A. W Faribault
§ Nutting, R. E Duluth
§Nydahl, M. J Minneapolis
Nye, Katherine A St. Paul
Nye, Lillian L St. Paul
Nygren, W. T Braham
§Nvlander, E. G Minneapolis
Nystrom, Ruth G Minneapolis
§Oberg, C. M Minneapolis
O’Brien, L. T Breckenridge
O’Brien, R. W Rochester
fO’Brien, W. A Minneapolis
O’Brien, W. M St. Paul
§Ochsnner, C. G Wabasha
O’Connor, D. C Eden Valley
O’Connor, L. J St. Paul
Odel, H. M Rochester
Odessky, Louis ..Staten Island, N. Y.
§0’Donnell, D. M Ortonville
O’Donnell, J. E Minneapolis
§Oeljen, S. C. G Waseca
Oerting, Harry St. Paul
§ Ogden, Warner St. Paul
§Ohage, Justus, Jr St. Paul
§0’Hanlon, J. A Lind'strom
O’Kane, T. W St. Paul
§0’Keefe, J. P St. Cloud
Olcott, E. D Rochester
§01ds, G. H New Richlafid
§ O’Leary, P. A Rochester
§OHver, I. L Graceville
§01iver, James Moorhead
§01manson, E. G St. Peter
§ Olsen, A. M Rochester
§01sen, E. G Minneapolis
Olsen, R. L St. Paul
Olsen, Gertrude E Georgetown
§01son, A. C Minneapolis
Olson, A. E Duluth
§01son, A. O Duluth
Olson, C. A St. Paul
Olson, C. J Belle Plaine
§01son, D. O. C ...Gaylord
§01son, E. A Pine Island
§ Olson, G. E West Concord
Olson, J. W Minneapolis
fOlson, O. A Minneapolis
Olson, O. C Rochester
§t01son, R. G Minneapolis
Olson, S. W Rochester
O’Neal, Ruth Rochester
Onsgard, L. K Houston
§Oppegaard, C. L Crookston
§Oppegaard, M. O Crookston
§Oppen, E. G Minneapolis
§0’Reilley, B. E St. Paul
JOsborn, J. E Rochester
Ostergaard, Erling ....Fergus Falls
§Ostergren, E. W .St. Paul
Otten, D. E Minneapolis
Otto, H. C Frazee
§Ouellette, A. J St. Paul
Owen, A. C Rochester
Owens, W. A Montevideo
fOwre, Oscar Minneapolis
§Paalman, R. J Rochester
§Page, R. L St. Charles
§Paine, T. R Minneapolis
Palen, 13. J Minneapolis
Palmer, C. F Albert Lea
Palmer, H. A Blackduck
Palmer, J. K Rochester
Palmer, W. L Albert Lea
Palmerton, E. S Albert Lea
Pankratz, P. J Mountain Lake
Parke, F. F Rochester
f Parker, O. W Duluth
§ Parker, H. L Rochester
§ Parker, R. L Rochester
Parker, W. E Sebeka
Parker, W. H Chisholm
Parkhill, Edith M Rochester
Parkin, T. W Rochester
Parson, E. I Duluth
Parson, Lillian B Elbow Lake'
Parson, L. R Elbow Lake
Parsons, J. G Crookston
Parsons. K. L Monterey
Paschall, Jack, Jr Rochester
Pasek, A. W Cloquet
§ Passer, A. A Olivia
§Patch, O. B Duluth
Patterson, H. D Slayton
Patterson, R. B .Marshall
§*Patterson, W. E Minneapolis
Patterson, W. L Fergus Falls
§ Paulson, E. C Elbow Lake
Paulson, G. S Evansville
Paulson, J. A Rochester
Paulson, T. S Fergus Falls
Pearsall, R. P Virginia
§ Pearson, B. F Shakopee
Pearson, C. C Rochester
Pearson, D. J. ..Battle Creek, Mich.
§ Pearson, F. R St. Paul
Pearson, L. O Warroad
Pearson, M. M St. Paul
Pease, Gertrude L Rochester
Peck, L. D Hastings
Peck, L. R Hastings
Pedersen, A. H St. Paul
§ Pedersen, R. C Duluth
§Peltzer, W Rochester
§ Pemberton, J. de*J Rochester
§ Pender, T. W Rochester
Penhall, F. W Willmar
§Penk, E. L Springfield
§Penn, G. E Mankato
566
Minnesota Medicine
ROSTER 1947
Pennie, D. F Duluth
§Peppard, T. A Minneapolis
Perkins, R. F Rochester
Perlman. E. C Minneapolis
§Perry, C. G St. Paul
§ Perry, E. L Rochester
§ Person, J. P Alden
Pertl, A. L Canby
JPeters, G. A Rochester.
Petersen, G. L Minneapolis
§f Petersen, J. R Minneapolis
ijPetersen, M. C Rochester
§ Petersen, P. C Mora
§ Petersen, R. T St. Cloud
§ Peterson, C. A Chisago City
Peterson, D. B St. Paul
PeteTson, E. N Virginia
§Peterson, H. O St. Paul
Peterson, H. W Minneapolis
§ Peterson, J. L. E St. Paul
Peterson, J. H Minneapolis
Peterson, J. R Rochester
Peterson, K. H Hutchinson
Peterson, L. J Minneapolis
§Peterson, N. P Minneapolis
Peterson, O. L Cokato
Peterson, O. H Minneapolis
§Peterson, P. E Minneapolis
Peterson, R. A ....Vesta
§Peterson, W. C Minneapolis
Peterson, W. E Willmar
Peterson, W. Henry Minneapolis
§Petit, J. V Minneapolis
§Petit, L. J Minneapolis
Petraborg, H. T Aitkin
PewteTS, J. T Minneapolis
Peyton, W. T Minneapolis
§Pfuetze, K. H Cannon Falls
Pfeutze, M. E Rochester
§Pfunder, M. C Minneapolis
§Phelps, K. A Minneapolis
Phillips, S. K Rochester
Pierce, C. H Wadena
§ Pierce, P. P Rochester
Pierson, R. F Slayton
§ Piper, M. C Rochester
§ Piper, W. A Mountain Lake
Plass, H. F. R Minneapolis
§Platou, E. S Minneapolis
§Pleissner, K. W St. Louis Park
§Plimpton, N. C., Jr. ....... Minneapolis
§Plondke, F. J St. Paul
§ Plummer, W. A Rochester
Pogue, R. E Watertown
§Pohl, J. F. M Minneapolis
Poirier, J. A Forest Lake
§ Pollard, D. W Minneapolis
Pollard, W. H., Jr Duluth
§Polley, H. F Rochester
§ Pollock. D. K Minneapolis
§*Pollock, L. W Rochester
§Polzak, J. A Minneapolis
{SPonterio, J. E Shakopee
§Pool, T. L Rochester
Poore, J. C Isle
§ Poore, T. N Rochester
§Popp, W. C Rochester
Poppe, F. H Minneapolis
Porter, O. M Willmar
Potek, D. M International Falls
§Potter, R. B Minneapolis
Potthoff, C. J Washington. D. C.
§ Power, J. E Duluth
§ Powers, F. H Rochester
§Prangen, A. D Rochester
Pratt, F. J Minneapolis
§Pratt, J. H.. Jr Rochester
Pratt, W. C Rochester
§Preine, I. A Minneapolis
Preisinger, J. W. . Renville
?Prendergast, H. J St. Paul
Preston, F. W Rochester
Preston, L. F Rochester
Preston, P. J Minneapolis
§Prickman, L. E Rochester
Priest, R. E Minneapolis
§Priestly, J. T Rochester
ItPrim, J. A Minneapolis
§Prins, L. R Albert Lea
Proeschel, R. K Willmar
Proffitt. W. E Minneapolis
§Proshek, C. E Minneapolis
§Pruitt, R. D Rochester
§Pugh, D. G Rochester
Pugh, P. F. H Rochester
Purves, G. H Hendricks
Pumula, E. E Minneapolis
SPuumala, R. H Cloquet
Pyle, Marjorie M Rochestei
IQuanstrom, V. E Brainerd
Quattlebaum, Frank St. Paul
SUuello, R. O. B Minneapolis
§*tQuinby, T. F Minneapolis
May, 1947
jjQuist, H. W Minneapolis
tQuist, H. W., Jr Minneapolis
Raadquist, C. S
Radabaugh, R. C. ..
§Raetz, S. J
Raihala, John
5 Ratter, R. F
Ralph, J. R
§ Ralston, D. E. ..
Ramsey, W. H., II
fRamsey, W. R
Randall, A. M
§Randall, L. M
Rang, R. H
§Ransom, H. R
Ransom, M. L
Rasmussen, R. C.. . .
§Rasmussen, W. C..
jjfRatcliffe, J. J
Rea, C. E
Reader, D. R
Reed, Paul
Reeve, E. T
§Reff, A. R
Regan, J. J
§Regnier, E. A
Reid, L. M
§Reif, H. A
§Reif, H. J
§Reiley, R. E
§fReineke, G. F
fReiter, H. W
Remington, J. IL. . .
Rempel, D. D
Remsberg, R. R.
Replogle, W. H. . . .
§ Reynolds, J. S
§Rice, C. O
Rice, H. G
Rice, Roberta G. .
^Richards, E. F. F. . .
§ Richards, W. B....
jjRichardson, H. E. .
Richardson, R. J...
§Richdorf, L. F. . . .
Rick, P. F. W
§Ridgway. A. M..
Riegel, G. S
§Rieke, W. W
Rigler, L. G
Ringle, O. F
Riordan. Elsie M...
Ripple, R. J
§Risch, R. E
§Risser, A. F
§ Ritchie, W. P
§Ritt, A. E
§Rivers, A. B
Rizer, D. K
Rizer, R. I
§*Roan, C. M
Roan, O. M
Robb, E. F
StRobbins, C. P. . . .
§ Robbins, O. F
Roberts, L. J
Roberts, O. W
Roberts, S. W
^Roberts, W. B
tRobertson, J. B
SRobertson, P. A....
§Robilliard, C. M...
t Robinson, J. M....
Robitshek, E. C....
Robson, J. T
§Rodda, F. C
Rodgers, C. L. . .
§Roehlke, A. B
SRoemer, H. J
§ Rogers, C. W
Rogers, G. E. B.
Rogers, T. D
§ Rogers, S. F
§Rogne, W. G
§Roholt, C. L
Rohrer, C. A
Rokala, H. E
Rolig. D. H
§tRood, D. C
§Rose, J. T
Rosenbaum, E. E.
§Rosenbladt, Louis..
Rosendahl, F. G...
Rosenfield, A. B.
Rosenholtz, Burton
Rosenow, E. C. . . .
Rosenow, J. H
§Rosenthal, F. H. .
§ Rosenthal, Robert.
§Rosenwald, R. M...
RoskiUy, G. C. P.. .
§Ross. A. J
Rossberg, R. A. .
Hibbing
Hastings
Maple Lake
Virginia
Cloquet
St. Paul
Rochester
Rochester
St. Paul
Ashby
Rochester
Rochester
Osseo
Hancock
St. Paul
Rochester
Aitkin
St. Paul
Minneapolis
Virginia
Elbow Lake
Crookston
Minneapolis
Minneapolis
Excelsior
Minneapolis
St. Cloud
Minneapolis
New Ulm
Shakopee
Rochester
... Lester Prairie
Tracy
Wabas.ia
..Minneapolis
Minneapolis
Aitkin
Aitkin
St. Paul
St. Cloud
St. Paul
St. Paul
Minneapolis
St. Paul
Annandale
. . . .Taylors Falls
Wayzata
..Minneapolis
Walker
Minneapolis
New London
Minneapolis
Stewartville
St. Paul
St. Paul
Rochester
Minneapolis
Minneapolis
Minneapolis
Minneapolis
Minneapolis
Winona
Minneapolis
Minneapolis
Owatonna
Minneapolis
Minneapolis
Minneapolis
Austin
Faribault
, . . Goshen, N. Y.
Minneapolis
Rochester
Minneapolis
Minneapolis
Elk River
Winona
Minneapolis
Minneapolis
Rochester
St. Paul
.... Spring Grove
Waverly
Waterville
Virginia
St. Paul
Duluth
Lakefield
Rochester
. . .Tacoma, Wash.
Minneapolis
Minneapolis
St. Paul
.Cincinnati, Ohio
Rochester
Austin
St. Paul
Minneapolis
Minneapolis
Minneapolis
Morris
§Roth, F. D Lewiston
§Roth, G. C St. Paul
Rothschild, H. J St. Paul
§Roust, H. A Montevideo
Rovelstad, R. A Rochester
Rowe, 'O. W Duluth
Rowe, W. H Fairmont
§Rowles, E. K Coleraine
§Roy, P. C St. Paul
§ Rucker, C. W Rochester
§Rucker, W. H Minneapolis
Rud, N. E Minneapolis
Rudell, G. L Minneapolis
§Rudie, P. S Duluth
Ruff, C. C Rochester
Ruggles, G. M Forest Lake
§tRuhberg, G. N St. Paul
Rulison, E. T., Jr Rochester
Rumpf, C. W Faribault
fRumpf, W. II Faribault
Ruona, M. A St. Paul
JRushton, J. G Rochester
§Russ, F. H Rochester
Russ, H. H Blue Earth
§Russeth, A. N Minneapolis
§Rusten, E. M Minneapolis
Rutherford, W. C Nisswa
Rutledge, L. H Detroit Lakes
Ryan, J. D St. Paul
§Ryan, J. J St. Paul
§Ryan, J. M St. Paul
§Ryan, M. E St. Paul
Ryan, R. E Rochester
§Ryan, W. J Duluth
§Rydburg, W. C Brooten
ISRyding, V. T Howard Lake
Rydland, A. D Crookston
Rygh, H. N Atwater
§Rynearson, E. H Rochester
Sach-Rowitz, Alvan Moose Lake
§Sadler W. P., Jr Minneapolis
§Saffert, C. A New Ulm
Sahr, W. G. C Hutchinson
§ St. Cyr, K. J Robbinsdale
Salassa, R. M Rochester
§Salitcrman, B. I Minneapolis
§*Salt, C. G Minneapolis
JSSalter, R. A Virginia
SSamson, E. R Stillwater
§Samuelson, L. G Mankato
Samuelson, Samuel Minneapolis
Sandell, S. T Nopeming
§ Sanderson, A. G Deer wood
t Sanderson, E. T Alexandria
§Sandt, K. E Minneapolis
Sandven, N. O Paynesville
§Sanford, A. H Rochester
Sanford. J. A Farmington
Sard, O. E Duluth
§Sarnecki, M. M St. Paul
SSatersmoen, Theodore. . Pelican Rapids
tSather, Allen Crookston
§ Sather, E. R Alexandria
Sather, G. A Fosston
Sather, R. N Mora
§Sather, R. O Crookston
§Satterlee, H. W Lewiston
Satterlund, V. L St. Paul
Sauer, W. G Rochester
§ Savage F. J St. Paul
§Sawatzky, W. A Minneapolis
Sax, ' M. H Duluth
Sax, S. G Duluth
§Sayre, G. P Rochester
Scales, J. R Kingsville, Texas
Scanlon, R. L Rochester
§Schaaf, F. H. K Minneapolis
§Schade, F. L Worthington
Schaefer, T. F Owatonna
§ Schaefer, Samuel Winona
§Schaefer. W. G Minneapolis
Schafer, L. A Rochester
Schamber, W. F Parkers Prairie
Schatz, F. J St. Cloud
§Scheifley, C. H Rochester
fScheldrup, N. H Minneapolis
§ Scherer, L. R Minneapolis
Schiele, B. C Minneapolis
Schimelpfenig, G. T Chaska
§Schleinitz, F. B Battle Lake
Schlesselman, G. H Anoka
§Schlesselman, J. T Mankato
Schmidt, E. C Rochester
§Schmidt, G. F Minneapolis
§Schmidt, H. W Rochester
Schmidt, P. A Good Thunder
§Schmidt, P. G., Jr Granite Falls
ijSchmidt, W. R Worthington
Schmidtke, R. L St. Paul
tSchmitt, A. F Minneapolis
tSchmitt, S. C Los Angeles, Calif.
§ Schmitz, A. A Mankato
§ Schmitz, E. J Holdingford
567
ROSTER 1947
ISchneider, J. P Minneapolis
§ Schneider, L. E Duluth
Schneider, P. J Adams
Schneider, R. A Minneapolis
tSchneidman, N. R Minneapolis
Schoch, R. B. J St. Paul
Scholpp, O. W Hutchinson
JScholten, R. A Rochester
§Schons, Edward St. Paul
ISchottler, G. J Dexter
Schottler, M. E Minneapolis
§SchrodtT, C. H .Duluth
Schroeckenstein. H. F St. Paul
ISchroeppel, J. E Winthrop
IfSchuldt, F. C St. Paul
Schultz, J. A Albert Lea
Schultz, J. H Minneapolis
ISchultz, P. J Minneapolis
ISchulze, A. G St. Paul
Schumacher, J. W St. Paul
tSchussler. O. F Minneapolis
Schutz, E. S Mountain Lake
ISchwartz, V. J Minneapolis
Schweiger, T. R Hibbing
ISchwyzer, Gustav Minneapolis
ISchwyzer, H. C St. Paul
tScofield, C. L Benson
IScott, E. E St. Paul
IScott, F. H Minneapolis
IScott, H. G Minneapolis
Seaberg, J. A Minneapolis
ItSeashore, Gilbert Minneapolis
Seashore, R. T St. Paul
Seebach, Lydia M Rochester
Seham, Max Minneapolis
ISeifert, M. H Excelsior
ISeifert, O. J New Ulnt
Seiler, H. H Rochester
Seitz, S. B Barnesville
ISeldon, T. H Rochester
ISelieskog. S. R Minneapolis
Sellers, G. K Dassel
Selmo, J. D Norwood
Selvig, H. S St. Paul
Senescall, C. R Enumclaw, Wash.
tSengpiel, G. W Rochester
tSenkler, G. E St. Paul
Senn, E. W Owatonna
ISerkland, J. C Rothsay
Sether, A. F Ruthton
ISetzer. H. J St. Paul
ISeybold, W. D Rochester
IShanJorf, J F Minneapolis
Shannon, W. R St. Paul
Shaperman. Eva P Minneapotsi
§Shapiro, M. J Minneapolis
Sharp. D. V Minneapolis
*Shastid T. H Duluth
Shaw, A. W Virginia
Shaw, H. A Minneapolis
IShedlov, Abraham Fosston
ISheedv. C. L Austin
IShellito, J. G Rochester
tShellman, J. L
Pacific Palisades, Calif.
§ Sheppard, C. G Hutchinson
Slier. D. A Virginia
Sheridan, Viola E Rochester
ISherman, C. H Bayport
Sherman, C. L Luverne
ISherman, 11. T Cambridge
ISherman. R. V Red Wing
Sherwood, G. E Kimball
IShick, R. M Rochester
§ Shimonek. S. W St. Paul
jShonyo, E. S Rochester
Short, C. A., Jr Rochester
Short. Jacob St. Paul
Shullenberger, C. C Rochester
Sicher, W. D Rochester
Siegel, Clarence St. Paul
Siegel, T. S Virginia
ISiegmann, W. C Minneapolis
Silver, J. D Minneapolis
Simison, Carl Barnesville
ISimons, B. H Chaska
ISimons, F. T Swanville
IlSimons, J. H Minneapolis
§ Simons, L. T St. Paul
Simonson, D. B Minneapolis
ISimonton, K. MacL Rochester
ISimpson, E. DeW Minneapolis
ISinamark, Andrew Hibbing
Singer, B. J St. Paul
Sinykin. M. B Minneapolis
Siperstein, D. M Minneapolis
Sisler, C. E Grand Rapids
ISivertsen, Andrew Nisswa
ISivertsen, Ivar Minneapolis
§Sjostrom, L. E St._Peter
tSkillern, P. G., Jr Rochester
IlSkinner, H. O St. Paul
ISkjold, A. C Minneapolis
Skoog-Smith, A. W Mahnomen
568
Skroch, E. E Rochester
§Slater, S. A Worthington
Slaughter, O. L Rochester
§Slocumb, C. H Rochester
ISmisek, E. A .St. Paul
ISmisek, F. M. E Minneapolis
ISmith, Adam M Minneapolis
ISmith, Archie M Minneapolis
ISmith, B. A Crosby
Smith, Baxter A., Jr Minneapolis
ISmith, C. M Duluth
Smith, F. II Rochester
§ Smith, F. L Rochester
ISmith, F. R Rochester
ISmith, H. L Rochester
Smith, H. R Minneapolis
ISmith, L. G Montevideo
ISmith, L. A Balaton
Smith, L. A Rochester
Smith, Margaret I Minneapolis
ISmith, M. W Red Wing
ISmith, N. D Rochester
§Smith, N. M Minneapolis
Smith, N. R Minneapolis
ISmith, O. O., Jr Rochester
Smith, R. S Rochester
ISmith, V. D. E St. Paul
Smith, W. R Grand Marais
ISnell, A. M.... Rochester
Snider, G. G. . . ." Rochester
Snyder, C. D Kiester
ISnyder, G. W St. Paul
Snyker, O. E Ely
Soderlind’, R. T Minneapolis
ISogge, L. L Windom
ISohlberg, O. I St. Paul
ISohmer, A. E Mankato
ISolhaug, S. B Minneapolis
Solsem, F. N. S Ah-Gwah-Ching
Sommer, A. W Elmore
ISommers, Ben St. Paul
ISonnesyn, N. N Le Sueur
ISorem, M. B St. Paul
ISorum, F. T Jasper
ISouster, B. B St. Paul
ISpang, A. J Duluth
I Spang, J. S Duluth
ISpano, J. P Minneapolis
Spar, A. A Rochester
Spicer, F. W Duluth
ISpink, W. W Minneapolis
ISpittler, R. O New Richland
ISprafka, J. M St. Paul
ISprague, R. G Rochester
ISpratt, C. N Minneapolis
tSpray, Paul Rochester
Spurbeck, R. G Cloquet
Spurzem, R. J Anoka
Stahr, A. C Hopkins
Stam, John Worthington
IStanford, C. E Minneapolis
Stangl, P. E St. Cloud
SStanley, C. R Worthington
IStarekow, M. D. . .Thief River Falls
IStark, D. B Rochester
t Stark, F. M Rochester
♦ Starks, W. O Rochester
State, David Minneapolis
Stebbins, T. L Minneapolis
ISteffens. L. A Red Wing
Stein, B. R Rochester
Stein, K. E Lakeville
Stein. R. J Pierz
ISteinberg. C. L St. Paul
ISteiner, I. W Winona
IStelter, I.. A Minneapolis
IStemsrud. H. L Alexandria
Stennes, J. L Minneapolis
Stensgaard, K. L. . .Thief River Falls
Stenstrom, Annette E. T. . Minneapolis
Stephan, E. L Hinckley
ISterner, E. G St. Paul
ISterner, E. R St. Paul
ISterner, O. W St. Paul
IStevens, J. E., Jr Rochester
Stevens, John Gonvick
Stevenson, B. M Fulda
| Stevenson. F. W Faribault
Stewart, Alexander St. Paul
Stewart. N. E. ..Si. Petersburg, Fla.
ISteward. R. I Minneapolis
ISticknev, T. M Rochester
§ Stillwell, W. C Mankato
IStillwell. G. G Rochester
*§Stinnette, S. E St. Paul
Stokes, G. D Rochester
Stoesser, A. V Minneapolis
IStolpestad, A. II St. Paul
IStolpestad, H. I St. Paul
fStomel, Joseph. .. .Los Angeles, Calif.
Stout, H. A Rochester
Stone, S. P Minneapolis
Stover, Lee Rochester
IStrachauer, A. C Minneapolis
Stransky, T. W Owatonna
IStrate, G. E St. Paul
IStrathern, C. S St. Peter
IStrathern, F. P St. Peter
Strathern, M. L Gilbert
IStratte, A. K Pine City
Stratte, H. C Windom
Straus, M. L St. Paul
IStrauss, E. C Duluth
Street, Bernard Northfield
Strem, E. L St. Paul
Strobel, W. G Duluth
IStroebel, C. F., Jr Rochester
Strom, G. W Minneapolis
Stromgren, D. T Minneapolis
IStromme, W. B Minneapolis
I Strong, M. L Rochester
IStrout, G. E Minneapolis
Stuart, A. B Cloquet
Stuart, R. L Rochester
IStuder, D. J Faribault
|Stuhr, J. W Stillwater
Sturley, R. F St. Paul
ISturre, J. R Minneapolis
IStuurmans, S. H Minneapolis
|Sukov, Marvin Minneapolis
Sullivan, R. M Minneapolis
Sullivan, R. R Minneapolis
|*Sundt, Mathias Minneapolis
ISutherland, C. G Rochester
Sutherland', H. N Ely
Sutton, H. R Hoffman
ISvien, H. J Rochester
Swanson, J. A St. Paul
Swanson, R. E Minneapolis
ISwanson, R. R Albert Lea
Swanson, V. F Minneapolis
Swedberg, W. A Duluth
Swedenburg, P. A Glenwood
ISweetser, H. B., Jr Minneapolis
ISweetser, H. B., Sr Minneapolis
ISweetser, T. H Minneapolis
Sweitzer, S. F, Minneapolis
ItSwendseen, C. G Minneapolis
ISwendson, J. J St. Paul
ISwensen, R. G North Branch
ISwenson, A. O Duluth
ISwenson, O. J Waseca
ISwezey, B. F Buffalo
ITangen, G. M Minneapolis
ITanquist, F.. J Alexandria
ITaylor, C. W Duluth
tTaylor, J. C Rochester
Tavlor, T. H Minneapolis
ITeich, K. W Duluth
ITeisberg, C. B St. Paul
Teisberg, J. E St. Paul
Telford, V. J Litchfield
ITenner, R. T Minneapolis
ITerrell, B. f Nopeming
ITesch, G. H Elk River
IThabes, J. A Brainerd
IThabes, J. A., Jr Brainerd
Thayer, E. A Fairmont
IThielen, R. D St. Michael
IThomas, G. F. Minneapolis
Thomas, G. H Minneapolis
Thomas, J. F Rochester
IThompson, Arthur Cokato
Thompson, C. O Hendricks
Thompson, F. A St. Paul
llThompson, G. J Rochester
IThompson, H. B Fergus Falls
Thompson, V. C. . . Marine-on-St. Croix
IThompson, W. H Minneapolis
Thomson, J. M Minneapolis
Thoreson, M. C. Bernice.. So. St. Paul
Thorson, S. B Rochester
IThysell, D. M Minneapolis
Thysell, F. A Moorhead
Thy. sell, V. D Hawley
|Tibbetts, M. H Duluth
Tice, G. I Rochester
JTice, W. A Rochester
Tifft, C. R St. Paul
Tilderquist, D. L Duluth
ITillisch, J. H Rochester
ITingdale, A. C Minneapolis
Tingdale. Carlyle Hibbing
Titrud, L. A Minneapolis
Todd,, R. L Minneapolis
Tofte, Tosephine Minneapolis
Tomlin, H. M Rochester
Tompkins, S. F Rochester
ITorgerson, W. B Oklee
Tosseland, N. E Rochester
ITrach, B. B Minneapolis
'Tracht, R. R St. Paul
Traeger, C. A Faribault
Travis, J. S. St. Paul
ITraxler, f. F .Henderson
ITregilgas, H. R So. St. Paul
Trommald, Gladys Brainerd
Minnesota Medicine
ROSTER 1947
STroost, H. B Mankato
§Trow, J. E Minneapolis
Trow, W. >1 Minneapolis
Troxil, Elizabeth Minneapolis
Trueman, H. S Minneapolis
Truesdale, C. W Glencoe
Trutna, T. J Silver Lake
Trytten, E. G Duluth
§ Tudor, R. B Minneapolis
ijTunstead, H. J Minneapolis
§Tuohy, E. B..' Rochester
§Tuohy, E. L Duluth
fjTurnacliff , D. D Minneapolis
Turner, J. L Rochester
§Tweedy, G. J Winona
Tweedy, J. A Winona
§Tweedy. R. B Winona
Tyler, S. H Raymond
§Ude, W. H Minneapolis
§Uhley, C. G Crookston
Uhrich, E. C Rochester
§Uihlein, Alfred Rochester
Ulrich, H. L Minneapolis
§UnderdahI, L. O Rochester
§Undine, C. A Minneapolis
Upshaw, Betty Y Rochester
tUrban, D. A Rochester
§Urberg, S. E Duluth
Vadheim, A. L Tyler
Vadheim, L. A Tyler
^Valentine, W. H Tracy
§Van Cleve, H. P., Jr. . .Dodge Center
Vandersluis, C. W Bemidji
Van Herik, Martin Rochester
Van Meier, Henry Stillwater
Van Rooy, G. T. ..Thief River Falls
Van Valkenberg, J. D Floodwood
Varco, R. L St. Paul
Varney, J. H Rochester
Vaughan, L. M Rochester
Vaughan, V. M Truman
§ Vaughn. L. D Rochester
Veirs, D. M St. Paul
Veirs Ruby J. S St. Paul
§ Venables, A. E St. Paul
Veranth, L. A St. Cloud
§Vezim, J. C Mapleton
Vigran, Myron ..Los Angeles, Calif.
Vik, A. E Minneapolis
Vik, Melvin Onamia
Virnig, M. P Wells
§ Vogel, H. A. L New Ulm
§ Vogel, J. H.. New Ulm
Voilmer, F. J Winona
§Von der Weyer, W. H St. Paul
§Waas, C. W St. Paul
§Wadd, C. T Tanesville
§Wagener, H. P Rochester
Wagner, N. W Graceville
§Wahlquist, H. F Minneapolis
§Wakefield, E. G Rochester
§Wa:ch, A. E Minneapolis
§Waldron C. W Minneapolis
§ Walfred, K. \ St. Cloud
§tW'alker, A. E Duluth
§Walker. A. E St. Paul
§Wall, C. R Minneapolis
§Wallace. M. O.... Duluth'
Waller, J. D Pine City
§Walsh, A. C Rochester
Walsh, F. M Minneapolis
W'alsh, M. N Rochester
Walsh, W. T Minneapolis
§ Walter, C. Wr St. Paul
Walter, G. F Farmington
§ Walters, Waltman Rochester
Wangensteen, O. H Minneapolis
tWard, B. H Rochester
Ward, P. A Minneapolis
§ tWard, P. D St. Paul
Warner, J. J Perham
Warren, C. A St. Paul
Warren, Ml. B Rochester
§ Wasson, L. F Alexandria
Washko, P. J Rochester
§ Watkins, C. H Rochester
Watkins, D. H Rochester
§ Watson, A. M Royalton
§ W atson, C. G Minneapolis
§ Watson, C. J Minneapolis
tWatson, J. D Minneapolis
Watson, P. T Northfield
Watson, R. M Thief River Falls
§ W atson, S. W Royalton
Watz, C. E St. Paul
§ Waugh, J. M Rochester
Weaver, M. M Minneapolis
§ Weaver, P. H Faribault
§Webb, E. A Minneapolis
Webb, Margaret A Rochester
§Webb, R. C Minneapolis
§ Webber, F. L St. Paul
§ Weber, H. M Rochester
Webster, L. J Battle Lake
§ Weed, L. A Rochester
§Weir, J. F Rochester
§ Weir, J. R Goodhue
§ Weis, B. A St. Paul
Weisberg, Maurice St. Paul
§Weiser, G. B.. . . New Ulm
Weisman, S. J Rochester
Weismann, R. E Rochester
Wellman, T. G Lake City
§ Wellner, T. O Rochester
§ Wells, A. H Duluth
Wells, G. R Rochester
§ Wells, J. J Rochester
§Wells, W. B Jackson
SWenner, W. T St. Cloud
§Wentworth, A. J Mankato
§ Wenzel, G. P St. Paul
Wenzel, R. E Albert Lea
Werner, George Minneapolis
Werner, O. S Cambridge
Werner, R. F Minneapolis
fWest, Catherine C Minneapolis
§Westby, Magnus Madison
Westby, Nels Madison
SfWesterman, A. E Montgomery
ijWesterman, F. C Montgomery
tWestphal, K. F Minneapolis
SWestrup, J. E % . . . .Lanesboro
§WethalI, A. G Minneapolis
Wetherby, Macnider Minneapolis
§Wetzel, E. V Minneapolis
§Weum, T. W Minneapolis
IWheeler, D. W Duluth
tWheeler, M. W St. Paul
Whitacre, J. C St. Paul
White, A. A Minneapolis
White, E. F., Jr Nopeming
White, N. K Rochester
§ White, S. M Minneapolis
SWhite, W. D Minneapolis
Whitehouse. F. R Rochester
Whitesell, F. B., Jr Rochester
§Whitesell, L. A Minneapolis
* Whitmore, F. W St. Paul
§ Whitney, R. A... Cambridge
§Whitson, S. A Albert Lea
Whittemore, D. D ..Bemidji
§Widen, W. F Minneapolis
Wiechman, F. H. ........ Minneapolis
Wilcox, A. E Minneapolis
Wilder, K. W Minneapolis
§ Wilder, R. L Minneapolis
§ Wilder, R. M Rochester
Wilder, R. M., Jr Minneapolis
§Wilken, P. A Minneapolis
Wilkinson, Stella L Faribault
§Wilkowske, R. T Owatonna
Will, C. B i Bertha
Will, W. W Bertha
§tWilIcutt, C. E Phoenix, Ariz.
Williams, A. B St. Paul
§Williams, C. A Pipestone
§ Williams, C. K St. Paul
§ Williams, H. L., Jr Rochester
Williams, H. O Lake Crystal
§ Williams, T. A St. Paul
Williams, L. A Slayton
§Williams, M. M Ah-Gwah-Chmg
Williams, M. R Cannon Falls
Williams, R. V Rushford
tWilliams, Robert Carthage, 111.
§ Williams, R. R., Jr Rochester
§ WTllius, F. A Rochester
§ Wilmer, H. A Rochester
Wilmot, C. A Litchfield
Wilmot, FI. E Litchfield
Wilson, C. E Blue Earth
§ Wilson, F. C Austin
Wilson, G. T Rochester
Wilson, J. M Rochester
§ Wilson, J. A St. Paul
§ Wilson, J. V St. Paul
Wilson, J. W Rochester
§ Wilson, R. B Rochester
§ Wilson, R. H Winona
Wilson, V. O Minneapolis
§ Wilson. W. E Northfield
§tWilson, W. F Lake City
§Wiltrout, I. G .Oslo
§ Winchester, W. W Rochester
Wingquist, C. G .Crosby
Winnick, J. B St. Paul
Winter, J. A Duluth
Winther, Nora M. C Minneapolis
Wipperman. F. F Minneapolis
§Wise, R. W. E Rochester
§ Witham, C. A Minneapolis
Withrow, M. E International Falls
Wittich, F. W Minneapolis
Wittrock, L. H Watkins
§ W ohlrabe, A. A Minneapolis
§ Wohlrabe, C. F No. Mankato
§ Wohlrabe, E. J Springfield
§ Wold, K. C St. Paul
Wold, I.. E Rochester
Wolf, A. H Minneapolis
*Wolf W. W Minneapolis
Wolff, H. J St. Paul
Wolkoff, H. J St. Paul
§ Wollaeger, E, E Rochester
Wolstan, , S. D Minneota
SWoltman, H. W Rochester
5 Wood, H. G Rochester
tWood, W. D Rochester
Woodruff, C. W Chatfield
Word, H. L St. Paul
Workman, W. G Tracy
Wozencraft, J. P Rochester
Wray, W. E Campbell
StWright, C. D Minneapolis
*Wright, C. O Luverne
§ Wright, R. H Austin
§ Wright, S. G Minneapolis
Wright, W. S Minneapolis
Wunder, H. E Shakopee
Wyatt, O. S Minneapolis
Wynne. H. M. N Minneapolis
Y aeger, W. W Marshall
§Ylvisaker, R. S Minneapolis
§Yoerg, O. W Minneapolis
§Young, H. H Rochester
§ Young, T. O Duluth
§ Y ounger, L. I Winona
Youngren, E. R St. Paul
Zachman, A. H Melrose
Zachman, L. L St. Paul
Zaslow, Jerry Rochester
SZemke, E. E Fairmont
Zierold, A. A Minneapolis
§Zimmermann, H. B St. Paul
§Zinter, F. A Minneapolis
Ziskin, Thomas Minneapolis
tZIatovski, M. L Duluth
Zorn, E. L Erskine
May, 1947
569
♦ Reports and Announceme n t s ♦
AMA CENTENNIAL
The annual meeting of the American Medical Asso-
ciation to be helcj in Atlantic City, June 9-13, 1947,
will celebrate the 100th anniversary of the association.
The resignation of Dr. Olin West, president-elect of
the AMA, because of ill health, will cause deep regrets
in many quarters. The presidency of the association
would have been a fitting culmination to the many years
of service rendered to the national organization by Dr.
West.
Announcement has been made that Dr. Edward L.
Bortz, of Philadelphia, at present a vice president,
will succeed Dr. West and will be inaugurated as presi-
dent of the association in June.
Dr. Bortz was born in Greenberg, Pennsylvania, Feb-
ruary 10, 1896, and now lives in Philadelphia. He be-
came a Fellow of the American College of Physicians
in 1929, was certified by the American Board of Internal
Medicine in 1937, and in 1942 was made a member of
the Council on Scientific Assembly of the AMA. He
has been a delegate to the AMA since 1945 and is
chairman of the Committee on National Emergency
Medical Service of the association. During World War
II, Dr. Bortz served as captain in the U. S. Naval
Medical Corps.
AMERICAN CONGRESS OF PHYSICAL MEDICINE
The American Congress of Physical Medicine will hold
its twenty-fifth annual scientific and clinical session Sep-
tember 2, 3, 4, 5 and 6, inclusive, at the Hotel Radisson,
Minneapolis. Scientific and clinical sessions will be given
the days of September 3, 4, 5 and 6. All sessions will
be open to members of the medical profession in good
standing with the American Medical Association.
In addition to the scientific sessions, the annual in-
struction courses will be held September 2, 3, 4 and 5.
These courses will be open to physicians and the thera-
pists registered with the American Registry of Physical
Therapy Technicians.
For information concerning the convention and the
instruction course, address the American Congress of
Physical Medicine, 30 North Michigan Avenue, Chi-
cago 2, Illinois.
NATIONAL GASTROENTEROLOGICAL
ASSOCIATION
The National Gastroenterological Association will hold
its 12th annual convention and scientific sessions at the
Hotel Chelsea in Atlantic City, N. J., on Tune 4, 5, 6,
1947, affording those interested in attending the centen-
nial celebration of the American Medical Association and
the meeting of the National Gastroenterological Associa-
tion a chance to be present at both.
The program will consist of eighteen papers on va-
rious phases of gastroenterology and allied subjects.
Among those presenting papers will be: Dr. Manuel G.
Spiesman, Chicago, 111. ; Dr. Emanuel M. Rappaport,
New York, N. Y. ; Dr. L. C. Sanders, Memphis, Tenn. ;
Dr. Herman Osgood, Boston, Mass.; Dr. James P.
Campbell and Dr. Harold A. Grimm, Wheaton, 111. ; Dr.
Edward T. Whitney, Boston, Mass. ; Dr. F. Steigmann
and Dr. Hans Popper, Chicago, 111. ; Dr. Lester M. Mor-
rison, Los Angeles, Calif. ; Dr. M. E. Steinberg, Port-
land, Oregon; Dr. John E. Cox, Memphis, Tenn.; Dr.
George Miley, Philadelphia, Pa. ; Dr. Tom D. Spies,
Birmingham, Ala. ; Dr. Fernando Milanes and Dr.
Guillermo Garcia Lopez, Havana, Cuba, and Mr. R.
Johnson, Birmingham, Ala.; Dr. Donald Cook, Chicago,
111.; Dr. Norman Jolliffe, New York, N. Y. ; Dr. Mat-
thew T. Moore, Philadelphia, Pa.; Dr. Verne G. Burden,
Philadelphia, P'a. ; Dr. Thomas J. Fitz-Hugh, Jr.,
and Dr. A. J. Creskoff, Philadelphia, Pa.
At the luncheon round-table conference Thursday,
June 5, 1947, Dr. Hyman I. Goldstein of Camden, N. J.,
will speak on “The History of Gastroenterology and the
Development of this Specialty in America.”
At the annual banquet to be held on Thursday eve-
ning, June 5, 1947, the winner of the National Gastro-
enterological Association’s 1947 Cash Prize Award Con-
test for the best unpublished contribution on gastro-
enterology or an allied subject, will receive the prize of
$100.00 and a Certificate of Merit. The guest speaker
of the evening will be Dr. Homer T. Smith of the New
York University College of Medicine whose subject
will be “Plato and Clementine.”
Program and further details may be obtained from the
National Gastroenterological Association, 1819 Broad-
way, New York 23, N. Y.
AMERICAN COLLEGE OF PHYSICIANS
During March the American College of Physicians
held two one-week postgraduate courses at Rochester,
one dealing with peripheral vascular disease, includ-
ing hypertension, and the other concerned with rheu-
matic diseases. The courses were under the direction
of Dr. E. V. Allen and Dr. P. S. Hench, respectively,
both of Rochester. Approximately seventy-five mem-
bers of the American College of Physicians came from
all parts of the United States to hear lectures and dis-
cussions presented by guest speakers from throughout
the nation.
CENTRAL ASSOCIATION OF OBSTETRICIANS
AND GYNECOLOGISTS
Two $100 prize awards are offered annually by the
Central Association of Obstetricians and Gynecologists
to any accredited physician, research worker or medical
student within the confines of the Central Association,
which includes Minnesota. One award is for the best
investigative work, and the other for the best clinical
work, in the field of obstetrics and/or gynecology. Pa-
( Con tin n ed on Page 572)
570
Minnesota Medicine
SEARLE
AMINOPHYLLIN *
SEARLE
RESEARCH
IN THE SERVICE
OF MEDICINE
— produces myocardial stimulation and increased cardiac
output, together with desired diuresis. Whether
administered orally or parenterally, it has a field of therapeutic
usefulness covering congestive heart failure.
Searle Aminophyllin is now widely used also for its
favorable effects on bronchial asthma, paroxysmal dyspnea
and Cheyne-Stokes respiration.
G. D. Searle & Co., Chicago 80, Illinois.
*Searle Aminophyllin contains at least 80% of anhydrous theophyllin.
May, 1947
571
REPORTS AND ANNOUNCEMENTS
ANNOUNCING
a new principle in
Support Design
SPENCERFLEX/ SsS?
FOR MEN
Individually designed
for each patient, the
Spencerflex provides pelvic control
and abdominal uplift with freedom
for muscular action. Improves posture
and body mechanics. Non-elastic. Will
not yield or slip under strain. Very
durable, moderate cost. Can be put on,
removed, or adjusted in a moment.
Also designed as adjunct to treatment
following upper abdominal surgery.
Completely covers and protects scar
without “digging in” at lower ribs. Re-
lieves fatigue and strain on tissues and
muscles of wound area. We know of
no other support for men providing
these benefits.
For information about Spencer Supports, tele-
phone your local “Spencer corsetiere” or "Spen-
cer Support Shop”, or send coupon below.
SPENCER, INCORPORATED
129 Derby Ave., New Haven 7, Conn.
In Canada: Rock Island, Quebec.
In England: Spencer (Banbury) Ltd.,
Banbury, Oxon.
Please send me booklet, "How Spencer
Supports Aid the Doctor's Treatment."
Name
Street
City & State O 5-47
SPENCER DESIGNED SUPPORTS
FOR ABDOMEN. BACK AND BREASTS
May IV e
Send You
Jiooklet?
M.D.
CENTRAL ASSOCIATION OF OBSTETRICIANS
AND GYNECOLOGISTS
(Continued from Page 570)
pers submitted for either award must be in the hands
of the secretary of the organization not later than Au-
gust 15, 1947. Further information may be obtained
from Dr. John I. Brewer, secretary-treasurer of the
association, 104 South Michigan Avenue, Chicago, Il-
linois.
MINNESOTA PATHOLOGICAL SOCIETY
The regular meeting of the Minnesota Pathological So-
ciety was held in the Medical Science Amphitheater of
the University of Minnesota Medical School on April
22, at 8:00 p.m. Dr. G. T. Evans and Dr. D. T. Kaung
presented a discussion of the topic, “A Consideration
of the Action of Insulin.”
MINNESOTA SOCIETY OF
NEUROLOGY AND PSYCHIATRY
Members of the Minnesota Society of Neurology and
Psychiatry attended a one-day clinic-lecture conference
at Rochester on May 3.
The program began at 8:00 a.m. with surgical clinics
conducted by the Mayo Clinic neurosurgical staff in the
operating rooms at St. Mary’s Hospital. At 10:30 a.m.
the lecture part of the program started. The following
subjects were presented:
“Classification of Nystagmus” (with motion picture
demonstration) — Dr. C. W. Rucker.
“Comments on Infantile Muscular Myopathies” — Dr.
Mary E. Giffin.
“Misleading Rhythms in the Electroencephalogram in
the Diagnosis of Tumors of the Brain”- — Dr. R. G. Bick-
ford.
“The Present Status of Thymectomy in the Treatment
of Myasthenia Gravis” — Dr. L. M. Eaton.
“Metastatic Brain Abscess” — Dr. E. M. Gates.
At 12 :30 p.m. the group was served a luncheon at the
Mayo Foundation House, after which Dr. F. J. Brace-
land spoke on “European Neuropsychiatry.”
MINNEAPOLIS SURGICAL SOCIETY
Newly elected officers of the Minneapolis Surgical
Society are Dr. L. Haynes Fowler, president; Dr. Carl
O. Rice, vice president ; Dr. Rudolph E. Hultkrans,
treasurer, and Dr. Theodore H. Sweetser, council presi-
dent.
WASHINGTON COUNTY
The Washington County Medical Society met April 8,
1947, and was addressed by Dr. Oswald S. Wyatt of
Minneapolis on the subject, “Appendicitis in Children.”
Two visitors were present: Captain Scott Swisher, Jr.,
of Bayport, who was home on terminal leave and will
soon begin a fourteen months’ residency at the Strong
Memorial Hospital at Rochester, New York, and Dr.
Edgar C. Bunseth, who is now associated with Dr. G.
McC. Ruggles of Forest Lake, Minnesota.
572
Minnesota Medicine
DISTINCTIVE
PENICILLIN PRODUCTS
K
© Schenley Laboratories, Inc,
PENICILLIN TABLETS
Schenley
A special coating masks the penicillin taste of these tablets.
Valuable in supplementing injections to maintain effective blood
levels. Given in five times the parenteral dose, they may be em-
ployed to replace injections after the acute phase of the disease
has subsided. Particularly useful in ambulatory cases.
Each tablet provides 50,000 units of calcium penicillin, buffered
with calcium carbonate. Requires no refrigeration.
Available in bottles of twelve.
PENICILLIN TROCHES
Schenley
Rectangular in shape, agreeably flavored, these troches provide
a rational means of obtaining the benefits of penicillin in infections
of ihe mouth and throat caused by penicillin-sensitive organisms.
Each troche supplies 1,000 units of calcium penicillin. They
dissolve slowly, thus prolonging the action of the drug.
A SCHENLEY SERVICE
Penicillin Paragraphs, providing a continuing
summary of penicillin therapy in specific
disease entities, will be sent to physicians
requesting to be placed on our mailing list.
Schenley laboratories, i\c.
EXECUTIVE OFFICES: 350 FIFTH AVENUE . NEW YORK 1, N. Y.
May, 1947
573
WOMAN’S AUXILIARY
|-*Ul»GtCAL SOLUT'^bJC
",^CUROCHR0wt
CS2Ct^_T
li ' J*1* mJN7xLn / «’*
MERCUROCHROME
(H. W. & D. brond of merbromin,
dibromoxymercurifluorescein-sodiumj
Extensive use of the Surgical
Solution of Mercurochrome
has demonstrated its value in
preoperative skin disinfec-
tion. Among the many advan-
tages of this solution are:
Solvents which permit the
antiseptic to reach bacteria
protected by fatty secretions
or epithelial debris.
Clear definition of treated
areas. Rapid drying.
Ease and economy of pre-
paring stock solutions.
Solutions keep indefinitely.
The Surgical Solution may
be prepared in the hospital or
purchased ready to use.
Mercurochrome is also sup-
plied in Aqueous Solution,
Powder and Tablets.
HYNSON, WESTCOTT
& DUNNING, INC.
Baltimore l, Maryland
WOMAN'S AUXILIARY
LAST CALL!
Last Call for reservations for the Twenty- fourth An-
nual Convention of the Woman’s Auxiliary to the Amer-
ican Medical Association, which will be held at Haddon
Hall Hotel, Atlantic City, New Jersey.
Atlantic City Extends a Hearty Welcome to You.
HENNEPIN COUNTY
To raise funds for its various philanthropies, the
Woman’s Auxiliary to the Hennepin County Medical So-
ciety sponsored their annual Easter Monday Benefit party
at the Calhoun Beach Club on April 7. Mrs. Harold G.
Benjamin was general chairman with Mrs. Ernest L.
Meland as co-chairman. Mrs. C. L. Norman Nelson was
in charge of tickets.
Luncheon was served at 1 :30 p.m., followed by a de-
lightful Dayton’s Style Show, and a short drama en-
titled, “If Men Played Bridge as Women Do,” pre-
sented by the North Star Drama Guild.
RAMSEY COUNTY
The Ramsey County Medical Auxiliary was the first
Red Cross group in Saint Paul, working in the current
drive, to complete solicitation in the campaign to raise
$200,000, it was announced by Mr. Douglas K. Baldwin,
Saint Paul and Ramsey County, campaign chairman.
On Monday, March 24, the Auxiliary entertained about
three hundred guests at its annual guest day tea and
program. Representatives of many women’s organiza-
tions were present, including Mrs. Luther Youngdahl
of Minneapolis and Mrs. Melvin S. Henderson of Roch-
ester.
Preceding the tea, Dr. Raymond N. Bieter, head of the
Department of Pharmacology at the University of Min-
nesota, talked on newly discovered drugs and how they
are helping the medical profession in its fight against
disease.
OLMSTED-HOUSTON-FILLMORE-DODGE COUNTY
At the quarterly meeting of the OHFD Auxiliary in
March, Mrs. Russell M. Wilder, a member of the Na-
tional Board on Juvenile Delinquency, and Dr. Maurice
N. Walsh from the Department of Neurology at the
Mayo Clinic, collaborated in presenting a program on
juvenile delinquency. Officers of the Parent-Teacher
Association and the principals of the city schools were
invited guests. The program and discussion embraced
both national and local problems and was well received.
The Auxiliary is sponsoring the cancer essay and
poster awards in all Junior and Senior High Schools in
the four counties.
Several members are working on the April drive for
funds by the county cancer society. Small informal
groups are organizing to make cancer dressings.
The Auxiliary is holding open house for the doctors’
wives in the outlying counties who wish to accompany
their husbands to Rochester on the evenings when the
Medical Society holds its meetings.
S74
Minnesota Medicine
HEXAVITAMIN
(U.S.P.)
i phytkion in
j n*W» of rtvj
1 *DJ=»U*v. J
lOO TABLETS |jk
WA
ASCORBIC
VITAMIN P
ACID
Mount Verr
(VITAMIN C)
WALKER
NIACINAMIDE
(NICOTINAMIDE)
RIBOFLAVI
THIAMINE
HYDROCHLORIDE
VITAMIN B
WALKER VITAMIN PRODUCTS
STABILIZED AQUEOUS SOLUTION
R#r CC
THIAMINE HYDROCHLORIDE (B,) 5 Mg.
DOSAGE: % M.D.R.
INFANT
CHILD l.iYrt -6
CHILD 6-12 Yru-9
50 MG.
Dose: 1 daily or
as prescribed
by physician
NIACIN
SOLUTION
THIAMINE
HYDROCHLORIDE
lO MG.
To be used only
by. or on prescrip-
tion of physician.
To be used only
by. or on prescrip-
tion of physician.
The hallmark of Walker manu-
facture is its uncompromising
emphasis on quality. Rigid con-
trols at every stage of produc-
tion, from raw materials to the
finished products, insure their
dependability. Physicians know
that Walker vitamin products can
be prescribed with confidence.
CON
FI
DENC
E
-tya&fob
VITAMIN PRODUCTS, INC.
MOUNT VERNON, NEW YORK
May, 1947
575
IN MEMORIAM
The Diagnostic *
Family is Growing
A new member has been added to the
ever-growing Ames Diagnostic Family.
The name of the latest arrival is —
Hematest.
Here are the 3 members of the group
to date:
1. Hematest
Tablet method for rapid detection of oc-
cult blood in feces, urine and other body
fluids. Bottles of 60 tablets supplied with
filter paper.
2. Alhutest
{Formerly Albumintest)
Tablet, no heating method for quick quali-
tative detection of albumin. Bottles of
36 and 100.
3. Clinitest
Tablet, no heating method of detection of
urine-sugar.
Laboratory Outfit (No. 2108).
Plastic Pocket-size Set (No. 2106).
Clinitest Reagent Tablets (No. 2101) 12x
100’s for laboratory and hospital use.
All products are ideally adapted to use by
physicians, public health workers and in
large laboratory operations.
Complete information upon request.
Distributed through regular drug
and medical supply channels only.
AMES COMPANY, Inc.
ELKHART, INDIANA
In Memoriam
JAMES LINN ADAMS
Dr. James L. Adams, for thirty-six years a general
practitioner at Morgan, Minnesota, died in March, 1947,
retiring in 1928. He was eighty-seven years old, and he
and Mrs. Adams had recently celebrated their golden
wedding.
Dr. Adams obtained his M.D. degree at the Missouri
Medical College in 1886. He came to Morgan, Min-
nesota, in 1892, and prided himself on being a “real
horse and buggy doctor.”
In 1941, he returned to Morgan when grateful citizens
unveiled a granite monument with a bronze plaque
bearing his likeness in Vernon Park. The legend on
the monument reads : “James L. Adams, a Pioneer
Doctor. Service to His People Filled the Life of This
Man, Without Thought of Personal Gain.”
Dr. Adams is survived by his widow; three daughters
— Frances of Long Beach, and Mildred and Marian of
Carmel, California; and one son, James, Jr., of Olivia,
Minnesota.
CLEMENT CAMPBELL BLAKELY
Dr. C. C. Blakely of Barnum, Minnesota, passed away
on March 29, 1947, following a stroke. He was seventy-
one years of age. He had practiced medicine and had
been active in the social life of Barnum since 1920.
Dr. Blakely was born in Foo Chow, China, March 13,
1876, the son of Presbyterian missionaries in that field.
In his early childhood, his family returned to America
and lived in Neenah, Wisconsin, where he attended
high school. Later, he attended Ripon College and
obtained his medical degree from the University of
Minnesota in 1909. After spending a year in pathology
at the University, he interned at Ancker Hospital,
Saint Paul, and began practicing at Saint Peter in 1911.
He entered the army in 1918, serving as captain in the
medical corps, 183rd Depot Brigade.
Following his discharge from the army, Dr. Blakely
came to Barnum in January, 1920, looking for a loca-
tion. The community, without a doctor, was in the
midst of a scarlet fever epidemic, and he was induced
to stay. This was two years after the disasterous Moose
Lake- Kettle River forest fire, and there were still many
reminders, of that tragedy in ruined dwellings and
burned-over woods. As a result of the fire, practice at
Barnum was rather primitive. The roads being poor,
the horse and buggy, bobsled, and even snow shoes
were resorted to. He at one time invested in a snow-
mobile which would make thirty miles an hour. With
the advent of the big county snowplows, the snowmobile
was given up. The doctor many times had reason to be
grateful to the snowplow crews who always responded
promptly to ,a call to open up snowfiflec|- roads, so he
could jpfach a 'patient in an emergency.
Dufif?)|| his residence at Barnum, Dr. ,J31akely was
active in various lines of endeavor. He w(s a member
576
Minnesota Medicine
IN MEMORIAM
of the Board of Education for twelve years, serving
as its president for several terms; president of the
Parent-Teachers Association ; trustee of the Presby-
terian church for six years ; and member of the Com-
mercial Club. He was also a member of the A.F. and
A.M., the IOOF, the American Legion, St. Louis Coun-
ty Medical Society, the Minnesota State and American
Medical Associations.
Dr. Blakely was a very successful practitioner. His
life was not an easy one — a country doctor’s life seldom
is. But he enjoyed his work and had the satisfaction
of feeling that he was working for the good of man-
kind. As one former patient wrote, “He has fought the
good fight and finished his course.”
GEORGE CLAUDE DITTMAN
Dr. George C. Dittman was born in Saint Paul, Min-
nesota, on October 9, 1882, and died after a short illness,
from heart disease, on January 9, 1947.
He attended the Webster grade school, Central High
School in Saint Paul, and received his degree of doctor
of medicine from the University of Minnesota in 1904.
After completing his internship at Ancker Hospital in
Saint Paul in 1905, he practiced for a year in South
Saint Paul. Not satisfied with his work there, he went
abroad and studied in his specialty in eye, ear, nose and
throat diseases. He returned in 1907 and practiced his
specialty for two years until 1909. At that time he be-
came associated with his uncle, the late Dr. Joseph
Bettingen, with whom he remained in partnership until
Dr. Bettingen’s death in 1921, after which he continued
in his specialty alone until his death in January, 1947.
Dr. Dittman served in World War I in the Medical
Corps. He was a member of the staff of St. Joseph’s
Hospital. He was an 'active member of the Ramsey
County Medical Society, Minnesota State Medical As-
sociation, and was a Fellow of the American Medical
Association.
Surviving Dr. Dittman is his sister, Miss Georgiana
Dittman of Saint Paul.
Karl Dedolph, M.D.
FLOYD LESTER GILLES
Dr. F. L. Gilles, Minneapolis, died of a heart attack as
he was entering his car in front of Fairview Hospital
on April 24, 1947. He was fifty-five years of age.
Dr. Gilles was born in Sherburne, New York, May
27, 1891. He attended high school in Shortsville, New
York, and obtained his medical education from Syracuse
College, receiving the degrees of B.S. and M.D. in 1917.
He interned at Asbury Hospital, Minneapolis, and
served with the Medical Corps of the Army, being dis-
charged in March, 1919. He was associated with Dr.
A. E. Wilcox from May, 1919, until October, 1920, and
has since practiced surgery, having been on the Fair-
view and Asbury hospital staffs.
Dr. Gilles was a past master of Khurum Lodge, A.F.
and AM., and a member of the Scottish Rite consis-
tory, Zuhrah Temple Legion of Honor. He was also a
member of the Hennepin County Medical Society, the
Minnesota State and American Medical Associations.
Surgical Principle
Accomplished
Medically
a
rainage in the
presence of infection or conges-
tion is a sound surgical principle.
9
In chronic inflammatory conditions
of the bile passages without stones,
drainage is accomplished by increasing
the production and flow of free-flowing,
low viscosity bile, employing Decholin
for its hydrocholeretic action.
Decholin (dehydrocholic acid) stim?*
ulates the production of thin bile by S ;
the liver cells, with a resultant cleans-
ing action on the entire biliary tract.'
DleeftoCtn
Decholin is supplied in boxes of 25,
■I COUNCIL ON
100, 500 and 1000 3H gr. tablets.
AMES COMPANY, Ine
Successors to Riedel - de-iiaen, "Inc.
ELKHART, INDIANA
May, 1947
577
IN MEMORIAM
BROWN & DAY, INC.
St. Paul I. Minnesota
ACCIDENT • HOSPITAL * SICKNESS
INSURANCE
FOR PHYSICIANS, SURGEONS, DENTISTS EXCLUSIVELY
f PHYSICIANS\
SURGEONS
V DENTISTS J
All
CLAIMS Z
$5,000.00 accidental death $8.00
1 25.00 weekly indemnity, accident Quarterly
and sickness
$10,000.00 accidental death $16.00
tSO.OO weekly indemnity, accident Quarterly
and sickness
$15,000.00 accidental death $24.00
1 75.00 weekly indemnity, accident Quarterly
and sickness
$20,000.00 accidental death $32.00
flOO.OO weekly indemnity , accident Quarterly
and sickness
ALSO HOSPITAL EXPENSE FOR MEMBERS
WIVES AND CHILDREN
86c out of each $1.00 gross income used for
members’ benefits
$3,000,000.00 $14,000,000.00
INVESTED ASSETS PAID FOR CLAIMS
J200. 000.00 deposited with $t»t> of Nebritk* for protection of our momboro.
Disability need not be incurred in line of duty — benefits from
the beginning day of disability
PHYSICIANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION
45 years under the the same management
400 FIRST NATIONAL BANK BUILDING • OMAHA 2, NEBRASKA
Dr. Gilles is survived by his wife; a son, Paul
Frederick of Minneapolis; a daughter, Mrs. Robert
Wood of Jamestown, North Dakota; and his mother,
living in New' York.
CARL M. JOHNSON
The death of Dr. Carl M. Johnson on February 1,
1947, removed one of the state’s leading physicians, a
valued Councilor of the State Medical Association, and
an outstanding citizen of Dawson, Minnesota.
Carl Johnson was born July 27, 1882, on a farm
northwest of Pelican Rapids, a spot chosen by his fa-
ther, John M. Johnson, when he came to that region as
the first settler.
It is always a matter for debate whether environment
or heredity is most important in formation of charac-
ter; this in his case was settled, by giving him both.
His parents were outstanding citizens for over fifty years
— very successful farmers, pillars of the church, and his
father’s advice was sought by large numbers throughout
his long life. Carl carried these ideals absorbed in youth
to the end.
Carl Johnson was educated in the Park Region Luth-
eran College, Fergus Falls ; Hamline University, and the
University of Minnesota, graduating in medicine in 1910.
He interned in St. Barnabas Hospital, and took post-
graduate work in New York. Following this, he was as-
sociated with Dr. L. G. Smith, Montevideo, until 1916,
when he joined his brother, Herman, in Dawson.
This partnership was ideal. Most, who know, agree
that Herman was one of Minnesota’s great men, pos-
sessing a remarkable mind, fine judgment, unlimited
drive, high ideals and character. Herman would have
dominated anywhere he chose, but was satisfied in giving
his community the best in medical and surgical service,
leading the citizens on the right road in civil and politi-
cal affairs, and acting as an outstanding advisor to the
Minnesota State Medical Association; refusing through
his whole life to accept public office.
Carl, though having equal ability, was Herman’s com-
plement— thoughtful, very slow in making a decision,
kindly and deliberate, never irritable. It was Carl who
always had time to discuss problems with anyone in the
city or hospital, thus becoming the greatly valued ad-
visor of the community. Though generous, he was wise
in finance ; at the time of his death being president of
the Northwestern State Bank of Dawson, president of
the City Council, and chief of staff of the Dawson
Community Hospital.
The high standards set by Herman and Carl will be
carried on by two cousins and Dr. J. G. Boody, a valued
partner in practice for many years.
Vilhem (Bill), Herman’s son, who greatly distin-
guished himself in the last war, becoming a Major, is
now carrying the chief burden. He will soon be joined
by Curtis, Carl’s son, who is now finishing his internship.
Besides Curtis, Carl leaves Douglas and Dorothea,
fine young people still in college, and Mrs. Johnson,
formerly Anna Loberg.
It can be said that Carl lived a full and useful life,
dying with as few reasons for regrets as it is humanly
possible.
W. L. Burnap.
578
Minnesota Medicine
IN MEMORIAM
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 2 1 1
LEE W. POLLOCK
Dr. Lee W. Pollock, head of the sections of
medicine at the Mayo Clinic at Rochester, died following
a stroke February 2, 1947.
Dr. Pollock was born at Evansville, Minnesota, Feb-
ruary 7, 1887. He attended high school at Rochester and
for fifteen months after graduation he worked in the lab-
oratory at St. Mary’s Hospital under the tutelage of
Dr. L. B. Wilson. His interest in laboratory work con-
tinued and while he was an undergraduate at the Uni-
versity of Minnesota his spare hours and summer vaca-
tions throughout his course were spent in the pathologic
laboratory under Dean F. F. Wesbrook, Dr. H. E. Rob-
ertson, Dr. R. H. Mullin and others. He received the
degrees of B. S. in 1911 and M.D. in 1912 from the Uni-
versity of Minnesota. After an internship in City and
County Hospital (later Ancker), St. Paul, he practiced
in Warren, Minnesota, for about a year and then went to
the Mayo Clinic in November, 1914. During World War
I he was a first lieutenant and served on the Board of
Examiners for tuberculosis in various army camps. He
returned to the clinic and in 1925 was made head of a
section. He was also an assistant professor of medicine
in the Mayo Foundation.
In the clinic his work was always associated with Dr.
A. H. Logan and for a number of years he performed
the proctoscopic examinations and supervised the tedious
treatment of ulcerative colitis and other medically treat-
ed colon conditions.
Because of his persistence in his diagnostic work and
his refusal to dismiss a patient until he himself was sat-
isfied, his pleasant personality and his patience, a great
number of patients always sought him on their return
visits. He was a great reader on medical subjects and
always purchased his own books so that he could util-
ize any free moments available from the care of his
patients. He was considered a good teacher by the fel-
lows who were fortunate enough to come under his in-
fluence and he wrote well but infrequently. His rather
retiring disposition deterred him from participating in
medical meetings.
His hobbies were numerous. As a student his chief
delight was playing baseball, and after college he was an
ardent follower of the University of Minnesota football
team. He always liked dogs and owned several good
ones. In 1926 he acquired some wooded hillside land in
the outskirts of Rochester and on this project expended
much energy and satisfied several urgent impulses .to
produce the best of whatever he undertook. He had
chickens, and being on the dietetic committee of the
clinic he early used his training to formulate a ration
for his laying hens which produced satisfying results in
growth of the birds and egg production. In 1926 crude
cod liver oil was added to the chicken mash as well as
the milk fed to his prize Jersey calves. During the year
preceding his death, his few excellently bred Jersey cows
topped the county records in milk production and butter-
fat.
He always loved to see things grow. His interest be-
gan with apples and plums, continued on into iris, lilacs
and gladiolus. His greatest effort was in his prize peo-
nies. On his small plat of land there were between 6,000
May, 1947
579
IN MEMORIAM
and 7,000 plants with more than 500 named varieties.
Many prizes were acquired for his beautiful blooms at
the peony shows.
He married Addie Baihly of Rochester on June 14,
1916, and is survived by his wife and a sister, Mrs. Frank
Jacobs, of Rochester, and a host of friends.
He was a member of the Southern Minnesota Medical
Association, the American Medical Association, the
Alumni Association of the Mayo Foundation and Sigma
Xi.
THOMAS HALL SHASTID
Dr. Thomas H. Shastid, a practicing ophthalmologist
and author in Duluth since 1920, died February 15,
1947, at the age of eighty.
Born in Pittsfield, Illinois, July 19, 1866, Dr. Shastid
attended the local schools and Eureka College, Illinois.
He obtained his medical education at Columbia Uni-
versity and the University of Vermont, obtaining his
M.D. degree in 1888. He also obtained a B.A. degree
from Harvard in 1893, an M.A. from the University of
Michigan in 1901, and an LL.B. from the same univer-
sity in 1902. P'ostgraduate work was taken also at
the Postgraduate Medical School in New York and
in Vienna on two occasions.
Dr. Shastid was indeed a remarkable individual, and
during his long life he took an active and combative
interest in anything and everything pertaining to medi-
cine and to his chosen specialty of eye, ear, nose and
throat. For many years he assisted in the editing and
the collecting of data pertaining to the American En-
cyclopedia of Ophthalmology and its publication.
Prior to coming to the Head of the Lakes (Superior
and Duluth) he traveled about considerably, and prac-
ticed in several cities of Illinois: Pittsfield, Galesburg,
Fairfield, Charleston and Marion. He is credited with
more than 3,000 publications. Two thick tomes, co-
piously illustrated, dealing with what he called his “first
and second lives,” were published by him. Much of
the information concerned in these books is extremely
personal but it has considerable historical value because
it connotes the gradual development of medicine in its
various fields within that extensive period of sixty
years in which he was student, practitioner, teacher and
specialist. Not a little of the material covered in these
books illustrates the limitless bickering and argument,
not to say controversy, written and spoken just prior
to the turn of the century, when doctors were finding
their way to more congenial associations and the medical
societies to more scientific pursuits. As an author, he
went into great detail concerning his own confusing
illnesses and the variety of approaches and diagnostic
impressions, as, for example, when violent indigestion
persecuted him at great length, only to be ultimately
solved by an abdominal operation and an exploration.
In later years he had a great fear of “sinus disease.”
He would frequently attend a medical meeting, where
the air in the room was never too satisfactory, wearing
a heavy fur cap pulled well down over his ears be-
cause, as he stated, “the slightest cold drives me fran-
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580
Minnesota Medicine
IN MEMORIAM
tic.” His writing was by no means confined to medical
fields, and one of his books, Simon of Cyrene, was very
well received and had excellent mention from the critics
about two decades ago.
His habits of living in later years became intensely
individual. He arose about noon, and then went to his
office, where he saw many people, for he had developed
an unusual reputation in rather complicated optometry.
In addition, he had some unusual avocations. One of
these was to go out to the zoo and make ophthalmo-
scopic examinations of the various animals, including
fish, birds, snakes, and in fact any other living creature
submitting to approach. He made extensive contribu-
tions relative to the pupil, both of human beings and
animals.
SHELBY E. STINNETTE
Dr. Shelby E. Stinnette died March 27, 1947, in
Los Angeles, California. The cause of death was coro-
nary thrombosis, complicated by cerebral thrombosis.
Dr. Stinnette was born August 10, 1886, at Louisville,
Kentucky. He was graduated from the Louisville Male
High School in 1907, the Kentucky School of Pharmacy
in 1909, and Hahnemann Medical College of Chicago
in 1913, following which he came to Saint Paul.
He was first associated with Dr. S. G. Cobb at 365
Prior Avenue. In 1920 he opened offices with Dr. Hugh
Beals at 322 Hamm Building, where he continued to
practice until his retirement in 1946.
He was a member of Ramsey County Medical So-
ciety and Minnesota State Medical Association, Triune
Lodge No. 190, A.F. and A.M. ; Palmyra Chapter No.
55, Royal Arch Masons; the Saint Paul Athletic Club,
Kiwanis Club, the Automobile Club and the Midway
Club. He was a trustee of Trinity Methodist Church
and a staff member of Midway and Bethesda Hospitals.
Dr. Stinnette was a man devoted to his family and
his patients, as they were to him. He lived cleanly and
honestly, and from those who knew him he achieved
an affection which is given to few men. He loved his
home and was a genial and charming host. He loved
the out-of-doors, and there could be no better fishing
or hunting companion. He was a faithful servant of his
church. These things made him an outstanding member
of his profession.
He is survived by his wife; two daughters, Mrs. W.
D. Schmidt of Saint Paul, and Mrs. H. F. Wilenchek of
Atlanta, Ga. ; two brothers, a sister, and four grand-
children.
There is peculiar pathos in the fact that Dr. Beals,
with whom Dr. Stinnette shared offices for twenty-six
years chanced to be near when Dr. Stinnette was stricken
and was in constant attendance during the last days of
his illness.
Charles C. Cooper, M.D.
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May, 1947
581
Of General Interest
♦
On March 29, Dr. Paul R. Lipscomb and Dr. G. B.
Logan, Rochester, participated in a clinic for crippled
children at Worthington.
* * *
Dr. H. H. Albrecht Lindstrom, purchased the Chisago
Lakes Clinic in Chisago City, March 14, taking over the
interests of Dr. C. A. Peterson.
* * *
A recent addition to the staff of the River Falls
Clinic is Dr. R. R. Davis, formerly of Wisconsin Gen-
eral Hospital, Madison, Wisconsin.
* * *
Dr. Henry J. Wynsen, after a year’s residency in
medicine at Ancker Hospital, Saint Paul, has entered a
residency in pathology at St. Mary’s Hospital, Duluth.
* * *
Dr. T. R. Fritsche, New Ulm, was elected president
of the Minnesota Academy of Ophthalmology and Oto-
largngology at a meeting held in Minneapolis on March
14.
* * *
Dr. J. C. Crabtree and Dr. Alfred Kapsner, Prince-
ton, have purchased the former Ewing Building in that
city and are having it remodeled to house a new medical
clinic.
* * *
After nine years of medical and surgical practice in
Two Harbors, Dr. Roland F. Mueller has moved to
Lincoln, Nebraska, where he is now a surgeon with
the Olney Clinic.
* * *
While Dr. N. F. Musachio, Foley, attended a short
course in surgery in Chicago, Illinois, in late March,
his practice was conducted by Dr. John H. O’Leary,
formerly of Minneapolis. ,
* * *
At a meeting of the Chicago Medical Society in Chi-
cago in the early part of March, Dr. H. W. Meyerding,
Rochester, received the first award for his scientific
exhibit on “Benign and Malignant Tumors of Bone.”
* * *
Speaking at a Rotary Club meeting in Fergus Falls
on March 12, Dr. H. K. Helseth of that city pointed
out the disadvantages of socialized medicine by discuss-
ing the reasons for which the medical and dental pro-
fessions are opposed to medical regimentation.
* * *
Dr. Victor Johnson, recently appointed director of
the Mayo Foundation, to take office in October, has ar-
rived in Rochester and has joined the staff of the Foun-
dation as professor of physiology, in order to begin
the task of learning the duties of director.
* * *
Seven army medical officers are attending continuation
courses this spring at the University of Minnesota, it
was recently announced. When the officers’ training
is completed, they will assist the army in setting up
basic science courses at service hospitals for the training
of regular officers in the various specialties.
* * *
Dr. Gordon R. Kamman, Saint Paul, addressed the
Polk County (Wisconsin) Medical Society at its monthly
meeting held in Stillwater on March 20. Dr. Kamman’s
subject was “Neuropsychiatry in General Office Prac-
tice.”
:j<
During the annual meeting of the American Medical
Association in Atlantic City, the Alumni Association
of the Jefferson Medical College will hold a smoker
at the Traymore Hotel, Atlantic City, on Wednesday,
June 11, 1947.
* * *
Speaking at the Surgeon General’s Conference at
Walter Reed General Hospital in Washington, D. C.,
March 20, was Dr. F. H. Krusen, Rochester, who dis-
cussed “The Developments of the Modern Era of
Physical Medicine as Observed During the Past Two
Decades.”
* * *
Dr. Carleton W. Leverenz has become associated with
Dr. Harry Oerting, with offices at 914 Lowry Medical
Arts Building, Saint Paul, specializing in internal medi-
cine. A graduate of the University of Illinois, Dr. Lev-
erenz served his internship and a residency at Ancker
Hospital, Saint Paul.
* * *
Dr. A. M. Snell, Rochester, spoke at the April 7
meeting of the Hennepin County Medical Society on
the subject, “Some Clinical and Physiologic Aspects of
Portal Cirrhosis.” While in Minneapolis, he also was
a speaker at the University of Minnesota Center for
Continuation Study, where his topic was “Some Cur-
rent Problems in the Field of Gastronenterology.”
* * *
At the eleventh annual meeting of the Saint Paul
Surgical Society, held April 19 at the Minnesota Club
in Saint Paul, 158 members and guests of the society
heard Dr. Karl Meyer, professor of surgery at North-
western University Medical School, speak on the sub-
ject, “The Early Ambulatory Treatment of the Post-
operative Patient.”
* * *
April showered lecture duties upon Dr. Philip S.
Hench, Rochester, who started the month by journeying
to Portland, Oregon, to deliver three Sommer Memorial
lectures. From there he went to Denver, Colorado,
where he gave four lectures at the Fort Logan Veterans
Hospital and at the University of Colorado School of
Medicine.
s|e ;jc sj:
Among the speakers at a meeting of the Missouri State
Medical Association at Kansas City in the first week
582
Minnesota Medicine
OF GENERAL INTEREST
in April were Dr. D. R. Nichols and Dr. A. M. Olsen,
Rochester. Dr. Nichols presented a paper entitled,
“Chemotherapy as Used in Medical Conditions,” while
the subject of Dr. Olsen’s address was “Diagnosis and
Treatment of Bronchial Lesions.”
* * *
April 3 was the ninety-first birthday aniversary of Dr.
Christopher Graham, Rochester, and was marked by
an all-day celebration that included the presentation of
a giant birthday cake at a Rotary Club meeting, a
constant flow of telegrams, telephone calls and gifts,
and an evening dinner party attended by all members
of his family.
j): ^ ^
The president of the Northwestern Pediatric Society,
Dr. George C. Kimmell, Red Wing, has endorsed the
campaign of the Minnesota American Legion to estab-
lish a research professorship for rheumatic fever and
heart disease in connection with the proposed heart
hospital at the University of Minnesota. Goal of the
campaign is $500,000.
* * *
Dr. Bruce Boynton, who formerly practiced in Park
River, North Dakota, has moved to Ada and opened
an office there. Dr. Boynton graduated from the Uni-
versity of Minnesota Medical School in 1944, after which
he served in the United States Navy. Upon discharge
in February, 1946, he began his medical practice in
Park River.
* * *
Dr. J. Arthur Myers, Minneapolis, was a member of
a fifteen-man delegation from the United States to the
seventh Pan-American Congress on Tuberculosis which
began its meeting on March 17 at Lima, Peru. The
delegation was headed by Dr. Herman E. Hilleboe,
assistant surgeon general of the United States ' Public
Health Service.
;jc
Dr. John P. Cooper, formerly an industrial surgeon at
the Minneapolis-Moline Company in Hopkins, has
opened offices in the Tonka Building in Excelsior. A
graduate of the University of Minnesota Medical
School, Dr. Cooper spent two years at the Hospital of
the Good Samaritan, Los Angeles, California, before
serving in the navy during World War II.
* * *
Dr. Bernard Zondek, professor of gynecology at the
Hebrew University in Jerusalem, and co-discoverer of
the Aschheim-Zondek pregnancy test, spoke at the Uni-
versity of Minnesota Center for Continuation Study on
April 19. He addressed approximately seventy Minne-
sota doctors recently discharged from the military serv-
ices, speaking on “Observations on Female Sterility.”
• * * *
The American Bureau for Medical Aid to China, a
co-operating agency of United Service to China, has
provided for 125 fellowship awards annually, to enable
Chinese doctors, dentists, public health experts, and
nurses to engage in advanced studies in leading American
universities. After a year of study they will return
to China to join the faculties of six national medical
colleges that have been selected to receive this assistance.
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May, 1947
583
OF GENERAL INTEREST
The Royal Flemish Academy of Medicine of Bel-
gium elected Dr. Frank D. Mann, Rochester, as a for-
eign honorary member of the organization, at a meet-
ing of the academy in Brussels on November 25, 1946,
The election of Dr. Mann was approved by a Decree
of the Regent of the Kingdom under the date of Jan-
uary 28, 1947, promulgated in the Belgian State Jour-
nal of February 19, 1947.
* * *
Remodeling of the long-unused Crosby Hotel building,
Crosby, was completed early in April to provide quarters
for a new medical clinic opened by Dr. L. N. Dale
and Dr. James Nixon of that city. The clinic consists
of nine rooms on the ground floor of the building,
including offices for both doctors, examining rooms, an
x-ray room, darkroom, laboratory and small operat-
ing room.
* * *
Acceptance of Dr. K. W. Anderson, Minneapolis,
of the newly appointed office of chairman of the Health
and Medical Care Division of the Minneapolis Council
of Social Agencies, has been announced. Dr. Ander-
son, a past president of the Minneapolis Academy of
Medicine, is the medical directorof the Northwestern
National Insurance Company and an associate professor
of medicine at the Lffiiversity of Minnesota.
* * *
More than forty public health specialists in the North-
west attended the Middle States Region Health Edu-
cators’ Conference at the University of Minnesota Cen-
ter for Continuation Study on April 25 and 26. Health
films were shown and panel discussions were held dur-
ing the business sessions. Governor Luther Youngdahl
spoke on “Conservation of Human Resources and Health
Education” at the conference banquet on April 25.
* * *
Formerly of Saint Paul, Dr. R. W. Maertz has begun
practice in Goodhue, replacing Dr. James R. Weir of
that city.
Dr. Maertz, a graduate of Creighton College, Omaha,
Nebraska, interned at St. Joseph’s Hospital, Saint
Paul.
Dr. Weir has moved to Monroe, Wisconsin, and has
become affiliated with a medical clinic there.
* * *
Dr. Albert V. Stoesser, clinical professor of pediatrics
at the University of Minnesota, and head of the allergy
clinics at Minneapolis General and University Hospitals,
was a guest instructor at a four-day symposium on
allergy held at the University of Kansas School of
Medicine, May 5 to 8. Dr. Stoesser spoke on “Hay
Fever — Diagnosis and Management” and “Dermatologic
Allergy in Children.”
* * *
Tribute was paid on March 20 to Dr. Charles W.
Mayo by the Rochester Elks Lodge, which selected him
at its annual honor night program as an outstanding
citizen of Rochester. Toastmaster at the program was
Allen J. Furlow, who said of Dr. Mayo : “He has
the heritage of a great name, but unless he had what
it takes, we wouldn’t be honoring him tonight.” Mr.
Furlow pointed out that the honor “is presented for
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i
5&4
Minnesota Medicine
OF GENERAL INTEREST
outstanding work in the community, the state and, in
this case, the nation.” He then presented Dr. Mayo
with the lodge’s token of the honor — a gold clock.
sf; % %
Dr. J. S. Lundy and Dr. E. B. Tuohy, Rochester
anesthesiologists, journeyed to Los Angeles in the middle
of April to attend a meeting of the American Board of
Anesthesiology, at which Dr. Lundy assisted with the
board’s oral examinations. While in Los Angeles, they
attended a joint meeting of the American Society of
Anesthesiologists, of which Dr. Tuohy is president,
and the Anesthesia Section of the Los Angeles County
Medical Society.
* * *
Dr. W. R. Lovelace II, a former Mayo Clinic staff
member, who left Rochester recently to join the staff
of the Lovelace Clinic in Albuquerque, New Mexico, has
been named physician-in-charge of passenger comforts
in high flying by the Trans World Airline. Dr. Love-
lace was a colonel in World War II, during which he
received international acclaim for his daring parachute
jumps from high altitudes — part of a research program
in high altitude flying.
Dr. Miriam M. Pennoyer, St. Louis, Missouri, who
was engaged in postgraduate work in pediatrics at the
University of Minnesota Hospitals from 1939 to 1944,
has been awarded a research fellowship in medicine by
the American College of Physicians, and will investi-
gate adrenal function in the newborn at the St. Louis
Children’s Hospital, under the direction of Dr. A. F.
Hartmann of the Washington University School of
Medicine.
% jfi
Recently Dr. H. S. Diehl, dean of the University of
Minnesota Medical School, stated that for some time 30
to 40 per cent of students admitted to the Medical
School had had positive Mantoux reactions, and that
two-thirds of those who reacted negatively on admis-
sion showed positive reactions before graduation. This
incidence has now been reduced to 10 per cent. In the
last five years only one medical student has developed
clinical tuberculosis.
* * *
The association of Dr. Robert H. Conley with Dr.
Roger G. Hassett, Mankato, was announced on March
17. Dr. Conley, a graduate of the University of Min-
nesota Medical School, served his internship at General
Hospital in Rochester, New York. During the war he
was in the naval medical corps for thirty-eight months,
thirty months of which were spent with amphibious
forces in the Pacific theater. Following his discharge,
Dr. Conley completed a year of postgraduate work
in medicine a the University of Minnesota.
♦ * *
Retirement in March of Dr. A. J. Wentworth, radiol-
ogist of the Mankato Clinic, ended a medical career
which began in Mankato in 1914. A graduate of the
University of Minnesota Medical School, Dr. Went-
worth conducted a private practice in Mankato for
two years before joining the x-ray department of the
Mankato Clinic. In the first World War he served
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ST. PAUL MINNEAPOLIS
Cook County
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Four-week course in General Surgery starting May 26,
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Two-week course, Surgical Anatomy & Clinical Surgery
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One-week course, Surgery of Colon & Rectum starting
May 5, June 2, September 15, November 3.
Two-week course. Surgical Pathology every two weeks.
FRACTURES & TRAUMATIC SURGERY— Two-week
intensive course starting June 16, October 6.
GYNECOLOGY — Two-week intensive course starting
May 12, June 16, September 22.
One-week course in Vaginal Approach to Pelvic Sur-
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OBSTETRICS — Two-week intensive course starting June
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Address:
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May, 1947
585
OF GENERAL INTEREST
for two years as a radiologist in this country and over-
seas.
Dr. Wentworth has been replaced by Dr. W. E.
Macklin, Jr., formerly of Litchfield.
* * *
Dr. Benjamin Spock, a pediatric psychiatrist, former
member of the Cornell University Medical School, and
consultant in child psychiatry in the New York City-
Health Department, has become a consultant in psychi-
atry at the Mayo Clinic and an associate of Dr. C.
Anderson Aldrich in the Rochester Child Health Project.
Dr. Spock, a graduate of Columbia University, is
the author of The Common Sense Book of Baby and
Child Care, which was published in 1946 and has
since been reprinted as The Pocket Book of Baby and
Child Care.
* * » *
Resigning from his positions as professor of surgery
at the University of Minnesota and head of the surgical
service at the Minneapolis Veterans Hospital, Dr. John
R. Paine has accepted the posts of professor of surgery
at the L^niversity of Buffalo Medical School and chief
of the Department of Surgery at Buffalo General
Hospital. He will assume his duties there on June 1.
A graduate of the medical school at Harvard Uni-
versity, Dr. Paine also holds the degrees of M.S. and
Ph.D. in surgery, both from the University of Min-
nesota. Dr. Paine has been on the faculty of the
University of Minnesota Medical School for ten years.
From 1942 to 1945 he served with an army hospital unit
in England, North Africa and Italy.
An opening for a young surgeon who has had a year
or two in the army, or a year or more of surgical
training as a hospital resident, is available, as an assist-
ant project surgeon on a large government construc-
tion job at Okinawa. The salary authorized by the War
Department is base pay of $6,500 per annum with a
possible maximum salary of $7,980 per year. The con-
tract is for one year, and all travel expenses are paid.
The project is expected to last from one and one-half
to eight years. Living quarters are furnished, and
“mess” is obtainable at $1.50 per day. Further infor-
mation may be obtained by communicating with C. J.
Iverson, Aetna Casualty and Surety Company, 1550
Northwestern Bank Building, Minneapolis.
* * *
On March 5, 1947, a bill setting aside $130,500 an-
nually, for providing state aid to counties that wish to
employ public health nurses, was passed unanimously by
the state legislature. In 1922 the legislature passed leg-
islation enabling counties to employ public health nurses.
Forty-nine of Minnesota’s eighty-seven counties have
voted funds to employ such nurses. At present there
are fifty-two public health nurses employed in counties
and eighty-six employed by school boards. Although
there is a shortage of qualified public health nurses at
present, it is hoped that many of the 300 students now
securing special training in public health at the LTni-
versity of Minnesota School of Public Health will seek
these county positions.
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586
Minnesota Medicine
OF GENERAL INTEREST
Two Minneapolis physicians have literally made an
art of a hobby.
Working at their hobbies during well-earned spare
moments, Dr. Carl G. Swendseen and Dr. Robert W'ilder
have won recognition at painting and sculpturing, re-
spectively. Both have been awarded top prizes in past
art contests, and both will exhibit their work again this
June in the annual meeting of the American Medical
Association in Atlantic City. The exhibit at the AMA
convention will be sponsored jointly by Mead Johnson
and Company and the American Physicians’ Art Asso-
ciation, of which both Dr. Swendseen and Dr. Wilder
are members.
Dr. Swendseen began his hobby of painting only
four years ago, while Dr. Wilder made his initial
attempt at sculpture ten years ago when he first started
wood carving. Dr. Swendseen now has a collection of
more than fifty of his own oil paintings, and Dr. Wilder
has progressed to advanced clay modeling and stone
sculpture.
% iji
HOSPITAL NEWS
At St. Mary’s Hospital in Duluth a three-man com-
mittee is planning a homecoming reunion for former
interns at the hospital, many of whom are expected
to attend the annual meeting of the Minnesota State
Medical Association in Duluth in July. Members of
the committee making arrangements for the reunion are
Dr. W. J. Ryan, Dr. R. P. Buckley and Dr. K. R.
Fawcett.
* * *
Announcement has been made by the hospital board
at Blue Earth that donations of several pieces of
equipment have been made for use in the local hos-
pital. Included in the equipment are an electric blanket,
a supply table and an instrument sterilizer. Further
contributions, the board stated, would be gratefully
welcomed.
* * *
Dr. Jorge Lazarte, Rochester, has been appointed
assistant superintendent of the Rochester State Hos-
pital.
Dr. Lazarte, who came to Rochester in 1941 from
Lima, Peru, has an M.A. degree in neurology from the
University of Minnesota, and has served five years on
a fellowship in the Mayo Foundation, majoring in
neurology and psychiatry. He joined the staff of the
state hospital in July, 1946. In addition to his local
duties, Dr. Lazarte represents the Peruvian government
on the United Nations committee for drug control.
* * *
Following the grant of a hospital permit to Green-
bush by the Federal government, officers and committee
chairmen of the Greenbush Hospital Association have
been announced. Officers are William Anderson, pres-
ident ; W. O. Gordon, vice president, and I. S. Fol-
land, secretary-treasurer.
Committee chairmen are Herbert Reese, building;
W. O. Gordon, medical ; R. W. Huggett, health insur-
ance, and William Paulson, executive.
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587
May, 1947
OF GENERAL INTEREST
A delegation of Brainerd representatives in March
appealed to the Civilian Production Authority in Min-
neapolis to reconsider a request for vital materials for
St. Joseph’s Hospital in Brainerd.
The delegation was formed after the Authority had
rejected a request for materials with which to build
a $50,000 service building and heating plant on the
hospital grounds. Engineers had previously informed
the hospital authorities that unless a new heating plant
is installed, the institution might be required to close
next winter.
Included in the delegation were Dr. John Thabes,
Sr., chief of the hospital medical staff ; Lester Hage,
chairman of the Brainerd Civic Association, and Norris
Ryder, secretary-manager of the association.
* * *
The initial step toward the construction of a hospital
at Isle was taken on March 10 when a citizens’ com-
mittee of Isle met with Dr. Viktor O. Wilson and
Ether McClure of the Hospital Licensing Division of
the State Department of Health, to discuss possibili-
ties for a hospital in that area. At the meeting Dr. Wil-
son suggested that a committee be organized to inves-
tigate the various aspects of the problem and to obtain
the necessary preliminary information for hospital
planning.
* * *
Increased efforts to reach an understanding between
the hospital boards of St. Luke’s and Mercy Hospitals,
TAILORS TO MEN
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Thief River Falls, were made by members of the Civic
and Commerce Association at their March 6 meeting
after the reading of an architect’s report dealing with
methods for expanding hospital facilities in Thief River
Falls. Although the detailed report was not made
public, it did recommend that an addition to St. Luke’s
Hospital would be the least costly means of prdviding
extra facilities.
Association members pointed out the need for a
prompt settlement of differences between the two hos-
pital boards if the city were to become eligible for Fed-
era financial aid. It was suggested that the services
of a hospital consultant be secured to survey the local
situation, with the understanding that the two boards be
guided by his recommendations.
Among the speakers at the meeting were Dr. M. D.
Starekow and Dr. Theodor Bratrud.
* * *
A community auction, with items contributed by
Zumbrota townspeople and farmers in the area, was
staged on May 1 as part of a drive to raise funds for
the construction of a municipal hospital at Zumbrota.
Objects placed on the hospital auction block ranged
from tractors and refrigerators to farm produce and
household goods.
Proceeds from a noon lunch and an evening dance
were added to the auction receipts and to funds ob-
tained by individual solicitation, in an effort to reach
the $35,000 total anticipated before the event by the
local planning board.
* * *
A report of the interim committee appointed by the
1945 legislature to study needs of the mental hospitals
of the state, submitted to the legislature in March,
emphasized the over-crowding in all seven of the state
mental hospitals.
The report indicated that at least 2,000 additional
beds are needed to meet present needs, and proposed
a building program that would provide $16,854,000
in improvements over a period of ten years. At the
St. Peter State Hospital, for example, rebuilding of
administrative offices, kitchen, bakery, steward’s offices,
warehouses and wards, would cost about $2,910,000,
while erection of two buildings, each to house 150 senile
patients, would require an additional $800,000.
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INSTRUMENTS • TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494
588
Minnesota Medicine
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
Dbstetrical Practice. Fourth Edition. Alfred C.
Beck, M.D. Professor of Obstetrics and Gynecology,
Long Island College of Medicine ; Obstetrician and
Gynecologist-in-Chief, Long Island College Hospital,
Brooklyn. 966 pages. Illus. Price, $7.00, cloth.
Baltimore : Williams & Wilkins Co., 1947.
— Its Relation to Congenital Hemolytic Dis-
ease and to Intragroup Transfusion Reactions.
Edith L. Potter, M.D., Ph.D., Assistant Professor
of Pathology, Department of Obstetrics and Gynecol-
ogy, the University of Chicago and the Chicago Lying-
in Hospital. 455 pages. Illus. Price, $5.50, cloth.
Chicago : Year Book Publishers, 1947.
Nutritional and Vitamin Therapy in General Prac-
tice. Third Edition. Edgar S. Gordon, M.D., Ph.D.
Associate Professor of Medicine, University of Wis-
consin. 410 pages. Price, $5.00, cloth. Chicago :
Year Book Publishers, Inc., 1947.
Physician’s Handbook. Fourth Edition. John War-
kentin, Ph.D., M.D., and Tack D. Lange, M.S., M.D.
272 pages. Illus. Price, $1.50, paper cover. Chicago :
University Medical Publishers, 1946
IADIOLOGY FOR MEDICAL STUDENTS. F. J. Hodges,
I. Lampe, and J. F. Holt. 424 pages. Illus. $6.75. Chicago:
Year Book Publishers, 1947.
The authors, who are members of the Department
)f Roentgenology of the University of Michigan, have
iroduced a more complete work than the title implies
md have understated themselves in speaking of it as a
‘limited treatise.” This book is in two parts ; one con-
:erns diagnostic roentgenology and the other x-ray and
•adium therapy. Either part could stand on its own
nerits. In the section on therapy, emphasis is placed on
:he clinical indications and probable results. Every
ioctor should be familiar with these aspects of thera-
leutic radiology and information on the subject of the
ype presented concisely in this work is not generally
available. Of interest is the fact that, excluding der-
■natologic conditions, 40 per cent of the x-ray therapy
patients at the University of Michigan have benign con-
ditions.
The first portion of the book takes the reader through
a brief history of medical roentgenology witli a discus-
sion of the generalities of equipment and the methods
of roentgenology, and defines the position of roentgen-
ology as a specialty, and the radiologist. The diagnostic
section represents the major portion of the book and is
excellently prepared and presented with regard to the
clinical aspect of x-ray diagnosis. Controversial sub-
jects are covered dogmatically enough for the beginner
but are free from prejudiced conclusions to serve the
more advanced reader. The limitations of x-ray diag-
nosis are mentioned. A bibliography is appended to each
chapter.
The publishers have again done an outstanding job in
the reproduction of actual radiographs used in the il-
lustrations. This book should find wide acceptance.
L. A. Nash, M.D.
EVERYDAY PSYCHIATRY. John D. Campbell, M.D., Com-
mander, MC, U.S.N.R., Chief Neuropsychiatrist, U. S. Naval
Base Hospital No. 8. Formerly Chief Neuropsychiatrist, U. S.
Naval Hospital, Charleston, S. C., and Visiting Lecturer in
Psychiatry, Medical College of South Carolina, Diplomate
American Board of Neurology and Psychiatry. 333 pages.
Price $6.00, cloth. Philadelphia: J. B. Lippincott Co., 1945.
The author states that this book “seeks to fill a gap
between medicine and psychiatry.” He opens Chapter
I with the following paragraph : “In an endeavor to
present psychiatry to practicing physicians, medical stu-
dents, and social workers in a usable practical manner,
I have concluded that the most expedient approach is
Practical Nursing Course
Nine months' course open to high school
graduates or women with equivalent
education.
For further information
write
Mrs. Lydia Zielke, Supt. of Nurses
FRANKLIN HOSPITAL
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May, 1947
589
BOOK REVIEWS
through the abnormal personality types. These milder
mental aberrations constitute 90 per cent of tbe private
practice of psychiatry, a large percentage of military
psychiatry, and approximately 30 per cent of all pa-
tients who consult physicians in general. Ten per cent
of the selectees rejected for military service are re-
jected because of these borderline mental conditions.”
This statement indicates the type of and prevalence of
the abnormalities discussed in the book.
Mental deficiency, psychopathic, personality, psycho-
neurosis, homosexual personality, schizoid personality,
and cycloid personality are each discussed under the
following headings : intelligence, conscience and work
record, emotional stability, socialability, psychosexual
development, and special modes of adjustment. In ad-
dition, the etiology and treatment of each of these en-
tities are considered. Chapters on chronic alcoholism,
personality examination, and rehabilitation, are included.
Early in the book the reader gains the impression that
the four basic personality traits which he describes, in-
telligence, conscience, emotional reaction, and psycho-
sexual development, as well as two secondary factors,
sociability and special modes of adjustment, “are in-
herited, constitutional and immutable, and are not sub-
ject to change by environment, education or training.”
This attitude may well discourage the reader from
perusing it further. Actually, as indicated above, con-
siderable material is devoted to treatment and rehabili-
tation. It would appear that the more optimistic attitude
developed as the material is presented is the correct one.
Although the section on mental deficiency and the
attitude that the autonomic nervous system and the
endocrine glands are not modifiable by environmental
factors will meet with adverse criticism from many
readers, the references to the literature and the content
of the work as a whole are deserving of commenda-
tion.
This book is easily read and is worthy of the care-
ful consideration of those to whom it is addressed.
Walter P. Gardner, M.D.
HOME SITES FOR SALE
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and live. Where low taxes deliver life's best.
Anoka Township has equipment and no debt.
On East River Drive, 1 mile off U. S. Highway
No. 10 and WCCO Tower. Bus service.
Owner, J. C. APPLETON
Rte. 3, Anoka, Minn.
Office, 1522 Henn. Ave.. Minneapolis 3
Atlantic 6521
Classified Advertising
WANTED — Physicians, class A graduates, with or
without psychiatric experience, licensed in Minnesota
or will obtain Minnesota license promptly. Full main-
tenance. State Hospital, Moose Lake, Minnesota.
FOR SALE — Active general practice; office equipment;
home in Minnesota town, 1800 population, 90 miles
north of Minneapolis. Large territory. No opposi-
tion. Address E-12, care Minnesota Medicine.
Position Wanted — Young physician desires position as
associate with another doctor in Minnesota town, or
will purchase practice. Addres E-15, c/o Minnesota
Medicine.
Wanted — Assistant for general practice with view to
permanent association by doctor with excellently
equipped small clinic. An internist or physician with
special training preferred. Give qualifications and ref-
erences. Address E-16, c/o Minnesota Medicine.
For Sale or Rent — Desirable building suitable for doc-
tor’s office. Small Minnesota town; twelve miles from
hospital ; large territory, unopposed practice. Address
E-17, c/o Minnesota Medicine.
For Sale — One white enamel office operating or exam-
ining table. Leather padded. Adjustable stirrups.
Come and take it away at any reasonable price. J. H.
Haines, M.D., 2nd and Burlington Streets, Stillwater,
Minnesota.
Wanteit — Resident physician. Immediate opening in old,
established hospital in Saint Paul. Salary is open.
Address E-18, c/o Minnesota Medicine.
DOCTOR WANTED — To take over general practice
of deceased physician ; established 25 years. Office
equipment, records, drugs, medical library included.
120 miles north of Saint Paul. Address E-19, care
Minnesota Medicine.
WANTED — Young physician to work with a group of
four physicians in Central Minnesota. Address E-20,
care Minnesota Medicine.
ThaJtwnaL filaatnumL Ss^wioL . . . roR H0SP,TALS - ‘“KlSSSfS*,.
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When in need of a PHYSICIAN, DENTIST, OFFICE NURSE, TECHNICIAN, MEDICAL SECRETARY, or
OTHER PERSONNEL for medical and dental offices, clinics, and hospitals contact —
Minneapolis, Minn. — GE. 7839 The Medical Placement Registry St. 5Paul^aMffin.— 'ga!” 6718
OLIVE H. KOHNER, Director
590
Minnesota Medicine
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
INSTRUMENTS • TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
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AUGUST F. KROLL
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Radiological and Clinical
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MURPHY LABORATORIES
Minneapolis: 612 Wesley Temple Bldg. - - At. 478f
St. Paul: 348 Hamm Bldg. ...... Ce. 7125
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MINNESOTA REPRESENTATIVE- S. E. STRUBLE, WYOMING, MINN.
VTay, 1947
591
BRIEF HISTORICAL NOTES ON
MEAD’S CEREAL, PABLUM
AND PABENA
Hand in hand with pediatric progress, the introduction of Mead’s Cereal
in 1930 marked a new concept in the function of cereals in the child’s dietary.
For 150 years before that, since the days of "pap” and "panada,” there had
been no noteworthy improvement in the nutritive quality of cereals for
infant feeding. Cereals were fed principally for their carbohydrate content.
The formula of Mead’s Cereal was de-
signed to supplement the baby’s diet in
minerals and vitamins, especially iron
and thiamine. How well it has succeeded
in these functions may be seen from two
examples:
(1) As little as one-sixth ounce of
Mead's Cereal* supplies over 50% of the
iron and 20% of the thiamine minimum
requirements of the 3-months-old infant.
(2) One-half ounce of Mead’s Cereal
furnishes all of the iron and 60% of the
thiamine minimum requirements of the
6-months-old baby.
o That the medical profession has recog-
nized the importance of this contribution
is indicated by the fact that cereal is now
routinely included in the infant’s diet as
early as the third or fourth month instead
of at the sixth to twelfth month as was
the custom only a decade or two ago.
In 1933 Mead Johnson & Company
went a step further, improving the
Mead’s Cereal mixture by a special proc-
ess of cooking, which rendered it easily
tolerated by the infant and at the same
time did away with the need for pro-
longed cereal cooking in the home. The
result is Pablum, an original product
which offers all of the nutritional quali-
ties of Mead s Cereal, plus the conven-
ience of thorough scientific cooking.
During the last twelve years, these
products have been used in a great deal
of clinical investigation of various as-
pects of nutrition, which have been
reported in the scientific literature.
Many physicians recognize the pioneer efforts on the part of Mead Johnson
& Company by specifying Mead’s Cereal and PABLUM — and also the new
Pablum-like oatmeal cereal known as PABENA.
*Pablum, the precooked form of Mead's Cereal, has practically the same composition: wheatmeal (farina),
oatmeal, cornmeal, wheat embryo, beef bone, brewers yeast, alfalfa leaf, sodium chloride, and reduced iron.
Mead Johnson & Co., Evansville 21, Indiana, U. S. A.
592
Minnesota Medici
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Many disability policies require that the insured be
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Write or Call
MASSACHUSETTS INDEMNITY INSURANCE COMPANY
Ralph H. Brastad, Agency Manager
1400 RAND TOWER GENEVA 8319
MINNEAPOLIS 2, MINNESOTA
594
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 June, 1947 No. 6
Contents
Community- Wide Chest X-Ray Surveys and the
General Practitioner.
Herman E. Hilleboe, M.D., Washington, D. C 625
The Meeker County Tuberculosis Control Project.
Karl A. Danielson, M.D. , Litchfield, Minnesota. . 635
Toxoplasmosis.
Paul Kabler, M.D. , M.P.H., and Marion Cooney,
B.A., Minneapolis, Minnesota 637
Trichinosis in Minnesota.
C. B. Nelson, M.D., M.P.H., Minneapolis, Minne-
sota ' 640
Deafness, A Therapeutic Problem.
A. C. Hilding, M.D., Duluth, Minnesota 642
Clinical-Pathological Conference :
Influenzal Meningitis.
5. N. Litman, M.D., R. P. Buckley, M.D., and
A. H. Wells., M.D., Duluth, Minnesota 647
Case Report:
Chronic Ulcers of the Leg Associated with Con-
genital Hemolytic Jaundice.
H. O. Skinner, M.D., Saint Paul, Minnesota... 651
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. ( Continued from May
issue.)
Nora H. Guthrey, Rochester, Minnesota 652
President’s Letter:
The Annual Meeting 660
Editorial :
State Meeting 661
Minnesota Medical Service, Inc 661
The Bell Lectureship and the Minneapolis
X-Ray Survey 661
Research Professorship in Rheumatic Fever 662
Medical Ethics in Veterans Program 663
Medical Economics :
Council Approves Additional Orthopedic Clinics. . 664
County Society Officers Plan National Conference. 664
Personal Debts Peril Patients’ Budgets 665
$3,000,000 Mayo Memorial Virtually Assured. . . . 665
Minnesota State Board of Medical Examiners. . . . 666
Minnesota State Medical Association — Program
Ninety-Fourth Annual Session 667
Reports and Announcements 676
Woman’s Auxiliary 679
In Memoriam 680
Of General Interest 682
Book Reviews 694
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918.
June, 1947
595
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction 6f its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul A. H. Wells, Duluth
Philip F. Donohue, Saint Paul O. W. Rowe, Duluth
H. W. Meyerding, Rochester T. A. Peppard, Minneapolis
H. A. Roust, Montevideo Henry L. Ulrich, Minneapolis
B. O. Mork, Jr., Worthington C. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — $3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions — >
The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
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Located on beautiful Lake St. Croix, eighteen miles from the Twin Cities, it has the advantages of both
City and Country. Every facility for treatment provided, including recreational activities and occupational
therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
NEUROPSYCHIATRISTS
PRESCOTT OFFICE Hewitt B. Hannah, M.D. SUPERINTENDENT
Prescott, Wis. Toel C. Hultkrans, M.D. Dorothy M. Most, R.N.
Howard J. Laney, M.D. Howard J. Laney, M.D. Prescott, Wisconsin
Tel. 39 and Res. 76 511 Medical Arts Building Tel. 69
Minneapolis, Minnesota
Tel. MAin 1357
596
Minnesota Medicine
ty&tc’ze fyJelao*rve 7)cuf
at the Dorseif i/Jootk
8 > ?
.Dorsey
AT THE
Minnesota State Medical Association
Annual Meeting
June 30— July 1-2, Duluth
THE DORSEY WATCHWORD
COOPERATION
THE SMITH-DORSEY COMPANY
Lincoln, Nebraska
BRANCHES AT DALLAS AND LOS ANGELES
June, 1947
597
The UPG 20
PROFESSIONAL MEN'S GROUP PROGRAM
Available to All Eligible Members of
MINNESOTA MEDICAL PROFESSION
MINNESOTA LEGAL PROFESSION
MINNESOTA DENTAL PROFESSION
3j$sdimsi,
ftonoPitA
Omaba\
N on-Cancellable and Guaranteed
Renewable Features
• Pays benefits for both sickness and accidents.
• Carries full waiver of premium for total permanent disability.
• Policy pays disability benefits regardless of whether disability is immediate.
• Policy does not automatically terminate at any age.
• Monthly benefits, $400.00; double indemnity, $800.00.
• Additional benefits, $200.00 per month while in hospital.
• Additional benefits, $200.00 per month for nurses care at home.
• Accident death benefits, $10,000.00; double indemnity, $20,000.00.
• Mutual Benefit and United Benefit licensed in everv state in the U.S.A.
A Special
Disability
Program
for Your
Professional
Group
Address:
Professional
Group Dept.;
420 Plymouth Bldg.
Minneapolis
Minn.
Notice: This Special Policy available only through Professional Group Department Repre-
sentatives. Authorized registrars will carry a letter of identification signed by State Manager,
Professional Group Dept.
598
Minnesota Medicine
Special TIoHol Id TUsunhs/u l
This Disability UPG20 Program shown on the opposite page, extended to the Minnesota
State Professional Groups is a program that provides protection which gives Lifetime Bene-
fits and is not subject to cancellation on account of age leaving you without protection
when your loss of time is most valuable. It pays benefits for one day or more and covers
permanent total disability. This UPG20 Program pays for every injury or accident, even
Commercial Air Line travel is fully covered. It covers all sickness and every disease except
insanity and venereal diseases. The maximum benefits are $600.00 monthly and its minimum
benefits are $200.00 monthly for any illness. Accident benefits pay double indemnity for
travel accidents on a common carrier, excepting air travel, which pays only the regular
indemnity benefits.
To broaden the benefits while this UPG20 Program is in operation, the following limi-
tations, common to most policies, have been omitted and are not a part of these policies.
(1) The Company’s right to cancel the policy at any time — (Standard Provision No. 16).
(2) The Company’s right to terminate the policy at a certain age — (Standard Provision No.
20).
(3) The Company’s right to refuse renewal of policy to any individual practicing member of
your group is forfeited except for non-payment of premium on or before due date.
(4) The Company’s power to impose a Rider, eliminating the benefit for something that may
happen or develop to render you an undesirable, or un-insurable risk, is canceled thru the
elimination of each of the above.
The Minnesota enrollment is proceeding most satisfactorily, but it is the desire of the
Companies, not only to conduct the enrollment in the manner found to be most successful
for completing the group, but with full consideration for the policy and practice of the Min-
nesota Professional Associations mentioned.
Most Professional Groups, Associations, or Societies find it inexpedient to make specific
endorsement of any company or plan to its members. It is the practice of the Mutual Bene-
fit Health and Accident Association and the United Benefit Life Insurance Company both
of Omaha, to submit their Disability Plan to the individual members of the group for their
personal consideration. This has proven to be the most successful way to complete the
enrollment of members of these groups since it brings about a decidedly better understanding
of the plan to the members and, thereby, increases the ultimate total enrollment.
Therefore, should any Authorized Registrar, or Mutual Benefit Salesman represent that
he is from either of the designated Associations, or that this plan has been endorsed by
either Association, will you kindly report same together with the name of the representative
to State Manager, Professional Group Department, 420 Plymouth Bldg., Minneapolis, Minn.
—Phone AT. 2579.
June, 1947
599
^■bohydiau- Syrup fur Supplement* *•*
b°R INFANT FEHDInG
Directed by Phy>ic'an
CONTAINING
J|Umin b comp1"
; : r :
k,i,„ - A 1
~ Mai'-tose - DEXTKO1
u from pure starch providing
—fcj?? 4bsorption, uniform comp®81
~-a h..T r 0 m irritating impurities
■'emetic seal of high vacuum.
Vei'vul »■ *vid ount*-
’ 20 calories per fluid puff®
Rumbus, Indiana, u.s a
§ n t p i n T
FLEXIBILITY
Pediatricians recognize the advantages of flexibility
in prescribing infant feeding formulas, as the pro-
tein, fat, and carbohydrate requirement may vary
with the individual baby. Formula preparation with
CARTOSE* is simple, rapid, and accurate.
CARTOSE supplies carefully balanced propor-
tions of nonfermentable dextrins in association with
maltose and dextrose. Due to the time required for
hydrolysis of the higher sugars, absorption is spaced.
This lessens the likelihood of distress attributable to
the pretence of excessive amounts of readily fer-
mentable sugars In the Intestinal tract at one time.
When supplementation with vitamins of the 1 com-
plex is indicated, KINNEY S YEAST
EXTRACT*!, suggested tin. incorpora-
tion in the daily feeding. The full daily dose is simply
added to the twenty-four-hour formula.
KINNEY’S YEAST EXTRACT!, prepared from a specially
cultured yeast and contain, all the known factors of
the B complex in natural, palatable form.
CARTOSE and KINNEY’S YEAST EXTRACT are offered
for use under the guidance of physicians. They are
available only at drugstores.
♦The word. CARTOSE and KINNEY'S YEAST EXTRACT ora
registered trademarks of H. W. Kinney & Sons, Inc.
H. W. KINNEY & SONS, INC.
— ( )
trademark'
COLUMBUS, INDIANA
600
Minnesota Medicine
LISTEN to the latest devel-
opments in research and
clinical medicine discussed
by eminent members of the
medical profession in the
Lederle radio series, "The
Doctors Talk It Over,"
broadcast coasf-to-coast
every Monday evening
over the American Broad-
casting Company network
and affiliated stations.
Liver Protein Hydrolysate supplying
AMINO ACIDS for ORAL THERAPY
The amino acids in LEDINAC Liver Protein Hydrolysate Lederle
provide a rapidly absorbable supplement which tends to combat
“protein starvation” in patients and secure normal nitrogen
balance in the tissues. Amino acids furnish one of the best means
of providing convalescent patients with nitrogenous foods.
LEDINAC Liver Protein Hydrolysate Lederle provides in a
palatable, chocolate-flavored form, a rapidly absorbable dietary
supplement that does not tax unduly the digestive powers of
the patient.
LEDINAC Liver Protein Hydrolysate Lederle is a source not only
of modified protein and amino acids, but also of vitamins, minerals,
and carbohydrates. It is derived from mammalian liver — the
richest nutritional storehouse in the body.
*Reg. U. S. Pat. Off.
FORMULA
Liver Protein Digest 54.0%
Maltose 38.5%
Flavoring Agents (including
chocolate and saccharin) . . 7.5%
Supplying: Carbohydrate 32.5%
Fat 3.5%
Protein 50.0%
Free Amino Nitrogen 1.0%
including the amino acids, Arginine,
Histidine, Lysine, Tryptophane, Phenylala-
nine, Methionine, Threonine, Leucine, Iso-
leucine, Valine, and Cystine.
Each 30 Gm. contains:
Thiamine Hydrochloride ( Bi ) 1.00 mg.
Riboflavin (Eb) 2.00 mg.
Niacinamide 6.60 mg.
Pantothenic Acid 2.30 mg.
Pyridoxine Hydro-
chloride (B6) . . . 0.24 mg.
Biotin 2.70 gamma
Inositol 23.00 mg.
Choline 120.00 mg.
Calcium 106.00 mg.
Phosphorus 297.00 mg.
I ron 4.80 mg.
Calories 103.8
Packaged in one-half pound, jars
LEDERLE LABORATORIES DIVISION
AMERICAN CYANAMID COMPANY • 30 ROCKEFELLER PLAZA, NEW YORK 20, N.Y.
VISIT OUR BOOTH AT ANNUAL MEETING
June, 1947
601
Brighter horizons for the petit mat patient
BIBLIOGRAPHY
1. Richardi, R. K., and Everett, G. M.
(1944), Analgesic and Anticonvulsant
Properties of 3,5,5-Trimethyloxaroli-
dine-2,4 - dione (Tridione), Federation
Proc., 3:39, March.
2. Goodman, L, and Manuel, C. (1945),
The Anticonvulsant Properties of Dim-
ethyl-N-methyl Barbituric Acid and 3,5,
5-Trimethyloxazolidine-2,4-dione (Tri*
dione), Federation Proc., 4:119, March.
3. Goodman, l. S., Toman, J. E. P. and
Swinyard, E. A. (1946), The Anticonvul-
sant Properties of Tridione, Am. J. Med.
1:213, September.
4. Richards, R. K., and Perlstein, M. A.
(1946), Tridione, a New Drug for the
Treatment of Convulsive and Related
Disorders, Arch. Neurol, and Psychiat.,
55:164, February.
5. Lennox, W. G. (1945), The Treatment
of Epilepsy, Med. Clin. North America,
29:1114, September.
6. Thorne, F. C. (1945), The Anticonvul-
sant Action of Tridione: Preliminary Re-
port, Psychiatric Quart., 19:686, Oct.
7. Lennox, W. G. (1945), Petit Mai Epi-
lepsies: Their Treatment with Tridione, J.
Amer. Med. Assn., 129:1069, Dec. 15.
8. Lennox, W. G. (1946), Newer Agents
in the Treatment of Epilepsy, J. Pediat.
29:356, September.
9. DeJong, R. N. (1946), Effect of Tri-
dione in Control of Psychomotor Attacks,
J. Amer. Med. Assn.. 130:565, March 2.
10. Perlstein, M. A., and Andelman, M.
8. (1946), Tridione: Its Use in Convulsive
and Related Disorders, J. Pediat. 29:20,
July.
11. Lennox, W. G. (1946), Two New
Drugs in Epilepsy Therapy, Am. J. Psy-
chiatry, 103.159, September.
12. DeJong, R. N. (1946), Further Ob-
servations on the Use of Tridione in the
Control of Psychomotor Attacks, Am. J.
Psychiatry, 103:162, September.
One important fact stands out in the rapidly expanding clinical record
of Tridione: Thousands of children formerly handicapped in
school and play by petit mal, myoclonic or akinetic seizures are finding
substantial relief through treatment with Tridione. In one
test, Tridione was given to 150 patients who had not received
material benefit from other drugs.11 With Tridione, 33%
became seizure free; 30% had a reduction of more than three-
fourths of their seizures; 21% were moderately improved;
13% were unchanged, and only 3% became worse.
In some cases, the seizures, once stopped, did not return
when medication was discontinued. Tridione also has
been shown to be beneficial in the control of certain psycho-
motor epileptic seizures when used in conjunction with other
antiepileptic drugs.12 Wish more information? Just drop
a line to Abbott Laboratories, North Chicago, 111.
Tridione
REG. U. S. PAT. OFF.
(Trimethadione, Abbott)
602
Minnesota Medicine
■HBl
The "sense of well-being" so frequently reported by patients following "Premarin"
therapy often means the difference between an active, enjoyable middle age
and a sedentary one. Not only prompt relief from distressing menopausal
symptoms but also a brighter mental outlook which may be translated into a
desire "to be doing things". ..such are the results which may usually be expected
following "Premarin" administration . . . therapy with a "plus."
"Premarin" provides effective estrogenic therapy through the oral route with
comparative freedom from untoward side effects.
"Premarin" is available as follows:
Tablets of 2.5 mg bottles of 20 and 100.
Tablets of 1.25 mg bottles of 20, 100 and 1000.
Tablets of 0.625 mg bottles of 100 and 1000.
liquid, containing 0.625 mg. in each 4 cc. (1 teaspoonful) bottles of 120 cc.
While sodium estrone sulfate is the principal estrogen in "Premarin," other equine
estrogens . . . estradiol, equilin, equilenin, hippulin . . . are also present as water-
soluble sulfates. The water solubility of conjugated estrogens (equine) assures rapid
absorption from the gastrointestinal tract.
CONJUGATED ESTROGENS
lequine)
AY ERST, McKENNA & HARRISON Limited
22 EAST 40th STREET, NEW YORK 16, N. Y.
June, 1947
603
". . . the physiological state of the patient affects the mortality
and morbidity of surgical practice as much or more than the
correctness or skillfulness of that practice.’*1 For that reason
the fork must share with the scalpel the responsibility of favor-
able prognosis. The food the patient eats contributes greatly
to the outcome of an operation. Faulty diet and a resultant
avitaminosis make surgery more hazardous and impede re-
covery. For pre- or postoperative supplementation and therapy,
Upjohn vitamins afford a full range of liigb-potency oral and
1. Surg., Gynec. and Obst
74:390 (Feb. 16) 1942 parenteral tormulas.
Upjohn
FINE PHARMACEUTICALS SINCE 1886
UPJOHN
VITAMINS
604
Minnesota Medlcine
Yes , experience
is the best teacher
in smoking too!
DURING the wartime cigarette
shortage, people smoked many
different brands — more than they
would normally try in years. That’s
how so many learned the differ-
ences in cigarette quality. And
from that experience millions more
smokers came to prefer Camels.
Today more people are smoking
Camels than ever before.
But, no matter how great the de-
mand, we don’t tamper with Camel
quality. Only choice tobaccos,
properly aged, and blended in the
time-honored Camel way, are used
in Camels.
According to a recent Nationwide survey :
More Doctors
smoke Camels
t/ian any ot/ier cigarette
B. J. Reynolds Tobacco Co. .Winston-Salem. N. C.
June, 1947
m
FOR AMBULATORY PATIENTS
with
INJURIES OR DISEASES
of the
LUMBAR SPINE
CAMP lumbosacral sup-
ports are widely recom-
mended by orthopedic
surgeons and physicians.
An important factor in the
good results reported from
their use is that they extend
downward over the sacro-
iliac and gluteal regions.
The Camp adjustment pro-
vides exceptional restraint
of movement.
In more severe lesions, alu-
minum uprights or the
Camp spinal brace are
easily incorporated.
Camp lumbosacral sup-
ports.are moderately
priced.
For patient of thin
type-of-build.
For patient of intermediate
or stocky type-of-build.
CAMP
#%**•■
ANATOMICAL SUPPORTS
S. H. CAMP & COMPANY • Jackson, Mich. • World’s largest Manufacturers of Scientific Supports
Offices in NEW YORK • CHICAGO • WINDSOR. ONTARIO • LONDON AND
606 Minnesota Medicine
radiographic vs. surgical
Exploration
When confusing abdominal symptoms and signs create a
diagnostic tangle or do not yield properly to medical
management, radio graphic exploration of the gallbladder
with PRIODAX will often reduce the need for surgical
exploration. PRIODAX cholecystography almost never
fails to reveal disease of the gallbladder if it exists,
P or to produce unequivocally clear silhouettes if the
■ organ is normal.
PRIODAX
(brand of iodoalphionic acid)
PRIODAX is rarely eliminated prematurely from the
gastrointestinal tract. The opacities produced by it are
homogeneous, sharp and unstratified. Moreover, clear
visualization will not be obscured by contrast substance
in the colon when PRIODAX is used. PRIODAX, there-
fore, provides maximum dependable concentration of the
most desirable type for reliable interpretation.
PRIODAX Tablets, beta-(4-hydroxy-t,5-diiodophenyl) -alpha-phenyl
propionic acid, available as six 0.5 Cm. tablets in individual cellophane
envelopes. Boxes of 1, 5, 25 and 100 envelopes.
Trade-Mark PRIODAX-Reg. U. S. Pat. Off.
CORPORATION • BLOOMFIELD, N. J.
In Canadaf'Schering Corporation Limited, Montreal
Mil DM, J
Jr
^ ^
•ii-f a imm
couoof of iiiiifiiii; i| HI
JOfil, jf J 7 ! i) f
i> ii i) u i d oor of ouonoijfo
i iifi/fo mmol
uoibjdo oooij 'njjijoo ro of ijmy
. JJIPPOOOOT
r* .ri
rl nd it is our own constant determination to keep faith with the
same high principles of the Oath of Hippocrates by which the
profession is bound. Our malpractice counsel > service and procedure
are confidential — and our coverage is complete.
Professional Protection exclusively. . . since 1899
MINNEAPOLIS Office: Robert L. McFerran and Stanley J. Werner, Representatives
816 Medical Arts Building, Telephone Atlantic 5724
608
Minnesota Medicine
1— Precoitus. Effective
occlusion of cervical
os by ••RAMSES"
Vaginal Jelly.
2 —One hour postcoi-
tus. Barrier action
maintained by film of
jelly.
3 — Four hours post-
coitus. Uterine os re-
mains occluded.
4 —Ten hours postcoi-
tus. Occlusion still
manifest — barring the
passage of sperm.
The direct-color photographs shown above establish the prolonged
barrier action of "RAMSES"* Vaginal Jelly. For photographic pur-
poses, the jelly, which has a transparent clarity, was stained with a
nonspermatocidal concentration of methylene blue.
In addition to the barrier action provided by its exclusive gum base
"RAMSES" Vaginal Jelly immobilizes sperm rapidly.
Tests by an accredited independent laboratory, supported by clinical
work of an outstanding research organization, confirm the lack of
irritation and toxicity under continuous use. For dependability in
spermatocidal jelly specify
uncmni jellv
TRADEMARK REO. U S. RAT. Off.
Active ingredients: Dodecaethyleneglycol
monolaurate 5%; Boric Acid 1%; Alcohol 5%.
gynecological division Julius scmihd, me.
gaa&p 423 We8‘ 5Sth St" New York 19' N* Y-
LJL
?? •cj'S
.
i
"4
•The word "RAMSES" is a registered trademark of Julius Schmid, Inc.
June, 1947
609
Presenting the
netrer and better
technics frown
i every wnedical and
ryicat center .
SCIENTIFICALLY ACCURATE.
CLINICALLY AUTHORITATIVE.
ACCEPTED THE WORLD OVER.
Each issue of General Practice
Clinics presents a concise and
authoritative description of the
important tried, proved and
accepted; new and better
clinical methods in:
MEDICINE
ALLERGY
GERIATRICS
PSYCHIATRY
NEUROLOGY
DERMATOLOGY AND
SYPHILOLOGY
PEDIATRICS
OBSTETRICS
GYNECOLOGY
SURGERY
ORTHOPEDICS _
UROLOGY
OPHTHALMOLOGY
OTORHINOLARYNG-
OLOGY
MEDICAL
JURISPRUDENCE
Every General Physician and Spe-
cialist will find on these pages the
very latest and best clinical methods
now being successfully used at every
medical and surgical center. Spe-
cific detailed dosages, exact infor-
mation which you may safely and
successfully employ in your own
practice — all of these data are com-
piled under the personal direction
of eminent authorities — whose abili-
ties and reputations are well known.
WASHINGTON INSTITUTE OF MEDICINE, 1720 M Street, N. W., Washington 6, D. C.
Please enter my subscription to the GENERAL PRACTICE CLINICS.
□ I YEAR $5.00 □ 3 YEARS $12.00
NAME.
STREET
CITY ZONE STATE
610
Minnesota Medicine
Parke, Davis & Company believes that people
need to be constantly reminded of the value
of prompt and proper medical care. Educa-
tional advertisements — like the latest one,
reproduced below — appear regularly, in
color, in LIFE and other national magazines.
Audience: more than 22 million people!
Reminding people to
"See Your Doctor"
stomach ulcers
>' ORINC recent . *
",cidc"cc ,nc"asc
n™g'‘ noc, raus ,
1 8™*° «»</ t ***
'•“"'y. <loci0,s lod .
trea,m“t « *dr command °f eff«,ivc metli.
medi(
’C!aM Pre"'ib*d * PV,c,ont
parke, davjs
June, 1947
611
HIGHLY NUTRITIOUS . . .
YET PALATABLE AND SATISFYING
Dietary supplements, in order to accomplish
their desired nutritional influence, must be tasty
and appealing to the palate. Otherwise, refusal
by the patient will defeat their very purpose and
will limit nutrient intake.
The food drink made by mixing Ovaltine
with milk ranks high in nutrient content and
palatability. This dietary supplement provides
generous amounts of virtually all essential nu-
trients including ascorbic acid, in readily digest-
ible, thoroughly bland form. Its delicious taste
is appealing to all patients, young and old, who
drink it with relish in the recommended quan-
tities— two to three glassfuls daily. This amount,
as can be seen from the table of composition,
readily complements to adequacy even a poor
daily dietary.
This nutritional supplement finds wide appli-
cation whenever nutrient intake must be aug-
mented, as in under-par nutrition, following
recovery from infectious disease, and during
chronic debilitating illnesses.
THE WANDER COMPANY, 360 N. MICHIGAN AVE., CHICAGO 1, ILL.
Three servings daily of Ovaltine, each made of
Vi oz. of Ovaltine and 8 oz. of whole milk,* provide:
CALORIES
669
VITAMIN A
3000 I.U.
PROTEIN
32.1 Gm.
VITAMIN Bi
1.16 mg.
FAT
31.5 Gm
RIBOFLAVIN
2.00 mg.
CARBOHYDRATE
NIACIN
6.8 mg.
CALCIUM
1.12 Gm.
VITAMIN C
30.0 mg.
PHOSPHORUS
0.94 Gm.
VITAMIN D
417 I.U.
IRON
12.0 mg.
COPPER
0.50 mg.
*Based on average reported values for milk.
Minnesota Medicinb
within the year: 50,000 new diabetics
CHANCES PER THOUSAND OF BECOMING DIABETIC.WITHIN THE YEAR OF AGE. Adapted from Statistical Bull.2
Of our present population, about 4,000,000 will
become diabetic sometime in their lives. More
than 4% of females and 2% of males under 50
will acquire the disease. With an increase of
50,000 a year, their number will grow in the
next few decades at a rate greater than that of
the total population. When our population
reaches its expected maximum in 1985, it will
be 22% larger than in 1940 — but by then the
diabetic population may increase by 74%!1,2
Control with but one injection a day of ‘Well-
come’ Globin Insulin with Zinc has been made
possible for many diabetic patients who form-
erly required multiple injections of regular
insulin alone or in conjunction with protamine
zinc insulin. Favorable results with Globin
Insulin have been achieved by virtue of the
following advantages:
1. The action of Globin Insulin is intermediate
between that of regular and protamine zinc insulin.
2. Its onset of action is moderately rapid; no ac-
companying injection of regular insulin is ordinarily
required to take care of breakfast carbohydrate.
3. Maximum activity of Globin Insulin occurs dur-
ing the day when the patient needs insulin most to
balance carbohydrate intake. This contributes to a
relatively uniform blood sugar level.
4. The action of Globin Insulin wanes during the
night. Since the patient is not eating and has less
need for insulin at this time, the danger of hypo-
glycemic night reactions is remote. However, ade-
quate action persists up to the 24th hour so that
a normal fasting blood sugar level is ordinarily
obtained the following morning.
5. The globin constituent does not appear to be
allergenic. It is thus comparable to regular insulin
in its freedom from allergic reactions.
6. Globin Insulin is a clear solution which requires
no mixing or shaking before use. The danger of
variable dosage is thereby minimized.
'We/lcome' Globin Insulin with Zinc is available in 40 and 80
units per cc., in vials of 10 <c. Accepted by the Council on
Pharmacy and Chemistry, American Medical Association.
Developed in The Wellcome Research Laboratories, Tuckahoe,
New York. U.S. Patent No. 2,161,198.
I. Spiegelman, M., and Marks, H. H.: Am. J. Pub. Health 36: 26
(Jan.) 1946.2. Statistical Bull.,Met. Life Ins. Co. 27:6 (Feb.) 1946.
'Wellcome' Trademark Registered
BURROUGHS WELLCOME & CO. (U.S.A.) INC., 9 & II EAST 4IST STREET, NEW YORK 17, N.Y.
June, 1947
613
OBSTETRICAL
SUPERVISORS SAY:
^•oMeort" *rme,hods°f
o4e -**#» c°„
rUSTISUIRLBS
A new technique for poslparlifm breast care.
PLASTISH I ELJ^S are transparent
shields, formed to receive the breast. They have an
extruded central portion to Iposcly receive the nipple.
Made from a plastic which does not/react with skin or milk, they
are moulded and /hand-finished to assure perfect
smoothness and comfort./A flange around the circumference
with a circular groove in its inner surface forms
a suction to hold the shield firmly to
the breast. Used with either a hospital
binder or brassiere. The method is adaptable
as a simple standard routine
technique, usable in both hospital and home.
ADVANTAGES:
1. Prevents irritation of nipples by
clothing.
2. Protects nipples and breasts from
infection.
3. Reduces nursing discomfort.
4. Simplifies nipple care.
5. Eliminates use of ointments, gauze, etc.
6. Increases patient’s comfort.
7. Easily sterilized by patient, after each
nursing, thus saving nurse’s time.
8. Shortens latent period of nursing.
9. Minimizes milk seepage and soiling of
clothing.
1 0. Corrects certain cases of flat or par-
tially inverted nipples.
1 1 . Not affected by ordinary antiseptics.
Now being successfully used in many hospitals throughout
the Northwest for routine postpartum breast care.
For further information write
PLASTISHIELD, INC
-v Minneapolis, Minnesota
°U’
■ • • Po^°''ofv °
C<ovrfPe °* 'a5” "ExceMentreceP*‘on by both
\ rt patients and nurses...
'n happy to recommend con-
tinued use at our hospital.'1
614
Minnesota Medicine
Wow irritation varies
#=
from different cigarettes
Tests * made on rabbits’ eyes reveal the influence of hygroscopic agents
TYPE OF CIGARETTE
2
3
5
6
Edema 0.8
Edema 2.1
Edema 2.7
Edema 2.6
Edema 2.7
Edema 2.7
Cigarettes made by the
Philip Morris method
Cigarettes made with
no hygroscopic agent
Popular cigarette # 1
(ordinary method)
Popular cigarette #2
(ordinary method)
Popular cigarette #3
(ordinary method)
Popular cigarette #4
(ordinary method)
CONCLUSION:* Results show that regardless of blend of tobacco, flavoring
materials, or method of manufacture, the irritation produced by all ordinary
cigarettes is substantially the same, and measurably greater than that caused
by Philip Morris.
CLINICAL CONFIRMATION: ** When smokers changed to Philip
Morris, substantially every case of irritation of the nose and
throat due to smoking cleared completely or definitely improved.
•A?, y. State Journ. Med. 35 No. 11,590 **Loryngoscope 193 5, XLV, No. 2, 149-154
TO THE PHYSICIAN WHO SMOKES A PIPE: We suggest an unusually fine new blend— Country
DOCTOR Pipe Mixture. Made by the same process as used in the manufacture of Philip Morris Cigarettes.
June, 1947
615
QflDDOMfll
for Derma tophytosis
EFFECTIVE— Sopronol is fungistatic and fungicidal. A preparation of propio-
nate and propionic acid, it combats invading fungi powerfully, yet mildly.
Sopronol, the modern fatty acid treatment, meets requirements for the man-
agement of superficial fungous infections of the feet and hands.
POWER OF MILDNESS— Sopronol has the power of mildness — vir-
tually nonirritating and nonsensitizing. The active principle of Sopronol is
propionic acid — a component of human sweat, and a natural physiological
defense against invasive organisms.
CLINICAL USE— Sopronol gives excellent results in tinea pedis. It does
not cause "id” reactions (due to absorption of mycotic debris), which are
likely to occur through use of agents with more violent action.
Sopronol Solution and Ointment contain sodium propionate 16.4%, propionic acid
3.6%. Sopronol Powder contains calcium propionate 15%, zinc propionate 5%.
Qo/o/'o/7o/ /s scs/p/sa/ //? 3 -tf/ms —
4it-
A % \ $-& -■V ,
LIQUID
2 oz. bottle
Ideal for office
treatment
® Trade Mark Reg. U.S. Pat. Oft.
A NATURAL PHYSIOLOGICAL DEFENSE
AGAINST INVASIVE ORGANISMS
WYETH INCORPORATED • PHILADELPHIA 3,
PA.
616
Minnesota Medicine
Life expectancy
30 days?
Infant mortality during the first 30 days
of life is on the increase. While the total
infant mortality has been declining, the
proportion of those who died within
the first month has actually increased from
52.7% to 62.1%*. During this fatal first month
the infant should be given every possible
benefit. One step in the right direction
is good feeding. In this way the gastro-
intestinal hazards of excessive fermentation,
upset digestion and diarrhea may be minimized
'Dexin' has proved an excellent "first carbohydrate"
because of its high dextrin content. It (1) resists
fermentation by the usual intestinal organisms; (2) tends to hold
gas formation, distention and diarrhea to a minimum, and (3) promotes
the formation of soft, flocculeht, easily digested curds.
j
Simply prepared in hot or cold milk, 'Dexin' brand High Dextrin Carbo-
hydrate provides well-taken and well -retained nourishment. 'Dexin'
does make a difference.
*Vital Statistics — Special Reports: Vol. 25, No. 12, National Office of
Vital Statistics, Washington, D. C. (Oct. 15) 1946, p. 206.
k
HIGH DEXTRIN CARBOHYDRATE
BRAND
Composition — Dextrins 75% • Maltose 24% • Mineral Ash 0.25% • Moisture
0.75% • Available carbohydrate 99% • 115 calories per ounce • 6 level packed
tablespoonfuls equal 1 ounce • Containers of twelve ounces and three pounds •
Accepted by the Council on Foods and Nutrition, American Medical Association.
‘Dexin’ Keg. Trademark
Literature on request ; •
BURROUGHS WELLCOME & CO. (U.S.A.) INC., 9 & 11 East 41st St., New York 17, N.Y
June, 1947
617
A Complete Jlitte ol ^bnu^A. fen.
Medical and cMai^xital Need
In addition to the hospital and medical equipment, instruments and sup-
plies of all kinds, that we handle, we are also distributors for a complete
line of pharmaceuticals manufactured by the Ulmer Pharmacal Company.
This is an extremely high quality as well as economical line of Ethical
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PHARMACEUTICALS
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• and many SPECIALTY ITEMS
Every one of these Ulmer products is prepared under strict control by
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prescription. >
We also handle a complete line of wholesale drugs — chemicals, biolog-
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general pharmaceuticals and pharmaceutical specialties of all the leading
drug manufacturers. We can supply you with any item in the line of drugs
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Send us your Order for any Drug Items you need. Write us for informa-
tion about any of the many outstanding Ulmer Quality products which you
may wish to prescribe.
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
MINNEAPOLIS MINNESOTA
618
Minnesota Medicine
a modern
lumii
wulac
<k
infant food
Formulac Infant Food is a concentrated milk in liquid form, for-
tified with all vitamins known to be necessary to adequate infant
nutrition. No supplementary vitamin administration is required.
By incorporating the vitamins into the milk itself, the risk of
human error or oversight is reduced. Formulac contains sufficient
B complex, Vitamin C in stabilized form, Vitamin D (800 U.S.P.
units), copper, manganese and easily assimilated ferric lactate —
rendering it a flexible formula basis both for normal and difficult
feeding cases. The only carbohydrate in Formulac is the natural
lactose found in cow’s milk. No carbohydrate has been added.
Formulac, a product of National Dairy research, has been
tested clinically, and proved satisfactory. It is promoted to the
medical profession alone. Formulac is on sale at grocery and drug
stores nationally.
: , ■ : t, ... <:
Distributed by KRAFT FOODS COMPANY
NATIONAL DAIRY PRODUCTS COMPANY, INC.
NEW YORK, N.Y.
• For further information about
FORMULAC, and for professional
samples, mail a card to National
Dairy Products Company, Inc., 230
Park Avenue, New York 17, N. Y.
June, 1947
PYOKTANIN SURGICAL GUT
Plain and Jcrtnalijed
Manufactured Since 1899 by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia
• • •
Price fast
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE G NONBOILABLE
Sizes 000 — 00 — 0—1 — 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
• • •
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FOR SALE BY SURGICAL DEALERS AND DRUGGISTS
620
Minnesota Medicine
An Appeal
to You.. Doctor
SCHOOL OF
PSYCHIATRIC
nuRSinG
•
FALL CLASS
will start in
September
Candidates for the Sep-
tember class should make
reservations at once.
School and health record
must be reviewed and
correspondence complet-
ed prior to acceptance.
Leading physicians recognize that there must be close co-oper-
ation between the doctor, hospital, and school of nursing if the
current trained-nurse shortage is to be overcome.
♦ ♦ ♦
“Hospital administrators and doctors throughout the country are
seriously concerned over the dangerously inadequate nursing care
available. Results of a recent survey indicate that 55 to 60 per cent
of the required amount is obtainable. . . .
“ ‘. . . approved hospitals should provide training for such voca-
tional nurses by means of short courses.’
“The doctor is responsible for the care of the patient. In order
to meet this obligation, the medical staff together with the hospital
and nursing administrators, are urged to undertake the develop-
ment and execution of this program.”1
“It is time that some of the present-day advantages of a nursing
career be made known to young women.”2
♦ ♦ ♦
A Career in Nursing Offers:
. Training in a highly paid profession
. A secure position unaffected by economic depression
. Work with skilled professional men and women
. The best preparation for marriage
♦ ♦ ♦
ONE YEAR NURSING COURSE
Glenwood Hills Hospitals are currently offering to qualified applicants
a one year course in psychiatric nursing. All phases of the subject are
skillfully presented by a capable and experienced faculty. Tuition is
free. Regular classes begin in January, June, and September.
YOUR HELP is greatly needed in recruiting candidates for such train-
ing schools as this. As a leading citizen of your community you are in
position to guide and advise. A trained nurse is a benefit to both you
and your patient. We are prepared to refer the student nurse back to
you on completion of her training. For full information write Miss
Margaret Chase, R.N., B.S., Director, School of Nursing, Glenwood
Hills Hospitals.
enwood
i s os:
uas
3501 Golden Valley Road : Route Seven : Minneapolis, Minn
1. Irvin Abell, M.D., Chairman, Bd. of Regents, Am. Col. of Surgeons; Am. Jl. of
Nursing, March 1947,
2. A. E. Hedback, M.D., Editor, Modern Medicine; Jl. -Lancet, April 1947.
June, 1947
621
Demerol hydrochloride ranks between morphine and
codeine in analgesic power. Furthermore, it possesses
marked spasmolytic and mild sedative action. It causes
less nausea and vomiting and less urinary retention than
morphine, and no constipation. The danger of respiratory
depression is also greatly reduced with Demerol hydro-
chloride. Warning: May be habit forming. Ampuls of 2 cc.
(100 mg.) and tablets of 50 mg. Narcotic blank required.
Write for detailed literature
HVDR0CHL0RIDE
Brand of meperidine hydrochloride (isonipecaine)
CHEMICAL COMPANY , INC .
New York 13, N. Y. • Windsor, Ont.
DEMEROL, trodemork Reg U.S. Pat. Off. & Canada
622
Minnesota Medicine
. . the protein deficient individual is a
poor operative risk."
Lund and Levenson: J.A.M.A. 128:95, 1945
“When time is available to improve pro-
tein nutrition before surgery and when
this time is used efficiently for this pur-
pose, the reduction in postoperative shock
and other complications is impressive.”
Editorial :Surg„Gynec.& Obst. 83:259, 1946
", . . the patient maintained in positive
nitrogen balance recovers from major sur-
gery more rapidly than does the patient
who is not in nitrogen equilibrium.”
K.oop: Geriatrics 1:269, 1946
Parenamine
Parenteral Amino Acids
FOR PROTEIN DEFICIENCY
• To improve and protect the nutri-
tional status of the severely malnourished or critically ill
patient ... as fortification against the shock of major
surgery.
0lefut^€i/lve : To provide, in ample quantity, the
amino acids essential to tissue repair ... to hasten heal-
ine and shorten convalescence.
^ahenowUne a i 5 per cent sterile solution of
all the amino acids known to be essential for humans . . ,
derived by acid hydrolysis from casein and fortified with
^/-tryptophane.
whenever dietary measures are inadequate
for correction and maintenance of positive nitrogen
balance ... to replenish depleted body protein stores.
Particularly indicated in pre- and. postoperative manage-
ment, extensive burns, gastro-intestinal obstruction, etc,
in 100 cc. rubber-capped bottles.
DETROIT 31, MICHIGAN
NEW YORK KANSAS CITY SAN FRANCISCO ATLANTA WINDSOR, ONTARIO SYDNEY, AUSTRALIA AUCKLAND, NEW ZEALAND
Trade-Mark Parenamine Reg. U. S. Pat, QfT«
June, 1947
623
Tftod&Ut ELECTRO-CARDIOGRAPHY
Portable, rugged, electrically o per*
ated without batteries. Cardiotron is
available with or without stand.
The first successful
*D&iect- ^econdwy
Electrocardiographs,
With more than 1 200 now in use throughout the
world, the Cardiotron has established the principle
of instantaneous recording in general clinical elec-
tro-cardiography.
The Cardiotron is fast, accurate and sensitive. It
makes an immediate black and white cardiogram-
on permanent chart paper. It is free from skin re-
sistance eirors. It reveals more information than any
other electrocardiograph instrument.
IMPORTANT: Factory-supervised installation and service
are available in most parts of the world. Good deliveries
are scheduled. Cardiotron is sensibly priced.
Send for 12-page descriptive booklet
Cattdiebim
ELECTRO-PHYSICAL LABORATORIES, INC., 298 Dyckman St., New York 34, N. Y.
0Jfta*tu£zct*t%enA <x£
ELECTROCARDIOGRAPHS, ELECTROENCEPHALOGRAPHS, SHOCK
THERAPY APPARATUS, AND SPECIAL ELECTRONIC EQUIPMENT
Distributed by
C. F. ANDERSON CO., INC.
901 MARQUETTE AVENUE MINNEAPOLIS 2, MINN.
b24
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 June, 1947 No. 6
COMMUNITY-WIDE CHEST X-RAY SURVEYS AND THE GENERAL PRACTITIONER
By HERMAN E. HILLEBOE, M.D.,
Assistant Surgeon General, Associate Chief. Bureau of State Services,
United States Public Health Service
Washington, D. C.
TF tuberculosis is to be effectively controlled in
the United States and finally rendered pow-
erless to destroy thousands of American lives,
the practicing physician must increasingly lend
his knowledge and skills to the concentrated action
of organized agencies that now are engaged in
a total assault on this community and family dis-
ease. The health department, even when its per-
formance is activated by a systematized plan for
tuberculosis control, cannot succeed alone. The
vigilance, the insight, the proximity to the people,
which uniquely the private physician possesses,
must be drawn upon for the invigoration and en-
hancement of current resources.
Any carefully planned program of control
recognizes and uses the important talents and
the strategic community position of the general
practitioner. Indeed, it must be said that the
physician in private practice is the principal force
in the control of tuberculosis ; and, certainly, in
case finding, as exemplified by city-wide x-ray
surveys, there can be no question of the individual
practitioner’s significant contribution. Such sur-
veys bring into prominence the true role of each
participating group — the health department, the
tuberculosis association, and the local medical
society. The members of this last group largely
determine the success or failure of any survey
anywhere in the country. Leadership in such a
community enterprise must come from them. The
driving force behind all action to find and treat
and cure tuberculous persons must arise from a
Ihirteenth Annual John W. Bell Tuberculosis Lecture
sponsored by the Hennepin County Tuberculosis Association
and delivered before the Hennepin County Medical Society,
April 28, 1947.
June, 1947
unanimity of professional purpose and must be
implemented by the experience and brains of the
local medical society members.
In a few communities, there has been expressed
occasionally a certain apprehension concerning
the effect of community-wide mass radiography
projects on private practice. Experience, how-
ever, has demonstrated that newly discovered
tuberculous patients and their families go to their
family physicians for supervision, advice, and
care. Mass x-ray surveys disclose a surprising
number of early cases that, though asymptomatic,
require long-term follow-up and guidance.
Increased knowledge of the epidemiology of
tuberculosis impels us to direct our attention not
only to the individual tuberculous person, but to
the community as a whole. Unless surveys are
done, relatively few tuberculous persons in any
community are discovered before symptoms de-
velop, and fewer still come under the care of
physicians experienced in diseases of the chest.
One cannot tell how many other infectious per-
sons are never seen by physicians. During life-
times they are spreaders of disease. It must be
emphasized that the community, in which hidden
cases of tuberculosis are positive disease entities,
is of greater moment than is the person who
spontaneously comes under care. There can be
no control worthy of our respect if, in any given
city, over half of the cases, especially early ones,
are hidden from our view.
Not only must such a program to find hidden
infectious cases be extensive, but it also must be
intensive in action and limited in time. Indeed,
625
CHEST X-RAY SURVEYS— HILLEBOE
one of the most interesting aspects of mass radi-
ography programs is the time element.
It has been emphasized in recent years that the
most effective method of controlling tuberculosis
is by means of chest x-ray examinations of the
adult population in a definite period of time. In
an attempt to achieve this objective, the U. S.
Public Health Service is assisting state and local
health departments with equipment, personnel,
and consultation. Indeed, through demonstration
of the effectiveness of community-wide mass
x-ray surveys, the people of the nation now real-
ize more fully the seriousness of the tuberculosis
problem in their communities and are initiating
action to stamp out the disease.
The action prompted by this new technique has
often been interrupted by confusion of public
health principles, a condition occasioned bv vary-
ing approaches to tuberculosis control.
One group believes that the single technique
of examining contacts of known tuberculous per-
sons will discover all the new cases in the com-
munity. Another group advocates an annual tu-
berculin test of every person as the sole means
of discovering all people with tuberculosis. A
third group, mostly epidemiologists, emphasizes
the damage done by people with hidden tubercu-
losis and by their many unknown contacts, and
urges a total assault on the disease by means of
( 1 ) community-wide x-ray surveys done within
a deliberately limited period of time; (2) the
concurrent establishment of adequate follow-up
facilities and the examination of contacts of pre-
viously known and newly discovered tuberculous
persons, and (3) tuberculin testing of samples
of the population at stated intervals.
Family studies and careful follow-up work in
some of the best health departments in the coun-
try have shown that examination of contacts dis-
covers as little as 25 per cent of new cases re-
ported each year. In other words, only one out
of four new cases may be found by examining con-
tacts of previously known patients. Three out of
four are new cases from the apparently healthy
population, about whom there has been no pre-
vious record. Moreover, the principle of exam-
ining the adult population in a limited time, which
is so important in the control of tuberculosis, can-
not be effectively applied in a program which ex-
amines the contacts of known tuberculous per-
sons only. Too large a portion of the population is
not reached at all. Unless contact examination
is reinforced by other case-finding services, in-
tense and continuous exposure of the public to
hidden cases will occur. In addition, this method,
if used alone, is prodigal of time, personnel, and
money, and can at best be only partially effective.
Annual tuberculin testing of the entire popu-
lation of the United States, accompanied by x-ray
examination of reactors, has been shown to be
impracticable. Particularly in large cities the ma-
jor portion of the adults are reactors to tuber-
culin, and little is gained by tuberculin testing
before x-ray examination. Tuberculin testing of
sample groups of the community at intervals is
useful in determining changes in the infection
rate from year to year. After the spreaders of
the disease have been identified, treated, and iso-
lated, and contacts supervised, it might be de-
sirable to test those whole communities where
the infection rate is low. The tuberculin test,
moreover, is a most efficient tool in the differ-
ential diagnosis of tuberculosis after the screen-
ing x-ray examination.
With full use of resources heretofore unreal-
ized and with a resolute determination to wipe
out tuberculosis as a social and individual prob-
lem, the large and small communities of the en-
tire United States could be covered by mass
radiography teams in less than five years’ time.
These modern methods, combined with efficient
clinical and laboratory procedures for exact diag-
nosis, will give communities a precise knowledge
of the local tuberculosis problem and will form
the basis for realistic plans to remove the danger
Of tuberculous infection and disease. Adequately
aided by money, trained personnel, and medical
facilities, every aroused community can bring
about the defeat of tuberculosis among its citi-
zens.
Tuberculosis presents at once a challenge and
an opportunity to the general practitioner. Thou-
sands of persons who have tuberculosis go to
private physicians for other illnesses, and no of-
ficial agency ever sees them. Although the phy-
sician deals directly with the source material of
tuberculosis, he often does not recognize the early
stages of the disease because he does not con-
stantly search for tuberculosis with the tools at
his command.
Too often it is assumed that the control of
tuberculosis is solely the health department’s do-
main of action. This is not true, nor can it ever
be true, so long as men practice the ancient art
626
Minnesota Medicine
CHEST X-RAY SURVEYS— HILLEBOE
of medicine. The family doctor in the city, the
country doctor going about from farm to farm,
the village doctor in his office over the drug store
know the people, have their trust, and guide their
physical destinies. The educational pamphlets
of a hundred organizations cannot have the en-
during effect nor the permeating persuasiveness
of the doctor’s personal advice. Tuberculosis is
so deeply a personal disease that news of its
tragic onset or advance can be more calmly ac-
cepted when its source is the family doctor and
not a stranger from a distant agency.
Participation by the private physician in the
control of tuberculosis need be no trouble in terms
of time or technique. There are many ways in
which the private physician can contribute his tal-
ents as a professional man and his influence as a
community leader in any integrated program of
control. The use of the intracutaneous tubercu-
lin test of chest x-ray film on every new patient
who has not been recently examined for tuber-
culosis should be a fundamental routine ; this is
a continuing and essential part of the community-
wide plan. Reactors to tuberculin should have
chest x-ray films made and interpreted by phy-
sicians with training in chest diseases. The
general practitioner can get expert help from
sanatorium physicians, chest specialists, and radi-
ologists in his area on all routine chest films.
Regularity of such conferences with more highly
specialized colleagues will provide many oppor-
tunities to develop skills in the interpretation of
films. Local health departments and tuberculosis
associations can make special consultation service
available for films of indigent patients.
It has been estimated that nearly 4 per cent
of all persons who visit physicians’ offices com-
plain of cough or expectoration. The alert physi-
cian will insist upon a sputum examination of
all such patients. Such practice will be rewarded
by the discovery of tubercle bacilli in three or
four out of every 100 specimens examined. The
family doctor will fairly often discover to his
astonishment that a patient with slowly resolving
pneumonia has an acid-fast reason for prolonged
convalescence.
In less populous areas the general practitioner
is required to carry on case finding and follow-up
almost singlehanded. He must give advice and
encouragement to his tuberculous patients and
their families. Indeed, it is at this time that the
practical philosophy of the private practitioner
June, 1947
is of great moment — at the height of that crisis
which often occurs upon the announcement of
tuberculosis. It is at this time that the general
practitioner can bring all his talents into play.
He is aware of the whole person. He knows the
patient’s background, habits, aspirations, and de-
sires. He does not think of his patient merely
as a pair of lungs ; he thinks of a man of spirit
as well as of body, who for a time has come,
through tuberculosis, upon disaster.
Through the utilization of modern methods of
case finding, the general physician can extend the
frontiers of medicine. Those physicians who
have not had actual experience with these new
techniques should be provided With training by
the county medical society, the medical school, the
health department and the tuberculosis associa-
tion. Postgraduate training and continuation
study should be provided, so that practitioners
who are removed from centers of medical knowl-
edge may take advantage of the latest informa-
tion. By means of such training, the case finding
of the general practitioner can be integrated with
the case finding of official and voluntary agen-
cies. The private physician has a vital part to
play in the campaign against tuberculosis ; the
success of the whole movement may well be de-
termined by the efforts and leadership of general
practitioners.
The private physician’s interest and enthusi-
asm will be increased and, as a result, his effec-
tiveness as a worker in the community-wide pro-
gram of tuberculosis control will grow if he takes
the time to learn about some of the latest ad-
vances in the field. A few of the more notewor-
thy developments merit your attention.
Within recent years some significant contri-
butions have been made to our understanding of
the tuberculin test and chest x-ray film. These
developments should enable us to understand bet-
ter how and why the tubercle bacillus invades
the human body. Studies by Furcolow and co-
workers have shown that there are great varia-
tions in human sensitivity to tuberculin and its
products, depending upon the dosage used and the
characteristics of the population groups tested.
It was demonstrated that effective contact with
the tubercle bacillus appears markedly to increase
sensitivity to tuberculin (very small doses give
typical reactions) ; on the other hand, almost all
persons tested will be reactors if sufficiently large
doses are given. (However, as the size of the dose
627
CHEST X-RAY SURVEYS— HILLEBOE
increases, the proportion of typical reactions in-
creases also, that is, reactions that often appear
early and disappear early and are soft and spongy
in appearance.) Consequently, proper interpreta-
tion of tuberculin tests requires a knowledge of
the size of the dose and the type of product used.
It appears that the tuberculin sensitivity of pa-
tients suffering from active tuberculosis is at such
a high level that the infection in these persons
may be detected by the use of an exceedingly
small dose of old tuberculin (OT) or of PPD
(purified protein derivative). The authors point
out that an intermediate dosage of approximately
1/10,000 mg. of the particular PPP used in their
studies was sufficient to pick up a high proportion
of infected persons. It is significant from the
point of view of usefulness of tuberculin testing
for determining infection rates and for differen-
tial diagnosis that both children and adults with
active tuberculosis almost always are reactors to
tuberculin, except in the terminal stages of the
disease.
Palmer and his co-workers have pointed out
that one of the significant problems in tuberculo-
sis involves the marked variations, in different
parts of the country, of the frequency of pulmon-
ary calcification observed in x-ray films of the
chest, especially among nonreactors to the tu-
berculin test. This is striking in view of the
fact that pulmonary calcification is generally in-
terpreted as evidence of healed tuberculosis.
There is incomplete epidemiological evidence that
tuberculosis is the only important cause of such
findings. Early in 1940 Palmer and his co-work-
ers were puzzled by the high correlation between
nonreactors to tuberculin and pulmonary calcifica-
tion. They began to search for other causes of
calcification ; coccidioidin reactions were studied
in relation to pulmonary calcification and failed
to show any correlation on a geographic basis.
It was natural to search for other fungi as one
of the offending factors.
About this time Christie and his group in Ten-
nessee were concerned with the same problem.
Christie had some children under his care who
were nonreactors to tuberculin and had pulmon-
ary calcifications. The patients reacted to histo-
plasmin, the testing material prepared from the
fungus Histoplasma capsulation. This relation-
ship suggested to Palmer the desirability of test-
ing a large number of student nurses throughout
the country, in order to determine the relationship
of histoplasmin sensitivity to tuberculin sensitivity
and pulmonary calcification. Preliminary reports
from Palmer and his group indicate that (1) a
mild, probably subclinical, infection with Histo-
plasma capsulatum (or immunologically related
organisms) is widely prevalent in certain states
and relatively infrequent in others, (2) that in
general those states in which the frequency of
reaction to histoplasmin is high are those in which
pulmonary calcification is also high, but reaction
to tuberculin is low, and (3) that a high propor-
tion of the pulmonary calcification observed in
x-ray films of nonreactors to tuberculin is not due
to tuberculosis.
A recent study, based on an analysis of skin
tests of siblings found among children who were
lifetime residents of the metropolitan area of
Kansas City, Missouri, is extremely interesting
because it demonstrates that there is a similarity
of histoplasmin reactions among children of the
same family. The percentage of reactors is high-
er among children whose older sibling does not
react.
The similarity grows less marked as the chil-
dren grow' older : the difference in the percentage
of reactors between children with an older sib-
ling who reacts and children with an older sib-
ling who does not, increases with increasing age
of the older child.
The closeness in age of siblings influences the
degree of similarity, as shown by the fact that the
differences in percentage of reactors among sib-
lings of a reactor and of a nonreactor are greater
when there is no more than two years’ difference
in age between the two children.
After the similarity between siblings produced
by the known factors affecting the frequency of
histoplasmin reactors (geography, age, sex, and
race) has been eliminated, there is still present
some factor which makes siblings of a reactor
more likely to react to histoplasmin than siblings
of a non reactor.
The epidemiological evidence indicates that a
very high proportion of the pulmonary calcifica-
tion observed in individuals living in these states
may be due to infection with Histoplasma capsu-
latum or related organisms and not to tubercu-
losis. The epidemiological studies are being pur-
sued vigorously by several groups throughout the
country. Many of the old concepts of primary
and reinfection tuberculosis will have to be re-
considered in the light of these recent findings.
It was in the decade between 1935 and 1945
628
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CHEST X-RAY SURVEYS— HI LLEBOE
that students of epidemiology were provided with
an important new instrument to assist them in
their field investigations — the photofluorograph.
Mass radiography made possible the examination
of hundreds of thousands of people — in fact, whole
communities — in a short period of time and at a
reasonable cost. The experience of Davies and
his co-workers in St. Louis County, Minnesota,
demonstrated that over 90 per cent of the popu-
lation of communities of fair size could be exam-
ined within a surprisingly short period. All open
cases, clinical cases, and suspects were detected
and later identified. Facilities were available for
the isolation of open cases and the medical super-
vision of the subclinical cases and suspects. If
the standards of living of the citizens of the
community can be raised to a higher level and
kept there, eradication for the first time becomes
possible.
Such community studies have not been fol-
lowed up for a long enough period of time to
measure the various risks of different population
groups in the community. Within the next few
years following the war, it should be possible to
answer some of the pressing questions regarding
the natural history of the disease in the com-
munity. Certainly it has been demonstrated that
rather complete community examinations are prac-
ticable and can become a precise tool in the study
of the epidemiology of the disease as well as an
important weapon in the fight against tubercu-
losis.
Now that the x-ray machine goes to the people,
and examines them in large groups, it discovers
tuberculosis in its minimal stage in a high pro-
portion of the cases found. The importance of
this finding in controlling the disease is made
clear by the fact that in recent years only 10 to
15 per cent of admissions to tuberculosis hospi-
tals have been minimal cases. Today, with new
mass radiographic techniques, 65 to 70 per cent
of all cases found have x-ray evidence of mini-
mal disease. Tuberculosis is at last being found
when it can be relatively easily arrested ; even
infectious cases can be detected earlier and pre-
vented from spreading their disease.
Scientific accomplishments during wartime have
clearly revealed the value of planned co-ordinated
research in arriving speedily at the solution of
trying problems in tuberculosis control. Strange-
ly enough not the least repercussion of atomic
fission is the stimulus it has given to group activ-
June, 1947
ity in research. Certainly this is true in the study
of variations in the interpretations of x-ray films
of the chest. Mass radiography brought in its
wake some troubling problems in film interpreta-
tion. Studies of Morgan and his co-workers
have demonstrated that various film techniques,
35 mm., 70 mm., 4 by 5, 14 by 17 paper, and
finally 14 by 17 celluloid film, are equally effi-
cient in detecting practically all of the significant
pathologic conditions present on x-ray films of
the chest. Group work is now going forward to
determine the human error in the interpreta-
tion of chest x-ray films.
The ingenious technique developed by Yeru-
shalmy for making comparative studies of various
types of films read by several interpreters is
worthy of further use in other fields of science
and public health. It avoids the use of one film
and one reader as standards because either of
these may have considerable variation. If five
readers use four different sized films (one to
twenty positives plus all twenty negatives) twen-
ty-one combinations are possible. Yerushalmy
uses eleven positives out of twenty readings -
as a standard.
Prior to the widespread use of photofluorog-
raphy in chest examinations, radiologists and
chest specialists were firmly convinced that x-ray
examination was one of the most precise labora-
tory tools at our disposal. The first compar-
ative studies appeared and astonished all ra-
diologists who formerly had assumed that roent-
genological diagnosis was synonymous with
high accuracy. The failure of an individual
reader to be consistent with other readers pre-
sents a problem of considerable magnitude in
the simple procedure of determining the pres-
ence or absence of a shadow “characteristic” of
tuberculosis of the lungs. The variation of one
person’s separate interpretation of the same films
at two different times, is even more astonishing.
Discrepancies in the determination of activity
and morphology of lesions among several expert
interpreters were so great that the toss of a coin
would have given about the same results.
Birkelo, Chamberlain and co-workers have
demonstrated that the human error is great and
that new techniques will have to be developed for
the uniform detection of pulmonary lesions and
that better classification will have to be devised to
describe shadows on x-ray films. The variation in
the • determination of activity of tuberculous le-
629
CHEST X-RAY SURVEYS— HILLEBOE
sions on x-ray films is so great that in the modern
clinics throughout the United States this differen-
tiation is not made without careful laboratory,
clinical, and serial x-ray examinations. All find-
ings must be interpreted in their entirety by a
competent clinician wfio considers subjective vari-
ations as well as objective findings. As these
investigations in x-ray diagnosis go forward, still
sharper tools will become available for the study
of the meaning of various types of pulmonary le-
sions demonstrated on the x-ray film.
The error is of great moment in the epidemiol-
ogy of tuberculosis, because the roentgenogram
of the chest is the principal tool in diagnosis and
follow-up of tuberculous persons. Great care
must be exercised in making comparisons of epi-
demiological studies done by different investigat-
ors. Variations in results based solely on interpre-
tations of x-ray films may be more apparent than
real. For the present, if results are to be mean-
ingful, comparative studies should include pro-
vision for interpretation of all chest films by
two or more well-trained interpreters, with care-
ful evaluation of their independent readings.
Such self-examination in the complex field of
roentgenography of the chest is essential if fun-
damental research is to contribute the additional
knowledge that is so urgently needed.
Another subject which has attracted the atten-
tion of scientific investigators in the field of tu-
berculosis has been vaccination with the bacillus
of Calmette and Guerin (BCG). Careful re-
view of the extensive literature on this subject
fails to reveal irrefutable epidemiologic evidence
of the permanent effectiveness of this vaccine.
Studies by competent workers in the Scandina-
vian countries and reports from the South Amer-
ican investigators demonstrate a relationship be-
tween vaccination and decreased incidence of the
disease among children and some adults over
limited periods of time. In the United States
the relative abundance of sanatoria and low mor-
tality rates in certain areas has minimized the
need for an immunizing campaign. Further-
more, there has been a strong objection on the
part of some of the tuberculosis clinicians in this
country to infect children who may have the
chance of going through life without ever be-
coming infected. The full effect of the vaccine
on tuberculosis in human beings must wait until
carefully controlled studies precisely measure a
reduction in morbidity and mortality in various
age groups for long periods of time. Where
there is inadequacy or complete absence of iso-
lation, lack of personnel and facilities for con-
trol, and where persons, particularly children and
susceptible racial groups, are subject to massive
exposures to tuberculosis, with little likelihood of
any change, BCG vaccination should be given
immediate consideration. BGG vaccine, and pos-
sibly other similar vaccines being developed,
would appear to hold more promise for the re-
duction and control of tuberculosis than strep-
tomycin, even though the results of the latter in
individual cases impress the public and the pro-
fession as more spectacular. The epidemiologist
must still convince the clinician that prevention
will contribute far more than treatment in the
control of tuberculosis.
The brilliant discovery by Waksman in 1944
of the antibiotic, streptomycin, however, offers
hope for suppressing pulmonary tuberculosis in
human beings. It appears to have a definite but
limited effect upon clinical progress of the disease ;
this includes retrogressive changes on the x-ray
film, but only occasional changes from positive
to negative sputum. Although the drug is too
new to have permitted careful study of its effect
over a long period of time, some interesting im-
plications immediately become apparent. The use
of this new antibiotic for advanced cases of tu-
berculosis is of limited value because of the irre-
versible pathological processes that have already
taken place. In most sanatoria throughout the
country, from 70 per cent to 90 per cent of first
admissions have advanced disease. It is for this
reason that Dr. Hinshaw of the Mayo Clinic
estimates that not more than 10 per cent of pa-
tients now in sanatoria in this country would be
likely to benefit by treatment with streptomycin,
and then only if cases were carefully selected
by experts in diseases of the chest. Yet for the
first time, both children and adults with tuber-
culous meningitis have recovered. The Veterans
Administration has treated over fifty cases with
the remarkable record of one recovery out of
every five cases. It is true that many of these
had serious complications. The follow-up experi-
ence of these cases is awaited with interest. This
contribution in meningitis is of great importance
because of the case-fatality rate of almost 100
per cent before the use of streptomycin.
Among experimental animals it has been dem-
onstrated that the use of streptomycin can cause
630
Minnesota Medicine
CHEST X-RAY SURVEYS— HILLEBOE
a tuberculin reactor to become a nonreactor.
Similar experiences have not yet, been reported
in human beings. Excessive cost of the drug
has prohibited its wide use up to the present time ;
furthermore, no adequately controlled studies of
patients treated with streptomycin have been pre-
sented. Greatly expanded clinical and labora-
tory research is urgently needed.
Several questions about streptomycin merit
consideration. Investigators find that after a four
months’ period of treatment with recommended
doses of streptomycin, the sputum still contains
virulent tubercle bacilli in a considerable num-
ber of patients with advanced tuberculosis, even
though there is some clinical improvement and
retrogression of tuberculous lesions on x-ray
films. Patients who are still infectious may wish
to leave the hospital because they feel better,
although their disease is not arrested. In this
instance, streptomycin plays the dubiously bene-
ficial role of temporarily helping the individual
but permanently harming the community by caus-
ing the spread of the disease to uninfected con-
tacts. Furthermore, laboratory studies have
shown that persons kept on treatment with strep-
tomycin for even short periods of time, develop
strains of tubercle bacilli that become resistant to
streptomycin but still retain their virulence. The
longer the patients are treated the more likely
this is to occur. Epidemiologically, a dangerous
situation could be created that would retard
rather than hasten the control of this disease.
The nonhospitalized infectious patient, whose dis-
ease is not arrested completely, would spread a
streptomycin-resistant strain of tubercle bacilli
capable of causing disease in susceptible con-
tacts, who, upon entering the hospital for care,
would not be amenable to streptomycin treatment
because their tubercle bacilli would be already
resistant to the drug. Careful study will have to
be made of these factors before such a drug is
used widely throughout the nation. Extensive
use of any antibiotic in the treatment of a chronic
disease like tuberculosis makes necessary plans
for the substitution of new antibiotics when re-
sistant strains become sufficiently prevalent in
the affected groups of the population to restrict
treatment possibilities. As Dr. Hart of England
points out, there is, at present, insufficient evi-
dence concerning the use of chemotherapeutic
agents in tuberculosis to warrant any cessation of
the successful campaign to provide more beds for
June, 1947
the isolation and treatment of persons with infec-
tious and remediable disease. Actually, when
a successful therapeutic agent emerges, as it un-
doubtedly will, additional personnel, beds and
other facilities must be available for the most
effective use of such an agent.
Laboratory examinations for tubercle bacilli are
in somewhat the same untenable position in the
United States today that serological tests for syph-
ilis were at the beginning of the venereal disease
control program over a decade ago. There is
no general agreement of the most effective
media for culture of tubercle bacilli in the rou-
tine or research laboratory. There is great
diversity of opinion on the relative value of cul-
ture methods versus guinea pig inoculation in the
identification of virulent organisms. Prolonged
discussions are a common occurrence at meetings
when professional men debate merits of the direct
smear, the concentrated specimen, and the exami-
nation of gastric lavage in laboratory detection of
tubercle bacilli. Recently the technique of pul-
monary lavage has been popularly acclaimed, only
to complicate the problem, further. Yet no sub-
ject is of greater significance in the epidemiology
of tuberculosis than the detection of virulent tu-
bercle bacilli in persons suspected of or having
the disease. Sputum examination is essential for
exact diagnosis ; prognosis rests largely on its
accuracy ; infectiousness is determined solely by
the presence or absence of infecting organisms in
bodily discharges. Much of our present knowl-
edge of epidemiology has come from combined
clinical and laboratory investigations. Without
the results of laboratory tests, the clinician would
find it difficult to diagnose accurately, predict
realistically, and treat effectively a high propor-
tion of his patients.
Too many persons have been labeled tuber-
culous on the basis of a single x-ray examination
of the chest ; laboratory diagnosis of tuberculosis
has been too often neglected. The pathologist in-
sists that he find tubercle bacilli before he can
assign tuberculosis as the cause of disease. This
is not always possible in office practice or in field
investigations. Yet before final diagnosis every
effort should be made to take careful histories, to
perform tuberculin tests, to make repeated spu-
tum or gastric lavage examinations, to repeat
x-ray examinations. It is clear that scientific
medicine cannot be practiced without laboratories
631
CHEST X-RAY SURVEYS— HILLEBOE
for the performance of scrupulous examinations
for tubercle bacilli.
To determine the effect of sanatorium care or
surgery on the natural history of tuberculosis
in a given population group, high standards of
laboratory diagnosis must be observed ; other-
wise such studies are likely to become a series
of unassociated case histories. Many of the re-
ports of the results of surgical treatment of tu-
berculosis of the lungs suffer from a paucity of
evidence concerning reversion of positive to nega-
tive sputum because of lack of laboratory controls.
The easily performed procedure of pneumo-
thorax is often initiated before tubercle bacilli
are demonstrated in the pulmonary discharges or
the pleural fluid. Epidemiology teaches us that
all shadows on the x-ray film are not tuberculosis.
All the wisdom and judgment of an experienced
chest clinician must be utilized before interfering
with the normal physiology of the respiratory
system. The possible advantages of surgery must
be carefully weighed against the dangers of inter-
ference with restoration of normal function bv
the body itself.
From the x-ray film alone even the experts
cannot consistently distinguish the fibroid from
the exudative type of pulmonary lesion. Pro-
longed study in a hospital by experts offers the
only solution to this difficult diagnostic problem.
Yet the truth is, there are not sufficient beds in
the United States to hospitalize all the minimal
cases now being discovered in increasing num-
bers by mass radiography of the adult popula-
tion. Furthermore, there probably will not be
enough beds for some time, in spite of concen-
trated efforts of powerful and influential agen-
cies and citizens. What is to be done in the mean-
time ? Supervise the minimal cases that cannot be
labeled active clinically, and use the hospital beds
for those minimal cases of uncertain or active
status and for the more advanced infectious
cases. The goal of a sound tuberculosis control
program is to prevent spread of disease. There-
fore vve must make the best use of existing
beds for known spreaders and known active
cases, which will become spreaders. We must
care also for all those who have suspicious
x-ray lesions to prevent their breaking down. We
must mobilize all resources at our command until
we get sufficient beds or learn more about the rela-
tive benefits of ambulatory and bed treatment of
all types of minimal cases.
The problem of proper disposition of a
person with a minimal lesion requires fur-
ther appraisal and research. Long-range stud-
ies of random groups of the tuberculous pop-
ulation with minimal disease are urgently need-
ed. In the meantime, caution is required in hos-
pitalizing every asymptomatic person with a mini-
mal lesion, especially if known cases with infec-
tious or remediable disease are awaiting admis-
sion to the sanatorium. At the same time, there
must be close supervision of ambulatory persons
with asymptomatic minimal lesions. Frequent
repetition of x-ray and laboratory examination
should be the rule. Abnormal pulmonary find-
ings of any kind that appear on serial study,
should be carefully scrutinized in the doctor’s
office or public clinic so that even the slightest
signs may be studied for possible evidence of
activity.
If such a practice is generally followed, chest
physicians will gain in skill of diagnosis ; limited
hospital resources will be conserved for urgent
cases ; and epidemiology will assume added sig-
nificance. Judgments based on positive and com-
plete evidence will give a final verdict that pre-
serves the health and productivity of the indi-
vidual and at the same time protects the public
health.
The unsolved problem of hospitalization of the
tuberculous in this country poses many questions.
In recent years over one-third of all deaths from
pulmonary tuberculosis occurred outside of hos-
pitals and institutions. There are many areas
in the country which cannot find the means to
provide hospital care for their tuberculous citi-
zens. Recent studies of mortality in nine popu-
lous southern states reveal that from 55 to 77 per
cent of deaths from tuberculosis occurred outside
of institutions and sanatoria. The opportunity
for spread of the infection from the family mem-
ber who died at home to the family associates
must have been tremendous, especially where pov-
erty and overcrowding existed in areas of severe
economic distress. Control of the disease will be
impeded until a more realistic distribution of hos-
pital facilities is accomplished. Tuberculosis does
not respect state lines, color, race, or creed. The
real value of case finding is measured by the
number of infectious cases that are given isola-
tion care and thereby prevented from spreading
infection to others.
632
Minnesota Medicine
CHEST X-RAY SURVEYS— HILLEBOE
In any community, there are specific epidem-
iological data which must be analyzed and evalu-
ated before a sound program of efficient bed
utilization can be instituted and maintained.
The morbidity and mortality rates are of great
importance in determining the extent of the local
problem. A knowledge of the quantity and avail-
ability of hospital beds, clinics, nursing, medical,
social, and other professional services for the care
and supervision of the tuberculous is equally im-
portant. The number and distribution of phy-
sicians trained in chest diseases constitute funda-
mental factors in the management of ambulatory
cases and in economy of bed usage.
Such critical studies provide the answers to
certain questions that leaders in tuberculosis con-
trol in every community must answer before they
can develop and operate an effective hospital pro-
gram.
1. What is the fundamental purpose of hospi-
talization of the tuberculous — isolation or treat-
ment? The answer to the first question is un-
equivocal : the protection of the health of all the
individuals in the community takes precedence
over the health of any one individual. Of course,
in the handling of individual patients, the physi-
cian must stress individual needs and the bene-
fits derived from hospitalization by the person
concerned.
2. Does the community, with a scarcity of
beds, benefit more through the hospitalization of
minimal cases with no sysmptoms or of advanced
infectious cases ? The answer to this question in-
evitably follows : the positive sputum case must
be hospitalized to prevent spread of the disease ;
the earlier the case is found the better.
3. Should communities develop preventoria for
children who are heavily exposed and certain to
become infected, but do not yet have clinical dis-
ease? Study of family contacts has provided the
answer to the third question : hospitalize the in-
fectious adult source and thereby remove the
danger of infecting children in the home. It is
easier and more economical to hospitalize one
parent than three or more children.
There is a known shortage of over 50,000 beds
for the tuberculous in the United States in 1947.
This condition appreciably affects the quantity
and quality of care that can be given. It is not
uncommon for a large area to have only 200 beds
June, 1947
and a register of more than 400 positive sputum
advanced cases and over 1,000 with minimal dis-
ease.
How can the limited number of beds be used
to greatest advantage? It is suggested that pos-
itive sputum cases be separated into two groups :
(1) the positive sputum patient with remedial
disease, and (2) the positive sputum patient who
has little hope of recovery. Hospitalize first the
remediable positive sputum group. In this way
both isolation and treatment are accomplished.
The irremediable positive sputum case might be
isolated in a single room in a general hospital
during the terminal episode. In the event that
such arrangements are impracticable, the hopeless
case must be cared for in the home under the
best possible isolation technique, with home in-
struction and contact follow-up by public health
nurses. Such a practice protects the community
and provides the opportunity to restore the health
of at least some whose disease is not yet beyond
repair.
We must think of the community first and the
individual next when hospital beds are limited.
We must guard the health of all the known tu-
berculous in the community and not just
the individuals who, often by chance, fall
into the hands of the expert in chest
diseases. Available beds should be used prin-
cipally for the spreaders of tuberculosis whose
lesions can be arrested, and for proved minimal
cases with definite clinical or laboratory evidence
of active disease. This is in accord with chang-
ing social views on illness. It is becoming more
and more widely recognized that a tuberculous
patient is not only a private patient under the
care of a doctor but also a carrier of a disease
in the community. Therefore, the physician has
a certain public as well as private responsibility.
The private physician must report all his tuber-
culous cases to the health department, so that the
number and whereabouts of the cases will be
known. If a patient does not return for super-
vision, the physician has the further responsi-
bility of reporting this fact to the health depart-
ment, so that the department can take immediate
action and bring the patient under medical care
and isolation. In this respect he is an agent of
the health department and is an extremely im-
portant factor in the promotion of community
health.
633
CHEST X-RAY SURVEYS— HILLEBOE
In spite of the increase in knowledge of the
epidemiology of tuberculosis since the time of
Pasteur and Koch, the principal question that
remains unanswered is, “Why do some people
develop tuberculosis and others fail to do so ?”
We have yet to determine the total and inter-re-
lated effect of time, intensity, frequency, and
duration of exposure. We must evaluate the
effects of unfavorable environmental conditions
in the family, community, and geographical area.
Such complex factors as sex, age, color, and many
racial stocks with complex hereditary and consti-
tutional attributes must be analyzed.
There are fields without number awaiting
exploration. Many guideposts are unmistakably
present, in the form of accurate and complete
statistics on tuberculosis. Unfortunately, the
number of scientific explorers is small. Each
year the group of trained epidemiologists is fur-
ther reduced to supply the need for public health
administrators for state and local health depart-
ments. Indeed, a basic problem of epidemiology
is that of recruiting and training an adequate
body of capable investigators. Our only hope is
for medical schools and general practice to pro-
vide some worthy candidates.
Many questions in the epidemiology of tuber-
culosis remain unsolved because of the lack of
efficient tuberculosis record systems in otherwise
effective health departments. Better records, and
time for their analysis, could reduce the number
of past mistakes and enable us to determine if
what we have proposed and carried out has ac-
complished the desired end. In areas that have
established tuberculosis control programs, case
registers can be used both for case management
and as current sources of valuable data for
epidemiologic investigation. A perpetual inventory
of the case load, with interval evaluation of the
effectiveness of activities, in relation to their cost,
provides a realistic appraisal of the extent of the
problem. Smoothly functioning record systems
are essential tools for successful administration
of a tuberculosis program, and create the oppor-
tunity for the discovery of new knowledge and
for improved methods of control. Carefully de-
vised record systems make the practice of public
health, as applied to tuberculosis, a science and not
just empirical guesswork. Long-range planning,
based on predictions derived from analysis of
reliable epidemiologic data, promotes economy of
program operation and definitive results.
634
Summary
Much could be learned about the epidemiology
of tuberculosis if we could encourage the par-
ticipation of more general practitioners in our
field studies throughout the country. Although
the general physician deals directly with the
source material of tuberculosis, he infrequently
recognizes the disease in its early stages, be-
cause he does not constantly search for it with
the tools at his command. The routine use of
the tuberculin test on every person who visits the
rural doctor’s office would uncover a surprising
number of hidden and unsuspected cases of tu-
berculosis. The examination of family contacts
and a search for the original spreader leads the
family physician away from his relentless daily
routine into exciting by-paths of epidemiologic in-
vestigations. Through the utilization of modern
methods of diagnosis and follow-up, the rural
physician extends the frontiers of knowledge in
this puzzling disease.
In spite of the great amount of knowledge
that still remains hidden from us, the study of
epidemiology, as Chapin has aptly pointed out,
has profoundly modified our methods of dealing
with contagious diseases. The discovery of the
cause of tuberculosis and some knowledge of its
mode of spread are fundamental to an effective
control program. As our knowledge increases it
becomes the province of epidemiology to plan
and try out new and more efficient methods of
control. Knowledge includes more than mor-
bidity and mortality statistics. The epidemiolo-
gist who studies the intricacies of the changing
pattern of the spread of tuberculosis must be
familiar with statistical methods in order to
avoid losing his way in a maze of figures. As
scientific investigations go forward, and as ac-
curate and complete data accumulate, the best
safeguards for sound inferences are: (1) proper
selection of data; (2) judicious use of controls;
and (3) the orderly array of facts in their prop-
er relation to present information about the dis-
ease. Conclusions based upon such interpreta-
tions of data will be sound and should increase
the efficiency of our methods of controlling tu-
berculosis.
The deadly quarrel between microbe and man
will continue unabated unless we apply all the
measures at our command to insure the protec-
tion of the whole population within a short
( Continued on Page 694)
Minnesota Medicine
THE MEEKER COUNTY TUBERCULOSIS CONTROL PROJECT
KARL A. DANIELSON, M.D.
Litchfield, Minnesota
T^ARLY in August, 1940, a telephone call was
received from the Committee on Tubercu-
losis of the Minnesota State Medical Association
requesting that a few of its members be permitted
to meet with the physicians of Meeker County.
A luncheon meeting was arranged on August 19,
and we were informed that in February, 1940,
the state committee had determined to recommend
a statewide tuberculosis control program to be
initiated and conducted by the State Medical As-
sociation. On March 26, 1940, this committee
decided to select a county in which an ideal tuber-
culosis control program would be developed by
local physicians and that this area would serve
as a demonstration for the remaining eighty-six
counties of the state. At subsequent meetings,
numerous counties were considered, and on Au-
gust first the members of the committee voted
unanimously to ask the physicians of Meeker
County to undertake the countywide proposed
demonstration. This county was selected because :
1. The first tuberculosis survey among humans
in Minnesota was conducted here by Dr. Lampson
in 1912.
2. When the county area plan of controlling
tuberculosis among cattle was undertaken by the
State of Minnesota in 1923, Meeker County was
selected for the beginning of this work. In other
words, this was the testing ground for the state
program.
3. The committee had determined that all phy-
sicians practicing in Meeker County had a mod-
ern viewpoint on tuberculosis control and would
work in harmony on a county wide project.
After all of this was explained on August 19,
our members agreed to give the project most
careful consideration. In November, 1940, and
for several months thereafter, the state commit-
tee held practically all of its regular meetings in
Litchfield, our county seat, and the physicians of
the county as well as a few from adjacent coun-
ties regularly attended these meetings. Presidents
of the state association, including B. S. Adams
and B. J. Branton, as well as members of the
council, including Carl Johnson, E. J. Simons
and C. A. Stewart, were present on several occa-
sions to assist in formulating our program. In
these evening meetings, which often lasted for
hours, various phases of the proposed project
were discussed. Meetings were also held for the
leaders of lay organizations and for the general
public, in order that everyone might have an
opportunity not only to know about the proposed
project but also to offer suggestions for its exe-
cution. In the early spring of 1941 it appeared
that the necessary preparations had been made,
and the physicians were ready to proceed with the
examinations the first of May. It had been
agreed that the procedure should consist of testing
the entire county population with tuberculin in
order to find all who were infected with tubercle
bacilli. This was to be followed by x-ray film
inspection of the chests of reactors, and those
with shadows indicating the presence of pulmo-
nary disease were to be completely examined in
order to ensure accurate diagnoses.
At first no funds were available to pay for
materials or any phase of the work. However,
it was not long before the Minnesota State Medi-
cal Association, the American Medical Associa-
tion, the National Tuberculosis Association, the
State Public Health Association and the local tu-
berculosis society contributed adequate funds.
Our physicians agreed to administer the tuber-
culin test, interpret all x-ray films and do all nec-
essary phases of the examination without charge.
The State Department of Health agreed to fur-
nish the tuberculin and to deliver it weekly in
dilutions ready for administration. Our physi-
cians decided to use x-ray films which were pur-
chased and delivered to us by the state committee.
From the same funds x-ray technicians were paid
a small amount for exposing and developing the
films and for purchasing necessary materials for
keeping records, postage, et cetera. Every detail
of the project was to be conducted by the citizens
of Meeker County.
Saint Paul and Minneapolis newspapers gave
wide publicity to the project, even publishing
articles concerning it in Sunday editions. Every-
body’s Health supported and publicized the proj-
ect in a wholehearted manner. Fine editorials
Dr. Danielson is chairman of the Meeker County project.
June, 1947
635
TUBERCULOSIS CONTROL PROJECT— DANIELSON
and articles were published in Minnesota Medi-
cine. The Meeker County newspapers were ex-
ceedingly generous with space, urging everyone
to co-operate. We received help from the pastors
of various churches, superintendents of schools,
and very substantial aid from the Farm Bureau.
Collier’s published an article with colored illus-
trations on May 2, 1942, entitled, ‘Worth More
than a Cow.” The Minnesota Public Health As-'
sociation lent us motion picture films pertaining
to tuberculosis which were shown in the rural
district schools and at parent-teacher association
meetings. At some of these sessions, talks were
given by local physicians.
Postcards were prepared containing the fol-
lowing message: “You and your family are in-
vited to come to your doctor’s office for a tuber-
culin test, and if a reaction occurs, an x-ray
film will be made of your chest for which there
will be no charge. Signed : The Meeker County
Medical Society.” These cards were mailed at
two-week intervals, first to the towns and villages
and then one township at a time, until the entire
county had been circularized. It was planned (o
follow up this volunteer program with one or
two public health nurses arranging meetings in
outlying districts and, if necessary, going from
home to home.
With the declaration and prosecution of war,
resulting in rationing of gasoline and restriction
of travel because of rubber shortage, it became
difficult for the farmers to respond to the invi-
tation as they did before these restrictions were
instituted.
Moreover, enlistment of physicians and nurses,
the removal from the county of so many persons
who were supporting the campaign, resulted in
marked retardation of our tuberculosis activities.
In fact, they came almost to a standstill for rea-
sons beyond our control. The population, which
was approximately 19,000 before the war, was
reduced to slightly more than 16,000 by Selective
Service and removal of defense workers. Ef-
forts made to procure workers nearly always
ended in failure.
Under the circumstances it seemed futile to con-
tinue the project as a demonstration. Therefore,
it was closed when approximately two-thirds of
the citizens had been examined. Most of the
10,733 persons who were examined reported early
in the campaign. No objection was voiced at that
time to the tuberculin test or any other phase of
the examination. The citizens were enthusiastic,
and had it not been for the war, we believe that
not less than 90 to 95 per cent of our citizens
would have been examined.
Among the 10,733 who reported, 2,445 (22.8
per cent) reacted to tuberculin. Of the total num-
ber of tuberculin reactors, 2,031 reported for
x-ray inspection of the chest. The failure of the
remaining 414 was largely due to travel difficulties
during the war. Among the 2,031 persons who
reacted to tuberculin and had x-ray film inspection
of the chest, there were sixteen who presented
x-ray shadows that were definitely proved by
other phases of the examination to represent
clinical tuberculous lesions. Thirteen of the six-
teen were sent to sanatoriums, and the remaining
three were treated by private physicians.
Our physicians are greatly pleased with the
results of this campaign, despite the fact that the
project had to be discontinued after approxi-
mately two-thirds of our citizens had been ex-
amined. It resulted in the removal from society
of sixteen active cases of the reinfection type of
tuberculosis. Of great importance to us is the
information obtained with reference to tubercu-
lous infection. We know that only approximately
23 per cent of our citizens carry living tubercle
bacilli in their bodies. In other words, the tuber-
culosis work previously done in Meeker County
has been effective, since 77 per cent of our popu-
lation have apparently been protected against
tubercle bacilli. The present 23 per cent repre-
sent such a limited group of the population that
it is possible to institute and maintain an in-
tensive education campaign among them so that
they may be on guard with reference to the sub-
sequent development of clinical lesions. The 77
per cent of uninfected persons have been ad-
vised to be retested from time to time and, if in-
fection occurs, to be periodically examined for
clinical lesions.
There was so much publicity throughout the
county concerning this project that there prob-
ably are few, if any, citizens who did not learn
something about tuberculosis. Therefore, we are
of the opinion that many of our citizens whom
the project did not reach will request adequate
examination for tuberculosis. Although the proj-
ect as such has been discontinued, many per-
sons, particularly since the end of the war, have
requested special examinations for tuberculosis.
(Continued on Page 692)
636
Minnesota Medicine
TOXOPLASMOSIS
PAUL KABLER, M.D., M.P.H., and MARION COONEY, B.A.
Minneapolis, Minnesota
'T'YPICAL toxoplasmosis occurring in a four-
**■ teen-year-old female resident of Minnesota
was reported by Adams, Horns and Eklund1 in
1946. Neutralizing antibodies for the toxoplasma
organism were present in the blood of the patient
as well as in that of the mother and in eight of
nine siblings tested. The mother and siblings
showed no clinical signs or symptoms of the dis-
ease by physical or roentgenologic examinations.
The first case of human infection with toxo-
plasma was reported in an infant in 1923 by
Janku,3 who described the organism but did not
identify it. The second case was reported in an
infant by Torres in 1927. Wolf and Cowen10 in
1937 described another infantile infection, giving
full clinical and pathological findings, and in 1939
Wolf, Cowen and Paige11 described a similar case
from which the toxoplasma organism was recov-
ered by intracerebral inoculations of rabbits and
mice with brain tissue taken at autopsy. Identity
of this organism with a strain of toxoplasma iso-
lated from laboratory animals was shown by
cross-immunity tests, thus definitely establishing
the etiological agent. Since 1940, cases of fatal
toxoplasmic infections in adults4’5 and in children7
as well as several nonfatal cases have been re-
corded.
The toxoplasma organism is regarded as a pro-
tozoan parasite and has at times been confused
with other protozoan parasites such as Leish-
mania, Encephalitozoon and avian malaria. Iden-
tification is definitely determined by animal inocu-
lation ; however, the presence of characteristic or-
ganisms in the tissues is now generally considered
diagnostic.
Although the parasites have more frequently
been demonstrated in nerve tissue — meninges,
cerebral cortex, basal ganglia, pons, medulla, spi-
nal cord and retina — they have also been found
in alveolar epithelium of the lung, myocardium,
adrenals, reticuloendothelial and parenchymal cells
of the liver, kidney, bone marrow, endothelium
of arterioles and venules, skeletal muscle, skin
and subcutaneous tissue.
Spontaneous infection in animals is widespread
From the Section of Medical Laboratories, Minnesota Depart-
ment of Health, University Campus, Minneapolis, Minnesota.
June. 1947
and has been recorded in the dog, cat, rat,
mouse, guinea pig, mole, sheep, baboon, chimpan-
zee and numerous kinds of birds. Instances of
human infection have been observed in Australia,
Europe, South America, and in several states of
the United States of America. At present the
routes of infection and other epidemiological fac-
tors are unknown.
Human toxoplasmic infections may present
several types of clinical manifestation. Sabin9
has summarized six clinical forms. Callahan,
Russel and Smith2 in a recent comprehensive re-
view of the disease described infantile and adult
toxoplasmosis with subtypes of each.
The infantile form is frequently fatal, the dis-,
ease being present at birth or appearing a few
days or weeks thereafter. The .outstanding signs
and symptoms of these cases are internal hydro-
cephalus, convulsions, muscular twitchings, chori-
oretinitis, ocular palsies, spasticity, jaundice, in-
tracerebral calcifications, hepatosplenomegaly and
respiratory disturbances. Usually this type of in-
fection is acquired in utero, and the mother has
neutralizing antibodies for toxoplasma in her
blood.
The juvenile form may or may not result fatal-
ly, and although it is most frequently of acute
encephalitic form, it may exhibit predominantly
the symptoms of acute exanthematic disease
and/or atypical pneumonia. It is not always evi-
dent whether juvenile toxoplasmosis is the result
of acquired infection or of a reactivation of latent
intra-uterine infection.
Adult toxoplasmic infections have been ob-
served in two main types. In one type, the clini-
cal signs and symptoms are variable but in gen-
eral are characterized by sudden onset, elevation
of temperature, maculopapular eruption and pul-
monary involvement. The signs and symptoms
referable to the central nervous system may be
relatively insignificant. There is more tendency
for Widespread involvement of the viscera than
in the infantile disease.
The other type of adult infection appears as a
chronic disease and may show no signs x>r symp-
toms of the process except that neutralizing anti-
637
TOXOPLASMOSIS — K ABLER AND COONEY
bodies are present in the blood. This type of dis-
ease has been observed in mothers of infants dead
of intra-uterine infection.
“Neutralizing antibodies against toxoplasma are
formed by the host, and their demonstration is
the most reliable method available for clinical
encephalitis; or from the parents and siblings of
individuals who had previously shown a positive
neutralization for toxoplasma. The series re-
ported includes patients from public and private
institutions as well as from general practice
throughout the state.
TABLE I. RESULTS OF NEUTRALIZATION TESTS FOR TOXOPLASMA
FOR THE YEARS 1944 TO 1946, INCLUSIVE
Results of Examination
Year
Positive
Negative
Unsatisfactory
Totals
Patients
Spec.
Patients
Spec.
Patients
Spec.
Patients
Spec.
1944
22
29
30
33
0
0
52
62
1945
46
56
184
196
2
2
232
254
1946
95
112
376
397
6
7
477
516
Totals
163
197
590
626
8
9
761
832
T
diagnosis of the disease.”2 Sabin8 has shown that,
in monkeys, neutralizing antibodies for toxo-
plasma persists after the organisms are no longer
demonstrable in the tissues, and that the presence
of antibodies alone is not indicative of active in-
fection ; however, it does show that the individual
has been exposed to the antigen substance of
toxoplasma at some time.
The neutralizing antibodies are quite labile and
may disappear in a day or two at room tempera-
ture, or in two weeks at ice box (5° C.) tempera-
ture. For this reason specimens of blood to be
examined for toxoplasmic antibodies must be sent
to the laboratory without delay. During warm
weather, or at any time when more than twenty-
four hours are required for the specimen to reach
the laboratory, the serum should be separated
from the cells and forwarded in a package con-
taining dry ice (solid C02).
Because of the growing interest in these infec-
tions, the Minnesota Department of Health Lab-
oratories began the neutralization tests* for the
toxoplasma organisms in January of 1944, and
have continued this service to date. The tech-
nique of the test is essentially that described by
Sabin6 in which patients’ blood serums are mixed
with suspensions of the organism and inoculated
into the skin of white rabbits.
The blood specimens usually were collected
from individuals showing one or more of the fol-
lowing : chorioretinitis, convulsions, hydrocepha-
lus, cerebral calcifications, mental retardation, and
*The neutralization tests were originally conducted by Dr.
Carl Eklund whose present address is U.S.P.H.S., Rocky
Mountain Laboratory, Hamilton, Montana.
In the years 1944 to 1949, inclusive, 832 speci-
mens were examined from 761 patients who were
residents of sixty-three Minnesota counties, and
twenty-two other states. The results of the tests
are summarized in Table I.
Sufficient data are not available to determine
the exact number of active infections represented
by the positive tests ; however, the relatively high
percentages — 42.3 in 1944, 19.8 in 1945 and 18.4
in 1946 — probably reflect the judicious choice of
patients on clinical grounds rather than the over-
all incidence of toxoplasmic infection in Minne-
sota. A sufficient number of apparently normal
individuals have not been examined as yet to de-
termine the incidence in the population at large.
Neutralizing antibodies were demonstrated in res-
idents of twenty-five counties in the state, which
indicates that the infection is widespread. Neu-
tralizing antibodies were also demonstrated in res-
idents of seventeen other states.
During the three years’ experience, ninety-three
pairs of serums from mother and child were
tested, with the following results :
Mother positive — child positive 19
Mother positive — child negative 13
Mother negative — child positive 9
Mother negative — child negative 52
The results of the tests for mother and child
agreed in seventy-one ( 76.3 per cent) pairs of the
specimens. The combination “mother positive —
child negative” occurred a little more frequently
than the combination “mother negative — child pos-
itive.” Conclusions relative to acquired infection
638
Minnesota Medicine
TOXOPLASMOSIS— KABLER AND COONEY
versus intra-uterine infection are not apparent
from these data.
Physicians who submitted blood specimens for
the neutralization tests were asked to supply a
short history for each patient. A part of this in-
formation is summarized in Table II.
febrile disease with extensive maculopapular rash
involving nearly the entire body. A second type
of adult infection appears as a chronic process
and presents no signs of symptoms of the dis-
ease except for neutralizing antibodies in the
blood.
TABLE II. ASSOCIATION OF CHORIORETINITIS, CONVULSIONS, HYDRO-
CEPHALUS AND CEREBRAL CALCIFICATIONS WITH POSITIVE AND
NEGATIVE NEUTRALIZATION TESTS FOR TOXOPLASMA
Positive Neutralization
N<
jgative Ne
iutralizati
on
Present
Absent
Not
Stated
Total
Present
Absent
Not
Stated
Total
Chorioretinitis
Convulsions
Hydrocephalus
Cerebral calcifications
19
18
7
4
33
32
37
36
30
32
38
42
82
82
82
82
10
23
16
1
66
46
51
64
24
31
33
35
100
100
100
100
In these groups of patients, chorioretinitis was
associated with postive neutralization tests (23.2
per cent) more than twice as often as with nega-
tive neutralizations (10 per cent). The incidence
of convulsion was about the same in the two
Toxoplasmic infections are probably wide-
spread in Minnesota as indicated by the presence
of neutralizing antibodies in the blood of indi-
viduals from twenty-five counties in the state.
References
is, F. A., Horns, Richard, and Eklund, Carl : Toxo-
losis in a large Minnesota family. J. Pediat., 28:165-
1946
lian, ' W. P., Russell, W. O., and Smith, M. G. :
in toxoplasmosis: a clinicopathologic study with pres-
on of five cases with review of the literature. Medi-
25:343-397, 1946. . , ,
■ T. : Pathogenesis and pathologic anatomy of colo-
of the mocula lueta in an eye of normal dimensions
n a micro-ophthalmic eye with parasites in the retina,
i. lek. cesk., 62:1021, 1052, 1081, 1111, and 1138,
■rton, H., and Weinman, D. : Toxoplasma infection
in. Arch. Path., 30:374, 1940.
irton, H., and Henderson, R. G. : Adult toxoplasmo-
irevious unrecognized disease entity simulating typhus-
■d fever group. J.A.M.A., 116:807, 1941.
A. B. : Toxoplasma neutralizing antibody in hu-
beings and morbid conditions associated with it.
Soc. Exper. Biol, and Med., 51 : 6, 1942.
A B. • Toxoplasmic encephalitis in children.
f.A., 116:801, 1941.
, A. B., and Ruchman, I.: Characteristics of the
lasma neutralizing antibody. Proc. Soc. Exper. Biol.
Vied., 51:1, 1942.
, A. B. : Toxoplasmosis, a recently recognized dis-
in human beings. Advances in Pediatrics, 1:1.
York: Interscience Publishers, 1942.
A., and’ Cowen, D. : Granulomatous encephalomye-
lue to an encephalitozoon (encephalotoxic encephalo-
:is). Bull. Neurol. Inst, of New York, 6:306, 1937.
A., Cowen, D., and Paige, B. H. : Human toxo-
osis ; occurrence in infants as an encephalomyelitis ;
ation by transmission to animals. Science, 89:226,
bacillus. It is the family physician to whom
pie go when troubled by signs of ill health,
■cords in the chest diagnosis clinics prove that
cians, if they are determined to do so, can per-
letter job of suspecting and discovering active
sis cases, year in and year out, than any other
Report of Comm, on Tbc. N. H. Med. Soc.,
7 land J. Med., Sept. 26, 1946.
639
TOXOPLASMOSIS— KABLER AND COONEY
bodies are present in the blood. This type of dis-
ease has been observed in mothers of infants dead
of intra-uterine infection.
“Neutralizing antibodies against toxoplasma are
formed by the host, and their demonstration is
the most reliable method available for clinical
encephalitis; or from the parents and siblings of
individuals who had previously shown a positive
neutralization for toxoplasma. The series re-
ported includes patients from public and private
institutions as well as from general practice
throughout the state.
TABLE I. RESULTS OF NEUTRALIZATION TESTS FOR TOXOPLASMA
FOR THE YEARS 1944 TO 1946, INCLUSIVE
Results of Examination
Year
Positive
Negative
Unsatisfactory
Totals
Patients
Spec.
Patients
Spec.
Patients
Spec.
Patients
Spec.
1944
22
29
30
33
0
0
52
62
1945
46
56
184
196
2
2
232
254
1946
95
112
376
397
6
7
477
516
Totals
163
197
590
626
8
9
761
832
T
diagnosis of the disease.”2 Sabin8 has shown that,
in monkeys, neutralizing antibodies for toxo-
plasma persists after the organisms are no longer
demonstrable in the tissues, and that the presence
of antibodies alone is not indicative of act!
fection ; however, it does show that the indi
has been exposed to the antigen substai
toxoplasma at some time.
The neutralizing antibodies are quite lab
may disappear in a day or two at room tei
ture, or in two weeks at ice box (5° C.) tei
ture. For this reason specimens of blood
examined for toxoplasmic antibodies must
to the laboratory without delay. During
weather, or at any time when more than t
four hours are required for the specimen t<
the laboratory, the serum should be se]
from the cells and forwarded in a packaj
taining dry ice (solid C02).
Because of the growing interest in these
tions, the Minnesota Department of Heali
oratories began the neutralization tests*
toxoplasma organisms in January of 19^
have continued this service to date. Th
nique of the test is essentially that descr
Sabin6 in which patients’ blood serums are
with suspensions of the organism and im
into the skin of white rabbits.
The blood specimens usually were c
from individuals showing one or more of
lowing: chorioretinitis, convulsions, hydr
lus, cerebral calcifications, mental retardat
In the years 1944 to 1946, inclusive, 832 speci-
mens were examined from 761 patients who were
residents of sixty-three Minnesota counties, and
twenty-two other states. The results of the tests
*The neutralization tests were originally conduct*
Carl Eklund whose present address is U.S.P.H.
Mountain Laboratory, Hamilton, Montana.
638
TOXOPLASMOSIS— KABLER AND COONEY
versus intra-uterine infection are not apparent
from these data.
Physicians who submitted blood specimens for
the neutralization tests were asked to supply a
short history for each patient. A part of this in-
formation is summarized in Table II.
febrile disease with extensive maculopapular rash
involving- nearly the entire body. A second type
of adult infection appears as a chronic process
and presents no signs or symptoms of the dis-
ease except for neutralizing antibodies in the
blood.
TABLE II. ASSOCIATION OF CHORIORETINITIS, CONVULSIONS, HYDRO-
CEPHALUS AND CEREBRAL CALCIFICATIONS WITH POSITIVE AND
NEGATIVE NEUTRALIZATION TESTS FOR TOXOPLASMA
p
Dsitive Neutralization
Negative Neutralizati
on
Present
Absent
Not
Stated
Total
Present
Absent
Not
Stated
Total
Chorioretinitis
19
33
30
82
10
66
24
100
Convulsions
18
32
32
82
23
46
31
100
Hydrocephalus
7
37
38
82
16
51
33
100
Cerebral calcifications
4
36
42
82
1
64
35
100
In these groups of patients, chorioretinitis was
associated with postive neutralization tests (23.2
per cent) more than twice as often as with nega-
tive neutralizations (10 per cent). The incidence
of convulsion was about the same in the two
groups, while hydrocephalus was associated with
negative neutralization tests (16 per cent) more
frequently than with positive neutralizations
(8.5 per cent). The number of cerebral calcifica-
tions was probably too small to permit a valid
comparison.
Summary
Toxoplasmosis is a disease resulting from in-
fection with the protozoan parasite toxoplasma.
Infection may occur in utero or be acquired at
any age. Infantile toxoplasmosis is usually char-
acterized by widespread destruction of the cen-
tral nervous system, and, in surviving cases, resid-
uals such as hydrocephalus, convulsions, chorio-
retinitis and mental retardation are frequent.
The symptoms of adult toxoplasmosis may be
extremely variable, with a greater tendency to
widespread involvement of the viscera than in
infantile infections. It may occur as an acute
Toxoplasmic infections are probably wide-
spread in Minnesota as indicated by the presence
of neutralizing antibodies in the blood of indi-
viduals from twenty-five counties in the state.
References
1. Adams, F. A., Horns, Richard, and Eklund, Carl: Toxo-
plasmosis in a large Minnesota family. J. Pediat., 28:165-
171, 1946.
2. Callahan, W. P., Russell, W. O., and Smith, M. G. :
Human toxoplasmosis : a clinicopathologic study with pres-
entation of five cases with review of the literature. Medi-
cine, 25:343-397, 1946.
3. Janku, J. : Pathogenesis and pathologic anatomy of colo-
boma of the mocula lueta in an eye of normal dimensions
and in a micro-ophthalmic eye with parasites in the retina.
Casop. lek. cesk., 62:1021, 1052, 1081, 1111, and 1138,
1923.
4. Pinkerton, H., and Weinman, D. : Toxoplasma infection
in man. Arch. Path., 30:374, 1940.
5. Pinkerton, H., and Henderson, R. G. : Adult toxoplasmo-
sis ; previous unrecognized disease entity simulating typhus-
spotted fever group. J.A.M.A., 116:807, 1941.
6. Sabin, A. B. : Toxoplasma neutralizing antibody in hu-
man beings and morbid conditions associated with it.
Proc. Soc. Exper. Biol, and Med., 51 :6, 1942.
7. Sabin. A. B. : Toxoplasmic encephalitis in children.
J.A.M.A., 116:801, 1941.
8. Sabin, A. B., and Ruchman, I. : Characteristics of the
toxoplasma neutralizing antibody. Proc. Soc. Exper. Biol,
and Med., 51:1, 1942.
9. Sabin, A. B. : Toxoplasmosis, a recently recognized dis-
ease in human beings. Advances in Pediatrics, 1:1.
New York: Interscience Publishers, 1942.
10. Wolf, A., and Cowen, D. : Granulomatous encephalomye-
litis due to an encephalitozoon (encephalotoxic encephalo-
myelitis). Bull. Neurol. Inst, of New York, 6:306, 1937.
11. Wolf, A., Cowen, D., and Paige, B. H. : Human toxo-
plasmosis ; occurrence in infants as an encephalomyelitis ;
verification bv transmission to animals. Science, 89:226,
1939.
There is no doubt that the most important of all case-
finding agencies in the fight against tuberculosis are its
practicing physicians. It is almost always true that the
family physician has the first opportunity not only to
ascertain the presence of tuberculosis among the people,
but also to give battle for the cure of the afflicted and
to safeguard the other members of the family from the
June, 1947
tubercle bacillus. It is the family physician to whom
most people go when troubled by signs of ill health.
The records in the chest diagnosis clinics prove that
the physicians, if they are determined to do so, can per-
form a better job of suspecting and discovering active
tuberculosis cases, year in and year out, than any other
agency. Report of Comm, on Tbc. N. H. Med. Soc.,
New England J. Med., Sept. 26, 1946.
639
TRICHINOSIS IN MINNESOTA
C. B. NELSON. M.D., M.P.H.
Minneapolis, Minnesota
P1NCE 1913, when reporting of communicable
^ diseases in Minnesota was made mandatory
by legislation, there have been 157 cases of trich-
inosis with fourteen deaths reported to the Min-
nesota Department of Health. The largest num-
ber, forty-two cases and one death, was reported
in 1934. In the ten-year period from 1937 to
1946, there were thirty-two cases with two deaths.
The cases have occurred sporadically and in small
family outbreaks and have been scattered through-
out the' entire state. The largest outbreak in
Minnesota was in 1934, when twenty-three cases,
including one death, occurred in one family and
its relatives.
In a report of an outbreak of eighty-four cases
in New York City in 1945, Shookhoff, Birnkrant
and Greenberg8 reviewed outbreaks involving
twenty or more cases reported in the literature
since 1900, and found twenty-one such outbreaks
ranging from twenty-one to 617 cases. Riley and
Scheifley,6 in examining material from 117 cadav-
ers from the dissecting room, found 17.9 per
cent infected with trichinosis. Nolan and Bozice-
vich4 report that 174 (17.4 per cent) of dia-
phragms of 1,000 autopsy cases were found to
be infested with trichinae. Evidently there are
many subclinical cases and others that are not
recognized clinically, and perhaps some that are
not reported.
On January 29, 1947, the possibility of an out-
break of trichinosis was brought to the attention
of the Minnesota Department of Health. On in-
vestigation, a total of thirty-seven clinical cases
of trichinosis, with dates of onset of symptoms
between January 10 and January 29, were dis-
closed. Thirty-three of the cases occurred in one
community, a small village whose inhabitants are
predominantly of Central European stock, ac-
customed to eating sausage frequently and often
raw. Two cases occurred in Chicago and one
each in Minneapolis and Saint Paul. There were
twenty-three males and fourteen females affected,
the ages ranging from fifteen to sixty years.
Clinical histories were obtained in twenty-two
of the thirty-seven cases, with symptoms as sum-
marized.
From the Division of Epidemiology, Section of Preventable
Diseases, Minnesota Department of Health, University of Min-
nesota campus.
Number
Per Cent
Edema of eyelids
18
82
Muscle pain
18
82
Fever
12
55
Malaise
10
46
Diarrhea
8
36
Weakness
5
23
The usual incubation period is six or seven
days, but may be as short as eighteen hours in
heavy infections, or as long as twenty-eight days.
The history of classical, initial diarrhea was ob-
tained in only three cases, though eight individ-
uals complained of diarrhea. The usual present-
ing symptoms were itching and redness of the
eyes with edema of the lids, and muscle pains,
especially of the extremities. Other frequent
symptoms were fever, malaise, and weakness.
Sore throat, edema of face, nausea and vomiting,
abdominal cramps, pain in chest, and sweating
were other complaints. Some of the individuals
appeared critically ill and very toxic, but there
were no fatalities, a situation which seems charac-
teristic of larger-scale outbreaks in recent years.
Differential leukocyte counts obtained in
twenty-three of the cases, January 30-31, 1947,
showed an eosinophilia ranging from 7 to 49 per
cent. In three of the cases there was a leukocy-
tosis ranging from 12,450 to 20,000.
Eosinophil Count Number Cases
( per cent)
7 to 10 1
10 to 19 3
20 to 29 8
30 to 39 7
40 to 49 3
In two cases, Trichinclla spiralis was demon-
strated in muscle biopsies, one from a specimen
submitted to the Section of Medical Laboratories,
Minnesota Department of Health, and one re-
ported from the Veterans Administration. Two
pathological specimens reported by private phy-
sicians showed a concentration of eosinophils
present in the muscle.
Of thirty cases in which an epidemiological
history was obtained, all gave a history of having
consumed smoked country sausage. In twenty-
four of the cases the sausage was eaten raw, in
two fried, and in four cases it was not deter-
mined whether the sausage was consumed raw
or cooked. The two afflicted individuals in Chi-
OO
Minnesota Medicine
TRICHINOSIS IN MINNESOTA— NELSON
cago had ordered the sausage by mail from rela-
tives living in the community. The Minneapolis
resident purchased sausage when passing through
the village and shared it with the Saint Paulite.
The sausage was prepared for public sale by a
local butcher from trimmings of freshly slaugh-
tered pork, ground, seasoned, and smoked for
twenty-four hours at a temperature that would
not cause the sausage to shrink. The sausage was
then refrigerated at 36° F. for one week. Ac-
cording to the butcher, patrons were advised to
eat the sausage only after cooking. Only pork
from hogs purchased and slaughtered locally was
used. As no record was kept on hogs slaughtered,
and trimmings from several hogs were used in
making approximately 100 pounds of sausage
weekly, it was impossible to determine the origin
of the pork used. No samples of the suspected
sausage were available for laboratory examina-
tion.
According to Ober5 and Gould,1 only 60 to 70
per cent of hogs slaughtered in this country are
slaughtered in Federally inspected slaughter
houses. The incidence of infection with live
trichinae among hogs is estimated by Gould2 as
between 1 and 2 per cent. Under Federal in-
spection, no attempt is made to examine pork for
the larvae of Trichinella spiralis, as the examina-
tion is considered time-consuming, expensive, and
impractical. Therefore, all pork or pork products
that are likely to be eaten raw are considered in-
fectious, and according to Federal meat inspection
regulation are processed either by heating to
137° F. or by storing for twenty days at a tem-
perature of 5° F.7 In Minnesota, as well as most
other states, this regulation does not apply to
local butchers or abattoirs not engaged in inter-
state shipment of pork or pork products. Trich-
inous meat can be rendered non-infective either
by heating to 55° C. or freezing at temperatures
sustained long enough to kill the larvae.
Pork has been involved in all cases in Minne-
sota where a source of trichinosis has been sus-
pected or found. Westphal9 reports a case of
trichinosis in which the apparent source was bear
meat from a bear killed in New York State.
Westphal also cites a report of Geiger and Hol-
maier involving twenty-nine cases with three
deaths occurring between 1930 and 1935 in Cali-
fornia, due to eating bear meat. These authors
maintained also the “possibility of the infection
of rats, wild hogs, cats, foxes, coyotes, badgers
June, 1947
and ferrets.” Hall3 states that two or three cases
have been reported from eating beef, and one
from dog meat, but he points out that these are
not important in the control of trichinosis, which
is essentially concerned with pork, “the customary
source of trichinosis.”
At present the prevention of trichinosis is the
concern of the consumer. No fresh pork should
be eaten “pink.” When pork has been changed
by cooking to a whitish color, it has reached a
temperature of at least 137° F., which destroys
the viable trichinae. The publication The Control
of Communicable Diseases, published in 1945 by
the American Public Health Association, recom-
mends a temperature of 150° F. Pork products
processed under Federal regulations are con-
sidered safe, but the consumer does not always
know when such products actually have been
processed at a Federally inspected plant. There-
fore, the only safe rule for the consumer is to
cook pork and pork products adequately.
Many measures have been advocated for the
control of trichinosis. These measures are prin-
cipally the following : ( 1 ) microscopic inspection
of pork ; (2) cooking of all garbage used for hog
feeding; and (3) processing of all pork prior to
sale to the consumer. Each method has its ad-
vocates and points to recommend it, and each
method has its drawbacks.
Summary
An outbreak of trichinosis involving thirty-
seven known clinical cases is reported in order
to call the attention of physicians in this state
to the fact that trichinosis is a serious problem
and an ever-present threat to the public. Preven-
tion of trichinosis is at present the concern of
the consumer, and the only safe advice is to be
sure that all pork is thoroughly cooked or ade-
quately processed before consumption.
Bibliography
1. Gould, S. E. : An effective method for the control of
trichinosis in the United States. J.A.M.A., 129:1251, (Dec.
29) 1945.
2. Gould, S. E. : Trichinosis. First ed Springfield, Illinois:
Charles C. Thomas, 1945.
3. Hall, M. C. : Trichinosis. VII. The past and present
status of tricinosis in the United States and the indicated
control measures. Pub. Health Rep., 53:1472, (Aug.) 1938.
4. Nolan, M. O., and Bozicevich, John: Studies on trichinosis.
V. The incidence of trichinosis as indicated by postmortem
examinations of 1,000 diaphragms. Pub. Health Rep.,
53:652, (April) 1938.
5. Ober, R. E. : Trichinosis. Review of cases in Massachu-
setts. New England J. Med., (Dec.) 1946.
6. Riley, W. A., and Scheifley, C. H. : Trichinosis of man
a common infection. J.A.M.A., 102:1217, 1934.
7. Rosenow, M. J. : Preventive Medicine and Hygiene. Sixth
ed. New York: D. Appleton-Century Co. Inc., 1935.
8. Shookhoff, H. B. ; Birnkrant, W. B., and Greenberg, M.:
An outbreak of trichinosis in New York City. Am. J. Pub.
Health, 36:1403, (Dec.) 1946.
9. Westphal, R. S.: Human trichinosis following ingestion
of bear meat. J.A.M.A., 122:227, (May 22) 1943.
641
DEAFNESS, A THERAPEUTIC PROBLEM
A. C. HILDING, M.D.
Duluth, Minnesota
\\ 7"E maintain contact with our environment
v * chiefly through two senses — vision and
hearing. Many people lose one of these senses
more or less completely, and occasionally some
unfortunate individual loses both. Patients who
lose their vision generally seem to make a satis-
factory adjustment to their handicap and live on
confidently and happily. On the other hand,
people who lose their hearing are prone to be-
come depressed, diffident, and uncertain. For this
and other reasons deafness is a therapeutic prob-
lem of utmost importance.
Deafness may be divided roughly into three
groups : The first group includes those cases
which are due to mechanical interference with
the vibrating parts (conduction deafness). The
second group includes those which have suffered
damage within the cochlea (nerve deafness). The
third group includes miscellaneous intracranial
conditions such as tumor, meningitis, certain rare
bone diseases and probably also cerebral arteri-
osclerosis.
This discussion is concerned with the first two
groups. These do not usually occur as separate
entities, but are generally combined, with one
type or the other predominating. Deafness from
acute otitis media is an example, however, of
pure mechanical deafness, whereas deafness from
mumps furnishes an example of pure nerve deaf-
ness.
Middle car or conduction deafness has a num-
ber of causes, prominent among which are acute
and chronic otitis media, mastoiditis, pathologic
changes of Eustachian tube and otosclerosis.
Acute otitis media interferes with vibration of
the drum head and the ossicles because of swell-
ing and exudation. It is usually self-limited and
leaves no permanent hearing loss, unless neglected.
Chronic otitis media causes some deterioration
of hearing as long as it exists and is prone to
make permanent pathologic changes in the middle
ear which cause permanent loss of hearing. These
sequelae include thickening of the drum and
epithelium, adhesions, retraction and perforation
of the drum.
Read before the Upper Mississippi Valley Medical Associa-
tion, February, 1946.
Chronic mastoiditis may be on a basis of os-
teitis, but is more often due to a cholesteotoma
in the attic and antrum. There is continuous dis-
charge with continuous low-grade inflammation
which interferes with vibration of the drum and
ossicles and eventually causes permanent changes
in these structures.
Inflammatory changes and hypertrophies in
the Eustachian tube or at its pharyngeal ex-
tremity, cause hearing loss by cutting off the
middle ear from atmospheric pressure. The
air pressure on both sides of the drum head must
be equal in order to permit free vibration. Nor-
mally the pressure is equalized frequently through
the Eustachian tube during swallowing and yawn-
ing. When the tube does not thus open, because
of swelling, or for some other reason, a partial
vacuum results in the middle ear together with
some impairment of hearing. In children, this
is often due to lymphoid hypertrophy at the
pharyngeal end. Many adults have slit-like Eu-
stachian openings in the pharynx instead of round
ones. These people are prone to have ear dis-
comfort and impaired hearing following marked
changes in barometric pressure. A new type of
ear disease related to the Eustachian tube has
developed as a result of aviation and of sub-
marine warfare known as aero-otitis media or
aerotitis. It has been reported (Schilling1) that
30 per cent of the men undergoing submarine
escape training have aural difficulty leading to
loss of auditory acuity.
Otosclerosis is an inherited disease of the bony
capsule which surrounds the internal ear. It is
thought to be harmless except for its mechanical
effect. It causes an overgrowth of the bony mar-
gin of the oval window thus impinging upon the
vibrating footplate of the stapes. When the foot-
plate of the stapes becomes fixed and ceases to
vibrate in response to the sound waves playing
against the drum membrane, the hearing acuity
becomes very seriously reduced (Fig. 1). The
hearing organ otherwise may remain more or
less normal, but it becomes separated from the
vibrating portions of the ear mechanism by a
wall of bone, so to speak.
642
Minnesota Medicine
DEAFNESS— HILDING
Treatment. — The treatment of acute otitis me-
dia and the deafness incidental to it is largely
preventive. If colds can be prevented, and when
they occur, if they are treated by bed rest and
isolation, otitis media ordinarily does not occur.
When otitis media does occur, it can usually be
cleared up fairly promptly with standard proce-
dures such as dry wiping, instillation of antisep-
tic solutions, free drainage, diathermy, and, when
necessary, bed rest, sulfonamides or penicillin.
Reduction in hearing acuity may persist for a
week or two after drainage ceases, but soon re-
turns to normal without any permanent effects.
Chronic otitis media is not nearly as prevalent
as it used to be because of the better care given
to acute otitis media and upper respiratory infec-
tions in general. When it does occur, it is much
more of a problem than the acute, but this also
can usually be cleared up with or without surgery,
and practical conversational hearing preserved.
Any loss will depend upon the permanent patho-
logic changes in the middle ear. A generation
ago, there was much enthusiasm about dividing
adhesions in the middle ear resulting from chronic
otitis media and freeing the malleus and drum
by stretching adhesions. One does not hear much
about this at present. Dividing adhesions wheth-
er in the ear or peritoneal cavity, is not highly
successful.
Perforations in the pars tensa (sequelae of
chronic otitis media) are more amenable to treat-
ment. They can sometimes be induced to close
up by gently cauterizing the margins and thus
encouraging scar formation. These scars tend
to contract and to close the hole. Patches placed
over perforations are successful in two ways :
They encourage closure of the opening by new
tissue and at the same time make the patients hear
better while the patch is worn. For instance,
we have a young housewife as a patient at pres-
ent, who has a large perforation in the left drum.
We have been treating her by placing a patch cut
from cigarette paper and soaked in glycerine
over the perforation. She hears very much bet-
ter as soon as this is in place. It must be re-
newed every two or three weeks.
The hearing is often improved, or at least con-
served by radical mastoid operation if a chronic
otitis or mastoiditis does not respond to more
conservative treatment. This is especially true if
the pathologic condition consists chiefly of a cho-
lesteatoma in the antrum and if the middle ear is
June, 1947
reasonably intact. If, on the other hand, there
is .osteitis in the wall of the middle ear, then the
middle ear and its contents must often be sacri-
ficed to effect a cure of a dangerous infection,
and the hearing may be further reduced.
There is another type of middle ear deafness
which is connected with infantile or undeveloped
mastoids. It is probably not essentially different
from the chronic adhesive process which follows
the healing of an extensively damaged middle
ear. However, there is nothing abnormal to be
found upon examination except reduced hearing
and an infantile mastoid. The latter usually
means that there has been otitis media in in-
fancy. For this deafness, there is not much that
can be done directly. But it is important to find
children who suffer from this handicap through
screening tests in school and to see that they
get proper aids to hearing, such as special seating
in the class room, special classes or even hearing
instruments. Much good is being accomplished
now by hearing tests in school and through the
educational programs of such organizations as the
American Hearing Society.
The success in treating a pathologic condition
in the Eustachian tube depends upon its nature.
If it is a true stenosis of the tube, treatment
will probably accomplish nothing. On the other
hand, as not infrequently happens, there may be
hypertrophied lymphoid tissue in the cushion and
pharyngeal orifice. This can be treated success-
fully by radium used in proper applicators or by
deep x-ray therapy.
Aero-otitis media can be largely avoided by
eliminating such young men from the air and
submarine service who have slit-like Eustachian
orifices and who develop ear discomfort under
an increased atmospheric pressure of ten or elev-
en pounds. Those who cannot inflate the middle
ears by holding the nose and mouth closed during
attempted expiration, should also be eliminated.
Blast injuries may damage the drum and mid-
dle ear as well as the cochlea, but these will be
discussed later.
The surgical treatment of otosclerosis is one
of the encouraging bright spots in otology. It
has been met by a wave of enthusiasm among
otologists similar to that which swept the intern-
ists with the advent of insulin.
There is no other treatment than surgery which
has been of any avail. Until the operation of
fenestration was developed, these patients experi-
enced a steadily progressive loss of hearing.
:643
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DEAFNESS— HILDING
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644
Minnesota Medicine
DEAFNESS— HILDING
The operation consists essentially in making a
new artificial window to replace the one which has
become ankylosed by the otosclerotic process. It
is technically difficult and time-consuming, and
the results are by no means perfect. Only a
selected group is suitable for operation — about
one-third of all the patients showing clinical oto-
sclerosis— and of those operated, none regain nor-
mal hearing. Most are greatly improved, some
are not improved and a few are made worse.
Nevertheless, the results are most gratifying com-
pared with the former hopeless outlook, and both
the otologists and their patients are very enthusi-
astic.. The patients whose hearing is restored to
a practical level vary from 70 to 90 per cent of
those operated upon. The percentage depends
upon the care with which the cases are selected,
and the boldness with which the surgeon under-
takes to operate upon the less favorable cases.
Very briefly, omitting details, the operation is
done as follows : The approach is made endaur-
ally through the mastoid. The body of the mas-
toid is exenterated and the antrum and attic ex-
posed to view. This brings into view the short
process of the incus as it lies upon the bulge of
the horizontal semicircular canal where the fen-
estrum is to be made. The posterior bony canal
wall is largely removed, exposing the entire incus
and the head of the malleus which must also be
removed. The site of the horizontal semicirculai
canal is now well exposed but the canal itself is
largely covered by bone and is brought clearly
into view only after the latter has been removed
by means of dental burrs used under magnifica-
tion. The fenestrum is made at the anterior am-
pullated end of the semicircular canal close to
the facial nerve. The fenestrum and surround-
ing bone must be so prepared that the skin flap
which is to cover it will heal down tightly and
smoothly before the bone gets a chance to re-
generate. Unless the fenestrum remains open the
operation is of no avail.
A skin flap is made from the thin skin of the
deepest portion of the external ear canal in such
a way that it remains attached to the upper mar-
gin of the drum and yet completely covers the
fenestrum with a generous margin to spare on
all sides. The flap is packed smoothly over the
fenestrum and held snugly in place. An epithe-
lial membrane of that sort has a mysterious power
of preventing bone growth, and, if the flap heals
quickly into place, there is little or no regeneration
of bone.
June, 1947
This operation of fenestration is not new.
However, its successful execution is new. It had
been tried many times in Vienna twenty or twen-
ty-five years ago, as well as elsewhere in Europe,
but it was not permanently successful because
the opening in the bone healed up. Several futile
devices, including metal plugs, have been used in
attempts to prevent closure. Holmgren, of Stock-
holm, was one of the first who was really suc-
cessful in procuring permanent results. For the
operation as it now stands, we are, however, large-
ly indebted to Lempert (Figs. 2, 3, and 4).
Nerve Deafness. — There are many types of
pathologic changes in the cochlea which are all
grouped under this term. The ordinary senile
type of nerve deafness is the most common. A
large percentage of all people in the latter half
of life are afflicted by it. I do not mean to imply
that it is a sign of senility — it often begins in
the fourth decade of otherwise vigorous people —
but use that term for want of a better one. The
disease is characterized by tinnitus and reduced
bone and air conduction, especially of the high
tone frequencies. Reduction of bone conduction
is due to the fact that the hearing organ itself is
damaged, in contrast to conduction deafness in
which there is some derangement of the mecha-
nism for conducting sound vibrations to the in-
ternal ear. The pathologic change is found in the
organ of Corti where the sense cells disappear
and the afferent nerve fibers atrophy. The ef-
fect, as far as the patient is concerned, is the
loss of consonant sounds which are high pitched
tones carried by vibration frequencies in the upper
register. With the consonant sounds lost from
speech, it seems to the patient that everyone with
whom he converses speaks indistinctly. He hears
the sound of the voice without any difficulty, but
cannot distinguish the words. He is apt to burst
forth, especially if talking to some of his own
family, “Stop mumbling and speak out so that
a body can understand what you’re saying.” To
the otologist he will complain that in a group
he can understand only that part of the conversa-
tion which is spoken directly to him. He can
easily “hear” everything that is said otherwise,
but cannot distinguish the words.
A very similar type of deafness is caused by
noisy occupations, such as boiler making, ship-
building, and rock crushing. It is very difficult
to study these things experimentally with any
degree of satisfaction. Pathologic changes can
645
DEAFNESS— HILDING
be produced readily in animals by subjecting them
to loud continuous noise. But it is difficult to
conceive of a method for determining the hearing
loss. The changes, whatever they may be, are re-
versible up to a point, beyond which they become
irreversible and the hearing loss is permanent.
It is possible experimentally to produce temporary
hearing loss and tinnitus in man under controlled
conditions, but there is no way of determining
the pathologic changes.
Blast injuries, such as those incident to war,
may cause both middle ear damage and cochlear
injury. An elderly Finnish gentleman came to
me during the hunting season, stating that a hunt-
ing companion had shot at a deer over the pa-
tient’s shoulder, and had hurt his ear terribly. In-
vestigation revealed that the drum had been rup-
tured and badly lacerated. This does not usually
happen with gun fire, but the internal ear may
suffer damage from which it may or may not
recover. Gunnery instructors may lose hearing
acuity. Hearing acuity has been measured at
varying intervals after exposure. Recovery takes
place gradually after days, weeks, or months, de-
pending upon the degree of injury and the in-
dividual’s susceptibility to ear damage. The lat-
ter varies widely. If damage has been sufficiently
severe, the process is not reversible, and hearing
loss is permanent.
Toxic nerve deafness occurs following adminis-
tration of various drugs and after certain infec-
tions. Quinine, salicylates and salol are examples
of the former. Again, there are wide variations
in susceptibility. Some individuals can take
quinine in considerable dosage over long periods
of time, whereas others cannot take small single
doses without developing tinnitus.
Treatment. — The cause of the ordinary spon-
taneous senile nerve deafness is unknown. There
is no known effective therapy. The hearing can-
not be restored, nor can the progress of loss be
stopped. Treatment is psychological and substi-
tutional. The patient must accept his handicap
and learn lip reading, or use a hearing aid. Treat-
ment at present is a problem for teachers, psy-
chologists, and producers of hearing aids, rather
than for the otologist.
Occupational deafness is treated best by pre-
vention. If it is impossible to reduce the noise
in a factory, then those who are susceptible to
noise should be screened out and urged to take
other occupation. One individual may be able to
work at a noisy job for years without injury to
his hearing, while another may begin to lose hear-
ing promptly. A shipyard worker of this type
consulted me last summer. He was told, after
examination, that he would suffer permanent
damage to his hearing unless he quit his job.
Since the shipyards were closing after sixty days,
he elected to chance it that much longer. We
have another patient at present who has been a
telephone operator for twenty-four years. She
has a marked loss of hearing which may be from
her work. She is only a year from retirement
and pension, and is, therefore, also loathe to quit.
The treatment of toxic nerve deafness is, of
course, the removal of the cause. If damage
by disease such as mumps or meningitis is suf-
ficiently severe, deafness will be permanent.
Summary
Deafness is a health problem of first magnitude.
That which is caused by infections can be very
largely prevented by proper treatment of the in-
fections. Sequelae of middle ear infection can-
not always be successfully treated ; however, much
can be accomplished, especially in schools, in de-
termining the presence of the handicap and giving
the individual appropriate consideration in class
work.
Otosclerosis is an inherited disease of unknown
etiology. No cure is known. However, through
the fenestration operation many victims can have
hearing restored to a practical useful level and
can be rehabilitated.
Nerve deafness of the usual type is a difficult
problem. Cause and cure are both unknown.
For the present, the patient must be satisfied with
a hearing aid and lip reading. Occupational and
toxic nerve deafness can be largely prevented.
Reference
1. Schilling, C. W., and Everly, I. A.: U. S. Navy M. Bull.,
664-685, (July) 1942.
646
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CLINICAL-PATHOLOGICAL CONFERENCE
INFLUENZAL MENINGITIS
Report of Five Cases
S. N. LITMAN, M.D., R. P. BUCKLEY, M.D., and A. H. WELLS, M.D.
Duluth, Minnesota
Dr. A. H. Wells : The remarkable effectiveness of
streptomycin, particularly when supported by rabbit
antiserum and sulfonamide therapy in the treatment
of Hemophilus influenzae meningitis, and the desirability
of certain laboratory controls over this therapy, make
this a very appropriate and timely subject for our con-
ference. There are five case studies of this disease from
our two hospitals to be described.
Case Reports
Dr. S. N. Litman : M.S., a two-year-old white girl,
was first seen by me on the day she was admitted to the
hospital, December 15, 1946. She had been having a
head cold for several days, but she was not considered
ill. On the night before admission, she became quite
fretful and appeared to be running a fever. She was
awakened at 2 A.M. by vomiting. This symptom was
repeated several times during the night ; and, on the
following day when I first saw her, there was an as-
sociated fever reaching 105.2° F. She was distinctly
listless and somewhat dehydrated. Her breathing was
shallow and her pulse rapid. There was no rigidity of
the neck or spine, and the cause of the fever was not
apparent. She was given Hartman’s solution and 5
per cent glucose, cold sponge baths, 10,000 units of
penicillin every three hours, and aspirin, grains 2. A
flat x-ray plate of the chest revealed slight increased
markings consistent with bronchitis. The white blood
cell count was 8,600 with 73 per cent neutrophils, 23
per cent lymphocytes, and 3 per cent monocytes. The
hemoglobin was 11.1 grams and the red blood cell count
3,800,000. Her temperature fell to 100° F. and ranged
up to 101° F., occasionally reaching 102° F. On the
second hospital day, she was very listless and ground
her teeth continuously. Again there were no positive
signs of meningeal infection. However, on the third
hospital day (December 17, 1946) there was definite
neck rigidity as well as stiffness of the spine. An
immediate spinal fluid examination revealed a cell count
of 2,111 with 100 per cent neutrophils present, sugar
15 milligrams per cent, protein 55 milligrams per cent,
and chlorides 750 milligrams per cent. Many Gram-
negative bacilli morphologically and tinctorially typical
of H. influenzae were found in the direct smears.
Later cultures substantiated the organism identification.
Two hundred milligrams of streptomycin were given
intrathecally once daily and 225 milligrams were injected
every three hours intramuscularly. She was also given
From the Clinical-Pathological Conference of the Duluth
Pediatric Society, Dr. E. E. Barrett, president.
Clerical Assistance by Miss Faith A. Gugler.
June, 1947
5 grains of sulfadiazine every four hours. The daily
spinal taps remained positive for H. influenzae until a
culture of the spinal fluid on February 21, 1947, was
sterile. A total of 1,400 milligrams of streptomycin were
given intrathecally and 12,600 milligrams intramuscu-
larly. It was discontinued on the seventh hospital day.
On February 20, 1947, the patient was given 10 c.c. of
Hemophilus influenzae type B rabbit antiserum in 100
c.c, of normal saline intravenously. She had a severe
chill, and her fever reached 105.2° F. There was also
cyanosis for which 0.4 c.c. of adrenalin was given. The
10 c.c. of antiserum was repeated the following day
without a reaction. The patient followed a turbulent
course from marked stupor to severe restlessness, to a
state of extreme negativism. Feeding was very diffi-
cult at. times. However, the intake of fluids was main-
tained, and the child was given 250 c.c. of blood. The
penicillin therapy was discontinued after four days, and
the sulfadiazine was discontinued on February 29. It
had reached a level of 10 to 21 milligrams per cent in
the blood. Her rather low-grade fever returned to nor-
mal on February 20, and remained there. Her recov-
ery was complete, and she had no residual symptoms
some months after her illness.
Dr. R. P. Buckley : My first patient, W. M., was
admitted to the hospital on June 16, 1946, and expired
on June 19, 1946. This five-year-old boy had ridden
in a car from Saint Phul to Duluth on the day before
admission with his head constantly held out of the car
window. He was ill that evening with a frontal head-
ache and a temperature of- 102° F. The following
morning he had a sudden chill, and his fever reached
106° F. He was delirious and his neck muscles were
stiff. He vomited twice and complained of headache
over the forehead. The physical examination revealed
a rigid neck and back muscles, cervical lymph adenopa-
thy, a few rales in the bases of the lungs, and a positive
Kernig’s sign. Twenty-five cubic centimeters of spinal
fluid were opalescent, and a cell count showed 1,121
neutrophils and 23 lymphocytes. The spinal fluid sugar
was 90 milligrams per cent, protein 350 milligrams per
cent and chlorides 806 milligrams per cent. A few
Gram-negative bacilli were found in direct smears which
were later proved culturally to be H. influenzae. He
was given 50,000 units of penicillin immediately and
20,000 units every three hours, together with sulfa-
diazine, grains 15 immediately and grains 7.5 every
four hours. As soon as the pleomorphic Gram-negative
bacilli were found in the spinal fluid, 25,000 micrograms
647
CLINICAL-PATHOLOGICAL CONFERENCE
of streptomycin were given intrathecally and 125,000
inicrograms were given every three hours intramuscu-
larly. There followed a convulsion, cyanosis, and a fall
in blood pressure to 82/60 following the intrathecal
injection. No more streptomycin was available the
following day (June 17). The patient was given H.
influenzae type B rabbit antiserum in divided doses
during this day, and the streptomycin therapy was re-
sumed in the evening. On the third hospital day (June
18), he was given a blood transfusion. The spinal
fluid contained H. influenzae, and there were 40 milli-
grams per cent sulfadiazine present. His temperature
was ranging between 100° and 103° F. It fell off to
102° F. on June 19, and his spinal fluid became sterile.
However, he expired rather suddenly and unexpectedly.
The postmortem examination, performed by Dr. Wil-
liam Knoll, revealed a purulent exudate throughout the
meninges and a small amount of clotted blood in the
meninges at the base of the brain.
My second patient was not so ill fated. She, K.T.,
was an eleven-month-old infant who was admitted to
St. Mary’s Hospital on February 27, 1947, and was
discharged on March 23, 1947, in good health. She
had become ill on February 23 with a fever, some vom-
iting, and one loose stool. These symptoms persisted
for two days when they disappeared except for some
listlessness. On February 26 there was a temperature
elevation of 103° F. She took very little liquid food
during the day. On February 27 she was admitted to
the hospital with a rectal temperature of 107° F., a
moderately stiff neck, soft fontanels, rolling eyeballs,
extreme dehydration, listlessness, and was obviously
acutely and seriously ill. An immediate smear of the
spinal fluid revealed typical plemorphic Gram negative
bacilli permitting the immediate use of 12,500 micro-
grams of streptomycin intrathecally and 1 gram every
twenty-four hours in divided doses of approximately
125,000 micrograms per dose. The spinal fluid had a
white blood cell count of 6,388 with 91 per cent neu-
trophils and 9 per cent lymphocytes, sugar 15 milligrams
per cent, and chlorides 790 milligrams per cent. There
was 75 per cent hemoglobin and a white blood cell
count of 13,600 with 55 per cent neutrophils, 36 per
cent lymphocytes, and 6 per cent monocytes. The in-
fant was also given sulfadiazine, grains 7.5 every eight
hours subcutaenously. Daily spinal fluid examinations
revealed a rapid disappearance of the organisms and a
return of the spinal fluid sugar to normal in six days.
The severe fever had subsided on the second hospital
day, after which it ranged from 99° to 103° F. for two
weeks, following which it fell gradually to normal.
The fever and the cell count in the spinal fluid both
remained elevated during the administration of the
streptomycin. There was, however, a gradual shift of
the cells in the spinal fluid from a neutrophil pre-
ponderance to ultimately 90 per cent lymphocyte pre-
ponderance. The infant was sent home on March 23,
almost a month after admission, without residuals.
Case Reports
Dr. R. E. Nutting: My three-and-a-half-year-old
girl patient, P.L.P., was admitted to the hospital on
November 21, 1946, and discharged as cured on De-
cember 18, 1946. She was apparently in good health
until three days before admission when she developed
a high fever, nausea, vomiting, apathy, and listlessness.
On the day before admission her neck became stiff.
The physical examination on admission revealed an
acutely ill, well-nourished child with a stiff extended
neck, who cried out whenever moved. There was opis-
thotonos, painful flexion of the rigid neck, congested
throat, cold sores about the nose, and a painful bilateral
positive Kernig’s sign. The spinal fluid revealed 8,100
neutrophils and Gram-negative rods which on culture
proved to be H. influenzae. There were 12.5 milli-
grams per cent sugar and 400 milligrams per cent pro-
tein in the spinal fluid. The infant was given 200 milli-
grams of streptomycin intrathecally and 2 grams intra-
muscularly in eight divided doses. She was also given
penicillin, 30,000 units immediately and 20,000 units
every three hours, as well as sulfadiazine, grains 20.
The streptomycin was given daily intrathecally and in-
tramuscularly until its discontinuance on November
28. The sulfadiazine was discontinued on December 3.
The patient suffered from pains in her legs and feet
and had a peculiar difficulty in holding her head up.
There were shaky, jerky movements of the head which
gradually subsided. Her temperature gradually rose
during the first five days to 104.5° F. and then sub-
sided during the following five days to 99.5° F. and
remained normal after three weeks in the hospital. The
spinal fluid became negative for H. influenzae on Novem-
ber 30, when the sugar was 40 milligrams per cent and
the protein 45 milligrams per cent. There were no re-
siduals at the time of discharge.
Dr. C. H. Schroeder: My patient, T.A.B., a nine-
month-old boy infant, was admitted to St. Luke’s Hos-
pital on January 21, 1947, and discharged “well” on
February 2, 1947. This infant had been ill for about
two weeks before admission. The principal symptoyns
were nausea and vomiting, associated with cough and
rhinopharyngitis. Other children in the family had
similar infections. I had seen him once at the resi-
dence about a week before admission. He had received
some sulfadiazine before admission.
For some days before he came in, the mother had
noticed pain and soreness in the muscles of the back
and especially of the left shoulder. There also seemed
to be pain in the legs, in fact, generalized tenderness
on handling.
He was very listless on admission, held his legs flexed
and abducted, while his hands clutched his head. The
neck and back were extremely rigid and the Kernig
strongly positive. The heart and lungs were negative.
There was some diffuse tenderness of the abdominal wall
but no rigidity. He was immediately placed on penicillin
(20,000 units every three hours) and also was given
sulfadiazine by mouth.
A lumbar puncture (January 21, 1947) showed a pres-
sure of 270 millimeters of water. Queckenstedt test was
negative. The fluid was just noticeably turbid. There
were 248 red blood cells, 87 white blood cells, 62 per cent
lymphocytes, and 38 per cent neutrophils. Sugar was
97.6 milligrams per cent and the protein 80.4 milligrams
648
Minnesota Medicine
CLINICAL-PATHOLOGICAL CONFERENCE
per cent. A direct smear revealed numerous Gram-nega-
tive bacilli morphologically suggestive of H. influenzae.
A culture was made. On January 22, he was given
streptomycin intrathecally. The intended dose was 100
milligrams but through error 200 milligrams was given.
That evening the baby seemed a little brighter and
was less rigid. Direct typing revealed typical capsular
swelling with anti-H. influenzae type B rabbit typing
serum. He was given a second intrathecal injection of
100 milligrams streptomycin. He was also given a small
dose of influenza virus vaccine intradermally (0.1 c.c.).
On January 23, the baby passed a good night and took
feedings well. A lumbar puncture that morning showed
a less turbid fluid. The pressure was not measured but
apparently was lower. The white blood cell count of
the spinal fluid was 309 ; the red blood cell count was 14;
chlorides were 700 milligrams per cent. With some mis-
givings a third dose of streptomycin was given intrathe-
cally. A couple of hours later the baby had a severe and
almost fatal reaction. He became unresponsive, and the
respirations became very slow and irregular. Oxygen
was given and a small dose of coramine was injected
subcutaneously. He did not improve and the respirations
dropped to 6 or 8 per minute. At 3 P.M. artificial
respiration had to be given. At 4 P.M. an attempt was
made to pass an intrathecal catheter after a small dose
of alpha lobeline was given. We did not succeed in
passing the catheter, but the stimulation aroused the
baby. He became more conscious, the respirations picked
up, and thereafter he steadily improved. After this
ordeal, it was noted that his skin presented a blotchy
appearance and that a definite exophthalmos was present.
The following day (January 24) he was taking his
feedings well and playing with a rattle. Opisthotonus
was still marked and a peculiar chorea-like muscular
activity was noted. No further intrathecal therapy was
given but streptomycin was resumed intramuscularly,
alternated with penicillin. This was continued for one
week. The temperature became normal on the seventh
hospital day, and the baby was discharged on the thir-
teenth day, perfectly well. To this date (April 5, 1947)
he has remained well.
I would like to add that he owes his recovery to the
painstaking and persistent efforts of Dr. R. A. Mac-
Donald, intern. I feel that our intrathecal doses were
somewhat too large and that the third one should not
have been given. On January 24 no organisms were seen.
The concentration test revealed 20 milligrams of strepto-
mycin per cubic centimeter of spinal fluid.
Clinical Manifestations
Dr. R. P. Buckley: Influenzal meningitis ranks among
the first three causes of suppurative meningitis in chil-
dren, the other two being meningococcus and pneumo-
coccus meningitis. The clinical manifestations of H.
Influenzae meningitis do not differ significantly from
the other types of suppurative meningitis, although there
may be less evidence pointing to meningeal involvement.
There are fulminating cases, fatal within forty-eight to
seventy-two hours, and at the other extreme there are
infections of very low grade nature lasting for weeks.
These are frequently difficult to diagnose because of their
June, 1947
incipient nature. The condition is particularly difficult
to recognize in infants under seven months since the
meningeal signs frequently do not develop in this group
until late. The disease tends to be seasonal, occurring
in the first half of the winter,12 mainly during November,
December, and January. About 50 per cent of the cases
of influenzal meningitis are associated with otitis media,
and 10 per cent have an arthritis. Laryngotracheitis,
pneumonia, and eighth nerve deafness8 have also been
noted in association with influenzal infections.
Laboratory Aids
Dr. A. H. Wells : Where other facilities are not
available, the simple demonstration of a Gram-negative,
delicate, small, pleomorphic bacillus is sufficient evidence
to start streptomycin therapy. There are, however, addi-
tional laboratory procedures which are considered of
the utmost importance by the best authorities.
1. The Gram-negative rods must be tinctorially and
morphologically distinguished from pneumococcus, men-
ingococcus, and streptococcus since the organism is pleo-
morphic and frequently occurs as a diplococcus. Good
Gram stains are essential.
2. The immediate identification of H. influenzae type B
is possible by the capsular swelling test with rabbit anti-
influenzal serum mixed directly with the spinal fluid.
This Neufeld-quelung reaction is identical with that for
pneumococcus typing. Since the great majority of in-
fluenzal meningitis is due to type B of Pittman, the test
is quite useful. The types A, C, D, E, and F are un-
common and specific antiserum therapy is not so effica-
cious as that for type B infection.
3. The specific soluble capsular substance can be
demonstrated in the spinal fluid at the interface over
one cubic centimeter of diagnostic anti-B serum.1
4. The organism can be identified as H. influenzae by
its growth requirements of hemoglobin.
5. The sensitivity to streptomycin of the strain of
organisms isolated can be tested with varying concen-
trations of the drug, so that the concentration of strepto-
mycin necessary to kill the organism can be determined.
This generally runs from 1.2 to 12.5 units per cubic centi-
meter.
6. The spinal fluid levels of streptomycin during therapy
can be determined and should be maintained between
25 and 130 units per cubic centimeter.4
7. Similarly the sensitivity of the strain of H. in-
fluenzae to sulfonamides, antisera type B, and even peni-
cillin can be determined to advantage. Also, the titers
of these antibiotics in blood or spinal fluid can be deter-
mined without much difficulty.
8. Blood cultures are positive in approximately 70 per
cent of the cases.14
9. Daily spinal fluid studies for the organism, chemical
analyses, and cellular reactions are considered essential
to the proper therapy of this disease, whereas in me-
ningococcic meningitis one spinal tap may prove adequate.
10. Alexander considers the determination of spinal
fluid sugar of fundamental importance in the treatment.2
She feels that this is an indicator of the severity of the
infection and gauges' the intensity of antiserum and anti-
biotic therapy by this test.
649
CLINICAL-PATHOLOGICAL CONFERENCE
The daily spinal fluid tests should continue until the
cultures are negative for several days and the sugar levels
return to normal. One should be alert to the occasional
complication of secondary invaders, especially Staphy-
lococcus aureus, in the meninges and blood stream.14 The
intrathecal streptomycin may result in an elevation of
cell count and protein possibly as the result of irritation
of the meninges due to this drug, and this pleocytosis
may persist in spite of the disappearance of the bacteria.
Therapy
Dr. S. N. Litman : It is interesting to review the
effectiveness of various forms of therapy of influenzal
meningitis advocated during the last decade. Without
therapy, H. influenzae meningitis is considered from
92 to 100 per cent fatal in all age groups. Infants and
younger children are particularly susceptible to the dis-
ease. Anti-influenzal horse serum was thought to reduce
the mortality slightly. Alexander’s rabbit serum proved
to be the first of the more practical forms of therapy
in that it reduced the mortality as much as 26 per cent.14
When the sulfonamides were introduced, there was an-
other efficacious agent which when combined with rabbit
antiserum reduced the mortality another 20 per cent.2-12
There are a few reports of the use of 10 milligrams of
heparin intrathecally in cases resistant to therapy, on
the theory that the fibrinous exudate may be partially
dissolved, permitting entrance of the drugs. With the
discovery of streptomycin, it was soon learned that this
drug was the most efficacious of any thus far advocated
for H. influenzae meningitis, reducing the mortality to
approximately 20 per cent. Streptomycin alone in the
case of average severity is considered adequate.1’2 How-
ever, in cases of greater severity the therapy should also
include rabbit antiserum and sulfadiazine. Some strains
of H. influenzae are sensitive to penicillin.2 However,
this antibiotic generally fails and is not to be considered
unless the more efficacious forms of therapy are in use.
Antiserum alone has been curative in seven out of eight
cases.3
In the use of streptomycin, it is essential to use large
initial doses to avoid producing a drug-resistant strain
in an otherwise sensitive strain. An organism inhibited
by 3.9 units of streptomycin can suddenly become resis-
tant to 250 units per cubic centimeter if permitted to be
exposed to nonlethal doses of the drug. For this reason
a repeat of the laboratory test of sensitivity of the organ-
ism to streptomycin may be indicated on occasions in a
patient not responding properly. Alexander et al1'2 used
approximately 20,000 units per pound for twenty-four
hours, given continuously intramuscularly in sodium
chloride or interruptedly intermuscularly every three
hours at 50,000 units or less per injection. A daily intra-
thecal dose of 25,000 to 50,000 units is considered neces-
sary. Toxic reactions to streptomycin include erythema,
urticaria, augmentation of meningeal signs, persistence of
phlebocytosis, local pain in injection, and mild shock
on initial administration. As described above, two of
our presented cases had rather severe shock reactions
from which they recovered.
Summary
We have presented five cases of Hemophilus influenzae
meningitis, in four of which there was recovery. In all
cases streptomycin and sulfadiazine were used, and in
some anti-influenzal type B rabbit serum and penicillin
were used. It would seem that we now have a means of
combating this disease which not so long ago represented
one of the hopeless types of infection.
There is a brief discussion of clinical recognition,
laboratory controls, and therapy.
References
1. Alexander, H. E. : Treatment of influenzal meningitis. Con-
necticut M. J., 6:167-173, (Mar.) 1942.
2. Alexander, H. E. : Treatment of type B Hemophilus in-
fluenzae meningitis. J. Pediat., 25:517-532, (Dec.) 1944.
3. Birdsong, M.; Waddell, W. W., Jr., and Whitehead, B. W.:
Influenzal meningitis- Am. T. Dis. Child., 67:194-198, (Mar.)
1944.
4. Birmingham, J. R. ; Kaye, Robert, and Smith, M. H. D.:
Streptomycin in the treatment of influenza meningitis. J.
Pediat., 29:1-13, (July) 1946.
5. Donovick, R. : Hamre, D. ; Kavanaugh, F., and Rake, G. :
A broth dilution method of assaying streptothricin and strep-
tomycin. J. Bact., 50:623, (Dec.) 1945.
6. Doyle, J. T.: Meningitis due to Hemophilus influenzae: a
report of 2 cases successfully treated with penicillin and
sulfadiazine. North Carolina M. J., 7:473-475, (Sept.) 1946.
7. Ide, A. W., Jr.: Influenzal meningitis. Minnesota Med.,
27:816-819, (Oct.) 1944.
8. Logan, G. B., and Herrell, W. E. : Streptomycin in the
treatment of influenzal meningitis of children. Proc. Staff
Meet. Mayo Clin., 21:393-400, (Oct. 16) 1946.
9. Netter, E. : Observations on Hemophilus influenzae (type
B) meningitis of children. T. Pediat., 20:699-706, (June)
1942.
10. Nussbaum, S.; Goodman, S.; Robinson, C., and Roy, L. :
Influenzal meningitis. J. Pediat., 29:14-19, (July) 1946.
11. Pittman, M.: Variation and type specificity in bacterial
species Hemophilus influenzae, f. Exper. Med., 53:471-492,
(Apr.) 1931.
12. Scully, J. P., and Menten, M. L. : Treatment of influenzal
meningitis with anti-influenzal rabbit serum and sulfapyridine.
T. Pediat., 21:198-206, (Aug.) 1942.
13. Smith, M. H. D.; Wilson, P. E., and Hodes, H. L. : The
treatment of influenza meningitis. J.A.M.A., 130:331-335,
(Feb. 9) 1946.
14. Weinstein, L. : The treatment of meningitis due to H.
influenzae with streptomycin. New England J. Med., 35:101-
111, (July 25) 1946.
BABIES POISONED BY WELL WATER
Minnesota physicians are warned of the possibility of
poisoning in young infants by nitrates in well water.
Two cases of such poisoning have recently been reported
to the Department of Health by physicians in western
Minnesota.
In one case, a 14-day-old girl died after a two-day
illness. The other case was that of a newborn infant
who was in good health when discharged from the hos-
pital but became very cyanotic ten days later. The phy-
sician stated that the findings in the case indicated a
methemoglobinemia possibly due to the nitrate content
of the well water used in preparing the baby’s food. At
the request of the doctor, the Health Department in-
vestigated the well and found that the water contained
a high concentration of nitrate nitrogen.
The poisoned infants are described as being cyanotic
and lethargic, and chemical analysis of their blood
showed a markedly increased concentration of methemo-
globin. The treatment given was a one-per-cent solu-
tion of methylene blue.
Poisoning caused by nitrates in well water seems
most likely to occur if the water comes from shallow
wells not properly located and constructed and therefore
subject to contamination by products of organic de-
composition. The Minnesota Department of Health
wishes to determine the incidence of nitrate poisoning
and the situations in which water of high nitrate con-
tent occurs. Any physician having a case in which pois-
oning from nitrates in well water appears likely may ask
for a field investigation by the Health Department.
650
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Case Report
CHRONIC ULCERS OF THE LEG ASSOCIATED WITH CONGENITAL
HEMOLYTIC JAUNDICE
H. O. SKINNER. M.D.
Saint Paul. Minnesota
rT,HE occurrence of chronic ulceration of the legs
complicating congenital hemolytic jaundice is still of
sufficient rarity and interest to justify reporting. Tay-
lor5 reported, in 1939, the first case of such an ulcer
at the Presbyterian Hospital, New York, among forty-
three patients suffering from this disease who had been
carefully observed for a number of years. Meulen-
gracht, in his careful study of thirty-four cases, makes
no mention of it.
A specific relationship between these two conditions
has not been generally recognized. Standard medical
textbooks and special articles either make very little
reference to the ulceration as a possible complication
to the hemolytic jaundice or ignore it altogether. Thus
Brenizer1 in a presentation of six cases of the jaundice
with a very thorough analysis and discussion of them,
says of one of them merely, that the patient “had two
ulcers of the left leg that healed after splenectomy.”
Gannssleri2 was one of the first to note this compli-
cation and its permanent recovery after splenectomy, al-
though he claimed no priority in this, and most of the
cases reported are from German or Scandinavian coun-
tries.
Taylor’s report5 gives an excellent summary and he
has found reports of “at least seventeen cases” with
ulceration.
Since then I have found in the literature only one ad-
ditional case. This was reported by Lowe4 who stated
that the patient’s past history disclosed an ulcer which
required three months for healing, before the hemolytic
jaundice was recognized. Krueger3 reported five cases
of hemolytic jaundice with no ulcerations but in his com-
ments recognized the rare occurrence of them and their
resistance to all treatment until splenectomy is done.
The reasons for accepting a specific relationship rests
on three grounds :
1. The ulcers are characteristic. They occur about
the malleolar areas. They are usually single, though
multiple ulcers are found in cases of long standing.
Trauma may or may not be an etiological factor but
they begin with a bluish discoloration which breaks
down in the center forming eventually an ulcer 3 to 5
cm. in diameter with punched-out but not undermined
edges ; with a yellowish slough in the center and cir-
cumscribed by a zone of bluish cyanosis. There is
usually much pain. They are indolent and respond
very poorly to all the usual treatments for ulcers.
2. They are not found in other states of severe
Presented before the Southern Minnesota Medical Association,
Manakto, Minnesota, September, 1946. Dr. Skinner received
the SMMA bronze medal award for this contribution.
June, 1947
anemia, secondary or primary, excepting in sickle cell
anemia which, incidentally, bears some resemblance to
that of hemolytic jaundice.
3. They heal with startling rapidity, and permanently,
after the spleen is removed.
Case Report
Mrs. J. W., aged twenty-four, a housewife, was in
the third month of her first pregnancy when I first
saw her in March, 1944. The diagnosis of congenital
hemolytic jaundice was suggested by her pallor and en-
larged spleen ; confirmed by her blood examination and
history ; and proved by her very complete recovery
after splenectomy.
Family History. — Her mother and one brother have
always been anemic. The mother has an enlarged spleen
which has never been removed although she has been
advised repeatedly to submit to this operation.
Past History. — This is irrelevant except that the pa-
tient has always been anemic and her spleen was found
to be enlarged when she had pneumonia at the age of
twelve. She has had spells of weakness, abdominal pain
and slight jaundice which may have been mild attacks
of hemoclastic crises. At these times, she thinks she
has been helped by liver. Also she has had three bouts
with indolent ulcers about her ankles. The first one
came in 1937 over the internal malleolus of her left leg,
as the result of scratching some mosquito bites. In
spite of various treatments and surgical closure, this did
not heal for eight months. In 1941 a similar ulcer oc-
curred over the external malleolus of the same leg.
This she attributed to the same cause, though similar
scratches elsewhere healed without infection. With bed
rest, elevation, and hot packs, this ulcer was made to
heal in two months. In September, 1943, after a bicycle
trip, the old area over the left internal malleolus broke
down and a new one appeared over the external malleo-
lus of the other leg. This did not heal for over three
months. The patient had been urged frequently to sub-
mit to splenectomy but had always refused to do so.
Physical Findings.— -These were essentially normal ex-
cept as follows : The spleen was enlarged and extended
3 inches below the costal arch ; it was firm and not
tender. The liver was not enlarged. The sclera showed
occasionally a slight tinge of yellow. There were scars
on both ankles from the ulcers referred to.
Blood Findings. — Wassermann test, negative; Group
IV; Rh positive; hemoglobin 9.8 gm. ; red blood cells,
2,950,000; white blood cells, 14,800; differential count,
polymorphonuclears 68, lymphocytes 20, monocytes 4,
eosinophiles 8, microcytosis (spherical type) 4 plus (hy-
perchromic), polychromatophilia 2 plus, anisocytosis 1
plus.
The fragility test showed increased fragility: hemol-
ysis began below .50 with complete hemolysis at .30;
control hemolysis began at .44, with complete hemolysis
at .34. Recticulocyte count was 4.1 per cent.
(Continued on Page 663)
651
History of Medicine In Minnesota
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester, Minnesota
(Continued from May issue)
Luke Milier, who was to become a prominent pioneer physician and citi-
zen in two communities of Fillmore County, Chatfield and Lanesboro, was
born at Peterborough, New Hampshire, on August 18, 1815. Presumably
his early education was obtained in Peterborough; in 1841 he was graduated
from the University of Vermont, at Burlington, and in 1844 he received his
medical degree from the Vermont Medical College, at Woodstock, Vermont.
Early displaying political acumen and ability, in the year of his gradua-
tion from medical school Dr. Miller was elected to the House of Representa-
tive from his native district and, postponing the beginning of his profes-
sional career, he served two years in the state legislature. On completion
of this term, in 1847, he began the practice of medicine in the county of his
birth. After ten years, in which he achieved a reputation as a good physician
and surgeon, he moved to the Middle West and in 1857 settled in Chatfield.
There, according to Andreas’ Historical Atlas of Minnesota of 1874, “he soon
found himself overrun with business, as a physician and surgeon, and he
gave himself up to the demands of his profession,” conducting his own prac-
tice and co-operating with his fellow physicians, among whom were Dr.
Isaac S. Cole, Dr. Refine W. Twitched, Dr. Nelson W. Allen and Dr. Augus-
tus H. Trow.
Dr. Miller’s professional interests extended beyond the actual care of the
sick. Soon after his arrival in Chatfield he began lecturing on anatomy,
physiology and hygiene to the students at the Chatfield Academy, an ex-
cellent institution which had been founded in 1856, and he presumably con-
tinued this work until the academy was superseded after a few years by
the schools of the state.
In 1862, in Minnesota, the problem of institutional care for the insane
first was considered officially, and in 1866, in Governor William R. Mar-
shall’s administration, legislation provided for a hospital for insane, which
was established that year at St. Peter, at first. in temporary, rented buildings.
Of the board of trustees of six members, Dr. Luke Miller (listed as of Rush-
ford) was one of the three who were appointed to serve six years. The Preston
Republican of January 4, 1867, carried the following pertinent item :
Twenty-one lunatics, ten males and eleven females, passed through Rochester on Thursday
of last week, says the Post, en route for the temporary State Asylum at St. Peter. They
were closely guarded by several officers from this state, Dr. Miller of Chatfield and others,
and were being removed from the Iowa State Asylum, where they have been temporarily
kept during the last year.
652
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HISTORY OF MEDICINE IN MINNESOTA
And further, as regards his office as trustee, at the third semi-annual meeting
of the Minnesota State Medical Society, held in Minneapolis on June 13
and 14, 1871, “Dr. Luke Miller of Lanesboro extended a cordial invitation
to the society to visit the Insane Asylum at St. Peter, on the occasion of the
next annual meeting. Accepted.”
When the Fillmore County Medical Society was founded in 1866 (some-
times given 1862) “for mutual benefit, and particularly to increase the medi-
cal knowledge and skill of the members,” Dr. Miller was a charter member
and he thereafter was active in the organization. In 1868 his name appeared
in the news of the society, to the effect that the president, Dr. R. W. Twitchell,
would give an address at the regular annual meeting to be held at Preston
on June 8 and that Dr. Luke Miller would give an essay “after the regu-
lar business of the society has been attended to.” In 1869 he was one of the
delegates to the annual meeting of the Minnesota State Medical Society.
Busy as he was professionally, Dr. Miller was not so engrossed that he
could not become closely concerned with civic and political affairs. A man
of such definite personality and ability could not avoid some degree of enmity,
and his changing political affiliations made him a target for acrimonious
comment, since, it has been said, he was a Democrat, a Republican, a member
of the People’s Party, and again a Republican in rapid succession. Shortly
after his arrival in Chatfield, he was defeated, on the Democratic ticket, for
the office of state senator, and also for membership on the local board of
supervisors. In 1858 he was elected a trustee of the school board of Chat-
field, to serve one term, and later, from 1860 to 1861 and from 1864 to 1867,
inclusive, he again held the office. In the meantime, in 1860, he once more
knew defeat, on the Republican ticket, in the village as candidate for the
office of justice of the peace and in the state as senator. In 1861, however,
still a Republican, he was elected state senator and so well did he fill the office
that he was returned on three successive elections.
In the early period of the Civil War Dr. Miller’s declaration that he was
in favor of fighting until every Negro should be free, even if all whites were
annihilated, drew down on his head the expressed wrath of the Chatfield
Democrat (issue of September 21, 1861). During the war Dr. Miller served
as medical examiner for the draft board. The Preston Republican of Sep-
tember 12, 1862, carried the following item:
Exemption : Dr. Miller, surgeon for the county, finished his labors Tuesday of last week
and left the remainder of the applicants in the hands of Dr. Lafayette Redmon. We under-
stand that a. good many persons of foreign birth are still coming forward to make oath to
the effect that they have never declared their intention of becoming citizens of the United
States. No examinations to date.
Later he was appointed state agent to care for sick and wounded soldiers,
a duty that he performed skillfully and kindly. In the issue of the Republican
for June 17, 1864, it was stated that Dr. Miller was going south to visit the
sick and wounded soldiers from Minnesota, and in August, 1864, there ap-
peared further comment: Dr. Miller had been appointed by the Governor to
go on this visit, he had had access to military hospitals, and had brought
back with him, for the information and comfort of the soldiers’ families,
lists of the men he had seen.
With other public-spirited citizens of Fillmore County, Dr. Miller was
influential in the building of the Root River and Southern Minnesota Rail-
road (later called the “Southern Minnesota”), between La Crosse, Wiscon-
June, 1947 ,
653
HISTORY OF MEDICINE IN MINNESOTA
sin, and St. Peter, Minnesota, originally planned to run through Chatfield,
and for three years he held the office of treasurer and vice president of the
road. Although the railway company first was incorporated in 1855, the
work of construction proceeded slowly. In the chapter devoted to railroads
in the History of Fillmore County of 1882 appears the sentence: “As to
the last land grant from Congress in 1866, without which the road could
not or would not have been extended west of Houston, perhaps the most
credit should be given to Charles D. Sherwood, Dr. Luke Miller, C. G.
Wykoff, and D. B. Sprague, who joined their fortunes with the enterprise
at the reorganization in 1865. The village of Lanesboro, which originated
in consequence of this railroad, was platted in 1868.”
The founding of Lanesboro, a railroad enterprise of which Col. Thomas R.
Brayton was agent, about forty miles west of the Mississippi River, perhaps
represented a new challenge to Dr. Miller, for he moved to that village in 1869
and thereafter devoted himself to promoting the welfare and prosperity of the
community. It seems probable, however, that his long-continued interest in the
railroad, the fact that he was still serving as one of its officers, and his disap-
pointment that Chatfield did not realize its hopes from the road, took him to
Lanesboro. Possibly it was in anticipation of this change that Dr. Miller, in
1867 or earlier, established an office in Rushford (ten miles northeast of Lanes-
boro), which, until 1869, was the western terminus of the railroad; his name
appears in the Minnesota Railroad and River Guide for 1867-1868, in the portion
devoted to physicians of Rushford : “Luke Miller, South Side.” Apparently
a mail of some substance financially, Dr. Miller was cashier of the Chatfield bank
in the early sixties and was rated by a commercial agency, in 1872, as a good
risk (the possessor of $20,000 or more). In fact, a distinguished resident of
the county, who was a young man when Dr. Miller was at the height of his career,
has recalled that “Dr. Miller was doubtless a good physician and he certainly
was a capable financier; in those times if one had a little money and knew how
to handle it he could get along. The rate of interest then was 3 per cent a month.”
And the doctor knew how to handle his money, if the experience of a certain
pioneer settler, a Maine Yankee, was typical, for this man once borrowed $100
from Dr. Miller and, it has been said, “it cost him a yoke of steers and forty acres
of good timber land before he got rid of the debt.”
After his removal to Lanesboro Dr. Miller continued his activities for nearly
twelve years. From time to time, in various connections, civic, social, political
and professional, his name appeared in the newspapers and an occasional item
has been preserved in histories of Fillmore County, as thus: “In August, 1877,
Dr. D. F. Powell [he who was called by the Indians ‘White Beaver’] was bitten by
a rattlesnake at the Big Spring, two miles from Lanesboro. On his return. Dr.
Luke Miller prescribed the formula which has kept in fashion so long as a panacea
in such cases, R. spiritus frumenti, ad lib., and the doctor recovered.” Notes
are found that at one time Dr. Miller served as village constable; as postmaster;
as treasurer of the local order of Odd Fellows ; that on the organization of the
Old Settlers of the Southern Tier of Counties of the State of Minnesota, on Oc-
tober 21, 1878, he served on the program committee.
When Dr. Miller arrived in Chatfield in 1857, he was accompanied by his wife,
Abbie D. Miller, of his own age, a native of Vermont, and their two children,
Luke L. and Jennie A., both of whom were born in Vermont. Although Dr.
Miller’s year of birth has come down in various accounts as 1815, a census of
1857-1860, taken at Chatfield, listed both him and Mrs. Miller as forty-seven
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HISTORY OF MEDICINE IN MINNESOTA
years old; the son Luke was eight years old and Jennie was four. Luke L.
Miller, for many years, throughout his adult life, was a resident of Chatfield.
Jennie A. Miller became the wife of Professor Gorman of St. Cloud.
Dr. Miller died in Lanesboro on July 12, 1881, and was buried with Masonic
rites and honors. There follows an excerpt from an obituary included in the
History of Fillmore County of 1882 :
His final earthly home was at Lanesboro, but he belonged quite as much perhaps in Chat-
field or in New Hampshire, the scene of his early triumphs, and in the county and state
which he loved and served so well. He was an upright man, an officer above corruption and
of good business qualities ; and as a skilled surgeon and physician he had a wide reputation.
Russell Lucretius Moore was a native of northeastern Ohio, born at Mont-
ville, Geauga County, on December 31, 1843. When he was nine years old his
parents moved with him to Michigan and soon after to Grant County, Wisconsin.
In the graded schools of this community he completed his early education before
entering the Platteville (Wisconsin) Academy. At the opening of the Civil War
he enlisted in the Seventh Wisconsin Volunteer Regiment of Infantry, which was
part of the well-known Iron Brigade of the Army of the Potomac, and served with
it four years, until after the end of the war. He achieved the rank of adjutant.
At the Battle of Spotsylvania Court House, on May 12, 1864, he received wounds
that incapacitated him and confined him to a hospital in Philadelphia for four
months.
On receiving his final discharge from the army, Russell Moore returned to
Platteville and there began the study of medicine under the preceptorship of George
W. Eastman, M.D., in preparation for entering Rush Medical College in Chicago.
During this period, on October 7, 1867, he was married to Elizabeth Howdle ; in
1869, immediately after receiving his degree from Rush, Dr. Moore brought his
wife to the village of Forestville, in the township of that name in Fillmore County,
where he began his professional life. His card appeared regularly in Western
Progress, the newspaper of Spring Valley, and in the Preston Republican. In
1869 also, on June 23, Dr. Moore joined the Masonic Blue Lodge of Preston; he
formerly had belonged to the Masons of Plattevile. In February, 1871, he settled
in Spring Valley and by December 25, 1872, his card announced him as physician,
surgeon and obstetrician, “office and residence in brown house, Griswold’s Addition,
north of the depot.”
It has been stressed that pioneer physicians, at all hours and in all seasons, faced
the hazards of poor roads. Dr. Moore was one who sustained a serious accident
in the course of a professional drive at midnight in June of 1870. On the narrow
road that rounded the bluff just west of Forestville he met a team that crowded
him off the edge so that he, his horses and vehicle rolled over and over down to
the bottom of a steep incline, a distance of about twenty-five feet, all three receiving
considerable damage. “Dr. Redmon” said the describing reporter “is attending
his professional brother and says it will be some weeks before he will be able to
resume practice.”
Dr. Moore, from all records, was a well-trained, intelligent, conscientious
physician who served his community in various professional capacities and who
gave his patients the best medical and surgical treatment available and sought for
better. That he was sued, in 1881, for malpractice, through malice, apparently, did
him no great harm and it was announced pointedly, editorially in the National Re
publican of Preston in the following summer, that Dr. R. L. Moore of Spring
Valley would not move to another field of usefulness as rumor had reported; that
June, 1947
655
HISTORY OF MEDICINE IN MINNESOTA
his practice was large and increasing; and that uterine surgery was one of his
specialties in which he wTas well posted and reliable.
From January 6, 1870, to March 26, 1872, Dr. Moore was county coroner.
He early became a member of the Fillmore County Medical Society (organized
in 1866) and was its president when, in 1879, the group suspended activity, the
officers holding over; in a record of 1882 Dr. Moore was mentioned as the last
president of the society. It is interesting that in October, 1882, he called a meeting
for the purpose of reviving the organization.
Soon after he arrived in Minnesota, Dr. Moore became a member of the Minne-
sota State Medical Society and the record of his work with the organization from
1870 to 1889, inclusive, is to his credit. He attended meetings regularly and he
held office: for several terms, beginning in 1878, as corresponding secretary, and,
in 1883, as third vice president; in this year also he was one of the delegates
to the annual meeting of the American Medical Association. He served on many
different committees, on some of them more than once : ethics, gynecology, medical
education, practical medicine, obstetrics, surgery, the use and abuse of alcohol,
diseases of the nervous system, diseases of children, epidemics, membership,
orthopedic surgery, nominations for chairmen of sections, and medical juris-
prudence (its chairman). The reports that he sent in reply to questionnaires from
committees of the state society on the treatment of specified diseases or surgical
conditions were concise and sound ; and the occasional letters asking for advice
and help that he wrote to men of special experience and knowledge were intelligent
and modest. One worthy of note is that written in April, 1883, to A. Blitz, M.D.,
of Minneapolis, chairman of the Committee on Ophthalmology', for it concerns
a field in which Dr. Moore had increasing interest :
In response to your circular I have the pleasure to say that as a country surgeon and
physician I am quite often called to treat diseases of the eye. During the year last past
I have not seen a single case of ophthalmia neo-natorum. I have seen a few cases in my field
in other years past. It certainly is of rare occurrence in this locality. I look upon it as an
aggravated form of purulent conjunctivitis. Am I right? I see a considerable number of
catarrhal, purulent and granular conjunctivitis (trachoma). Next in frequency is iritis,
and phlegu-tenular conjunctivitis. Keratitis is seen almost as frequently as the last two.
I try to make a correct diagnosis of each case as it presents itself. I try to treat each case
properly. I try to see more than simply “sore eyes,” for which the same unvarying nitrate
of silver “eye water” is given, as is the manner of some “medicine men.” What do you
think of the treatment of some of these diseases by the “dry method?” I have found it of
great benefit. A powder something like the following I have found very useful : Iodoform r
Hydrang. clilor. Nietis; Sach Alba . . . equal parts. (Formula as printed in Transactions.)
Triturate long and well in a wedgewood mortar. Sift a little into the eye off a camel’s
hair brush two or three times a day. Perhaps you will smile at my idea of these things.
I am aware that many specialists have a thought that the general practitioner knows but
little or nothing of the diseases which fall into his special line, but from sheer necessity the
said general man of all work, the “country doctor,” often treats some of these cases with
as fine results as are ever achieved by the specialist. In all our small towns and villages
there are always people who cannot afford to go from home to consult gentlemen of your
class. These people some of us must treat. We wish to do it well. Give us all the light
you can upon these common diseases of the eye in your forthcoming report.
An ardent advocate of measures promoting- sanitation and public health, Dr..
Moore co-operated actively and faithfully with the State Board of Health, as
a private physician and, in the middle eighties, as local health officer. It speaks
well for him and for his townsmen that they gave him willing support in this
work. Excerpts from his reports on diphtheria were used in the notes on medical
656
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
history in Fillmore County which preceded the present series of biographical
sketches.
In 1883, after the “Diploma Law” to regulate medical practice in the state was
passed, Dr. Moore received license No. 149 (R) on October 13 and filed it in
the county on October 19.
Not by inclination a politician, but evidently willing to serve the state as well
as the community, Dr. Moore was a candidate for the state legislature, according
to a county history, in 1875 and 1878. On a Republican ticket in a Democratic
district, it was not surprising that he was defeated both times, first by a Democrat
and next by a Greenbacker, and that he thereupon decided that he had had enough
of politics.
After practicing in Spring Valley for twenty-nine years, in 1889 Dr. Moore
moved to Lincoln, Nebraska; in the early or the middle nineties he returned, how-
ever, to devote the remainder of his active life to specialization in diseases of
the eye and ear. He died in Spring Valley on August 13, 1902 ; his wife’s death
had occurred earlier ; there were no children.
J. J. Morey (sometimes Morrey), an eclectic practitioner, is known to have
been in Fillmore County from the late sixties into the early seventies, and
it is likely that he practiced in the county over a longer period, beginning
perhaps in the fifties.
In 1869, when eclecticism became established in Minnesota (the Minnesota
State Eclectic Medical Society was organized on May 26; the Southern Min-
nesota Eclectic Medical Society on November 14), a small group of Fillmore
County practitioners organized the Fillmore County Eclectic Medical Society,
as has been described, and of this group J. J. Morey (Morrey) was a member
and an officer. If Dr. Morey was a resident of Preston in 1869, he soon moved
to Spring Valley where, early in 1870, he had become established in associa-
tion with Dr. M. G. Pingree, with offices in the Rogers Drug Store. The
partnership was short-lived, for in August, 1870, J. J. Morey, physician and
surgeon, had settled in Etna, a village in the southeastern corner of Bloom-
field Township, which adjoins Spring Valley Township on the south. Dr.
Morey was still practicing in Etna in the spring of 1871.
W. (?) Morrison, an herb doctor, was early in Chatfield and vicinity, part
of the time on a near-by farm south of town, part of the time, in the eighties,
a resident of the village, in the “Durgan-Halloran” house. He’is remembered
as a contemporary of Dr. Augustus H. Trow (“Old Doc Trow”), who was
in Chatfield from 1856 to 1887, inclusive. It is said that sometimes the two
men were called on cases together, and that occasionally Dr. Morrison was
summoned in the absence of Dr. Trow. One venerable citizen has recollected
in detail the treatment, as it appeared to him, administered to him by Dr.
Morrison for lung fever; namely, the giving of herb medicine “to draw the
poison out of the lungs to the legs,” and the care of the supposedly resultant
lesions of those members by washing with more herb medicine; also of his
curing Bright’s disease when the patient, a young girl, had been given up
by other physicians. Other senior residents of the village, however, have
recalled Dr. Morrison with faint praise; “but none of them (medical prac-
titioners) knew much in those days.”
That for many years, however, this practitioner played a part in the life
of the community, as a “doctor” and as a participant in civic affairs, notably
at the proceeding at town meetings, is unquestioned. There is still quoted
June, 1947
657
HISTORY OF MEDICINE IN MINNESOTA
with delight his retort to the village atheist, at an important civic gathering
at which the location of the new Elmira town hall was to be decided. This
atheist had been contending belligerently that the hall must be placed within
the borders of the village of Chatfield rather than a mile or more north of the
settlement as some of the Elmira farmers wished, and he declared loudly into
Dr. Morrison’s somewhat deaf ears his intention of leaving the community
forever unless the new hall were placed according to his desire. Dr. Morrison
inquired gently, “Where will you be going, sir?” which to his hearers savored
of subtle humor as referring to destination in the hereafter.
On February 26, 1886, there died in Elmira Township, Olmsted County,
in which part of the village of Chatfield lies, William Morrison, “doctor,”
married, native of New Hampshire, at the age of seventy-eight years.
In a business directory of 1896-1897 a Dr. W. A. Morrison was listed as in
Chatfield. It appears likely that this entry referred to Dr. W. S. Morrison,
of Fremont, Winona County, some fifteen miles to the northwest of Chatfield,
who over a period of years maintained an office in Chatfield and practiced
in the village two days a week, driving back and forth between the two towns.
(Because of his practice in Fillmore County and because through an apparent inadvertence,
only a few lines about Dr. William Shaw Morrison appeared in the notes on medical history
in Winona County that were published in Minnesota Medicine in 1940, a brief sketch of
this interesting and well-qualified physician follows.)
William Shaw Morrison, although usually remembered as a pioneer physi-
cian of Winona County, where the greater part of his life was spent, is claimed
by Fillmore County also as a practicing physician of the early days. So large
and so far distant did his following become in Fillmore County that he found
it well, as has been stated, because those were literally horse and buggy days, to
maintain offices in Chatfield, a village of both Fillmore and Olmsted Counties.
William S. Morrison was born in Waddington, New York, in 1840, the son
of The Reverend and Mrs. John Dow Morrison, both of whom were natives of
Keith, Scotland; John Dow Morrison came to this country in 1838 to become
pastor of the United Presbyterian Church of Waddington. There were three
other children in the family: John, who became a physician of Winnipeg, Canada;
James Dow, doctor of divinity and doctor of laws, Bishop of the Protestant
Episcopal Church, with residence at Ogdensburg, New York; and Maria Jane,
a teacher of piano in Waddington.
William Morrison received his early education in the schools of Waddington
and later attended Huntington Academy, in Canada. His formal medical training
he obtained at McGill University, Montreal, from which he was graduated in
1865. In the following two years he served an internship at the Montreal Hos-
pital and began his practice of medicine in Waddington.
Some years previous to his graduation in medicine, a group of his father’s
parishioners had gone into the Middle West, to settle at Fremont, Winona County,
Minnesota, and in 1867, when the community was in need of a physician. Dr.
Morrison at the urging of these old friends joined the community, to devote his
care and skill to them and to the settlers of a widespread surrounding territory.
He drove from Waddington, New York, to a port on Fake Michigan, where he
embarked for Milwaukee, Wisconsin, shipping his Morgan mare on the boat;
from Milwaukee he drove to Fremont over almost impassable roads.
In 1884 Dr. Morrison opened an office in the village of Fewiston, Winona
County, a few miles north of Fremont, and it is remembered well by residents of
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HISTORY OF MEDICINE IN MINNESOTA
Chatfield, that over a considerable period in the eighties and nineties he had an
office in that village and observed there a regular consulting schedule two days
a week. But whatever the conditions of his medical practice, he always resided at
his farm home a mile from Fremont. After the enactment of the “Diploma
Law” of 1883 he practiced under an exemption certificate and was listed in the
official register of physicians of the state as a member of the regular school of
medicine.
Among the physicians of a later generation who remember Dr. Morrison well
are Dr. Conrad A. Neumann, of Winona, and Dr. George B. Eusterman, of
Rochester, both of whom were residents of Lewiston when Dr. Morrison was in
his prime. Dr. Eusterman has described Dr. Morrison as a dark-complexioned,
short, stocky man; energetic, vigorous to the point of being athletic; of fine
personal and professional appearance ; of a genuine, cordial kindness that won
him friends and kept them; a man who during his sixty years of service to his
neighbors and friends became a vital factor in the well-being and growth of his
community.
In 1869 William S. Morrison was married to Margaret Ferguson of Fremont;
Mrs. Morrison died in 1909. Of the marriage there were eight children, six
boys and two girls. Two of the sons died in early childhood. When Dr. Mor-
rison’s death occurred in July, 1928, there were six living children: John, of
Witoka ; Kenneth Reid, of Minneapolis; James Dow, of Winona; William Shaw,
of Evanston, Illinois, and Maria Morrison Henry and Harriet Morrison, both of
Fremont ; and one brother, The Right Reverend James Dow Morrison, of Ogdens-
burg, New York. In 1943 all of this group were living except Bishop Morrison,
who had died in January, 1934.
William Shaw Morrison died at the age of eighty-eight years, after a life
filled with service ; although age forced him to retire from active practice a few
years before his death, up to his last year many of his old patients still came to
his home for advice and medical attention. Dr. Morrison was a life-long member
of the Masonic Lodge of Lewiston. He was buried from the Scotch Presby-
terian Church of Fremont with Masonic rites at the grave. The whole com-
munity mourned the passing of an able physician whose professional activities
had spanned the years from 1867 to 1928.
(To be continued in the July issue)
June, 1947
659
Preside h t s Heite>i
THE ANNUAL MEETING
The acquisition of knowledge is accomplished only by great labor. It must be sought
before it can be acquired and only individuals who are willing to exercise sufficient effort
to gain knowledge can become the authors of new ideas. Often such ideas or discoveries
possess an importance which it is impossible to exaggerate. However, unless and until such
ideas are accepted and such discoveries are adopted, they can exercise small influence and
can accomplish little benefit. Believing in this doctrine, the physicians of Minnesota hold a
scientific meeting each year. This great traditional assemblage brings together the physicians
of Minnesota and other states in order that they may continue their efforts to advance medical
knowledge and medical science. Opportunity is provided for discussion which may eventuate
in solution of certain of the perplexing problems of organized medicine and possibly in a
more capable medical profession.
A high ideal has been maintained by the Committee on Scientific Assembly. An earnest
attempt has been made to provide a program which will prove attractive and beneficial to
members of the Association and its guests. The scientific program includes papers and lec-
tures of superlative quality on important, vibrant topics. Those who will participate in the
program are members of our own Association and well-known authorities from other states.
In addition to the general assembly, special sectional meetings will be held on the morning
of each of the three convention days and on Monday and Tuesday afternoons. On Monday
morning the Minnesota Academy of Ophthalmology and Otolaryngology is sponsoring a pro-
gram, and in the afternoon there will be a special symposium on rheumatic fever. Tuesday
morning features discussions on the subject of orthopedic surgery, and the American College
of Chest Physicians meets on Tuesday afternoon. A special symposium on research prob-
lems is scheduled for Wednesday morning.
A program of demonstrations has been arranged for each intermission and immediately
preceding and following each scientific session. These include gross pathologic specimens,
presented by the Minnesota Society of Clinical Pathologists ; roentgenologic diagnosis and
interpretation by members of the Minnesota Radiological Society; obstetric manikin demon-
strations, and, in addition, a demonstration on Rh blood-testing procedures and blood-com-
patibility testing in connection with one of the scientific exhibits. Other scientific exhibits
will be provided by Association committees, hospitals, societies and governmental departments.
These exhibits will provide information on the various services available and the progress
which is being made.
Round-table luncheons have always provided an excellent opportunity for an exchange of
ideas and opinions. This year they will occupy a prominent place in the program of the
second and third days of the meeting.
The commercial exhibits will attract and deserve your attention ; well-informed representa-
tives will be present to discuss with physicians the latest developments in their particular
Wednesday afternoon has been set aside for consideration of the problem of medical serv-
ice in rural areas. Members of allied health organizations, social welfare workers, school
authorities, representatives of farm, professional, and civic groups have been invited to this
part of the meeting, and we hope that they as well as others interested in this problem will
attend this informative portion of the program.
In these confusing years there is great need for the sort of opportunity which this annual
meeting affords. As usual, the meeting will mark the climax of another year’s work. Those
who participate in the program have worked diligently and will present their reports, hoping
that they may provide information which will be of assistance to other members of the pro-
fession. Every member of the Association is urged to participate in the deliberations of the
meeting. Only by discussion can our experience be interpreted properly and a wide under-
standing of its application be attained.
fields.
President, Minnesota State Medical Association
660
Minnesota Medicine
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
STATE MEETING
ASA STATE medical association we are ac-
quiring age and dignity. This year’s meet-
ing in Duluth will be the ninety-fourth annual
get-together, and according to the advance regis-
trations will be a large gathering. The program
which has been mailed to each member and which
also appears in this issue speaks for itself.
The annual meeting of our state medical as-
sociation serves as a real stimulus to the members
of the profession of the state, not only to those
who listen but perhaps more to those who present
the scientific program. The meeting also affords an
opportunity for everyone to talk shop in off hours,
to meet others with common interests and to
renew acquaintanceships. The out-of-state speak-
ers who are recognized in their special fields serve
to prevent too much provincialism in our scien-
tific thought. That the medical profession appre-
ciates the value of our annual meeting is shown
by the yearly attendance.
Our Duluth hosts have arranged an informal
entertainment for members and their wives for
Monday night. The annual banquet Tuesday
night will be addressed by Mr. Tom Collins of
Kansas City, who has a reputation as an eminent
speaker on public affairs, and by Dr. Louis A.
Buie, president of our association.
Remember the date — Monday, June 30.
MINNESOTA MEDICAL SERVICE. INC.
VER $85,000 has been paid to Minnesota
Medical Service, Inc. This is a sufficient
amount to develop and carry on the Medical Serv-
ice Program.
The Board of Directors decided at the last meet-
ing held May 27, 1947, that no further contribu-
tion will be accepted after July 1, 1947, and that
all members of the Minnesota State Medical As-
sociation who have not sent in their check by that
date are honorably relieved of remitting their
pledge.
Minnesota Medical Service, Inc., will have a
booth at the state meeting in Duluth where all
June, 1947
information can be obtained. Acceptance agree-
ments will be available whereby physicians agree
to provide medical service according to contract.
A complete report of the progress of Minne-
sota Medical Service, Inc., will be given on Sun-
day, June 29, at the meeting of the House of Dele-
gates.
THE BELL LECTURESHIP AND THE
MINNEAPOLIS X-RAY SURVEY
h I * HE Bell lecture by Dr. Herman E. Hille-
boe was the opening gun which started the
Minneapolis community-wide chest x-ray' sur-
vey. Our lecturer was a distinguished Minnesotan
who1 received his common school and medical
education and much of his training in tuberculosis
while in this state. That he came back to his
home state to launch the first community-wide
chest x-ray survey in any large city in the coun-
try, was especially appropriate. But the greatest
import of the occasion was that from his com-
prehensive knowledge of the tuberculosis prob-
lem he was enabled to give unexcelled guidance
to us, and to all who contemplate mass attacks
against chest diseases.
He also brilliantly represented one of the chief
participants in the Minneapolis survey, the United
S.tates Public Health Service. He w*as for some
years the Director of Tuberculosis Services of
this bureau, and is now the Assistant Surgeon
General and Associate Chief of the Bureau.
Dr. Hilleboe’s discussion of recent evaluations
of the accuracy of roentgenographic diagnosis of
chest plates will startle most doctors. It is evi-
dent from this study that chest films, both large
and small, are after all only a part of the process
of complete chest and heart diagnosis. One might
best consider the filming process with the small
film to be only a crude first sifting process. Only
through this medium, however, can we separate
from the general population that small percentage
of individuals upon whom it is feasible to con-
Dr. Hilleboe’s address, entitled “Community- Wide Chest X-Ray
Surveys and the General Practitioner,” appears in this issue.
661
EDITORIAL
cent rate our clinical and laboratory efforts, in-
cluding the use of larger x-ray film.
In a recent editorial on chest surveys in this
Journal, there was a timely admonition that many
cases in this smaller group will have healed tuber-
culosis and should not be subjected to active
treatment. It might well have been said also that
until the true seriousness of the lesion has been
proven, intelligent and gentle handling of such ap-
prehensive patients should be the aim of all of us.
It is equally true that earliest diagnosis of lung
tumors and early appraisal of activity and con-
tagiousness of active tuberculosis cases, followed
by active treatment and isolation, are of tremen-
dous importance, both to the patient and to the
public at large.
Dr. Hilleboe has attempted to answer one of
the problems most disturbing to us who planned
the Minneapolis survey, and that is the probabil-
ity of swamping our excellent and up-to-this-time
adequate county sanatorium facilities. Some of
his suggestions as to selection of patients for
sanatorium care have been planned and adopted
by E. S. Mariette, Superintendent of Glen Lake
Sanatorium. Increase of facilities, medical serv-
ice, and nursing personnel await more adequate
financing by the governmental units involved, and,
at best, will not be available when first needed.
In view of the inability of the sanatorium to
carry on its customary study of x-ray positive
cases, much of this follow-up work will have to
be done by the medical profession and outpatient
clinics. Even many active cases will have to be
treated by home care and home isolation until
sanatorium shortages can be corrected.
Dr. Hilleboe has stressed the importance of tu-
berculin testing, sputum and gastric washing cul-
tures of those who show lesions on the large
film, suggesting active tuberculosis.
The Medical Technical Committee of the sur-
vey, in close co-operation with Dr. Hilbert Mark
of the State Board of Health, Dr. Frank Hill,
City Health Commissioner, and Dr. E. S. Mari-
ette, Superintendent of Glen Lake Sanatorium,
have planned for increased laboratory facilities to
provide smears and cultures of sputum and gas-
tric washings. Limited facilities for overnight
hospitalization and gastric lavage at Glen Lake
Sanatorium are offered by its management. All
arrangements for gastric washings by the doctors
of private patients can also be made by calling
the City Health Department tuberculosis control
office.
The committee appeals to the profession for co-
operation in reporting their findings and diagno-
ses, not only in tuberculous cases as required by
law, but in all chest and heart lesions. These sta-
tistics will be of important scientific medical in-
terest only if most reports are received.
The success of any chest survey depends to a
great extent upon the percentage of the population
that responds to the appeal to have a chest x-ray.
The intelligent use of the latest laboratory proce-
dures for diagnosis and determination of activity
is also of great importance. However, most of
us realize that gentleness, ability, and persistence
of the doctor in handling patients, plus his clini-
cal skill in interpreting symptoms, physical find-
ings, and laboratory procedures, and, most of all,
his diagnostic ability, are still the most important
part of any x-ray chest survey. One could only
wish that all of us might be possessed to some
degree at least of these excellent qualities that
were so often exhibited by our great teachers and
physicians of the past generation — which qualities
were so truly exemplified by Dr. J. W. Bell, in
whose honor Dr. Hilleboe presented his momen-
tous address.
Charles E. Merkert, M.D.
Chairman, Medical Technical Committee,
Minneapolis Chest X-ray Survey
RESEARCH PROFESSORSHIP IN
RHEUMATIC FEVER
THE American Legion of the State of Minne-
sota is embarking on a campaign which it has
termed the “Minnesota Project.” According to
this plan, it is proposed to give aid to those wffio
study heart disease and rheumatic fever of chil-
dren.
A committee of prominent legionnaires has met
with the dean of the medical school and the presi-
dent of the University of Minnesota. Together
they have formulated plans to establish at the
University of Minnesota, a professional chair,
the occupant of which will direct research in heart
disease and rheumatic fever of children. To
maintain this chair in perpetuity, as a memorial
to veterans of World Wars I and II, the commit-
tee expects to secure a half million dollars from
members of the American Legion of the State of
Minnesota.
This undertaking deserves the support of the
Minnesota State Medical Association. Every phy-
662
Minnesota Medicine
EDITORIAL
sician, with the knowledge which he possesses
concerning rheumatic fever and its relationship to
heart disease, can offer his services to Legion posts
and can assist in stimulating the interest of legion-
naires and other citizens in his community.
L.A.B.
MEDICAL ETHICS IN VETERANS PROGRAM
T NSTANCES of unethical or questionable prac-
tices by physicians have recently come to light
in connection with the Minnesota Veterans Medi-
cal Service program. These practices were the
subject of discussion at a meeting May 14 of
the Operating Committee of the Veterans Medical
Service Division of the Minnesota State Medical
Association.
Inasmuch as the veterans medical service pro-
gram was inaugurated in this state to provide
veterans with the same high quality medical care
that private patients receive, it is indeed unfor-
tunate when veterans are over-treated or care-
lessly treated. This practice of over-treating is
making neurotics out of many veterans.
Cases have been found by the Committee
where certain doctors have reported and claimed
payment for medical care never rendered and
have falsified records to show nonservice-con-
nected disabilities as being service-connected.
The procedure of the Operating Committee in
each instance of a breach or suspected breach of
ethics is first of all to notify the physician by
letter in order to give him a chance to clear him-
self. If this warning is ignored, the Committee
then refers the case to the Councilor in the doc-
tor’s particular district. The Operating Commit-
tee has been given unlimited policing power by
the Council of the State Medical Association.
The Committee recommends that doctors in
treating veterans should conduct themselves at
all times so that they will not in any way lay
themselves open to criticism later. Reports sub-
mitted should always be complete, accurate and
truthful. Upon this good faith depends the suc-
cess of the entire program.
Honesty is one of the most important qualities
of human character, and is an essential in a
member of the medical profession. A strange
quirk in human make-up lies in the fact that a
man who is quite honest in other human relations
will be as crooked as a dog’s hind leg in dealing
with his government. Honesty is a quality which
is not limited in its application.
June, 1947
It is our humble opinion that medicine, and or-
ganized medicine in particular, has no place for
crooks. In the interest. of maintaining the fair
name of our organization, members who are
guilty of these dishonest practices as disclosed by
our Operating Committee should be deprived of
membership in their county societies.
CHRONIC ULCERS OF THE LEG
(Continued from Page 651)
This constituted a typical picture of congenital hemo-
lytic jaundice.
Possibly pregnancy in such a case also is rare ; at least
I could find nothing on this subject in the medical lit-
erature. Apparently there is nothing more to be done
than to be prepared for a hemoclastic crisis and re-
member that these patients do not take kindly to trans-
fusions of whole blood. Accordingly, I carried this pa-
tient on expectantly, giving first the liver which she
had been taking with no obvious benefit, and then stop-
ping it, with no untoward results, but continuing the
routine calcium and the vitamins. The pregnancy was
uneventful.
Labor occurred on the two hundred and eighty-fifth
day and was normal. There was no crisis or other
complication and only a moderate perineal laceration,
which healed without difficulty. The patient went home
on the tenth day. She led a very active life with vary-
ing icterus but her red cell count continued under three
million and her hemoglobin ran about 8 gm.
About March 1, 1945, she developed another ulcer, this
time over the right external malleolus, from causes un-
known. She treated it herself for three weeks before
calling on me. By then the ulcer was 2 cm. in diameter,
was punched out but the edges were not elevated or
undermined. There was a yellowish gray base and
a purplish surrounding areola. There was little dis-
charge and little pain. My treatment was no more suc-
cessful than that of my predecessors but I was more
successful than they in persuading her to have the spleen
removed.
This was done on May 11, 1945. The spleen was
found to weigh 900 gm. Surgical recovery was excellent
and the patient went home on the ninth day.
The response of the blood picture and ulcer was spec-
tacular. From the day before the operation to that of
her discharge, nine days later, the red blood cells
jumped from 2,950,000 to 3,990,000, and the hemoglobin
from 7.9 gm. to 12.7 gm. The ulcer, covered only with
vasoline, took on a healthy appearance at once, was
nearly healed at the end of her hospital stay and the
last scab dropped off in less than a month.
The patient has enjoyed exuberant health ever since
then, has had another baby (born August 26, 1946) and
has had no trouble of any kind at the site of her ulcers.
Conclusions
Chronic ulcerations about the malleoli seem to bear
a specific relationship to chronic hemolytic jaundice and
are healed very rapidly and permanently by splenectomy.
References
1. Brenizer, Addison G. : Hemolytic jaundice. Ann. Surg.,
111:998 (Dec.) 1940.
2. Gannsslen, M. ; Zipperlen, E., and Schuz, E. : Hemolytic
constitution. Deutsches Arch. f. klin. Med., 146:1-46, (Tan.)
1925.
3. Krueger, J. T. : Familial hemolytic jaundice. Texas State
J. Med., 40:520, (Feb.) 1945.
4. Lowe, Robert G. : Study of hemoglobin, metabolism and
hematology, et cetera. Am. J. M. Sc., 206:347, (Sept.)
1943.
5. Taylor, Earl S. : Chronic ulcer of the leg associated
with congenital hemolytic jaundice. J.A.M.A., 112:1574,
(April 22) 1939.
663
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
COUNCIL APPROVES ADDITIONAL
ORTHOPEDIC CLINICS
In order to provide more adequately for the
1,800 rural Minnesota indigent poliomyelitis pa-
tients who are known to need follow-up care, it
has been found necessary to set up more ortho-
pedic clinics in the state.
Dr. Edwin J. Simons, chief of the medical serv-
ice unit of the Division of Social Welfare, has
appeared before the Council of the Minnesota
State Medical Association and has received its
approval for holding four additional orthopedic
clinics each spring and fall and permission to ask
patients to come to the centers for follow-up
examinations when necessary.
All of these clinics are held only with the ap-
proval of the local medical society of the partic-
ular district, and only those patients are seen
at the clinic who are referred by their family
physicians.
In a survey made some time ago, Dr. Simons
reported, it was found that one out of 138 pa-
tients was able to pay. The Social Welfare di-
vision investigates each case, and those that are
able to pay in whole or in part for their care,
are asked to do so.
Physicians Request Clinics
In asking approval for the additional clinics,
Dr. Simons said that physicians of the state in
the different districts have asked for these clinics
and the approval of the medical societies con-
cerned will be secured before the clinics are held.
Reporting plans for these additional clinics, Dr.
Simons said that it is very desirable to have a
clinic at Virginia because of the considerable
number of polio cases on the Range; one at Fari-
bault is in prospect in order to have some dis-
position in the southern part of the state. It
is also expected to hold one in Cambridge and
one in Thief River Falls, Dr. Simons said.
The Sister Kenny method has prolonged the
follow-up care of polio patients, Dr. Simons re-
ported ; where patients used to go to the hospitals
during the entire period until they were dis-
charged some months later, he said, they are now
kept under physiotherapy for months and years,
and the hospital costs are much higher.
In Dr. Simons’ opinion, it is necessary to es-
tablish these additional clinics to solve this prob-
lem. Dr. Simons assures the medical profession
that the work is being done in each instance for
the improvement of medical practice. It is im-
possible to get enough physiotherapists, he says ;
therefore, it is necessary to ask patients to come
to the centers. This involves less expense and
less trouble; the National Foundation for In-
fantile Paralysis will help cover the cost.
COUNTY SOCIETY OFFICERS PLAN
NATIONAL CONFERENCE
In an effort to make the American Medical
Association the working partner of every in-
dividual physician, the AMA is planning a Na-
tional Conference of County Medical Society
Officers, to be held Sunday, June 8, at 2:30 p.m.,
in Hotel Traymore, Atlantic City, just prior to
the opening of the AMA Centennial Convention.
Dr. B. O. Mork, Jr., of Worthington, secre-
tary of the Southwestern Minnesota Medical
Society, is a member of a special committee which
was appointed to arrange for the conference.
This is the first conference of this type ever
attempted, and it is hoped that a permanent or-
ganization may grow out of it, an organization
through which it will be possible for all members
of the medical profession to work more easily
together in solving common problems and which
will bring the AMA closer to every member.
It has been decided that this first conference
should concentrate on local problems, that it
should last three hours and that, insofar as possi-
ble, everyone present should have opportunity to
find out just what goes on and how the facilities
of medical organization — national, state and local
— may be made available to the individual doc-
tor.
664
Minnesota Medicine
MEDICAL ECONOMICS
Question and Answer Plan
The committee hit upon the workshop ques-
tion and answer conference as the most effective
type of program. According to preliminary plans,
here is how the program has been set up :
On stage will be a panel of twelve persons
familiar with subjects under consideration, to
answer questions. Also available will be the of-
ficers and heads of the AMA’s various depart-
ments. Questions will come from the floor in
regard to any subject having to do with medical
organization problems. All questions must be
written and may be submitted before or during
the meeting. Members of the committee will
process the questions, and the moderator will
designate the person or persons who can throw
light upon the particular subject under discussion.
To allow for discussion on a variety of subjects
and answers on as many questions as possible,
each speaker will be limited to three minutes for
discussing the question put to him.
Suggested topics for discussion are professional
relations, which includes such problems as the
functions and duties of county society officers,
hospital staff problems and the doctor in rela-
tion to specialty boards, postgraduate education
and legislation ; medical service, including pre-
payment plans, rural health, labor union pro-
grams, et' cetera, and public relations, including
relations between the doctor and the individual
patient and the doctor and the general public.
PERSONAL DEBTS PERIL
PATIENTS' BUDGETS
American consumers are going into debt twice
as fast as in any other period in history, accord-
ing to a recent bulletin from the Institute of Life
Insurance. Goods are being bought on credit at
an all-time record rate.
This is perhaps only natural, the bulletin notes,
since people have waited a long time to buy some
of the items that are just beginning to come back
on the market since the end of the war.
However natural the trend is, it is well worth
taking note of it. For the extent of the increased
use of credit raises the question of whether some
people may not be undermining their own well-
being and financial security by going into debt too
heavily in relation to their prospective income.
It also points to the fact that budgets and paying
abilities of each individual doctor’s patients are
being STRETCHED TO THE BREAKING
POINT !
Total Debt Nears 1929 Peak
At the end of 1946, the total personal debt in
this country had reached an estimated high of
39.6 billion. That is only 1.1 billion from the
peak of 40.7 billion in 1929, just before the crash
came.
That means that this country is nearing a dan-
gerous breaking point, that the time has come
for caution in not extending credit too freely and
not letting accounts slide. Laxity now in making
collections may mean a loss of a good share of
income. Physicians everywhere would do well to
watch this trend closely for their own protection.
$3,000,000 MAYO MEMORIAL
VIRTUALLY ASSURED
If Minnesota residents will subscribe a final
$350,000 needed toward a total of $3,000,000,
the construction of an outstanding medical cen-
ter at the University of Minnesota, dedicated to
the memory of the late Drs. Will and Charles
Mayo, will be assured.
Recent action by the State Legislature in grant-
ing an appropriation of $750,000 practically as-
sures the fact that a Mayo Memorial research
center will materialize. Funds already raised in-
clude $750,000 granted by the 1945 Legislature
and $1,162,000 subscribed by more than 3,000
corporations and individuals.
Plans for the memorial provide for a central
19-story tower unit. The building will be con-
nected with the medical sciences building by a
four-story extension, which will house the Mayo
Memorial auditorium, with a seating capacity of
six hundred.
The main building will also be connected with
the students’ health service, the outpatient de-
partment and Elliot and Todd sections of the
hospital.
To Contain School of Public Health
According to an announcement by the Com-
mittee of Founders, the Mayo Memorial will con-
tain the school of public health and the medical
library, and enough hospital beds to help lighten
the load on University Hospitals and to contribute
to research and training.
The Committee of Founders, authorized by
resolution of the 1943 Legislature, includes the
following: James F. Bell, Earle Brown, Walter
Burdick, Mrs. George Chase Christian, Frank T.
Heffelfinger, Jay C. Hormel, Raymond J. Jul-
June, 1947
665
MEDICAL ECONOMICS
kowski, George W. Lawson, Ward Lucas, Leo
D. Madden, Archbishop John Gregory Murray,
Charles N. Orr, I. A. O’Shaughnessy, Mrs. Ma-
beth Hurd Paige, Dr. Edward L. Tuohy, Dr.
Donald J. Cowling, chairman, and Dr. George
Earl, secretary.
MINNESOTA STATE BOARD OF MEDICAL
EXAMINERS
230 Lowry Medical Arts Building
Saint Paul, Minnesota
Julian F. Dubois, M.D., Secretary
LICENSE OF MINNEAPOLIS PHYSICIAN REVOKED
FOLLOWING PLEA OF GUILTY TO MAN-
SLAUGHTER CHARGE
Re State of Minnesota vs. Harry Gilbert, M.D.
On April 23, 1947, Harry Gilbert, M.D., forty-nine
years of age, with offices at 547 Medical Arts Bldg.,
Minneapolis, entered a plea of guilty in. the District
Court of Hennepin County to an information charging
him with the crime of manslaughter in the first degree.
Dr. Gilbert was arrested on March 14, 1947, following
the death of a twenty-two-year-old unmarried Min-
neapolis girl at a Minneapolis hospital. Dr. Gil-
bert had performed a criminal abortion on the
decedent on March 4, 1947, for which he was paid the
sum of $300. The abortion was performed by the use
of a catheter. The patient became critically ill but
was not removed to a hospital until March 12, at which
time the defendant had the patient admitted as a pa-
tient of his brother, Dr. Maurice Gilbert, 330 W. Broad-
way, Minneapolis. Neither the hospital nor the legal
authorities were notified by the defendant or his brother.
However, on the date of the decedent’s death the Min-
neapolis Police Department was notified of the facts
and the body was removed from a Minneapolis mor-
tuary to the Hennepin County morgue where a post-
mortem examination disclosed the true facts. Dr.
Harry Gilbert was immediately arrested and signed a
confession admitting the abortion on the decedent, and
also admitting that he had performed numerous other
criminal abortions.
The Hon. Levi M. Hall, Judge of the District Court,
ordered the defendant to surrender his basic science
certificate to the Basic Science Board for cancellation
and his medical license to the State Board of Medical
Examiners for permanent revocation. Dr. Gilbert sur-
rendered both documents in open court, with a signed
authorization for their cancellation and revocation, re-
spectively, endorsed on the back of each instrument.
Thereupon, Judge Hall sentenced the defendant to a
term of not to exceed five years at hard labor in the
State Prison, stayed the sentence and placed the de-
fendant on probation for the same length of time. Judge
Hall warned the defendant that notwithstanding the
punishment of the permanent loss of his medical license
and basic science certificate, that if there was any
further violation of the laws of this State, the Court
would make a further order revoking the stay of sen-
tence and committing the defendant to the State Prison.
At the regular meeting of the Minnesota State Board
of Medical Examiners held on May 16, 1947, Dr. Gil-
bert’s medical license was formally revoked. Dr. Gil-
bert’s basic science certificate has been delivered to the
Basic Science Board for cancellation by that Board.
MANKATO DENTIST AND ACCOMPLICE
PLEAD GUILTY TO ABORTION CHARGE
Re State of Minnesota vs. W. A. Groebner
Re State of Minnesota vs. Raymond E. Older
On May 24, 1947, Dr. Willard A. Groebner, twenty-
four years of age, licensed to practice dentistry in
the State of Minnesota, entered a plea of guilty in the
District Court of Blue Earth County, Minnesota, to an
information charging him with the crime of abortion.
Groebner, who maintained a dental office in the City of
Mankato, was arrested on March 25, 1947, on a com-
plaint issued in the Municipal Court of Mankato, charg-
ing him with the crime of abortion. The complaint
charged Groebner with performing a criminal abortion
on a twenty-four-year-old unmarried Fairmont girl on
March 21, 1947. The patient died three days later after
the attempted abortion. Groebner was arraigned in the
Municipal Court at Mankato on March 27, 1947, at
which time he demanded a preliminary hearing and was
released on $1500 bond. The preliminary hearing was
continued to await a report from pathologists at the
University of Minnesota. The report showed the cause
of death to be “acute endometritis and hemorrhagic
pneumonia due to an attempted induced abortion.” On
May 2, 1947, Groebner waived his preliminary hearing
and was held to the District Court where he was ar-
raigned on May 13 at which time he entered a plea of
not guilty and the case was set for trial. However, on
May 24, Groebner withdrew his plea of not guilty and
entered a plea of guilty to an information charging him
with the crime of abortion. Groebner was sentenced by
the Hon. Harry A. Johnson, Judge of the District
Court, to a term of not to exceed four years in the
State Reformatory at St. Cloud, which sentence was
suspended upon several conditions, one of which forbids
Groebner to practice dentistry either in Mankato or
North Mankato.
The Minnesota State Board of Dental Examiners
has announced that proceedings are being instituted to
require the defendant to show cause why his dental
license should not be revoked. Groebner graduated from
the School of Dentistry at the University of Minnesota,
in 1944, and was licensed to practice the same year.
On June 2, 1947, Raymond E. Older, thirty-nine years
of age, Granada, Minnesota, was sentenced by Judge
Harry A. Johnson to a term of not to exceed three
years in the State Reformatory, which sentence was
suspended and the defendant placed on probation. Older
had entered a plea of guilty on May 19, 1947, to an in-
formation charging him with the crime of abortion in
the same case involving Groebner. Older admitted to
the Court that he made the arrangements with Groebner
for the criminal abortion and paid Groebner the sum of
$75.00. The patient became unconscious in Groebner’s
dental office and was removed by Older to a filling sta-
tion at Granada where she was kept over night. The
following day she was taken to a hospital at Fairmont
where she died the next evening.
666
Minnesota Medicine
MINNESOTA STATE MEDICAL ASSOCIATION
Ninety-Fourth Annual Session
Duluth Armory# Duluth, Minnesota
June 30, July 1 and 2, 1947
ANNOUNCEMENTS
Sectional Program — This year’s program is again di-
vided into two sections to be conducted simultaneously
in the St. Louis and Duluth Rooms, respectively. The
St. Louis Room, where the general scientific assembly
will convene each day, is located on the second floor of
the Armory, and the Duluth Room, where special sec-
tional meetings will be held, is off the main arena.
Scientific Cinema — Scientific motion pictures will be
shown in the East arena before each morning and aft-
ernoon session, at the conclusion of the Monday and
Tuesday sessions, and at each intermission. Provided
by the courtesy of the Medical Film Guild, these films,
developed under the guidance of outstanding authorities
associated with medical schools or national medical
societies, are authentic scientific reports on research
which has been conducted for many years.
Luncheons — Twenty Round Table Discussion Lunch-
eons have been arranged for Tuesday and Wednesday,
July 1 and 2, at the Duluth, Spalding and Holland
Hotels. Tickets must be purchased in advance. Lists of
subjects and discussion leaders are printed in the pro-
grams, and reservation cards are being mailed out with
the program. Attendance at each luncheon is limited
to thirty ; late comers are accommodated according to
their choice if limits have not already been reached.
Tickets are $1.50.
Annual Banquet — The annual dinner for members,
guests and wives, will be held at Hotel Duluth, Tues-
day evening, July 1, at 7 p.m. Mr. Tom Collins, prom-
inent Kansas City businessman and eminent speaker on
public affairs, and Louis A. Buie, Rochester, President
of the Minnesota State Medical Association, are speak-
ers. Tickets are $3.00.
“Variety Night”— All convention visitors and their
wives will be guests of the State Association and the
St. Louis County Medical Society at an informal party,
7 :30 p.m., Monday, June 30, Hotel Duluth. There
will be special music, entertainment and refreshments.
Guest Speakers — We are indebted to the following
organizations for guest speakers at this meeting:
The Minnesota Society of Clinical Pathologists is
inaugurating the Arthur H. Sanford Lectureship in
Patholo,gy at this year’s meeting, to become a feature
of all future annual meetings. Speaker, Elexious T.
Bell, Professor of Pathology, University of Minnesota.
The Northern Minnesota Medical Association — Speak-
er, Robert E. Gross, who is Wm. E. Ladd Professor of
Children’s Surgery, Harvard Medical School and Sur-
geon in Chief, Children’s Hospital, Boston.
June, 1947
The Minnesota Radiological Society • — Speaker, Marcy
L. Sussman, Director, Department of Roentgen Diag-
nosis, Mount Sinai Hospital, New York City, who will
deliver the annual Russell D. Carman Memorial Lec-
ture in Radiology.
The Northwestern Pediatrics Society — Speaker, Ben-
jamin Spock, Section on Pediatrics, Mayo Clinic, Roch-
ester.
The Minnesota Academy of Ophthalmology and Oto-
laryngology— Speakers, George E. Shambaugh, Jr., As-
sistant Professor of Otolaryngology, Northwestern Uni-
versity, Chicago; and Frederick A. Davis, Chairman,
Department of Ophthalmology, University of Wiscon-
sin, Madison.
The American College of Chest Physicians — Speak-
er, William Roemmich, S. A. Surgeon, United States
Public Health Service, acting Tuberculosis Control Of-
ficer, Minneapolis Health Department.
The National Foundation for Infantile Paralysis, Inc.
— Speaker, Joseph G. Molner, Medical Consultant, Na-
tional Foundation for Infantile Paralysis, Wayne Uni-
versity, Detroit.
The Minnesota Department of Health — Obstetric
Manikin Demonstrations by Willis E. Brown, Associ-
ate Professor of Obstetrics and Gynecology, University
of Iowa Medical School, Iowa City; Ralph E. Camp-
bell, Associate Professor of Obstetrics and Gynecology,
University of Wisconsin Medical School, Madison ; and
Mancel T. Mitchell, Clinical Assistant Professor, Ob-
stetrics and Gynecology, LTniversity of Minnesota Medi-
cal School.
Other visiting speakers at this meeting:
Benedict F. Massell, Associate Research Director,
House of Good Samaritan, Boston.
Haven Emerson, School of Public Health, Columbia
University, New York.
Roy H. Turner, Professor of Medicine, Tulane Uni-
versity, New Orleans, and Chairman, Committee on
Diseases of the Liver, National Research Council.
Mrs. Charles W. Sewell, Administrative Director,
American Farm Women’s Division, American Farm
Bureau Federation, Chicago.
Dean F. Smiley and Fred V. Hein, Ph.D., Consult-
ants in Health and Physical Fitness, Bureau of Health
Education, American Medical Association, Chicago.
Hiram E. Essex, Ph.D., and Alfonso Grana, Mayo
Clinic, Rochester.
Medical Women’s Luncheon — The American Medical
Women’s Association, Minnesota Branch, will hold a
luncheon meeting at the Ivitchi Gammi Club, Duluth,
Monday, June 30, at 12:15 p.m. All women physicians
are invited. Make reservations in advance through
Marie K. Bepko, Cloquet, Minnesota.
667
MINNESOTA STATE MEDICAL ASSOCIATION
Nu Sigma Nu Get-Together — On Monday, June 30,
at 5 :30 p.m. there will be a reunion of members of the
Nu Sigma Nu fraternity at the Duluth Athletic Club for
cocktails, dinner and a social evening. Notify Charles
N. Hensel, 613 Lowry Medical Arts Building, St. Paul,
if you plan to attend.
Minnesota Academy of Ophthalmology and Oto-
laryngology Luncheon — The Academy is holding a lunch-
eon meeting at 12:30 p.m. Monday, Tune 30, at The
Flame. Make reservations in advance through Archie
Olson, 815 Medical Arts Building, Duluth.
American College of Chest Physicians Luncheon —
Tuesday, July 1, at 12 :30 p.m. chest physicians will hold
a luncheon meeting in the Tally-ho Room, Hotel Hol-
land. Reservations should be made with G. A. Hed-
berg, Nopeming Sanatorium, Nopeming.
Minnesota Surgical Society Luncheon — At 12 :30 p.m.
Tuesday, July 1, the Minnesota Surgical Society is hav-
ing a luncheon meeting at The Flame. All members may
attend if they make reservations in advance through
M. G. Gillespie, 205 W. Second Street, Duluth.
Medical Veterans Meeting — All doctors who served
in World War II are invited to a luncheon meeting at
12:30 p.m. Monday, June 30, in the Tally-ho Room of
the Holland Hotel, sponsored by the Society of Medical
Veterans in Duluth. Purpose of the meeting is to give
returned medical officers opportunity to offer construc-
tive criticism as to the way medical departments of
the army and navy were administered during the war.
It is hoped to prepare definite suggestions or recom-
mendations for better utilization of medical resources
in this country in the event of another national emer-
gency.
Medal — The Southern Minnesota Medical Association
will present its annual medal for the best scientific
exhibit presented by an individual physician at this
meeting. Presentation will be made at the banquet Tues-
day evening, July 1, Hotel Duluth.
Fifty Club — This year’s candidates for election to
Minnesota’s “Fifty Club” will be honor guests of the
Association at the banquet. Presentation of lapel but-
tons and certificates to candidates who have practiced
medicine for fifty years in Minnesota will be a feature
of the banquet program.
Technical Exhibits — One of the largest technical ex-
hibits in the history of the Minnesota State Medical
Association meetings w ill be on display in the Armory
Arena at Duluth. This exhibit plays an important part
in the interest and value of every state meeting. Also,
the revenue from sale of exhibit space makes j>ossible
the high quality of scientific program and events which
characterizes our Minnesota meetings. Every conven-
tion visitor should make a special point of visiting the
technical exhibits.
Woman’s Auxiliary — Wives of physicians attending
the meeting may secure programs of the business and
social sessions of the Woman’s Auxiliary at the Wom-
en’s Registration Desk in the lobby of the Hotel Duluth.
All visiting women are cordially invited to attend the
special events arranged by hostesses of the St. Louis
County Medical Auxiliary. Among these is a tea Mon-
day, 3 p.m., at the home of Mrs. Anthony J. Bianco.
The Annual Meeting and Luncheon to be held Tuesday,
July 1, at Hotel Duluth are open to all Auxiliary mem-
bers. Out-of-town members will be guests of the St.
Louis County Medical Auxiliary at a Round-up Break-
fast to be held Wednesday, July 2, at 10 a.m. at Hotel
Duluth.
Golf — The annual Golf Tournament of the Minnesota
State Medical Association will be held Sunday, June 29,
at 1 p.m. at the Northland Country Club. All medical
golfers are invited to enter competition for the attrac-
tive prizes that have been donated. Advance registra-
tion must be made through R. L. Nelson, Duluth.
Fishing — Deep sea fishing excursions along the North
Shore of beautiful Lake Superior are being arranged
by Karl E. Johnson, Duluth. All that is needed is ap-
propriate fishing togs, no equipment or license neces-
sary. Price is $3.00 per person for a party of four or
more. Reservations must be made in advance.
SPECIAL SESSIONS
In addition to the general sessions to be held on Mon-
day, Tuesday and Wednesday in the St. Louis Room of
the Armory, there will be five special sessions in the
Duluth Room. These will be held during the morning
of each of the three convention days and Monday and
Tuesday afternoons, with a special conference on Rural
Health on Wednesday afternoon in the St. Louis Room.
Special sessions are open to all convention visitors. De-
tails are given in the program listings.
Monday, June 30
9 a.m. — Minnesota Academy of Ophthalmology and
Otolaryngology
2 p.m. — Symposium on Rheumatic Fever
Tuesday, July 1
9 a.m. — Special program on Orthopedic and Fracture
Surgery
2 p.m. — American College of Chest Physicians
Wednesday, July 2
9 a.m. — Symposium on Research Problems
2 p.m. — “Rural Health — A Joint Responsibility,” a
special conference on the timely subject of
rural health concludes the convention pro-
gram. Nationally known authorities will dis-
cuss various phases of the local and national
problem. Invited are members of allied health
organizations, social welfare workers, school
authorities and representatives from various
farm, professional and civic groups.
668
Minnesota Medicine
MINNESOTA STATE MEDICAL ASSOCIATION
DEMONSTRATIONS
A program of demonstrations has been arranged for
each intermission period and immediately preceding and
following each general session on Monday, Tuesday and
Wednesday, and to be held in Rooms D-l, D-2, D-3
and D-4 in the Armory Arena. A series of five obstetric
manikin demonstrations will be held this year, arranged
by the Committee on Maternal Health and sponsored by
the Minnesota Department of Health. Three of these
will be given in the Armory ; two will be given at
Hotel Duluth.
D-l Obstetric Manikin Demonstration
1 p.m. and 5 p.m. Monday, June 30, by Willis E.
Brown, Associate Professor of Obstetrics and
Gynecology, University of Iowa.
5 p.m. Tuesday, July 1, Ralph E. Campbell, As-
sociate Professor of Obstetrics and Gynecology,
University of Wisconsin.
D-2 “Rh Blood Testing Procedures and Blood Com-
patibility Testing," given by D. R. Mathieson,
daily, 8:30 and 10:15 a.m. and 3:15 and 5 p.m.,
sponsored by the Mayo Foundation and Mayo
Clinic in connection with an extensive scientific
exhibit, details of which are listed under Scien-
tific Exhibits.
D-3 X-Ray Diagnosis and Interpretation
Sponsored by the Minnesota Radiological Society,
daily at 8:30 and 10:15 a.m. and 3:15 and 5 p.m.
D-4 Gross Pathological Specimens
Sponsored by the Minnesota Society of Clinical
Pathologists, to be held before each scientific
session, at intermission periods and at the close
of Monday and Tuesday sessions.
In addition, on Tuesday, July 1, Dr. Campbell will
give an obstetric manikin demonstration at 12:15 p.m.
in the Arrowhead Room, Hotel Duluth ; and on
Wednesday, July 2, Mancel T. Mitchell, Clinical As-
sistant Professor of Obstetrics and Gynecology, Uni-
versity of Minnesota, will give an obstetric demonstra-
tion at 12:15 p.m. in the Arrowhead Room, Hotel Du-
luth.
SCIENTIFIC PROGRAM
Monday, June 30
Section I — General Session
Scientific Cinema East Arena
Visit Scientific and Technical Exhibits - Mezzanine Arena
Demonstrations — Rooms D-2, D-3 and D-4
9 :00 Hypertension _• • • • • St. Louis Room
Classification of Hypertension — Howard Kaliher, Pelican Rapids
Medical Treatment — William D. Coventry, Duluth
Surgical Treatment — Harold F. Buchstein, Minneapolis
A.M.
00
30
10:15 Intermission
Scientific Cinema ■ ■ • -East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Demonstrations — Rooms D-2, D-3 and D-4
11 :00 Management of Heart Disease •••••St- Louis Room
Treatment of Congestive Heart Failure— Ben Sommers, St. Paul
Diagnosis and Treatment of Cardiac Emergencies— Wilburn O. B. Nelson, ber-
gus Falls . ,T
Recent Advances in the Treatment of Cardiovascular Diseases — Charles INaumann
McCloud, Jr., St. Paul
11 -30 Surgery for Congenital Cardiovascular Diseases — Robert E. Gross, Chief of Surgery,
Children’s Hospital, and Wm. E. Ladd Professor of Children’s Surgery, Harvard
Medical School, Boston
P.M.
Afternoon
1:00 Scientific Cinema .....East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Obstetric Manikin Demonstration — Room D-l .
Willis E. Brown, Associate Professor of Obstetrics and Gynecology, University
of Iowa, Iowa City
2:00 Gastrointestinal Ulcerative Disease Louis Room
Medical Therapy in Ulcerative Colitis— Paul G. Boman, Duluth
Medical Therapy in Peptic Ulcer— J. Allen Wilson, St. Paul
Vagotomy in Peptic Ulcer— Waltman Walters, Rochester
2:45 Fenestration Operation for Otosclerosis— George E. Shambaugh, Jr., Assistant Pro-
fessor of Otolaryngology, Northwestern University, Chicago
June, 1947
669
MINNESOTA STATE MEDICAL ASSOCIATION
3:15 In ter mission
Scientific Cinema East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Demonstrations — Rooms D-2, D-3 and D-4
4:00 Russell D. Carman Memorial Lecture St. Louis Room
A Physiologic Approach to Cardiovascular Roentgenology — -Marcy L. Sussman,
Director, Department of Roentgen Diagnosis, Mount Sinai Hospital, New York
City
Presentation of Speaker by Robert E. Fricke, Rochester, President, Minnesota
Radiological Society
5:00 Scientific Cinema East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Demonstrations — Rooms D-l, D-2, D-3 and D-4
7:30 “Variety Night” Ballroom, Hotel Duluth
All convention visitors and wives will be guests of the Minnesota State Medical
Association and the St. Louis County Medical Society for an evening of music and
special entertainment, Monday, at 7 :30 p.m. Refreshments will be served throughout
the evening in the Arrowhead Room. Everybody is invited.
Monday, June 30
Section II — Special Session
A.M.
9:00 Minnesota Academy of Ophthalmology and Otolaryngology Duluth Room
Case Reports — Frank N. Knapp, David L. Tilderquist, Alvin G. Athens and Orien
B. Patch, Duluth
10:15 Intermission
Scientific Cinema East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Demonstrations — Rooms D-2, D-3 and D-4
11:00 Minnesota Academy" of Ophthalmology and Otolaryngology, Continued. Duluth Room
The Incision and Closure of the Wound in Cataract Extraction — Frederick A.
Davis, Chairman, Department of Ophthalmology, University of Wisconsin,
Madison
P.M, Afternoon
1:00 Scientific Cinema East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Obstetric Manikin Demonstration — Room D-l
Willis E. Brown, Associate Professor of Obstetrics and Gynecology, University
of Iowa, Iowa City
2:00 Symposium on Rheumatic Fever Duluth Room
Paul F. Dwan, Minneapolis, Chairman
Genesis of Rheumatic Fever — Wesley W. Spink, University of Minnesota, Min-
neapolis
Diagnosis of Rheumatic Fever — -Morse J. Shapiro, Minneapolis
3:15 Intermission
Scientific Cinema East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Demonstrations — Rooms D-2, D-3 and D-4
4:00 Symposium on Rheumatic Fever, (Continued) Duluth Room
Management of Rheumatic Fever and Rheumatic Heart Disease — Benedict F.
Massed, Associate Research Director, House of Good Samaritan, Boston
Discussion Period
5:00 Scientific Cinema East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Demonstrations — Rooms D-l, D-2, D-3 and D-4
7:30 “Variety Night” Ballroom, Hotel Duluth
(Listed under Section I, General Session)
670
Minnesota Medicine
MINNESOTA STATE MEDICAL ASSOCIATION
A.M.
8:00
8:30
11 :00
P.M.
12:15
1:00
2:00
3:00
3:15
4:00
5:00
7:00
A.M.
9:00
10:15
11:00
P.M.
12:15
Tuesday, July 1
Section I — General Session
Scientific Cinema ■■■ ■
Visit Scientific and Technical Exhibits
. ! . . . East Arena
Mezzanine Arena
Demonstrations — Rooms D-2, D-3 and D-4
. St. Louis Room
0fapS„ghGSor' Sf Social Reference Postpartum Hemorrhage-Alexander
ManagmenLofRObstetric Emergencies— Frederick L. s'ha^.e' ]?0R™h)£”r
General Problem of Anesthesia in Obstetrics— Edward B. Tuohy, Rochester
Round Table Luncheons
(Listed under Section II, Special Session)
Afternoon
Scientific Cinema
Visit Scientific and Technical Exhibits
New Trends in Infant Care — Benjamin Spock, Rochester. ■ •
Presentation of Speaker by Irvine McQuame, Minneapolis,
Northwestern Pediatrics Society
East Arena
Mezzanine Arena
.St. Louis Room
representing the
Fifteen-minute discussion period
Intermission
Scientific Cinema
Visit Scientific and Technical Exhibits
Demonstrations — Rooms D-2, D-3 and D-4
East Arena
Mezzanine Arena
Arthur H. Sanford Lectureship in Pathology . .. . .. L
Pathology of Diabetes Mellitus — Elexious T. Bell, Professoi of 1 atholo&y, L
versity of Minnesota, Minneapolis T1 , ~ p ,
Dedication of Lectureship and Presentation of Speaker by Kano Ikeda, St. Paul,
President, Minnesota Society of Clinical Pathologists
Scientific Cinema
Visit Scientific and Technical Exhibits ■ • •
Demonstrations — Rooms D-l> D-2, D-3 and D-4
Annual Banquet •
(Listed under Section II, Special Session)
East Arena
Mezzanine Arena
Hotel Duluth
Tuesday, July 1
Section II — Special Session
Orthopedic and Fracture Surgery. Duluth Room
Edward T. Evans, Minneapolis, Chairman . T tt *.
Congenital Dislocation of the Hip Before Walking Begins— Vernon L. Halt,
TreaTment°ofS Fractures of the Patella, S. Sverre Houkom, Duluth
Intermission
Jicist Arena
Vis^^Scieniific and Technical Exhibits Mezzanine Arena
Demonstrations — Rooms D-2, D-3 and D-4
Orthopedic and Fracture Surgery (Continued) ....... • ■ •••••■'■ ■■ V,)P^luth R°°m
Recurrent Dislocations of the Shoulder— Edward H. Juers, Red Wing
Differential Diagnosis of Painful Feet— Mark B. Coventry, Rocnester
R°U^bItftr\c ^Manikin ^ Demonstration— Ralph E. Campbell, Associate Professor,
Obstetrics and Gynecology, University of Wisconsin Madison .
Newer Drugs and Therapeutic Methods— Raymond N. Bieter, Umveisity of
Minnesota , ^ ..
Common Foot Ailments— Edward T. Evans, Minneapolis
Trends in Pediatric Practice— Frank G. Hedenstrom, St. Paul
Management of Sinusitis— Jerome A. Hilger, St. Paul
Parenteral Fluids-John J Boehrer, Jr., Minneapolis
Urological Procedures in General Practice— Waldo N. Graves, Duluth
Use of Digitalis and Quinidine— Ben Sommers St Paul
Dermatology in General Practice— Frederick T. Becker, Duluth
Diabetes— Archibald E. Cardie, Minneapolis
June, 1947
671
MINNESOTA STATE MEDICAL ASSOCIATION
2.00 American College of Chest Physicians Duluth Room
J. Arthur Myers, Minneapolis, Chairman
FOllW-'irP Di£Postic. Procedures of Roentgen Lesions Found by Survey Methods
William Roemmich S. A Surgeon, United States Public Health Service
Acting Tuberculosis Control Officer, Minneapolis Health Department
Discussion by Dr. Myers
More Common Intrathoracic Tumors — Thomas J. Kinsella, Minneapolis
'P Intermission
Scientific Cinema rr t a
Visit Scientific and Technical Exhibits 7 7 71 a
Demonstrations-Rooms D-2, D-3 and D-4 Mezzanine Arena
4:00 American College, of Chest Physicians (Continued) Duluth Room
Roentgenologic Diagnosis of Early Carcinoma of the Lung— Leo G. Rigler Uni-
versity of Minnesota, Minneapolis
Discussion by Sumner S. Cohen, Glen Lake Sanatorium, Oak Terrace
Streptomycin in the Treatment of Tuberculosis— Karl H. Pfuetze, Cannon Falls
“SSSffi, 'SinSeapdiU “Kin. Ve.erS
5:00 Scientific Cinema T7 f a
Visit Scientific and Technical Exhibits '. 1 '. 1 '. 1 ! 1 ! 1 1 ! ! ! 1 Mezzanffie Arena
Demonstrations— Rooms D-l, D-2, D-3 and D-4 ezzanme Arena
7:00 Annual Banquet . HotCl Duluth
Pl"society Dan'e W' Wheeler’ Duluth> President, St. Louis County Medical
InffiaryCtl°n °f MrS' ^°hn A' Thabes’ Sr-- Brainerd, President, Woman's Aux-
Presentation of Fifty Club Certificates
Presentation of Southern Minnesota Medical Association Medal
Presentation of Distinguished Service Medal
President’s Address: “For Manners Are Not Idle”— Louis A Buie Rochester
President Minnesota State Medical Association ’ Kochester-
Address : “Price Tags on Progress”— Mr. Tom Collins, Kansas City, Missouri
A.M.
8:00
8:30
9:00
9:45
10:15
11:00
P.M.
12:15
Wednesday, July 2
Section I — General Session
Scientific Cinema rr * a
Visit Scientific and Technical Exhibits .' .' .' 7 7 '. '. '. 7.7.777 ! Mezzanine Arena
Demonstrations— Rooms D-2, D-3 and D-4
Chemotherapy of Venereal Disease St. Louis Room
1 reatment of Gonorrhea — Walter E. Hatch Duluth
treatment of Syphilis— Paul A. O’Leary, Rochester
Serum He paMts— Roy H. Turner, Professor of Medicine, Tulane University, New
Council30^ ^ iairman’ Committee on Diseases of the Liver, National Research
/ ntermission
Scientific Cinema tt t A
Visit Scientific and Technical Exhibits'. 7 7 1 7 7 1 ! 7 7 1 Mezzanine Arena
Demonstrations— Rooms D-2, D-3 and D-4 tezzamne Arena
Management of Poliomyelitis St. Louis Room
ENaetffin0il0SFof,nl?eCenf Pf^opments-Joseph G Molner, Medical Consultant,
National Foundation for Infantile Paralysis, Inc., Wayne Univereitv Detroit
Treatment of the Sick Child-Erling S. Platou, Minneapolis y’
treatment of the Paralysis— Miland E. Knapp, Minneapolis
Round Table Luncheons
(Listed under Section II, Special Session)
672
Minnesota Medicine
MINNESOTA STATE MEDICAL ASSOCIATION
Afternoon
1:00 Scientific Cinema East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
2:00 Rural Health — A Joint Responsibility St. Louis Room
Louis A. Buie, Rochester, Chairman
The Plan of Action for Farm Communities — Mrs. Charles W. Sewell, Admin-
istrative Director, American Farm Women’s Division, American Farm Bureau
Federation, Chicago
A Sound Public Health Program — Haven Emerson, School of Public Health,
Columbia University, New York City
The Health Program in Rural Schools — Dean F. Smiley, Consultant in Health
and Physical Fitness, Bureau of Health Education, American Medical Associ-
ation, Chicago
Physical Education in Rural Schools — Fred V. Hein, Ph.D., Consultant in Health
and Physical Fitness, Bureau of Health Education, American Medical Associa-
tion, Chicago
Hospital Facilities for All — Viktor O. Wilson, Director, Minnesota Hospital Sur-
vey and Planning Program, Director, Division of Hospital Services, Minne-
sota Department of Health
Medical Services — Frank J. Hirschboeck, Duluth
Wednesday, July 2
Section II — Special Session
A.M.
9:00 Symposium on Research Problems Duluth Room
James T. Priestley, Rochester, Chairman
Intravenous Protein Therapy — Arnold J. Kremen, University of Minnesota
Evaluation of the Short Proximal Loop in Gastric Resection — Fred Kolouch,
Jr., University of Minnesota
Drainage of Liver and Thoracic Duct Lymph — John H. Grindlay, Rochester
Experimental Study of Lymph from Liver and Thoracic Duct — James C. Cain,
Rochester
Idiopathic Degeneration of the Meningeal Dura, A New Pathological Entity —
Arthur H. Wells, Duluth
(A five-minute discussion period will follow each talk)
10:15 • Intermission
Scientific Cinema East Arena
Visit Scientific and Technical Exhibits Mezzanine Arena
Demonstrations — Rooms D-2, D-3 and D-4
11:00 Symposium on Research Problems (Continued) Duluth Room
The Mechanism of Transient Leukopenia: A Motion Picture — Hiram E. Essex,
Ph.D., and Alfonso Grana, Rochester ' -
The Role of Chronic Portal Thrombosis in Splenic Anemia — Mavis P. Kelsey,
Rochester
Hemolytic and Non-hemolytic Transfusion Reactions — Edmund B. Flink, Uni-
versity of Minnesota
The Present Status of the Relation of Cholesterol to Arteriosclerosis — E. Rus-
sell Hayes, University of Minnesota
(A five-minute discussion period will follozv each talk )
P.M.
12:15 Round Table Luncheons
Obstetric Manikin Demonstration — Mancel T. Mitchell, Minneapolis
Meningitis and Its Treatment — Erling S. Platou, Minneapolis
The Anemias — Walter S. Neff, Virginia
Management of Hepatic Disease — Roy H. Turner, Professor of Medicine, Tulane
University, New Orleans
Pelvic Pain — Anatomic and Physiologic Aspects — Philip N. Bray, Duluth
Chemotherapy in Wound Management — David P. Anderson, Jr., Austin
Diagnosis of Obscure Fevers in General Practice — Daniel W. Wheeler, Duluth
Management of Patients with Chronic Headaches — Bayard T. Horton, Rochester
Office Practice in Ano-rectal Diseases — William C. Bernstein, St. Paul
Dermatology and Syphilology — Paul A. O’Leary, Rochester
UNE, 1947
673
MINNESOTA STATE MEDICAL ASSOCIATION
SCIENTIFIC EXHIBITS
S-9 American College of Physicians and Surgeons
S— 15 Committee on Rural Medical Service
S— 17 Committee on Tuberculosis
S-6 “Dangerous Drugs”
Minnesota State Pharmaceutical Association
S-7 “Health Education”
Minnesota Public Health Association
S-5 “Here’s That Nurse”
Minnesota Nurses Association
S~16 “Hospital Services”
Minnesota Department of Health
S-3 Insurance Liaison Committee
S-12 “Macular Diseases"
Minnesota Society for the Prevention of Blindness
University of Minnesota Department of Ophthalmology
D-2 Mayo Foundation for Medical Education and Research and the Mayo Clinic
(1) ‘‘Partial and Total Loss of the Nose, Plastic Reconstruction”
G. B. New and J. B. Erich
(2) “Congenital Anomalies of the Heart and Great Vessels,
Clinicopathologic Study of 115 Cases”
T. J. Dry, J. E. Edwards, R. L. Parker, H. B. Burchell,
A. H. Bulbulian and H. M. Rogers (Fellow in Medicine)
(3) “Cranioplasties with Tantalum Plates, A New Method of
Forming Plate Prior to Surgery”
G. S. Baker and A. H. Bulbulian
(4) “Accidents on the Farm and How They Happen, An Analysis of
575 Accidents (569 Patients) seen at the Mayo Clinic from
January, 1935, to January, 1944”
H. H. Young and R. K. Ghormley
(5) “The Fundus of the Eye, In Disorders of the Central Nervous System”
C. W. Rucker
(6) “Streptomycin : Experimental and Clinical Observations”
W. H. Feldman, Ph.D. and H. C. Hinshaw
S-8 Minnesota Department of Education
Division of Vocational Rehabilitation
S-2 Minnesota Medical Service, Inc.
S-10 Minnesota Safety Council
D-4 Minnesota Society of Clinical Pathologists
S-l Minnesota State Medical Association
Veterans Medical Service Division
D-4 “Pathologic Anatomy Exhibit ”
St. Luke’s Hospital, Duluth
Arthur H. Wells
Harold H. Joffe
S-13 “Radiologic Exhibit”
University of Minnesota Hospitals
Leo G. Rigler
Thomas B. Merner
S-17 St. Louis County Tuberculosis Control Program
St. Louis County Tuberculosis and Health Association
Duluth and St. Louis County Health Departments
Nopeming Sanatorium
S-ll “Teamwork in Cancer Diagnosis”
Minnesota Division, American Cancer Society, Inc.
S-14 “Trichinosis”
American Medical Association
S— 4 Woman’s Auxiliary to the Minnesota State Medical Association
674
Minnesota Medicine
“Constipation is not an important symptom of ulcer, but is often the outstanding
complaint. Many patients either disregard the 'indigestion,' distress or pain . . . Such
patients frequently become established cathartic addicts, with resultant bowel
dysfunction and abdominal discomfort to confuse the distress picture.”
— Portis, S. A.: Diseases of the Digestive System, ed. 2,
Philadelphia, Lea & Febiger, 1944, p. 199.
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Metamucil is the registered trademark of G. D. Searle & Co., Chicago 80, Illinois.
SEARLE
RESEARCH IN THE SERVICE OF MEDICINE
June, 1947
675
* Reports and Announcements ♦
THE AMERICAN BOARD OF ORTHOPAEDIC SURGERY
Any candidate applying for Part I of the examina-
tion of the American Board of Orthopaedic Surgery
after January 1, 1951, must have the following gen-
eral qualifications :
1. He must be a citizen of the United States or Can-
ada.
2. He must be a graduate of a medical school ap-
proved by the Council on Medical Education and Hos-
pitals of the American Medical Association. In the
case of an applicant whose training has been received
outside the United States or Canada, his credentials
must be satisfactory to the Council on Medical Educa-
tion and Hospitals of the American Medical Association
and to the National Board of Medical Examiners; he
must have been engaged in the practice of orthopedic
surgery in the United States or Canada for at least three
years prior to submission of his application.
3. He must have served an internship of twelve
months in a general hospital acceptable to the Board.
4. He must have spent a year on an approved surgical
residency subsequent to the completion of his intern-
ship. .
NOTE: This change consists of an additional re-
quired year of surgical training before entering on spe-
cial work in orthopedic surgery.
No individual may apply for Part I of the examina-
tion of the American Board of Orthopaedic Surgery who
has not completed at least one year in special ortho-
pedic training in addition to meeting the general re-
quirements.
The special qualifications to fulfill the requirements
for eligibility to both Part I and Part II of the exami-
nation will be furnished on request to the secretary of
the American Board of Orthopaedic Surgery, Dr. Fran-
cis M. McKeever, 1136 West 6th Street, Los Angeles
14, California.
AMERICAN COLLEGE OF PHYSICIANS
AND SURGEONS
The Southern Minnesota Chapter of the American
College of Physicians and Surgeons was formed on
April 8 at a meeting held in Mankato.
Elected president of the chapter at the meeting, which
was attended by thirty physicians from the city and
surrounding area, was Dr. L. Gordon Samuelson of
Mankato. Other officers named were Dr. Roger Hassett,
Mankato, president-elect; Dr. E. A. Thayer, Fairmont,
first vice president ; Dr. O. J. Swenson, Waseca, second
vice president, and Dr. C. F. Wohlrabe, North Mankato,
secretary-treasurer. Elected to the board of directors
were Dr. M. F„ Lenander, St. Peter, and Dr. F. W.
Franchere, Lake Crystal.
PHYSICIANS’ LIABILITY INSURANCE
1. We suggest every Doctor consider increased Liability lim-
its at this time.
10/20,000 limits cost $30.00 — 25/50,000 limits cost $35.31
2. Be sure you notify your insurance agent or broker of any
existing business relationship such as co-partnerships, corpora-
tion, clinic, or joint office arrangements, so adequate coverage
can be arranged for in addition to your individual coverage.
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676
Minnesota Medicine
REPORTS AND ANNOUNCEMENTS
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In connection with the FLAME — Speedboats and Cruisers for hire — Trips around the harbor.
Seaplane for hire for trips to inland lakes of Minnesota Arrowhead Country.
TRULY A “VyiuAJL-S&&-" WHEW I X DULUTH
Principal speakers at the meeting included Dr. F. G.
Benn, Minneapolis, president of the state chapter; Dr.
0. A. Lenz, secretary-treasurer of the Minneapolis re-
gional chapter, and R. H. Muehlberg, executive- secretary
of the state chapter.
In his talk Dr. Benn announced that the board of di-
rectors of the organization is considering a plan to
award scholarships to a number of first-year medical
students, on a competitive basis, if the students agree
to study to become general practitioners. The directors
feel that the plan would benefit rural communities
throughout the state by providing an additional supply
of family doctors in small towns and farming areas,
Dr. Benn stated.
AMERICAN RADIUM SOCIETY
Dr. Robert S. Stone, professor of radiology at the
University of California Medical School, San Francisco,
who was closely associated with atomic research during
World War II, was selected to deliver the Janeway lec-
ture at the twenty-ninth annual meeting of the Ameri-
can Radium Society held at the Seaside Hotel in Atlan-
tic City on June 9 and 10.
The lecture carried the Janeway medal which was
awarded to Dr. Stone at a dinner June 9. Dr. Stone’s
lecture, entitled “Neutron Therapy and Specific Ioniza-
tion,” was delivered that afternoon.
The J aneway lecturer is selected annually by a com-
mittee of six members of the American Radium Society,
which is composed of many of the country’s leading
cancer specialists. The award was established in 1933 in
memory of Henry Harrington Janeway for his pioneer
work in the field of radium therapy.
The society’s two-day convention this year was held
in connection with the centennial meeting of the Ameri-
can Medical Association in Atlantic City, June 9-13.
Among those taking part in the scientific program was
Dr. Eugene T. Leddy, Rochester, Minnesota.
COLLEGE OF AMERICAN PATHOLOGISTS
At a meeting held at the Drake Hotel in Chicago on
December 13, 1946, which was attended by 130 pathol-
ogists from almost every state in the union and from
Canada, a constitution and by-laws of the College of
American Pathologists were adopted and the following
officers were elected : Dr. Frank W. Hartman, Detroit,
president ; Dr. Granville A. Bennett, Chicago, vice pres-
ident, and Dr. Tracy B. Mallory, Boston, secretary-
treasurer.
AMERICAN CONGRESS OF PHYSICAL MEDICINE
The American Congress of Physical Medicine will
hold its twenty-fifth annual scientific and clinical ses-
sion September 2 to 6, at the Hotel Radisson, Minneap-
olis. Scientific and clinical sessions will be given the
days of September 3, 4, 5 and 6. All sessions will be
open to members of the medical profession in good
standing with the American Medical Association. In
addition to the scientific sessions, the annual instruc-
tion courses will be held September 2, 3, 4 and 5. These
June, 1947
677
REPORTS AND ANNOUNCEMENTS
courses will be open to physicians and the therapists
registered with the American Registry of Physical
Therapy Technicians. For information concerning the
convention and the instruction course, address the Amer-
ican Congress of Physical Medicine, 30 North Michigan
Avenue, Chicago 2, Illinois.
SOCIETY OF CLINICAL SURGERY
The seventy-sixth semi-annual session of the Society
of Clinical Surgery was held in Rochester on May 9
and 10. Members of the Mayo Clinic staff provided the
program for the two-day meeting, with operative clinics
in the mornings and presentation of papers in the after-
noons.
President of the society is Dr. Daniel C. Elkin of
Emory University in Atlanta, Georgia. Other officers
are Dr. Leland S. McKittrick, Boston, vice president ;
Dr. Howard K. Gray, Rochester, secretary, and Dr.
Warren H. Cole, Chicago, treasurer. Dr. Waltman Wal-
ters, Rochester, is a member of the committee on ad-
missions.
HEARING AID FIRM OFFERS FELLOWSHIP
L. A. Watson, president of the Maico Company, Inc.,
of Minneapolis, has announced a $500 graduate fellow-
ship to the University of Minnesota for research in the
field of deafness and hearing. The Board of Regents
of the University has accepted the $500 stipend, and a
graduate student in the department of speech will be
given an opportunity to pursue original research and
investigation in the field of hearing and deafness.
Among the many unsolved problems of deafness and
hearing which offer promising fields of research are :
the effects of fatigue and distortion on speech intelli-
gibility, the value of selective frequency emphasis in
speech intelligibility for hard-of-hearing persons, and
how deafened persons hear at intense loudness levels.
HENNEPIN COUNTY SOCIETY
A symposium on “Bowel Obstruction” was presented
at the meeting of the Hennepin County Medical So-
ciety held in Minneapolis on May 5. Participants in the
symposium were members of the department, of surgery
of the University of Minnesota Medical School, and in-
cluded Dr. Clarence Dennis, Dr. Fred Kolouch, Jr., Dr.
Arnold Kremen, and Dr. Christian Bruusgaard. Dr.
Bruusgaard, who is from Oslo, Norway, is a traveling
Fellow in Surgery.
RED RIVER VALLEY SOCIETY
At the quarterly meeting of the Red River Valley
Medical Society, held in Crookston on April 15, a dis-
cussion of “Psychosomatic Medicine” was presented by
Dr. O. L. Norman Nelson of Minneapolis. Dr. Nel-
son, who is associated with the department of medicine
at the University of Minnesota Hospitals and Minneap-
(Continued on Page1 681)
678
Minnesota Medicine
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WOMAN’S AUXILIARY
Hennepin County
The annual meeting of the Hennepin County Medical
Auxiliary was held at the Curtis Hotel, Minneapolis, on
Friday, May 2, 1947.
After a one o’clock luncheon, the following officers
were elected for 1947-1948:
President — Mrs. Frederick H. K. Schaaf.
President-elect — Mrs. Reuben F. Erickson.
First Vice President — Mrs. L. R. Boies.
Recording Secretary — Mrs. Frank R. Hirshfield.
Corresponding Secretary— -Mrs. Frank T. Cavanor.
Treasurer — Mrs. Arthur W. Russeth.
Auditor- — Mrs. Johannes K. Moen.
Custodian — Mrs. Leo W. Fink.
Ramsey County
The April meeting of the Ramsey County Medical
Auxiliary was a tea at the home of Mrs. L. W. Barry,
2193 Sargent Avenue, Saint Paul. Miss Etta Lubbert,
Superintendent of Nurses at Ancker Hospital, presented
a program for recruiting nurses.
Mrs. Lyle Fisher of Saint Paul sang a group of chil-
dren’s songs which she has composed.
Red River Valley
Election of officers featured the meeting of the Red
River Valley Medical Auxiliary which was held April 15
at the home of Mrs. M. 'O. Oppegaard.
The meeting immediately followed the dinner meeting
at the Hotel Crookston which was attended by members
of the medical association and its auxiliary.
All officers were re-elected for the coming year. They
are Mrs. Oppegaard, president; Mrs. O. K. Behr, vice
president; Mrs. A. R. Reff, secretary, and Mrs. C. L.
Oppegaard, treasurer.
The office of social secretary was added to the slate
and Mrs. R. O. Sather was elected to that office.
Sixteen members attended the meeting.
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June, 1947
679
IN MEMORIAM
In Memoriam
FRANCIS E. HARRINGTON
Dr. Francis E. Harrington, for twenty-four years
healtli commissioner of Minneapolis until his retirement
in 1944, died at West Palm Beach, Florida, on May 10,
1947.
Born in Norfolk, Virginia, on June 19, 1879, the son
of a brigadier general in the U. S. Marine Corps, Dr.
Harrington later attended public schools in Boston and
Washington, D. C. He received a B.Sc. degree from
Gonzaga College, Washington, in 1899 and an M.D. de-
gree from Columbia University, Washington, now known
as George Washington University, in 1904. After in-
terning at the Casualty Hospital, Washington, he prac-
ticed in Washington from 1904 until 1910 and at Cum-
berland, Maryland, from 1910 to 1914. He then joined
the U. S. Public Health Service and had assignments
in nine different states between the years 1914 and 1920.
In 1920 Dr. Harrington was called to be commissioner
of health in Minneapolis, in which capacity he served
until he resigned in 1944. In addition to this full-time
job, he acted as superintendent of Minneapolis General
Hospital from 1937 to 1939 and again from 1942 until
1944. In 1945 he was appointed superintendent of the
Elizabeth Kenny Institute.
In addition, he was director of Lymanhurst Health
Center, clinical professor of preventive medicine and
public health at the University of Minnesota, and a
member of the Glen Lake Sanatorium Commission of
Hennepin County.
Dr. Harrington was a charter member and first presi-
dent of the International Society of Medical Health Of-
ficers in 1928. He was also a past secretary and treas-
urer of the society.
He was a member of many organizations, including
the Association of Military Surgeons of the United
States, the Military Order of Carabao, the National
Tuberculosis Association; a Fellow of the American
College of Physicians ; a past president of the Minne-
sota Trudeau Society, the Minnesota Sons of the Revolu-
tion, the National Society of the Sons of the American
Revolution, the Knights of Columbus, and the St. Thom-
as Catholic Church.
Dr. Harrington is survived by his wife, two sons and
five daughters.
One of Dr. Harrington’s outstanding characteristics
was his executive ability. His energy and honesty and
his pleasing personality enabled him to accomplish much
in his chosen field of public health.
PETER M. HOLL
Dr. Peter M. Holl, Minneapolis, died April 13, 1947,
at the age of eighty-four.
Dr. Holl was born in Lake Prairie Township, Nicol-
let County, on August 19, 1862. He obtained his medical
education at the Minnesota Hospital College, Minneapo-
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680
Minnesota Medicine
IN MEMORIAM
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lis, from which he graduated in 1887 and at Bellevue
Medical College, New York. Postgraduate work was
taken in pediatrics at the New York Polyclinic.
Dr. Holl was a city physician from 1907 to 1909. He
was a, member of the Hennepin Lodge, A.F. and A.M.,
and of the Hennepin County Medical Society, and the
Minnesota State and American Medical Associations.
Dr. Holl’s wife, the former Annie May Fillmore,
passed away in 1931.
THOMAS M. JOYCE
Dr. Thomas Af. Joyce, of Portland, Oregon, died on
April 18, 1947.
Dr. Joyce was born January 28, 1885, at Emmets-
burg, Iowa; attended Notre Dame University from
1903 to 1906; received the degree of M.D. in 1910 from
the University of Michigan, and was an intern at the
University Hospital, Ann Arbor, from 1910 to 1911. He
entered the Mayo Clinic in June, 1911, and was an in-
tern at St. Mary’s Hospital for twenty-five months and
a surgical assistant for nine months. He left the Mayo
Clinic in April, 1914.
During World War I he was chief surgeon at Base
Hospital 46, and was with the AEF for nine months.
At the time of his death he was head of the department
of surgery at the University of Oregon Medical School
and head of the department of surgery at the Mult-
nomah Hospital and Portland Clinic. He also was at-
tending surgeon at St. Vincent’s Hospital.
Dr. Joyce was a member of the American College of
June, 1947
Surgeons, the American Medical, the American Surgi-
cal, and the Pacific Coast Surgical Associations, was
president of the Alumni Association of the Mayo
Foundation in 1923-24 and a member of Alpha Omega
Alpha.
RED RIVER VALLEY SOCIETY
(Continued from Page 678)
olis General Hospital, was introduced by the president
of the society, Dr. C. G. Uhley, Crookston.
Another feature of the meeting was a talk by Dr.
J. F. Norman, Crookston, On the development of plans
for pre-paid medical service by the state medical as-
sociation.
WASHINGTON COUNTY SOCIETY
At the regular session of the Washington County
Medical Society in Stillwater on May 13, Dr. Wade R.
Humphrey, Stillwater, was in charge of a discussion of
plans for the enlargement and improvement of Lake
View Memorial Hospital in Stillwater. To clarify the
discussion, Dr. Humphrey showed enlarged photographs
of the hospital as it is at the present time, and pointed
out just where additions could be made. He then showed
the group a colored drawing to demonstrate how the
suggested changes would appear from a scenic point of
view. After the presentation a committee was appointed
to investigate the possibility of carrying out such a
project.
681
♦ Of General Interest ♦
MOWER COUNTY HONORS
THREE FIFTY-YEAR PHYSICIANS
On March 26, 1947, the members of the Mower County
Medical Society gave a dinner in honor of three Mow'er
County physicians, each of w'hom has served his com-
munity continuously for over fifty years.
The recipients of the tributes were Dr. A. E. Henslin,
eighty-one, who has practiced at LeRoy for fifty-six
years; Dr. O. H. Hegge, seventy-five, who has been a
physician in Austin for fifty-four years; and Dr. G. J.
Schottler, seventy-six, who has practiced at Dexter for
fifty-one years.
Each of the three deans of Mower County medicine
has a son who is a physician. At the honor dinner,
biographies of their fathers were read hy Dr. M. E.
Henslin, Leroy, and Dr. R. S. Hegge, Austin. Dr. Max
Schottler, Minneapolis, was unable to attend the dinner,
but he prepared a biography of his father which was
read by Dr. Paul Leek, president of the Mower County
Medical Society, who was master of ceremonies.
A highlight of the program was the reminiscing done
by the three guests of honor, who recalled vivid episodes,
both humorous and grim, from their days of horse-and-
buggy medicine — nerve-wracking journeys through mud-
tri tutors
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From left to right: Dr. G. J. Schottler, Dexter; Dr. A. E.
Henslin, LeRoy, and Dr. O. H. Hegge, Austin, Minnesota.
covered country, on-the-spot amputations in farm shant-
ies, struggles with x-ray machines that had hand-
cranked generators and plate glass films.
At the dinner which was attended by members of
the medical society and their wives, Dr. Henslin was
also honored for his thirty years of continuous service
as treasurer of the society.
Dr. R. L. 1. Kennedy, Rochester, district counselor for
the Minnesota State Medical Association, paid tribute
e Ico me
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Gail R. Freeman and C. H Young
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335 West Superior Street
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682
Minnesota Medicine
OF GENERAL INTEREST
to the three physicians on behalf of the state organiza-
tion. Dr. L. A. Buie, Rochester, president of the state
association, spoke on “Present Trends in Medical Prac-
tice and Social Legislation Affecting Medicine.”
DR. WENDELL GRINNELL HONORED
A record of forty-seven years in the practice of medi-
cine belongs to Dr. Wendell Grinnell who recently cele-
brated a birthday in Preston, Minnesota. On Sunday,
April 20, 1947, he was honored and feted by hundreds
of his townspeople as well as by patients throughout
the surrounding country.
To do honor to his forty-seven years of faithful
service, a general homecoming was held in Preston’s
town hall. There his countless friends and patients gath-
ered to wish him well.
Dr. Grinnell came to Fillmore County in 1900, locat-
ed in Wykoff for one year, then moved to Preston, the
county seat. In those early days the horse and buggy
provided the general means of travel for a country
doctor. He kept several driving horses, along with a
driver to transport him to the outlying towns. For
many years he owned and operated his own hospital in
Preston but this since has been closed.
Many a night he would keep vigil at the bedside of
a patient, only to find an urgent case waiting when he
returned home, necessitating perhaps another long drive
before he could snatch a few hours of sleep.
At this birthday celebration a program was presented
with Charles V. Michener acting as master of cere-
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683
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Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY — Two-week intensive course in Surgical
Technique starting July 21, August 18, September 22.
Four-week course in General Surgery starting July 7,
August 4, September 8, October 6.
Two-week course in Surgical Anatomy & Clinical Sur-
gery Starting July 21, August 18, September 22.
One-week course in surgery of Colon & Rectum start-
ing September 15 and November 3.
Two-week course in Surgical Pathology every two
weeks.
FRACTURES & TRAUMATIC SURGERY Two-week
intensive course starting June 16, October 6.
GYNECOLOGY Two-week intensive course starting
September 22. October 20. One-week course in Vag-
inal Approach to Pelvic Surgery starting September
15, October 13.
OBSTETRICS — Two-week intensive course starting Sep-
tember 8, October 6.
MEDICINE — Two-week intensive course starting Octo-
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Two-week course in Gastro-Enterology starting Octo-
ber 20.
One-week course in Hematology starting September 29.
One-month course in Electrocardiography & Heart
Disease starting June 16, September 15.
Two-week intensive course in Electrocardiography &
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General, Intensive and Special Courses in all Branches
of Medicine, Surgery and the Specialties
TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar. 427 S. Honor® St.. Chicago 12. 111.
monies. Rev. Allen W. Flohr gave the invocation. Mu-
sical selections consisted of vocal solos by Rev. Donald
Roesti and Mrs. M. Anderson and group singing by Mrs.
Claude Cutter and daughters Fauntie and Doris. Rev.
P. J. Nestande of Lanesboro and Rev. Gaede spoke in
tribute to Dr. Grinnell, following which the audience
sang “Happy Birthday” to the honor guest.
At this time a tray with hundreds of birthday cards
was presented to Dr. Grinnell, who in turn responded
with a short talk of appreciation and thanks for the
gifts. He stressed the fact that his many good friends
meant more to him than all the honors he might re-
ceive. He compared Preston and the township to a gar-
den which he claimed as his own, with his numerous
friends and patients as the flowers in that garden.
Many out-of-town guests attended the function ; in
fact, the hall was overflowing. The demonstration of
good fellowship and friendship must have been a source
of great satisfaction to Dr. Grinnell after his faithful
service for almost half a century.
4*
Dr. M. M. Loucks has installed a new x-ray machine
in his offices at Kelliher.
* * *
Dr. E. V. Allen, Rochester, ha> been re-elected gov-
ernor of the American College of Physicians for a
term of three years.
* * *
Dr. F. G. Chermak, International Falls, attended the
April meeting of the St. Louis County Medical Society
held in Eveleth.
* * *
During the last week of April, Dr. R. V. Sherman,
Red Wing, attended a meeting of the American Col-
lege of Physicians in Chicago.
* * *
Early this spring, Dr. E. R. Samson, Stillwater,
spent two weeks at the Cook County General Hospital,
Chicago, studying surgery.
* * *
On May 1, Dr. T. H. Leitschuh, formerly associated
with Dr. J. A. Cosgriff in Olivia, opened a medical
office in the Hensch Building in Sanborn.
* * *
Discontinuing his practice in Gibbon, Dr. Paul C. Ben-
ton of that city is beginning a three-year course in
neuro-psychiatry at the University of Minnesota.
* * *
Dr. Clyde A. Undine, Minneapolis, attended the
clinical meeting of the American College of Physicians
held in Chicago April 28 to May 2.
% s(; jfc
In Winnipeg on May 5, at the sectional meeting of the
American College of Surgeons, Dr. R. K. Ghormley,
Rochester, led a panel discussion on fractures and spoke
on “Fractures of the Hip.”
>jc Jf: :jc
Dr. Charles Vandersluis was named by the Bemidji
City Council to fill the unexpired term of Dr. D. H.
Garlock who resigned as city health officer early in
May.
684
Minnesota Medicine
OF GENERAL INTEREST
Dr. Everett C. Perlman, Minneapolis, announces the
removal of his offices to 301 Kenwood Parkway, Min-
neapolis, and his association with Dr. Max Seham in
the practice of pediatrics.
* * *
It was recently announced that Dr. O. J. Hagen,
Moorhead, has been made an emeritus member of the
executive committee of the Minnesota Public Health As-
sociation, of which he is a former president.
* * *
Dr. Ramby C. Rasmussen, Newport, has been ap-
pointed medical consultant for the Master Eye Foun-
dation, a nonprofit organization that supplies guiding
dogs free of charge to eligible blind persons.
* * *
Dr. M. E. Mosby, Long Prairie, has been taking a
three-month postgraduate course in eye, ear, nose and
throat diseases at the New York Polyclinic Hospital,
New York City.
* * *
At the sectional meeting of the American College
of Surgeons, held in Winnipeg on April 28 and 29, Dr.
Fred Kolouch, Jr., Dr. James M. Hayes and Dr. Clar-
ence Dennis, all of Minneapolis, were speakers.
* * *
Dr. Clare Gates, assistant health commissioner of
Minneapolis, spoke at the graduation exercises for forty-
three Franklin Hospital practical nurses on April 23
at the Woman’s Club Assembly, Minneapolis.
^ !|C ^
Recently appointed assistant professor in the depart-
ment of bacteriology and immunology at the University
of Minnesota is Dr. W. F. M. Limans, formerly of
Duluth, who received his Ph.D. degree from the Lhii-
versity in March.
^ ^
The former medical director of St. Barnabas Hospi-
tal, Minneapolis, Dr. Clement C. Clay has been appointed
director of a graduate course in hospital administration
which will be held at Yale University, starting in Sep-
tember.
%
“Streptomycin : An Antibiotic Effective Against Some
Forms of Clinical Tuberculosis” was the topic of a
paper presented by Dr. H. C. Hinshaw, Rochester, at
a meeting in Atlantic City in early May of the Amer-
ican Society for Clinical Investigation.
% 3{j sf:
Dr. Owen H. Wangensteen, director of the depart-
ment of surgery at the University of Minnesota Medical
School, spoke on new medical discoveries at the West-
minster Youth Fellowship service on April 20 at West-
minster Presbyterian Church in Minneapolis.
* * *
At a meeting sponsored jointly by the Colorado State
Medical Society and the University of Colorado School
of Medicine on May 12 and 13 in Denver, Dr. F. H.
Krusen, Rochester, spoke on “The Development of the
Modern Era of Physical Medicine” and “Physical Medi-
cine in Diagnosis and Treatment of Poliomyelitis.”
June, 1947
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OF GENERAL INTEREST
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ST. PAUL MINNEAPOLIS
Dr. Cecil J. Watson, chief of the department of medi-
cine at the University of Minnesota Medical School, was
elected recorder of the Association of American Physi-
cians during the May convention of the organization at
Atlantic City, New Jersey.
sf: ^ %
Coeds at the University of Minnesota were told of
present-day vocational opportunities for women at a
conference on May 20 conducted by a select group of
faculty members, one of whom was Dr. Ruth Boynton,
director of the Student Health Service.
* * *
Speaking at a meeting of the Minnesota Association
of Hospital and Medical Librarians, at the Radisson
Hotel in Minneapolis on May 17, Dr. Olga S. Hansen
discussed new developments in medicine, and Dr. Francis
Walsh talked on the characteristics of the eye.
* * *
Dr. M. B. Hebeisen, Dr. G. T. Schimelpfenig and
Dr. B. H. Simons, all of Chaska, attended the annual
meeting and banquet of the Scott-Carver Medical So-
ciety in Shakopee on April 9, where they heard Dr.
Wayne S. Hagen, Minneapolis, speak on liver disease.
* * *
Dr. E. B. Flink, assistant professor of medicine at
the University of Minnesota Medical School, who has
been Lffiiversity representative at Ancker Hospital, Saint
Paul, for the past two years, became supervisor of
the outpatient department of the University Medical
School on June 15, 1947.
* * *
Dr. W. D. Holcomb, formerly of Colorado Springs,
Colorado, accepted the senior residency at Abbott Hos-
pital, Minneapolis, and began his work there on April 1.
A graduate of Boston University, Dr. Holcomb has
been approved for visiting membership by the Hennepin
County Medical Society.
* * *
The Minnesota Hospital Association has received the
first award of the American Hospital Association in
recognition of its public education program led by Dr.
William A. O’Brien of the University of Minnesota.
The Minnesota group has been given the first award each
year since 1943.
s{: sfc
Announcement has been made that Dr. F. Paul Kortsch
has opened offices for the practice of medicine at 6614
Lyndale Avenue South, Richfield, Minneapolis. A grad-
uate of the University of Colorado, Dr. Kortsch has
conducted a clinic and general practice at Prior Lake
for the past ten and one-half years.
;{e jfc
Dr. A. W. Skoog-Smith, who left Mahnomen in March
to study radiology at the University of Minnesota and at
Cornell Medical Center, has been replaced by Dr. Ken-
neth Danford, formerly of Minneapolis. Dr. Danford,
a graduate of the Temple University School of Medi-
cine, is associated with Dr. K. W. Covey in Mahnomen.
* * *
Campbell physician, Dr. W. E. Wray, was honored at
an April dinner at which he was paid tribute for fifty
686
Minnesota Medicine
OF GENERAL INTEREST
>ears of medical practice. Since he began practice, Dr.
Wray has brought 2,500 babies into the world. Now
seventy-three years old, he intends to continue his medi-
cal practice.
* * *
Chairman of the Blue Earth County Medical Society
Tuberculosis Committee, Dr. A. G. Liedloff of Mankato,
attended a meeting in Saint Paul on May 9 to confer
with other county chairmen and with members of the
Committee on Tuberculosis of the state medical associa-
tion.
Jfc 5*S
Honor guests for the annual Pioneer Dinner of the
Chisholm Chamber of Commerce on May 26 were Dr.
and Mrs. A. W. Graham of Chisholm. Dr. Graham,
author of numerous articles in medical journals, has
been the school physician of the Chisholm district for
many years.
^ ^ ^
With his resignation, early in May, Dr. H. C. Dorns,
Slayton, ended fifteen years of service as Murray
County representative on the board of commissioners of
the Southwestern Minnesota Tuberculosis Sanatorium in
Worthington. Appointed to fill the vacancy was Dr.
R. F. Pierson, also of Slayton.
3fC 3{C
Dr. Earl H. Wood, Rochester, Mayo clinic staff
member, plans to attend the seventeenth International
Physiological Congress to be held in Oxford, England,
from July 22 to 25. Dr. Wood is one of ten men in
the country to receive an attendance award to the
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Congress given by the American Physiological Society
to physiologists under thirty-five years of age who have
made outstanding research contributions.
* h= , *
Dr. Charles A. Haberle, formerly of Minneapolis, has
become affiliated with the clinic operated by Dr. O. G.
Lynde in Thief River Falls. A graduate of the Uni-
versity of Minnesota Medical School, Dr. Haberle served
his internship at Minneapolis General Hospital and then
joined the staff of Glen Lake Sanatorium near Minne-
apolis.
* * *
Chosen to represent Saint Paul Jewish physicians, Dr.
Wfilliam Ginsberg in April signed a goodwill certificate
which was to be sealed in the cornerstone of a new
tuberculosis hospital, a unit of Hebrew University Hos-
pital on Mt. Scopus, Jerusalem. Funds for the erec-
tion of the hospital were raised by Hadassah Medical
Organization.
^
Dr. Karl H. Pfeutze, superintendent and director of
the Mineral Springs Sanatorium in Cannon Falls, con-
ducted a chest clinic in Faribault on April 21. At the
clinic, which is an annual spring event in Faribault,
Dr. Pfeutze interviewed former patients of the sana-
torium and administered free Mantoux tests to all -vol-
unteers.
* * 5jS
The recently organized army community relations
committee in Rochester is headed by Dr. Charles W.
Mayo. Part of a program being launched by the Fifth
June, 1947
687
OF GENERAL INTEREST
Army of the United States, the committee will inform
the public of army activities, will advise the command-
ing general on public trends in regard to army affairs,
and will assist in the army recruiting campaign.
sjc jje
At the annual meeting of the Children’s Hospital As-
sociation in Saint Paul on April 28, Dr. Clifford G.
Grulee, Jr., spoke on “Acute Poliomyelitis in Children.”
A member of the staff of the University of Minnesota
Hospitals, Dr. Grulee has done extensive research work
in connection with the poliomyelitis project of the hos-
pitals.
As a guest of the Section of Radiology and Physio-
therapy of the State Medical Association of Texas,
Dr. H. M. Weber, Rochester, presented three papers
at the group’s meeting during the first week of May.
His topics were “Roentgenologic Contribution to the
Diagnosis of Colitis and Enteritis,” "Roentgenologic Ex-
amination in the Diagnosis of Functional Intestinal Ab-
normality,” and “Conduct of Roentgenologic Examina-
tion of the Colon and Small Intestine.”
* * *
At a dinner following the .American College of Phy-
sicians postgraduate course in rheumatic diseases, held
in Rochester during March, Dr. Francis J. Braceland
of the Mayo Clinic staff presented “The Saga of a
Psychiatrist in World War II.” Dr. Braceland, who
studied in Germany in 19J5 and 1936, and who was a
visitor at the Nuernberg war trials, drew comparisons
between the arrogant Nazi leaders before the war and
the confused defeated men who were on trial. He
also discussed aspects of the psychiatric situation in
Europe today.
* * *
Dr. and Mrs. B. O. Mork, Sr., Worthington, took
off from LaGuardia Field, New York, on May 25 for a
trans-Atlantic flight to Oslo, Norway. Time for the
trip was expected to be sixteen hours. After more than
a month in Norway and Sweden, they plan to begin
their homeward flight from Stockholm on July 2. That
will be the thirteenth Atlantic crossing for Dr. Mork.
His first, years ago, from Norway to the United States,
required three weeks.
* * *
Miss Isabelle J. Anderson, librarian of the Ramsey
County Medical Society library since 1930, has accepted
the position of librarian of the medical division of the
University of Utah library at Salt Lake City. She will
assume her new duties there on July 1, 1947.
Miss Anderson will be succeeded at the Ramsey libra-
ry by Miss Mary M. Post, who has been assistant libra-
rian at the library of the University of Louisville School
of Medicine.
* * *
Two weeks after his arrival home in March from
medical service in Europe, Dr. Mentor H. Christensen,
Northfield, enrolled at the Center for Continuation
Study at the University of Minnesota, planning to study
orthopedics. Dr. Christensen, who was graduated from
the University of Minnesota Medical School shortly
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688
Minnesota Medicine
OF GENERAL INTEREST
before beginning thirty-two months in the army, spent
seventeen months in service in Germany, France, and
Africa.
* * *
April 29 was the date of the marriage of Dr. Anthony
L. Ourada of Walnut Grove and Miss Mary Henkels of
Heron Lake. Their double ring ceremony was held in
the Sacred Heart Church in the bride’s home town.
Dr. Ourada received his medical degree from the
University of Minnesota Medical School in March, 1946.
A reserve officer in the U. S. Army Medical Corps
Dr. Ourada will report to Fort Sam Houston, Texas, in
July to be assigned to active duty.
* * *
Dr. A. M. Snell, Rochester, had a busy week in Los
Angeles early in May as a guest speaker at a meeting
of the California State Medical Association. He was
moderator in a panel discussion on diseases of the
stomach, conducted a pathologic conference on diseases
of the liver, participated in a symposium on “What’s
New?” spoke to the general assembly on “Viral Hepa-
titis and the Public Health,” and conducted a patho-
logic conference on liver diseases at the Cottage Hos-
pital, Santa Barbara.
- 5$: %
Antibiotics, anesthetic aids, and aviation medical ad-
vances were some of the subjects covered by Dr.
David A. Sher, Virginia, in a talk before the Virginia
Study Club at its regular meeting in' April. Speaking
on the topic, “Recent Advances in the Field of Medicine
and Peeps at Things to Come,” Dr. Sher, a mem-
ber of the Lenont-Peterson Clinic, pointed out the many
discoveries made and the new methods developed in
medicine and surgery in the ten years between 1936 and
1946.
ifc ^ *
Landing a 128-pound tarpon during a fishing rodeo in
Tampico, Mexico, won second prize for Dr. H. W.
Goehrs, St. Cloud, while on a vacation trip this spring.
Dr. Goehrs, who made his catch at the mouth of the
Panuco River, fishing from a skiff about half again
as large as an ordinary rowboat, was pleased but not
particularly amazed at the size of his prize-winning
fish. A few days earlier he had landed two tarpons
which were over six feet in length and tipped the
scales at 150 pounds.
5<C
Dr. Duane R. Ausman announces that he has opened
offices for the general practice of medicine and surgery
at 1673 Arona Street, in the Falcon Heights District,
Saint Paul. A graduate of the University of Minnesota
Medical School, Dr. Ausman entered the army in 1942
and served in Australia, New Guinea and the Philip-
pines. He was awarded the Bronze Star for meritorius
conduct during the invasion of the Philippines. Follow-
ing his discharge from service, he was associated with
the Health Service of the University of Minnesota.
H1 ^
One of the papers presented at the meeting of the
Association of American Physicians in Atlantic City on
May 6 and 7 was “Striking Syndrome of Marked Bloat-
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OF GENERAL INTEREST
ing Without Gas in the Bowel” by Dr. W. C. Alvarez,
Rochester. F'rom Atlantic City Dr. Alvarez went to
Charleston, West Virginia, to speak on “Puzzling Types
of Abdominal Pain” at a meeting of the West Virginia
State Medical Association. By May 16 he was in
Toronto, Canada, where he addressed the Toronto Medi-
cal Association on the subject, “What Is Wrong with
the Dyspeptic Whose Findings Are All Negative.”
% *
In Lake City, on May 1, Dr. Robert N. Bowers an-
nounced that Dr. William P. Gjerde, formerly of Saint
Paul, had joined him in a partnership medical practice.
Dr. Gjerde, a native of Staples before entering the
University of Minnesota, received his medical degree in
1939 and then joined the staff of the Northern Pacific
Hospital in Saint Paul. During the war he served in
the army for four years, spending two of the years
in China. Following his discharge from miltary service,
he returned to Saint Paul. For the last six months be-
fore he joined Dr. Bowers in Lake City, Dr. Gjerde
took postgraduate work at the University of Minnesota
Hospitals.
Dr. Harry E. Bowers, father of Dr. Robert N. Bow-
ers, announced his retirement at the same time. He has
practiced at Lake City since 1919.
* * *
The man who invented a workable external “artificial
kidney,” Dr. W. J. Kolff of Holland, was in Minneapolis
on May 17 to inspect a model of his invention construct-
ed by Dr. Roger M. Reinecke, assistant professor of
physiology at the LTniversity of Minnesota.
While Dr. Kolff’s device has been used on patients,
and Dr. Reinecke’s has , been used only in animal ex-
periments, both machines work on the same principle :
the removal of urea from the blood by passing the
blood through 30 to 40 yards of cellophane tubing
stretched on a mesh-covered cylinder which is rotated
through a salt solution.
Dr. Reinecke first heard of Dr. Kolff’s machine in
September, 1944, when as an army medical corps of-
ficer he landed in Holland with the 82nd Airborne Divi-
sion. From various reports of the original device — he
never actually saw it himself — Dr. Reinecke later was
able to construct his own model after he joined the
staff of the LTniversity of Minnesota last fall.
“Doctor to a Million” was the title conferred on Dr.
William A. O’Brien, LTniversity of Minnesota director
of postgraduate medical education, in the May issue of
Radio Mirror magazine. The title-bestowing article
commented on Dr. O’Brien’s public health programs
which have been broadcast on station WCCO since 1928.
During the last two weeks of April, extracurric-
ular speaking assignments for Dr. O’Brien included
( 1 ) comments on patent medicines at the Minnesota
State Pharmaceutical Association convention in Min-
neapolis, (2) a talk on “Social Organizations for Health
Maintenance,” one of a series of lectures on “Our
World and Our Times” sponsored by the general exten-
sion division of the University of Minnesota at the Cen-
ter for Continuation Study, and (3) an address in Still-
water at a dinner marking the completion of the first
year of county nurse work in Washington County.
* * *
Principal speakers at the annual meeting of the Group
Health Association, held in Minneapolis in April, were
Dr. Frederick W. Jackson, deputy public health minister
of Manitoba, Canada, and Dr. M. W. Shadid, Elk City,
Oklahoma.
Dr. Jackson described a government-sponsored medical
program to attract physicians from cities into the rural
areas of Manitoba. Dr. Shadid, founder of the first
rural co-operative hospital in the United States, stated
that medicine has become “so complex that the individual
doctor is not able to render adequate care,” and as-
serted that medical care must be based on group work to
be effective. During the weeks following the associa-
tion meeting, Dr. Shadid advocated his ideas on com-
munity co-operative hospitals in speeches delivered at
various cities in Minnesota, including Benson, Bagley
and Duluth.
!{c ^ ^
Domesticated radar may become a valuable therapeutic
aid in the future.
Experiments being conducted by the Mayo Founda-
tion for Medical Education and Research have sug-
gested that ultrahigh-frequency radio waves, similar to
those used in wartime radar, may produce better results
than the short-wave diathermy machines now being
used in physical medicine.
The basic unit of both radar and the portable micro-
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Minnesota Medicine
OF GENERAL INTEREST
wave-producing units being tested by the Mayo Founda-
tion experimenters is a small vacuum tube called the
cavity magnetron, which emits a beam of ultrahigh-
frequency radio waves that can be focused or even bent
around a corner. The frequency of such waves is 2,450
megacycles (close to two and one-half billion cycles per
second).
It is hoped that the experiments will show that these
microwaves will penetrate more deeply and produce
longer-lasting heat than the waves emitted by present-
day short-wave diathermy machines.
HOSPITAL NEWS
Work was begun in late April on alterations and ad-
ditions to a building in Forest Lake which will become
the new Forest Lake Clinic Hospital. The hospital when
completed will consist of three floors, each 30 by 60
feet in area.
Complete equipment has already been purchased and
is ready for installation as soon as the structure is
finished. Much of the equipment, which includes a new
x-ray machine, sterilizers, and mechanical beds with
inner-spring mattresses, was obtained from war sur-
plus material.
The hospital is being planned as a twelve-bed unit
but will be able to take care of additional patients on an
emergency basis. Kitchen and dining room facilities
will be located in the basement, with a dumb-waiter ar-
rangement for conveying food to the upper floors. An
emergency room, x-ray room, laboratory, waiting room
and two wards will be located on the first floor, while
second floor will be devoted to a maternity department,
with a delivery room, nursery, two wards and two
private rooms. Two graduate nurses will be employed
by the hospital.
Dr. E. C. Burseth, recently discharged from army
service, will be associated with Dr. G. M. Ruggles, of
the Forest Lake Clinic, in the operation of the new
hospital.
^ ^ ^
On April 1 the board of directors of the Kittson War
Veterans’ Memorial Hospital in Hallock provided per-
manent unified living quarters for the hospital nursing
staff by purchasing a private residence near the hos-
pital to serve as a nurses home.
Dr. Henry Hutchinson, former assistant superinten-
dent at Moose Lake State Hospital, has been appointed
acting superintendent to succeed Dr. M. W. Kemp who
resigned several months ago. During the war Dr. Hutch-
inson served as acting superintendent of the Hastings
State Hospital while its superintendent, Dr. Ralph Ros-
sen, was in the navy.
At a meeting of the Commercial Club of Cannon Falls
in late March, Dr. Viktor O. Wilson, of the Minnesota
State Department of Health, discussed the building of a
local hospital and the expense involved in the con-
struction of such a structure. He also described the
Federal aid plan to assist communities in the financing
of needed local hospitals, under a state administration.
* * *
The new board of directors of Sanford Hospital in
Farmington met during April and named Lawrence
Thorson, Northfield, as the new hospital manager.
Elected to office at the meeting were Dr. J. A. Sanford,
Farmington, president; L. A. Godby, vice president, and
Helen Kakac, secretary-treasurer.
Plans for refinancing the hospital were left for fur-
ther discussion at the next meeting. The institution is
now handling an average of 500 patients per year.
* * *
General solicitation for funds to help finance a $1,500,-
000 addition to St. Luke’s Hospital, Duluth, began on
June 1 under the direction of G. A. Andresen, presi-
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June, 1947 ‘
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dent of the Duluth Chamber of Commerce and gen-
eral chairman of the campaign.
Leaders of the public subscription campaign hope to
raise $750,000 to insure erection of a proposed 141-bed
addition to the hospital, with expanded laboratory,
pathological and other technical facilities.
•K •i' ^
The annual convention of the Minnesota Hospital
Association was held in Minneapolis at Hotel Radisson
on May 15, 16, and 17, with President Earl C. Wolf,
Rochester, presiding.
One of the featured speakers at the meeting was
George Bugbee, executive director of ’ the American
Hospital Association, who discussd “National Problems
Confronting Hospitals’’ and also spoke on “Hospital
Accounting and Its Relationship to Reimbursable For-
mula.”
Other speakers on the three-day program were Miss
Nellie Gorgas, administrator of St. Barnabas Hospital,
Minneapolis, and president-elect of the Minnesota Hos-
pital Association ; Hubert Humphrey, mayor of Min-
neapolis ; Dr. Malcolm MacEachern, associate director
of the American College of Surgeons ; and Miss Lucille
Pietry, nursing consultor of the U. S. Public Health
Service.
* * *
At a meeting held on May 6, citizens of Anoka and
the surrounding area began preliminary organization to
start a drive for the construction of a hospital in the
community. It was voted at the general meeting to
elect a board of directors, to incorporate, and to have
a large public relations committee with representatives
from each township, rural Hennepin county and each
ward in Anoka.
% % sfc
Recent speakers at the monthly staff meetings of St.
Luke’s Hospital in Duluth have been Dr. L. N. Leven,
Saint Paul (Skin Transplants); Dr. Norman Johnson,
Minneapolis (Neuropyschiatric Dis-zaszs ) ; Dr. Mark B.
Coventry, Rochester (The Surgical Treatment of Arth-
ritis) ; and Dr. E. Gordon, Madison, Wisconsin (Amino
Acids).
Staff members of St. Luke’s Hospital have recently-
participated in several regional medical meetings :
Rice Lake (Wis.) County Medical Society meeting —
Papers were presented by Dr. A. H. Wells, Dr. Harold
Joffe, and Dr. E. E. Barrett.
Tricounty Medical Society meeting — Papers presented
by Dr. S. H. Boyer, Jr., Dr. F. C. Jacobson, Dr. A. L.
Abraham, and Dr. C. H. Mead.
Interurban Academy of Medicine meeting — Papers
presented by Dr. Harold R. Joffe, Dr. P. B. Boman, and
Dr. C. H. Mead.
Douglas County Medical Society meeting — Papers
presented by Dr. F. C. Jacobson and Dr. C. H. Mead.
MEEKER COUNTY TUBERCULOSIS
CONTROL PROJECT
(Continued from Page 636)
A considerable number from adjacent counties
who have heard of the Meeker County physi-
cians’ interest in tuberculosis are requesting ex-
aminations. At present, all patients entering the
Litchfield hospital have the tuberculin test ad-
ministered, and the reactors are completely ex-
amined for clinical disease. Moreover, each phy-
sician in the county continues to administer as
many tuberculin tests as possible in his office each
week. Thus, our tuberculosis activities are being
perpetuated, and when normal conditions have
been restored throughout the county, we plan to
resume an even more vigorous campaign against
this disease.
Through the demonstration project, our phy-
sicians have become well informed on all phases
of tuberculosis work. Their present capabilities
in this field probably never would have been
achieved without the demonstration. Inasmuch
as the physicians donated their time and work,
and no outside equipment or personnel was in-
troduced, the general public has a kindly feel-
ing toward the medical profession, as well as
confidence in its integrity and ability to provide
them with all that is necessary to control dis-
ease. Our satisfaction in the accomplishment to
date is such that we feel justified in recommend-
ing an identical program to the physicians of all
other counties of the State of Minnesota.
BORCHERDT
MALT SOUP
EXTRACT
EST. 1868
Borcherdt’s Malt Soup Extract is a laxative
modifier of milk. One or two teaspoonfuls in a
single feeding produce a marked change in the
stool. Council Accepted. Send for sample.
BORCHERDT MALT EXTRACT COMPANY, 217 N. Wolcott Ave., Chicago 12,111.
692
Minnesota Medicine
The Mary E. Pogue School
Complete facilities for training Retarded and
Epileptic children educationally and socially.
Pupils, per teacher strictly limited. Excellent
educational, physical and occupational therapy
programs.
Recreational facilities include riding, group
games, selected movies under competent super-
vision of skilled personnel.
Catalogue on request.
G. H. Marquardt, M.D. Barclay J. MacGregor
Medical Director Registrar
26 Geneva Road, Wheaton, Illinois
(Near Chicago)
The Birches Sanitarium, Inc.
2391 Woodland Avenue
Duluth 3, Minnesota
A hospital for the care and treatment of
Nervous and Mental disorders. Quiet, cheer-
ful environment. Specially trained personnel.
Recreational and occupational therapy.
Psychiatrists in Charge
L„ R. Gowan, M.D. L. E. Schneider, M.D.
Practical Nursing Course
Nine months' course open to high school
graduates or women with equivalent
education.
For further information
write
Mrs. Lydia Zielke, Supt. of Nurses
FRANKLIN HOSPITAL
501 Franklin Avenue Minneapolis 5, Minnesota
TAILORS TO MEN
SINCE 1886
The finest imported and
domestic woolens such as
SCHUSLER'S have in stock
are not too fine to match
the hand tailoring we al-
ways have and always
will employ.
J.T.SCHUSLER co.
379 Robert St. St. Paul
George Dejmek
TJOMEWOOD HOSPITAL is one of the
■L Northwest's outstanding hospitals for the
treatment of Nervous Disorders — equipped
with all the essentials for rendering high-grade
service to patient and physician.
Operated in Connection with
Glenwood Hills Hospitals
HOMEWOOD HOSPITAL
Corner Penn and Plymouth Avenues North
Minneapolis Minnesota
June, 1947
693
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
Color Atlas of Hematology, With Brief Clinical
Descriptions of Various Diseases. Roy R. Kracke,
M.D., Dean and Professor of Clinical Medicine, Medi-
cal College of Alabama, Birmingham, Alabama. 204
pages. Illus. Price, cloth, $5.00. Philadelphia: J. B.
Lippincott Co., 1947.
Milk anh Food Sanitation Practice. H. S. Adams,
B.Sc. Chief, Bureau of Environmental Hygiene, Di-
vision of Public Health, Minneapolis, and Lecturer,
School of Public Health, University of Minnesota.
311 pages. Illus. Price, cloth, $3.25. New York: The
Commonwealth Fund, 1947.
Office Immunology, Including Allergy. A Guide
for the Practitioner. Edited by Marion B. Sulz-
berger, Professor of Clinical Dermatology and
Syphilology and Director of New York Skin and Can-
cer LTnit, New York Post-Graduate Medical School
and Hospital ; and Rudolph L. Baer, Instructor in
Dermatology and Syphilology, New York Skin and
Cancer LTnit, New York Post-Graduate Medical
School and Hospital. 420 pages. Illus. Price, $6.50,
cloth. Chicago: Year Book Publishers, Inc., 1947.
Classified Advertising
TEMPORARY LOCATION WANTED— August 25
through September 27 on locum tenens basis, on North
Shore of Lake Superior, to avoid ragweed. Experi-
ence— three years general practice, two years surgical
fellowship Mayo Clinic. Write E-21, care Minnesota
Medicine.
FOR SALE — Used x-ray equipment in good condition.
Placed for quick sale as room is needed for other
purposes. Address E-22, care Minnesota Medicine.
HOME SITES FOR SALE
Large, beautiful shore fronts. Where Coon Rap-
ids Dam broadens the Mississippi into a wide
lake. Boating, fishing, swimming, skating. On-
ly 15 miles to Minneapolis. 20 miles to St. Paul.
No blinding sun driving to and from work morn-
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and live. Where low taxes deliver life's best
Anoka Township has equipment and no debt.
On East River Drive, 1 mile off U. S. Highway
No. 10 and WCCO Tower. Bus service.
Owner, J. C. APPLETON
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Office, 1522 Henn. Ave., Minneapolis 3
Atlantic 6521
COMMUNITY-WIDE CHEST
X-RAY SURVEYS
(Continued from Page 634)
enough span of time to prevent the disease from
spreading to a new generation of contacts. Five
years should be the maximum time in which to
examine and follow up the majority of the adult
population in the entire United States.
Such rapidity of program expansion will be
costly as a short-time expenditure, but inexpen-
sive when compared to the cost of control over
a period of several decades. The savings in sick-
ness and death, although not easily demonstrated
in the coldly impersonal columns of balance
sheets, are the real accomplishments of such a
plan. Prevention is cheap, compared to the cost
of redemption after the damage is done. The
common rights of humanity call for such a course
of action.
Poverty remains, however, as the principal
obstacle still standing in the path of national
efforts to banish tuberculosis from among the
people of the United States. We cannot con-
quer this disease until the standard of living
improves greatly, especially among many of the
nonwhite groups of our population. Their death
rates from tuberculosis are unnaturally high, ex-
posure is intense and continuous, and living con-
ditions are often deplorable.
The effective strength of a broad program of
control, based on sound epidemiological princi-
ples, will develop it only in proportion to its
public acceptance and support. When the people
demand a total assault on tuberculosis, we are
prepared to measure the problem, plan the offen-
sive and destroy the tubercle bacillus within a
measurable time.
The ubiquity of tuberculosis and the magni-
tude of its harmful effect on the health and happi-
ness of the American people are at last arousing
the public conscience and stimulating the people
into nation-wide action.
TlcdumaL ffllacemsaiL S&wIol. . . . for HOSP,Tflls " ““S’S Offices
PART TIME— TEMPORARY— PERMANENT
When in need of a PHYSICIAN, DENTIST, OFFICE NURSE, TECHNICIAN, MEDICAL SECRETARY, or
OTHER PERSONNEL for medical and dental offices, clinics, and hospitals contact —
Mi?n1neapo^s?alMtnn-BGuEdl7!39 The Medical Placement Registry st. 5piuiHaMinn.-GA!n67i8
OLIVE H. KOHNER, Director
694
Minnesota Medicine
PHYSICIANS AND HOSPITALS SUPPLY CO.r Inc.
414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
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Orthopedic Braces and
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Physicians' specifications
followed precisely.
Scientific manufacture
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AUGUST F. KROLL
Manufacturer
230 WEST KELLOGG BLVD.
St. Paul, Minn. CE. 5330
Hall & Anderson
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Fire - Tornado - Automobile Insurance Service
REPRESENTATIVE-S, E. STRUBLE, WYOMING, MINN.
June, 1947
695
WARNINC . Do n
solution is cloudy £
is present. Th«* c°
bottle must not b*
than one infusion
keep the unopen*-
cool pi*1'
»us, non-
(weight
a pancre-
f casern
ci<Js and
1 LB. NET (454 GM->
PROTOLYSATE
For Oral Administration
^ d ry enzymic digest of casein containing arn
acidsand polypeptides, useful as a source of rfS ^
!l} absorbed food nitrogen when given orally <*
y tube Protolysate is designed for administr
10n cases requiring predigested protein-
mjQe of administration and the amount .0
given should be prescribed by the physicran
MEAD JOHNSON & CO
EVANSVILLE, IND. USA
1 lb. cans at drug stores
Like Amigen, Protolysate is an enzymic
digest of casein and consists of amino
acids and polypeptides. Like Amigen,
Protolysate supplies the nitrogen es-
sential for maintenance, repair and
growth.
Unlike Amigen, which may be em-
ployed both orally and parenterally,
Protolysate is designed only for oral
use.
The function of Amigen and Protolysate
is to supply the amino acids essential
for nutrition. Both can be given in place
of proteinwhen protein cannot be eaten
or digested, or in addition to protein
when the protein intake is insufficient.
Administered in adequate amounts,
they prevent wastage of protein, restore
previous losses, or build up new body
protein.
1000 cc. flasks
500 cc. flasks
125 cc. flasks
for hospitals.
''(a
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MEAD JOHNSON & CO., EVANSVILLE 21, INDIANA
“There is no shortage now of AMIGEN for parenteral us_e. There is no shortage now of PROTOLYSATE for oral use.
696
Minnesota Medicine
Ivery epileptic seizure takes its toll— psychically and somatically,
lental deterioration, extreme emotional instability and physical
ecline are generally the ultimate fate of the untreated.
'ILANTIN SODIUM KAPSEALS, by effective anti-convulsant
ction with comparatively little hypnotic effect,
elp grant the epileptic a happier life— freer from attacks
nd from the fear of attacks.
ILANTIN SODIUM KAPSEALS are one of a long line of Parke-Davis
reparations whose service to the profession created a dependable
^mbol of significance in medical therapeutics -medicamenta vera.
ILANTIN SODIUM KAPSEALS
liphenylhydantoin sodium), containing 0.03 gm
1/2 grain) and 0.1 gm. (1-1/2 grains), are
ipplied in bottles of 100 and 1000.
idividual dosage is determined by the response
: the patient.
ARKE, DAVIS & COMPANY • DETROIT 32, MICHIGAN
Your Ability to Earn
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Life Insurance protects you in case you die too soon or
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THE MASSACHUSETTS INDEMNITY GIVES
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Both Massachusetts Indemnity and Life Insurance poli-
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2. Are incontestable after two years
3. Are guaranteed renewable
4. Provide waiver of premium
5. And have 31 days of grace
Don't make your policy part of the hazard of disability.
Protect your earning capacity with long term, non-
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Write or Call
MASSACHUSETTS INDEMNITY INSURANCE COMPANY
Ralph H. Brastad, Agency Manager
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MINNEAPOLIS 2, MINNESOTA
698
Minnesota Medicine
Qttmmssk Qfleaicme
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 July, 1947 No. 7
Contents
Acute Poliomyelitis in Pregnancy.
Milton E. Baker, M.D., and Ilene Godfrey Baker,
R.N., B.S., Minneapolis, Minnesota 729
A Review of 174 Cases of Cancer With
Necropsies.
Harold H. Joffe, M.D., and Arthur H. Wells,
M.D., Duluth, Minnesota 735
General Principles in the Treatment of Peptic
Ulcer.
Joseph M. Ryan, M.D., Saint Paul, Minnesota... 742
Congenital Diaphragm of the Duodenum.
Wallace I. Nelson, M.D., F.A.C.S., Minneapolis,
Minnesota 745
The Minnesota Multiphasic Personality
Inventory.
A. E. Watch, M.D., and Robert A. Schneider,
M.D., Minneapolis, Minnesota 753
Reconstruction of the Extrahepatic Bile Duct.
Charles E. Rea, M.D., Saint Paul, Minnesota. . . . 759
Clinical-Pathological Conferences.
Parathyroid Adenoma.
Harold H. Joffe, M.D., F. H. Magney, M.D., and
Arthur H. Wells, M.D., Duluth, Minnesota 760
Case for Diagnosis.
A. J. Hertzog, M.D., and Julian Sether, M.D.,
Minneapolis, Minnesota 765
Case Report.
The Surgical History of a Centenarian.
Daniel J. Moos, M.D., and John V. Farkas,
M.D., Minneapolis, Minnesota 767
History of Medicine in Minnesota.
Notes on the History of Medicine in Fillmore
County Prior to 1900. ( Continued from June
issue.)
Nora H. Guthrey, Rochester, Minnesota 769
President’s Letter:
Tuberculosis in Minnesota 776
Editorial :
State Meeting a Success , 777
Laboratory Abuse 777
The National Foundation for Infantile Paralysis.. 777
Folic Acid in Pernicious Anemia 778
Lemon Juice and Teeth 778
The Mayo Memorial 779
Bond-a-Month Plan 779
Doctor Chesley Honored 780
Metopon Hydrochloride 781
Medical Economics :
Advisory Committee Formed to Tackle
Nurse Shortage 783
Hearings Being Held on National Health Bill. . 784
Minnesota Academy of Medicine:
Meeting of February 12, 1947 786
Present-Day Concepts in the- Treatment of Hyper-
thyroidism.
Charles E. Rea, M.D., Saint Paul, Minnesota.. 786
Experiences in the Treatment of Hydrocephalus
in Infants.
Wallace P. Ritchie, M.D., Saint Paul, Minnesota 790
Reports and Announcements 796
In Memoriam: 798
Of General Interest 799
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918.
July, 1947
699
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
C. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
^nual Subscription — $3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions— $3.50.
The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
ST. CROIXD ALE ON LAKE ST. CROIX
PRESCOTT. WISCONSIN
MAIN BUILDING— ONE OF THE 8 UNITS in “COTTAGE PLAN”
A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous and Mental Disorders
Located on beautiful Lake St. Croix, eighteen miles from the Twin Cities, it has the advantages of both
City and Country. Every facility for treatment provided, including recreational activities and occupational
therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
NEUROPSYCHIATRISTS
PRESCOTT OFFICE
Prescott, Wis.
Howard J. Laney, M.D.
Tel. 39 and Res. 76
Hewitt B. Hannah, M.D.
Joel C. Hultkrans, M.D.
Howard J. Laney, M.D.
511 Medical Arts Building
Minneapolis, Minnesota
Tel. MAin 1357
SUPERINTENDENT
Dorothy M. Most, R.N.
Prescott, Wisconsin
Tel. 69
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Minnesota Medicine
»
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McKesson
WATERLESS
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This new basal metabolism apparatus in-
corporates all the desirable features of
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The technique of operation is simple . . .
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Complete information and price will be furnished upon request. Write for
descriptive booklet No. M-747. Give voltage and cycle of electric current.
Distributed By
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MINNEAPOLIS MINNESOTA
t
July, 1947
701
85% of petit mat cases improve with Tridione
BIBLIOGRAPHY
1 . Richards, R K., and Everett, G. M
(1944), Analgesic ond Anticonvul-
sant Properties of 3,5,5-Trimethyl-
oxazolidme-2,4-dione (Tridione),
Federation Proc , 3 39, March.
5. Goodman, L , and Manuel C.
(1945), The Anticonvulsant Proper-
ties of Dimethyl-N-methyl Barbituric
Acid and 3,5,5-Trimethvloxazoli-
dine-2,4-dione (Tridione), Federa-
tion Proc , 4-119, Mar. 3. Good-
man, L.S., Toman, J E P, and
Swinyard, E A (1946), The Anti-
convulsant Properties of Tridione,
Am J Med , 1.213, September.
4. Richards, R K., Perlstein, M. A.
(1946), Tridione, a New Drug for
the Treatment of Convulsive and
Related Disorders, Arch. Neurol,
and Psychiat., 55:164, February.
5. Lennox, W. G. (1945), The Treat-
ment of Epilepsy, Med Clin North
America, 29:1114, September.
6. Thorne, F C (1945), The Anticon-
vulsant Action of Tridione Prelimi-
nary Report, Psychiatric Quart., 19:
686, Oct. 7. Lennox, W G.
(1945), Petit Mai Epilepsies:
Their Treatment with Tridione, J.
Amer. Med Assn. ,129 1069, Dec. 1 5.
8. Lennox, W G. (1946), Newer
Agents in the Treatment of Epilepsy,
J Pediat., 29:356, Sept. 9., Do
Jong, R. N. (1946), Effect of Tri-
dione in Control of Psychomotor
Attacks, J Amer. Med. Assn., 130:
565, Mar. 2 10. Perlstein, M. A.,
and Andelman, M. B (1946), Tri-
dione Its Use in Convulsive and Re-
lated Disorders, J. Pediat., 29:20,
July . 11. Lennox, W. G.
(1946), Two New Drugs in Epilepsy
Therapy, Am J Psychiat., 103 1 59,
Sept 12. Dejong, R. N (1946).
Further Observations on the Use of
Tridione in the Control of Psycho-
motor Attacks, Am. J. Psychiat.,
103 162, Sept 13. Lennox,
W G. (1947), Tridione in the Treat-
ment of Epilepsy, J Amer. Med.
Assn., 134 138, May 10.
Here's new evidence of the effectiveness of Tridione in the
treatment of petit mal. In a recent study, Tridione was given
to 166 patients suffering from petit mal (pyknoepilepsy) , myo-
clonic jerks or akinetic seizures.13 This group as a whole had
received but mediocre benefits from other medicaments. With
Tridione, 31% of the 166 became free of seizures; 32% had
fewer than one-fourth of the previous number of seizures;
20% improved to a lesser extent; 13% remained unchanged,
and only 4% became worse. Thus 83% showed improvement. In
some cases the seizures did not return after Tridione was
discontinued, the longest seizure-free period thus far being
18 months. Studies also have shown that Tridione is of
benefit to certain psychomotor patients when given in
conjunction with other antiepileptic drugs.12 Tridione is
available through your pharmacy in 0.3-Gm. capsules
and in pleasant-tasting aqueous solution containing 0.15
Gin. per fluidrachm. Capsules in bottles of 100 and
1000; solution in 1-pint and 1-gallon bottles. If you
wish to know more about Tridione, just write to
Abbott Laboratories, North Chicago, Illinois.
Tridione
(T R I M E T H A D I O N E , ABBOTT)
702
Minnesota Medicine
Formulae—
a modern
infant food
Formulac Infant Food is a concentrated milk in liquid form, for-
tified with all vitamins known to be necessary to adequate infant
nutrition. No supplementary vitamin administration is required.
By incorporating the vitamins into the milk itself, the risk of
human error or oversight is reduced. Formulac contains sufficient
B complex, Vitamin C in stabilized form, Vitamin D (800 U.S.P.
units), copper, manganese and easily assimilated ferric lactate —
rendering it a flexible formula basis both for normal and difficult
feeding cases. The only carbohydrate in Formulac is the natural
lactose found in cow’s milk. No carbohydrate has been added.
Formulac, a product of National Dairy research, has been
tested clinically, and proved satisfactory. It is promoted to the
medical profession alone. Formulac is on sale at grocery and drug
stores nationally.
Distributed by KRAFT FOODS COMPANY
NATIONAL DAIRY PRODUCTS COMPANY, INC.
NEW YORK, N.Y.
• For further information about
FORMULAC, and for professional
samples, mail a card to National
Dairy Products Company, Inc., 230
Park Avenue, New York 17, N. Y.
July, 1947
703
On the occasion of the 100th Anniversary
of the American Medical Association ...
IN TRIBUTE TO THE
• 99
w services
q sLaif measure devotion, or jmt ajmee
on sacrifice?
TVho shad assess tfic Cony war ayainst
ttie joower ofJdeatfi?
Or set a sum ujxm tkeyft of Jfe?
re 15 a service beyonb the measure of ajee.
A cause above remuneration.
An ibeal for tchich there is no price.
'Dus is the service...the cause...the utaaL.^f the American 6octor
|-{oxo shall we reckon it, an6 bij whatjormuiae?
How much for the laughter of a little chil6 rescued out crisis?
Whats the cost of itscouragement?
Wlao can pai] Jor a sleepless mcjht?
Name tlae price of a cure!
704
Minnesota Medicine
AMERICAN DOCTOR.
rendered...
cohere is no a^ebrajor it, no scribble pj'jkjures, no proper value.
For this is a service as larye as Ufe, and as manjold.
It is a soldier crying in aycny on a thousand battlefields.
It is the terrible word 'Why? hinder the surgeon's probe.
It is the end pain.
It is Hope.
It is the lonely, unendiny ^uestjbr knowledge.
It is thejight against tynorance., sloth, superstition.
It is the dumb, unspeakable joy in the eyes pf a parent.
It is the rock
It is cold rain and pounding storm and bone~xoeariness and the
nevo-bom babe yaspirig itsjirst breath in theyrey daton.
Jt is all this, and the ^uiet ylory ^ the job done,
Dedicated to service — in the name Mercy
And the commoia brotherhood £j- man.
PHILIP MORRIS & COMPANY
g PHILIP MORRIS will be happy to send you a handsomely printed and illuminated copy of this
r tribute, suitable for framing. Please make your request on your professional stationery.
Address Research Dept., PHILIP MORRIS & CO., LTD., INC. 119 Fifth Ave., New York 3, N. Y.
July, 1947
705
The First Surgical Operation was
performed with a sharp stone and firebrand
in Neolithic Egypt. A skull was pierced to
let out evil spirits. The patient survived.
Modern trephining was on the way.
The First Dental Operation, in the era
of the Pharaohs, was extraction by an in-
strument shaped like a goat’s foot. Re-
placements were of wood, ivory, metal
buttons and ox teeth. Modern dentures
were on the way. But the modern concept
of the doctor’s responsibility, as set forth in
malpractice law, was not yet on the way.
A First Operation Today is wisely
avoided by most doctors until they have
secured their Medical Protective policy-
providing, as it does, complete coverage and
confidential preventive counsel.
Professional Protection exclusively. . . since 1899
706
MINNEAPOLIS Office: Stanley J. Werner, Representative, 816 Medical Arts Building, Telephone Atlantic 5724
Minnesota Medicine
Urinary Stimulation
Stimulation of urinary secretion with
Salyrgan-Theophylline appears to be
due chiefly to its renal action
consisting of depression of tubular
reabsorption. In addition, there is a
direct influence on edematous tissue,
mobilizing sodium chloride and water.
Salyrgan-Theophylline is indicated
primarily in congestive heart failure
when edema and dyspnea persist
after rest and adequate digitalization.
Gratifying diuresis usually sets in
promptly and often totals from 3000
to 4000 cc. in twenty-four hours.
Injections at about weekly intervals
help to insure circulatory balance for
long periods of time.
Good results may also be obtained in
chronic nephritis and nephrosis.
Ampuls of 1 cc. and 2 cc. for
intramuscular and intravenous injection.
Enteric coated tablets for oral use.
CHEMICAL* COMPANY, INC.
New York 13, N. Y. • Windsor, Ont.
SALYRGAN
THEOPHYLLINE
Brand of Mersalyl and Theophylline
WELL TOLERATED POTENT MERCURIAL DIURETIC
707
SALYRGAN, trademark Reg. U. S. Pat. Off. & Canada
July, 1947
★ No refrigeration required for dry form.
★ Therapeutically inert materials which may act as aller-
gens have been virtually eliminated.
★ Minimum irritation on injection as a result of removal of
therapeutically inert materials.
★ Meets exacting Government specifications for Crystalline
Penicillin G.
★ Penicillin G has been proved to be a highly effective
therapeutic agent.
Crystalline Penicillin G Sodium Merck— An
Improved, Highly Purified Product
CRYSTALLINE
PENICILLIN G SODIUM
MERCK
MERCK & CO., Inc. RAHWAY, N; J.
t/Z (ft
708
Minnesota Medicine
Menopausal
Relief...
Plus
A General
Sense of
Well-Being
There is usually a “plus" in the treatment of the menopause when “Premarin "
is employed. The “plus” is the gratifying “sense of well-being” so many
women experience following orally active “Premarin" therapy. It is the
intangible factor which, added to relief of distressing symptoms, enables the
middle-aged woman to resume her normal routine of useful and enjoy-
able occupations.
To permit flexibility of dosage and enable the physician to adapt oral
estrogenic therapy to the particular needs of the patient, “Premarin" is
supplied in three potencies:
Tablets of 2.5 mg bottles of 20 and 100.
Tablets of 1.25 mg bottles of 20, 100 and 1000.
Tablets of 0.625 mg bottles of 100 and 1000.
Liquid, containing 0.625 mg. in each 4 cc. (1 teaspoonful) — bottles of 120 cc.
While sodium estrone sulfate is the principal estrogen in "Premarin," other
equine estrogens . . . estradiol, equilin, equilenin, hippulin . . . are also present
as wafer soluble sulfates. The water solubility of conjugated estrogens (equine!
permits rapid absorption from the gastrointestinal tract.
CONJUGATED ESTROGENS
(equine)
“Premarin®
AYERST, McKENNA & HARRISON Limited
22 EAST 40th STREET, NEW YORK 16, N. Y.
709
t
On the Plus Values
Jn Variety Meats
L
Variety meats — as the meat industry terms liver, kidney,
heart, thymus (sweetbreads), and tongue — are at least as
nutritionally desirable as muscle meat. In fact, in some respects
certain organ meats are superior.
They provide the indispensable amino acids in the same
advantageous complete assortment as muscle meat. Hence
their protein is of the same high biologic value, capable of
meeting every protein need of the organism. Quantitatively
their protein content is approximately equal to that of
muscle meat. t
For hemoglobin synthesis, liver and kidney have been
found superior not only to all other protein sources so far
studied but also to muscle meat itself.
All organ meats are good sources of the B-complex vitamins.
Some of them, such as liver and kidney, are especially rich
in niacin. Liver is also an excellent source of vitamin A.
Apparently the vital role these organs play in the func-
tioning of the animal body is reflected in the valuable con-
tribution they can make to human nutrition. Their frequent
inclusion in the human dietary — during disease as well as
in health — is amply justified.
The Seal of Acceptance denotes that the nutri-
tional statements made in this advertisement
are acceptable to the Council on Foods and
Nutrition of the American Medical Association.
AMERICAN MEAT INSTITUTE
MAIN OFFICE, CHICAGO . . . MEMBERS THROUGHOUT THE UNITED STATES
710
Minnesota Medicine
DRUGS
REXALL FOR RELIABILITY
In medieval times, the dragon was the symbol
of the chemist and apothecary. Ancient alche-
mists were said to use dragon's blood in their
potions, and the dragon came to mean certain
chemical actions. An apothecary advertised
his wares to the world by painting a dragon
on a drug pot, and hanging it over his door.
Today it is the familiar Rexall sign which
assures you of superior and dependable phar-
macal service. Displayed over more than
10,000 independent drug stores throughout the
country, the Rexall symbol on drugs means
pure, potent and uniform drugs, laboratory
tested under the rigid Rexall system of controls.
It means unexcelled pharmacal skill in com-
pounding them.
REXALL DRUG COMPANY
DO
YOU
KNOW
WHAT
THESE
SYMBOLS
STAND
FOR?
LOS ANGELES, CALIFORNIA
uly, 1947
PHARMACEUTICAL CHEMISTS FOR MORE THAN 44 YEARS
711
‘TfCtotetot ELECTRO-CARDIOGRAPHY
Portable , rugged , electrically o per-
ated without batteries. Cardiotron is
available with or without stand.
Th e first success ful
“Detect- 7QeancU*ty
Electrocardiographs*
With more than 1 200 now in use throughout the
world, the Cardiotron has established the principle
of instantaneous recording in general clinical elec-
tro-cardiography.
The Cardiotron is fast, accurate and sensitive. It
makes an immediate black and white cardiogram —
on permanent chart paper. It is free from skin re-
sistance errors. It reveals more information than any
other electrocardiograph instrument.
IMPORTANT: Factory-supervised installation and service
are available in most parts of the world. Good deliveries
are scheduled. Cardiotron is sensibly priced.
Send for 12-page descriptive booklet
GafuUettim
ELECTRO-PHYSICAL LABORATORIES. INC., 298 Dyckman St.. New York 34, N. Y.
‘Tfautccfacbvteru
ELECTROCARDIOGRAPHS, ELECTROENCEPHALOGRAPHS, SHOCK
THERAPY APPARATUS, AND SPECIAL ELECTRONIC EQUIPMENT
Distributed by
C F. ANDERSON CO.. INC
901 MARQUETTE AVENUE
MINNEAPOLIS 2. MINN.
712
Minnesota Medicine
KOROMEX JELLY
■ *
• Fastest Spermicidal Time
measurable under Brown and Gamble technique
• Proper Viscosity
for cervical occlusion
• Stable Over Long Period of Time
pH consistent with that of the normal vagina
• and in addition
time-fested clinical record
ACTIVE INGREDIENTS: Boric acid 2.0%, oxyquinolin benzoate
0.02% and phenylmercuric acetate 0.02% in a base of glycerin,
gum tragacanth, gum acacia, perfume and de-ionized water.
Prescribe Koromex Jelly with Confidence
. . . send for literature
HOLLAND-RANTOS COMPANY, INC., 551 FIFTH AVENUE, NEW YORK 17, N. Y.
July, 1947
713
EASE AND ECONOMY OF USE
',9d Corbohydrote for Supp»*n*e"»ia» ^
°R INFANT FEEDING
** Directed 'by
°tv2^,INS - MALTOSE - OEXTfiOS*
" uniform comgr
'•pa.IrS.i'KSSSfST
v'° ^Wespoonfute eauat 1 A ^
120 calories per fl. o*-
Specification of CARTOSE* as the
mixed carbohydrate for infant feed-
ing formulas provides ease and econ-
omy of use. The liquid form of this
milk modifier permits rapid, accurate
measurement, thereby avoiding
waste.
Double protection against con-
tamination is afforded by: (1) the
narrow neck of the bottle, preventing
spoon insertion, and (2) the press-on
cap, assuring effective resealing.
CARTOSE supplies nonferment-
able dextrins in association with mal-
tose and dextrose ... a combination
providing spaced absorption that
minimizes gastrointestinal distress
due to fermentation.
Available in clear glass bottles
containing 1 pt. • Two tablespoonfuls
(1 fl. oz.) provide 120 calories.
CARTOSE
•CC, U. S. «»*». Off.
Mixed Carbohydrates
♦The word CARTOSE is a registered trademark of H. W.
Kinney & Sons, Inc.
H. W. KINNEY & SONS, INC..
COLUMBUS, INDIANA
Minnesota Medicine
714
The fact that thousands of physicians are today using
G-E X-Ray’s Model F Portable is perhaps the most
convincing evidence of its recognized value.
You too, would soon conclude that for office x-ray
examinations, the Model F Portable atop your desk or
table greatly simplifies matters; also that the inambu-
lant patient is grateful for this service right in
his home.
Within the practical range of service for which this
unit is intended, the quality of radiographs it is ca-
pable of producing is second to none, regardless of
price. You’ll also appreciate the high standard of
workmanship throughout.
The moderate investment required, and the poten-
tial value of a Model F in your practice, assuredly
justify your investigation. Mail this coupon today.
\ General Electric X-Ray Corporation,
Dept. 2610, 175 W. Jackson Blvd.
Chicago 4, Illinois
1 Send me complete information on the G-E
Model F Portable X-Ray.
Name
Address
City
State c 13
GENERAL @ ELECTRIC
X-RAY CORPORATION
j_i— i - - 1
July, 1947
715
Sv/W’s
ced NVe«'s
patient fine
at. t"1 1 Ss Diced
rained. ^ andcon-
jtovide variety tender.
:e. They ate t ^
pieces ° . particles
d into smaller P
fs Diced Meats aUo
f U aPP--nvlilVivet
'^’Tounces P« tin.
heart- '
Swifts Meals
for juniors
When surgery, injury or disease indicates
chemically and physically non-irritating
foods in a high-protein, low-residue diet.
Swift’s Strained Meats offer a highly palat-
able, natural source of proteins, B vitamins
and minerals in easily assimilated form.
The six kinds of Swift’s Strained Meats:
beef, lamb, pork, veal, liver and heart, pro-
vide a tempting variety that appeals to pa-
tients, even when normal appetiteis impaired.
Finely strained lean meats—
prepared for infant feeding
Designed to be fed to young infants, these
all-meat products are soft, smooth and moist
— Swift’s Strained Meats are actually fine
enough to pass through the nipple of a nurs-
ing bottle. They are well adapted to use by
patients who cannot eat meat prepared in
the ordinary manner . . . may easily be used
in tube-feeding. These products are pre-
pared from selected, lean U. S. Government
Inspected Meats, carefully trimmed to re-
duce fat content to a minimum. Swift’s
Strained Meats are slightly salted to enhance
the natural meat flavor. They require no
cooking — come all ready to heat and serve.
Each vacuum-sealed tin contains
yA ounces of Strained Meat.
Write for complete information
about Swift’s Strained and Diced
Meats with samples, to: Swift &
Company, Dept. BF, Chicago 9, III.
All nutritional statements made in this advertisement are accepted
by the Council on Foods and Nutrition of the American Medical
Association.
FT & COMPANY
CHICAGO 9. ILLINOIS
716
Minnesota Medicine
When You Choose
"Dorseq
Constantly aware of the responsibility to your patient, your profession and
yourself, you and every careful physician will think twice- -or a dozen times--
before prescribing the products of a given pharmaceutical manufacturer.
When you do name a manufacturer, you speak with conviction.
Many doctors are prescribing Dorsey pharmaceuticals routinely, confidently.
Their confidence is justified because Dorsey products are made according
to rigidly standardized procedures ... in fully equipped modern labora-
tories . . . under the supervision of capable chemists and technicians.
Whenever a Dorsey product will serve your purpose, you can prescribe
with conviction: "Dorsey."
THE SMITH-DORSEY COMPANY
LINCOLN, NEBRASKA
Branches at Dallas and Los Angeles
MANUFACTURERS OF
PURIFIED SOLUTION OF LIVER-DORSEY
SOLUTION OF ESTROGENIC SUBSTANCES-DORSEY
July, 1947
717
1 Extensive clinical experience
• has established that the com-
bined use of an occlusive dia-
phragm and a spermatocidal
jelly affords the optimum in pro-
tection to the patient.
2 A comprehensive report
• shows an overwhelming
preference for the diaphragm-
jelly technique of conception
control. In a survey comprising
36,955 cases, clinicians pre-
scribed this method for 34,314
or 93 per cent1
3 Warner.2 in a study of 500
• cases in private practice,
concludes that the combined
technique is the most efficient
method; there was no case of
unexplained failure.
4 For the optimum of protec-
• tion and simplicity in use
we suggest the "RAMSES" Pre-
scription Packet NO. SOI ... a
complete unit, containing a
"RAMSES" Patented Flexible
Cushioned Diaphragm of pre-
scribed size, a "RAMSES" Dia-
phragm Introducer of corre-
sponding size, and a large tube
of "RAMSES" Vaginal Jelly.i
Available through all prescrip-
tion pharmacies. Complete lit-
erature to physicians on request
'Human Fertility 10: 25 (Mar.) 1945.
"Warner, M. P.: J.A.M.A. 115: 279 (July
27) 1940.
JULIUS SCHMID, INC. 423 W. 55th ST. • NEW YORK 19, N.Y.
/S83
The word "RAMSES" is a registered trademark of Julius Schmid. Inc.
tActive ingredients: Dodecaethyleneglycol
monolaurate 5%; Boric Acid 1%; Alcohol 5%.
718
M innesota Medicine
\xfwmnau
Marshall
Hall
(J 790-185?)
Pr°Vedit^VoW
greatest ach- ^
W3S his discovery0fhlZeniem
tlon ■ He noted freffexac-
re]»tionship of I1,6 esse*tial
and m°to r nerves and TnS°ry
toent of the « • , d the seg-
"*** theyZTal °0rd ^
Snored by hi/'"a,e4 At firs,
c"'"'JiocJ his " eag,'«. lie
<*e weigh,
«Perie„ces fo« * of vas,
accWance 0{ hisd^^1
discovery.
Yes , experience is the best teacher in smoking too!
IT was their experience during the wartime
shortage of cigarettes which taught people
the big differences in cigarette quality. People
smoked many different brands then — whatever
brand was available. And so many more smok-
ers came to prefer Camels as a result of that
experience that now more people are smoking
Camels than ever before. However, no matter
how great the demand, tee don't tamper with
Camel quality. Only choice tobaccos, properly
aged, and blended in the time-honored Camel
way, are used in Camels.
According to a recent Nationwide survey'.
More Doctors smoke Camels
B. J. Reynolds Tobacco Company, Winston-Salem, N. C.
than any other cigarette
July, 1947
719
the art of eating
Too many people "seem to feel that the art of eating consists
of filling the stomach to capacity three times a day.”1 They
ignore the fact that "calories alone do not make a balanced
diet.”1 They need, therefore, and will continue to need, support
of vitamin supplements. To better reconcile the science of nu-
trition with the "art of eating,” Upjohn provides a full range
of potent, balanced vitamin preparations. In a variety of dosage
forms, Upjohn vitamins help paint a better nutritional picture
for all age groups by obviating deficiencies or providing for
1 J. South Carolina M. Assn. # t
52:186 (July) 1946. their treatment in the practice of medicine and surgery.
Upjohn
FINE PHARMACEUTICALS SINCE 1886
UPJOHN VITAMINS
720
Minnesota Medicine
8
W BENADRYL
hydrochloride
K A P SEALS®
50 mg. each,
in bottles of 1 00
and 1000.
The results of a recent survey of the clinical use of
Benadryl (diphenhydramine hydrochloride) in 2665
patients are shown in the -accompanying table.
The efficacy of this new antihisiaminic
is also attested to in over 150 reports
published in the medical literature.
ELIXIR
10 mg. in each
teaspoonful, in pints
and gallons.
CAPSULES
25 mg. each,
in bottles of
100 and 1000.
Clinical Entity
to
1-
Z
UJ
Patients
Satisfactory
Questionable
No
Benefit
% Showing
Improvement
1-
<
URTICARIA
Qu
766
692
16
58
90.3
VASOMOTOR RHINITIS
in
O
349
268
2
79
76.7
ECZEMA
*o
cs
128
79
7
42
61.7
HAY FEVER
z
425
350
36
39
82.4
ASTHMA
ml
435
275
7
153
63.2
MIGRAINE
>
tc
73
48
1
24
65.7
ANGIONEUROTIC EDEMA
a
54
46
1
7
85.2
ATOPIC DERMATITIS
z
66
42
l
23
63.6
PRURITUS
UJ
GO
24
18
6
75.0
ERYTHEMA MULTIFORME
z
28
22
6
78.6
DERMOGRAPHIA
20
15
5
75.0
FOOD ALLERGY
>
37
32
5
86.5
CONTACT DERMATITIS
I/I
»-
63
49
14
77.7
ml
PHYSICAL ALLERGY
3
n
7
4
63.6
C/I
REACTIONS — ANTIBIOTIC
UJ
84
81
t
2
96.4
REACTIONS— DRUGS
46
42
4
91.3
REACTIONS — BIOLOGICS
p
12
12
100.0
DYSMENORRHEA*
3
UJ
44
38
6
86.3
a.
<
-
te.
TOTALS
UJ
X
2665
2116
72
478
79.39
t-
* those cases due to histamine-induced spasm of smooth muscle.
Benadryl
hydrochloride
a
«
t
*
*
*
PARKE. DAVIS & COMPANY, DETROIT 32, MICHIGAN**'***
July, 1947
721
PYOKTANIN SURGICAL GUT
Plain and Jwtnal'qed
Manufactured Since 1899 by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia.
• • •
Price fait
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE C NONBOILABLE
Sizes 000 — 00 — 0 — 1 — 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
• • •
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FDR SALE BY SURGICAL DEALERS AND DRUGGISTS
722
Minnesota Medicine
"Better Call the Doctor”
A familiar phrase in these United States. Self sacrificing, and
willing to help at all times, the doctor has indeed earned his high place in
our social esteem.
Right now we’re “calling the doctor.” Physicians and hospitals
across the country are seriously concerned over the shortage of trained nurses
available. We feel that in this case, too — the doctor is best able to solve the
problem. A well trained corps of nurses is vitally necessary to insure the high
standard of medicine as we now know it.
Glenwood Hills Hospital — through its school of nursing — is anxious
to cooperate with you in your effort to increase the number of nurses in your
community. A student from your locality will result in increased nursing as-
sistance to you in the near future. Your help is greatly needed in recruiting
candidates for this profession. For full information write Miss Margaret Chase,
R.N., B.S., Director, School of Nursing.
SCHOOL OF
PSYCHIATRIC
OORSIHG
•
FALL CLASS
will start in
September
Candidates for the Sep-
tember class should make
reservations at once . . .
School and health record
must be reviewed and
correspondence complet-
ed prior to acceptance.
“Hospital administrators and doctors throughout the country are
seriously concerned over the dangerously inadequate nursing care
available. Results of a recent survey indicate that 55 to 60 per cent
of the required amount is obtainable . . .
“ . . approved hospitals should provide training for such voca-
tional nurses by means of short courses.’
“The doctor is responsible for the care of the patient. In order to
meet this obligation, the medical staff together with the hospital and
nursing administrators, are urged to undertake the development and
execution of this program.”1
“It is time that some of the present-day advantages of a nursing
career be made known to young women.”2
ONE YEAR NURSING COURSE
Glenwood Hills Hospitals are currently offering to qualified
applicants a one year course in psychiatric nursing. All phases
of the subject are skillfully presented by a capable and experi-
enced faculty. TUITION IS FREE. Regular classes begin in
January, June, and September.
P \
enmflod
s os
3i a s
350 1 Golden Valley Road : Route Seven : Minneapolis, Minn.
1. Irvin Abell, M.D., Chairman, Bd. of Regents, Am. Col. Surgeons; Am. Jl. of Nursing, March 1947.
2. A. E. Hedback, M.D., Editor, Modern Medicine; Jl. -Lancet, April 1947.
July, 1947
723
(Above) Fining practice session at recent CAMP Instructional Course
YOUR PATIENTS ARE PROPERLY FITTED
When You Recommend C/y\AP Scientific Supports
CAMP fitters are conscientiously trained to work on the physician’s
team as technicians in scientfic supports. Annual four-day sessions
in New York and Chicago (now in their 19th year), a steady
schedule of regional classes, individual instruction by the corps of
CAMP registered nurses and professionally edited handbooks and
other helpful literature have trained thousands of fitters in pre-
scription accuracy and ethical procedure.
S. H. CAMP AND COMPANY, JACKSON, MICHIGAN
World’s Largest Manufacturers of Scientific Supports
Offices in New York • Chicago • Windsor, Ontario • London, England
(
724
Minnesota Medicine
Easily calculated. . . quickly pre-
pared. 1 Jl. oz. Biolac to V/2 fl. oz.
water per pound of body weight.
Even under the handicaps of travel or vacation accommo-
dations, a mother can easily prepare a safe formula for her
infant ... by just adding cooled boiled water to Biolac
^according to the physician’s directions. The simplicity of
preparation (dilution only) minimizes possibilities of formula
contamination even under adverse conditions.
In addition to safety and simplicity of preparation, Biolac
formulas provide complete nutrition when supplemented
with vitamin C. No chance omission of needed vitamins,
x
carbohydrates or iron can occur. Biolac simply and safely
affords nutritional elements for optimum health.
BORDEN’S PRESCRIPTION PRODUCTS DIVISION
350 MADISON AVENUE • • NEW YORK 17, N. Y.
Biolac
"BABY TALK” FOB A GOOD SQUARE MEAL
B iolac is a liquid modified milk, prepared from whole and skim milk,
with added lactose, and fortified with vitamin Bj, concentrate of vitamins
A and D from cod liver oil, and iron citrate. Evaporated, homogenized,
.and sterilized. Biolac is available in 13 fl. oz. cans at all drug stores.
July, 1947
725
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
EMPHASIS ©IV
FLOW —
DecftoCin.
3% gr. tablets. Boxes of 25, 100, 500 and 1000;
powder 25 Gm.
Fluidity of the bile is the factor which
determines success in removal of
thickened and purulent material from
the hile passages. Decholin (chemi-
cally pure dehydrocholic acid) stimu-
lates the liver cells to produce a thin,
easily flowing bile, which flushes the
ducts, and promotes drainage.
AMES COMPANY, Inc.
Successors to Riedel - de Haen, Inc.
ELKHART, INDIANA
726
Minnesota Medicine
Some things you would like your patients to know
about Epilepsy
The educational message on Epilepsy, shown below, will appear in full color
in LIFE and other national magazines . . . reaching an audience of more than
22 million people. This is No. 205 in the “See Your Doctor” series, published
by Parke-Davis in behalf of the medical profession.
” a w'm of
!mPotiance of ,
niEPsy ;s
- "nderstuo <1
M '".v people believe
'•lent f„r ,(la| .
that it ,
J'"a>s becom
“Wer' a"d that he
nornidf life.
L (
7 °f'hc "'us. |
1 all diseases.
" “'at there's no c/ft
J l'"<l of feeble-m
? "°rse Js "« pati
,as "O chance of
n'e truth
ph'shed a g„
epilepsy, and
'Wio have the ,
101 s<*nce has
" a,l<""pl (o
"Ulloi.l for ,„„SI
n""«Iy hopeful.
5 JCCOIII.
control
persons
in iv/ijVi ‘i s,mple term,
sehtures Th “ Pa“Cnt su
Sc„t c rur,2urcs'1
“d
“on, and i ntenslty ^ gr"
^nelahlshT’'0'^
chances X ^ "'ajc"' ro
chiw::ettt^cw;
ts ,epSy “ a disorder
often begins
-adreX,“hr;S'’a
ca« usually g,v/.i ^Wow
C"courage^7 hePare"‘S-
explain
con f rotted?
"chiltlh oodoradoUs.
diagnosis of cpi|c
B" today, he doc, of
following figures
'^'his7sdsoh°Pe-
!::>°Xt;zlrnr°u'
? ™apP'ars~and c
&T-are~wlth
»al Ur, J J e> an<f
treatment of.
,7 *“ cn>«, I/,, d-
appears completely,
,UtPPtar’n'arb50pcr
" most cases, m„der„
TPui0"h"‘rJ‘"-tor
Usi"g these medicine,
^veep;,eptl.csanws
/ he 'hrea, of seu„res .
™a! deter, „ratlo„, 'he
cag'c seclusion. But
schools°and^er tT “
id' their schoolmates.
°UR DOCTOR' rr
cc a sei™e JlyOUOrf°
haunted
gradual
Makers
Prescribed
iieians
PARKE. DAVis
July, 1947
727
a switch to ‘Wellcome’ Globin Insulin with
Zinc can often save the annoyance of a second
or third daily insulin injection — for in many
cases the patient’s needs can be supplied with
only one injection a day of this unique inter-
mediate-acting insulin, Three distinct steps pro-
vide the welcomed change-over:
3. ADJUSTMENT OF DIET: Simultaneously adjust
carbohydrate distribution of diet to balance
insulin activity; initially 2/10, 4/10 and 4/10.
Any midafternoon hypoglycemia may usually
be offset by 10 to 20 grams carbohydrate at
3 to 4 p.m. Base final carbohydrate adjustment
on fractional urinalyses.
I. THE INITIAL CHANGE-OVER DOSAGE: The first
day, 30 minutes or more before breakfast, give
a single dose of Globin Insulin, equal to Vi the
total previous daily dose of protamine zinc
insulin or of protamine zinc insulin combined
with regular insulin. The next day, dose may
be increased to I. 2A former total.
Most mild and many moderately severe cases
maybe controlled by one daily injection of' Well-
come’ Globin Insulin with Zinc. Vials of 10 cc.;
40 and 80 units per cc. Developed in The Well-
come Research Laboratories, Tuckahoe, New
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'Wellcome' Trademark Registered
2. ADJUSTMENT TO 24-HOUR CONTROL: Gradually
adjust the Globin Insulin dosage to provide
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urine in the fasting sample.
BURROUGHS WELLCOME & CO. (U.S.A.) INC., 9 & II EAST 4IST STREET, NEW YORK 17, N.Y.
728
i
Minnesota Medicine
hiumal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surqical Society
Volume 30 July. 1947 No. 7
ACUTE POLIOMYELITIS IN PREGNANCY
Report of Thirty Cases
MILTON E. BAKER, M.D., and ILENE GODFREY BAKER, R.N., B.S.
Minneapolis, Minnesota
TOURING the Minnesota poliomyelitis epidemic
in the summer of 1946, a total of 695 patients
with acute poliomyelitis were admitted to the
Minneapolis General Hospital on the contagion
service between July 29 and September 21. Of
this group, 115 were women between the ages of
fifteen and forty-five years, and of this last group,
thirty were pregnant. The ages of these pregnant
women varied between seventeen and thirty-two
years. Stages of gestation at the time of admis-
sion varied between six weeks and nine lunar
months. Seven women were admitted during the
first trimester of pregnancy, sixteen during the
second trimester, and seven during the third tri-
mester. Determination of the length of gestation
was based on history, physical findings, and in
case of abortion, on fetal and placental findings.
There were seven cases of spontaneous abortion
which occurred in patients with various types of
poliomyelitis, and at various periods of gestation,
as is shown in Table I. Three women had signs
of threatened abortion, such as low abdominal
cramping pain and vaginal spotting, but did not
go on to abort. One woman with bulbar polio-
myelitis, who aborted on the third day following
admission, expired as a result of respiratory fail-
ure on the seventh day.
Four patients were delivered in the Minne-
apolis General Hospital during their admission for
poliomyelitis. One of these was a spontaneous
delivery, and two were low forceps deliveries.
Two of these infants were apparently normal,
but one of those delivered with low forceps had
From the Department of Obstetrics and Gynecology, Minne-
apolis General Hospital.
July, 1947
an occipital-frontal diameter of 36.5 centimeters.
One living fetus of seven lunar months’ gestation
was surgically removed from the mother imme-
diately after her death.
Twelve deliveries were carried out by private
physicians after discharge of the mother from
the Minneapolis General Hospital. Seven of these
deliveries were spontaneous or by outlet forceps
extraction, and the infants were normal and full-
term. Patient No, 6 was delivered by cesarean
section. This mother had had a previous difficult
delivery, pelvic measurements of questionable
adequacy, and a history of rickets. Patient No. 8
was delivered spontaneously of a 2,174 gram in-
fant which was normal aside from prematurity,
the length of gestation being thirty-six weeks. Pa-
tient No. 7 was delivered of an 1,812 gram infant
by breech extraction. This last infant was a foot-
ling, and the length of gestation was approximate-
ly thirty-six weeks. The present diagnosis of this
infant is osteogenesis imperfecta, and it has bi-
lateral fractures of the femurs. Patient No. 19
was delivered spontaneously of a macerated still-
born fetus. The estimated length of gestation was
thirty-six weeks, despite the small estimated
weight of 900 to 1,350 grams and the relatively
underdeveloped state of the fetus.
Patient No. 3 spent twelve days in a respirator,
and on the fifth day of this period went into labor
spontaneously and was delivered of a slightly mac-
erated fetus by low forceps extraction. The fetus
weighed 3,130 grams, measured 52 centimeters,
crown-heel length, and was found to have a horse-
shoe kidney. During the mother’s stay in the res-
729
POLIOMYELITIS IN PREGNANCY— BAKER AND BAKER
TABLE I. PREGNANT NONPARALYTIC POLIOMYELITIS ADMISSIONS TO MINNEAPOLIS
GENERAL HOSPITAL, JULY 29 TO SEPTEMBER 21, 1946
Case No.
Admission
Date
Age
Parity
Admission
Length of
Gestation
Termination of Pregnancy
Poliomyelitis Status on March 15, 1947
i
8- 2-46
20
i
12 weeks
Normal spontaneous delivery 1-25-47
No residual paralysis
5
8- 2-46
21
1
36 weeks
Normal spontaneous delivery 8-31-46
No residual paralysis
6
8- 4-46
25
2
38 weeks
Cesarean section — contracted pelvis 8-24-46
No residual paralysis
7
8- 7-46
20
0
14 weeks
Breech extraction premature infant with
osteogenesis imperfecta 12-25-46
No residual paralysis
8
8- 7-46
31
2
10 weeks
Normal spontaneous delivery
Generalized weakness and fatiguability
9
8- 9-46
19
1
12 weeks
Unknown
Unknown
10
8- 9-46
27
0
24 weeks
Normal spontaneous delivery
No residual paralysis
14
9-11-46
17
0
18 weeks
Unknown
Unknown
16
9-12-46
21
0
38 weeks
Brow:manual conversion to occiput pos-
terior. Difficult low forceps extraction.
No residual paralysis
18
9- 7-46
17
0
20 weeks
Unknown
Unknown
21
8-11-46
19
0
26 weeks
Normal spontaneous delivery 12-2-46
Weakness of right leg and knee
22
8-11-46
20
0
18 weeks
Normal spontaneous delivery
No residual paralysis
23
8-14-46
31
1
20 weeks
Spontaneous abortion 8-15-46
No residual paralysis
26
8-27-46
32
1
18 weeks
Spontaneous abortion 9-1-46
No residual paralysis
27
8-14-46
16
0
8 weeks
Spontaneous abortion 8-19-46
No residual paralysis
28
8-10-46
20
?
24-26 weeks
Spontaneous abortion
No residual paralysis
29
9-10-46
17
?
20 weeks
Spontaneous abortion 9-14-46
No residual paralysis
TABLE II. PREGNANT BULBAR AND SPINAL PARALYTIC POLIOMYELITIS ADMISSIONS TO
MINNEAPOLIS GENERAL HOSPITAL, JULY 29 TO SEPTEMBER 21, 1946
Case No.
Admission
Date
Age
Parity
Admission
Length of
Gestation
Termination of Pregnancy
Poliomyelitis Status on March 15, 1947
2
8- 2-46
30
1
20 weeks
Death of mother 8-4-46
Bulbar and spinal paralytic types.
Respiratory death.
3
7-29-46
20
1
36 weeks
Low forceps extraction of a slightly
macerated fetus 8-12-46
Spinal paralytic type. Death 8-17-46.
Probable pulmonary embolus
4
7-31-46
17
0
6 weeks
Spontaneous incomplete abortion 8-2-46
Bulbar type. Respiratory death 8-5-46
11
8-13-46
23
1
37 weeks
Normal spontaneous delivery 9-7-46
Spinal paralytic type. Minimal stiffness
of legs 9-20-46
12
9- 7-46
22
0
18 weeks
Normal spontaneous delivery
Spinal paralytic type. No residual
paralysis
13
9- 9-46
26
1
18 weeks
Normal spontaneous delivery
Bulbar type. No residual paralysis
15
8-30-46
17
0
20 weeks
Death of mother 8-31-46
Bulbar type. Respiratory death
17
8-11-46
25
1
20 weeks
Death of mother 8-11-46
Bulbar type. Respiratory death
19
9-21-46
28
3
12 weeks
Spontaneous delivery of a macerated pre-
mature fetus 3-4-47
Bulbar and spinal paralytic types.
Difficulty holding body erect
20
9-21-46
26
0
10 weeks
Spontaneous incomplete abortion 9-24-46
Spinal paralytic type. Weakness of both
legs 1 1-1-47
24
8-26-46
22
1
26 weeks
Outlet forceps extraction
Spinal paralytic type. Weakness of leg
muscles, left side and back
25
8-28-46
29
3
30 weeks
Post-mortem hysterotomy 8-29-46. Baby
expired 5 minutes after delivery
Bulbar type. Respiratory death.
30
8-30-46
24
1
38 weeks
Low forceps extraction
Spinal paralytic type. No residual
paralysis
pirator, she had had many episodes of marked cy-
anosis, and on several occasions it was feared that
she would not survive. Fetal heart tones were heard
three days before delivery. Spontaneous onset of
labor occurred at nine lunar months’ gestation.
After a labor of nine hours, low forceps were
applied because the patient was having respiratory
embarrassment. She had to be replaced in and out
of the respirator several times during the delivery
and repair of the episiotomy. After the delivery,
the patient improved markedly. She was removed
from the respirator and was transferred to a con-
valescent ward five days postpartum, where she
continued to improve until the sixth day post-
partum when she suddenly developed symptoms
and signs of a pulmonary embolus and expired.
Permission for autopsy was not granted.
Patient No. 25 was admitted with a diagnosis
of bulbar poliomyelitis. On the day following
admission, her condition was critical. She had
been in a respirator more than twenty-four hours
when she expired. The gestation was estimated
to be at seven lunar months. The fetal heart was
frequently heard up to one hour before death, at
which time the patient became so cyanotic that
it was considered necessary to keep her in the
respirator continuously. After she had been pro-
nounced dead by three doctors, an immediate post-
mortem hysterotomy was performed and the in-
fant delivered. The fetal heart continued for five
minutes after delivery, and the infant took one
gasp. Its weight was 1,812 grams and the crown-
heel length was 43 centimeters.
Patient No. 16 was delivered by low forceps on
September 12. She was a primigravida with nor-
mal pelvic measurements who was diagnosed as
730
Minnesota Medicine
POLIOMYELITIS IN PREGNANCY— BAKER AND BAKER
acute poliomyelitis, nonparalytic, and was con-
sidered a noninfectious patient at the time of de-
livery. Labor progressed normally until the late
second stage when progress stopped with full
dilatation of the cervix and the head at a 2 +
station. Sterile vaginal examination revealed the
presenting part to be the brow. The head was
large despite the fact that abdominal examination
had not revealed an abnormally large baby. A
manual conversion to an occiput posterior posi-
tion was carried out and the head delivered in
this position by Tucker-McLane forceps. The
extraction was difficult, but no apparent maternal
injury resulted. The occipital-frontal circum-
ference of the fetal head was 36.5 centimeters.
The mother had a normal post-partum course
except for relatively slow involution of the uterus,
a finding noted in three poliomyelitis patients de-
livered at Minneapolis General Hospital.
The discharge diagnosis was nonparalytic acute
poliomyelitis in seventeen patients, spinal paralytic
in six patients, bulbar in five patients, and a com-
bination of bulbar and spinal paralytic in two pa-
tients. In the series, there were six deaths. Of
these, five occurred in patients with bulbar lesions,
one of whom had a combination of bulbar and
spinal involvement. One death occurred in a pa-
tient with spinal involvement only and was prob-
ably the result of a pulmonary embolus. This
followed delivery of a macerated fetus of nine
lunar months’ gestation. An autopsy was car-
ried out on only one of these patients. Death
was due to respiratory failure. Autopsies were
performed on the fetuses from patients No. 3
and No. 25. The spinal cords were soft but this
could not be determined to be due to poliomyelitis.
Discussion
Most of the current literature dealing with the
association of pregnancy and poliomyelitis seems
to be concerned with these four major questions :
1. What effect has pregnancy on susceptibility to, or
resistance against poliomyelitis?
2. What effect has pregnancy on the course of the dis-
ease in the poliomyelitis patient?
3. What effect has poliomyelitis on the course of the
pregnancy?
4. Can the fetus contract poliomyelitis in utero from
a diseased mother?
There is, apparently, a diversity of opinion as
to the frequency of the coincidental occurrence of
poliomyelitis and pregnancy. Berg4 states that
July, 1947
TABLE III. PERCENTAGE OF PREGNANT POLIO
CASES TO CASES OF POLIO IN WOMEN
OF CHILD-BEARING AGE
Author
Locality
Women of
Approxi-
mately
Child-
bearing
Age
Number
of
Cases in
Preg-
nancy
Percentage of
Pregnant
Cases Among
Women of
Child-bearing
Age
Aycock
(Vaughn)
Detroit 1939
11
3
27.3
Brahdy and
Lenarsky
New York
15
3
20.0
Fox and
Sennett
Milwaukee
1943
6
4
66.7
Aycock
Duluth
8
1
12.5
Aycock
Dist. of Co-
lumbia 1944
18
4
22.0
Aycock
(Waaler)
Bergen, Nor-
way 1941
18
7
30.0
Aycock
Massachusetts
1945
54
10
18.5
Baker and
Baker
Mpls. Gen.
Hosp. 1946
115
30
26.0
Total
245
62
25.3
“in the many years in which poliomyelitis has
been a problem, doctors had remarked on the
small incidence in women who were pregnant”
(p. 148). McGoogan13 likewise speaks of the oc-
currence of poliomyelitis in pregnancy as being
rare. Aycock,3 who believes pregnant women are
more susceptible to poliomyelitis than nonpregnant
women, has calculated the chance coincidence of
the two conditions to be less than once for every
1 ,000 cases of poliomyelitis. Since thirty of the
695 cases of poliomyelitis admitted to the Minne-
apolis General Hospital were pregnant (a ratio
of approximately 43 pregnancies per 1,000 cases
of poliomyelitis), it would appear that factors
other than chance were operating.
In the Detroit epidemic of 1939, Aycock3 re-
ports (from a personal communication from
Vaughan) eleven cases of poliomyelitis in women
over twenty-one years of age. Three of them (27.3
per cent) were pregnant. In the New York
epidemic, as reported by Brahdy and Lenarsky,7
fifteen patients were women over nineteen years of
age; three of these (20 per cent) were pregnant.
Fox and Sennett8 summarized the above data, and
added to them their own findings reported in Wis-
consin in 1943 : four pregnant poliomyelitis pa-
tients out of a total of six female cases (66.7 per
cent). Totaling the three reports showed that
31.3 per cent of the female poliomyelitis patients
in the child-bearing age were pregnant. Four ad-
ditions to these reports were made by Aycock2
in a later study: (1) Duluth, Minnesota, series,
where one of eight female patients was pregnant ;
(2) District of Columbia, where in 1944, of
731
POLIOMYELITIS IN PREGNANCY— BAKER AND BAKER
eighteen female patients twenty to forty-five years
of age, four (22 per cent) were pregnant; (3)
Waaler’s report of twenty-three female patients
over eighteen years of age (Bergen, Norway,
1941), seven of whom (30 per cent) were preg-
nant, and (4) Massachusetts, 1945, where ten
out of fifty-four female patients between the ages
of fifteen and forty-five were found to be preg-
nant. To these reports, we add those for the Min-
neapolis General Hospital during the two-month
period covered by this study. Of 115 cases of
poliomyelitis in women fifteen to forty-five years
of age, 30 (26 per cent) were pregnant. Com-
bining these findings with those of the above-men-
tioned investigators, it is found that 25.3 per cent
of the women in the child-bearing age in these
eight studies were pregnant. (These reports are
reasonably comparable, although the definition of
child-bearing age differs slightly in each report.)
According to calculations based on data obtained
from the Statistical Abstract of the United States
Census Bureau for 1946, 16 approximately 6 per
cent of the female population of child-bearing age
are pregnant at any one time.* Since the per-
centage of pregnant women among female polio-
myelitis patients of the child-bearing age (as
determined in these studies) is more than four
times that of pregnant women among the cor-
responding group of the population at large, it
would appear that pregnant women are more sus-
ceptible to poliomyelitis than nonpregnant women.
Some investigators find evidence to support the
conclusion that the pregnant female is somewhat
more resistant to poliomyelitis during the first
trimester of pregnancy. The International Com-
mittee for the Study of Infantile Paralysis11 re-
ports that “there is a general impression that, al-
though the disease is likely to occur in the late
months of pregnancy, it does not occur in the
early months. We have met with no instances of
the disease occurring in early pregnancy” (p.
416). Weaver and Steiner,17 using pregnant cot-
ton rats experimentally inoculated with poliomy-
elitis virus, found rats in the first trimester of
pregnancy were more resistant than those in
more advanced stages of pregnancy, but all preg-
nant rats were somewhat more resistant than vir-
gin rats. Brahdy and Lenarsky7 conclude from
their study of three patients and a review of eight
*This figure was computed by taking 9/12 (period of gestation)
of the ratio of births during 1944 to female population fifteen
to forty-five years of age for that same year.
cases from literature, that poliomyelitis can occur
in early pregnancy as well as in late. Aycock,17
in a survey of seventy-five pregnant poliomyelitis
cases from the literature and from his personal
records, found 17.1 per cent of these infections to
have occurred in the first trimester of pregnancy,
34.3 per cent in the second, and 48.8 per cent in
the last. He expresses the belief in a later study,2
however, that “there is no indication of a ten-
dency of the disease to occur at any specific period
of pregnancy” and that the apparent dearth of
infections in early pregnancy is probably due to
“discrepancy in the data.” Of the thirty pregnant
women with poliomyelitis at the Minneapolis Gen-
eral Hospital, 23.3 per cent were in the first
trimester, 53.3 per cent in the second, and 23.3
per cent in the last. This would tend to support
Aycock’s views.
Pregnancy has little influence on the course of
poliomyelitis or the extent of paralysis in the
mother, according to Harmon and Hoyne.10 Mc-
Googan,13 on the other hand, believes that preg-
nancy may be a factor in the severity and outcome
of poliomyelitis, in that such complications as
cystitis and respiratory paralysis are aggravated
by pregnancy, and that recovery seems to occur
more rapidly after its termination. Brahdy and
Lenarsky7 imply that respiratory paralysis is the
only indication for the termination of pregnancy
in a patient with poliomyelitis. Gillespie9 reports
a patient who improved markedly after a cesarean
section was performed in a respirator. A similar
patient, described by Spishakoff et al,15 appeared
to be so seriously ill that post-mortem cesarean
was considered. However, after spontaneous de-
livery occurred, the patient’s respirations im-
proved immediately, she became afebrile within
twenty-four hours, and was removed from the
respirator a week later. They offer this as the
only reported case of full-term pregnancy com-
plicated by ascending poliomyelitis and respiratory
paralysis. To this, we can add case No. 3 of our
study, as described above, which closely resembles
it. Due to the capricious nature of the disease
itself, however, it is difficult to determine how
much of its course can be attributed to the in-
fluence of pregnancy or to its termination. The
present study showed that 20 per cent of the
pregnant poliomyelitis patients expired, while 14.1
per cent of the nonpregnant female patients of
child-bearing age expired. Although this is too
732
Minnesota Medicine
POLIOMYELITIS IN PREGNANCY— BAKER AND BAKER
slight a difference to warrant any conclusions as
to the influence of pregnancy on the prognosis of
the patient with poliomyelitis, it is, perhaps,
worthy of mention.
exhausted and the maternal outlook grave. (The
cases reported by these authors are tabulated in
Table IV. The authors reporting the therapeutic
abortion and one of the therapeutic cesarean sec-
TABLE IV. TERMINATION OF PREGNANCIES IN PREGNANT POLIO PATIENTS
Author
Total
No.
of
Cases
Death of
Mother
Before
Delivery
Nor-
mal
Term
Low
For-
ceps
Mid
For-
ceps
Breech
Pre-
mature
Abort-
ed
Cesa-
rean
Un-
known
Blair et al
6
i
3
i
i
Brahdy and Lenarsky
3
1
1
Thera-
peutic
Harmen and Hoyne
2
1
i
Kleinberg and Horwitz
28
15
6
2
2
1
2
McGoogan
3
2
i
Fox and Sennett
3
i
1
1
Spiskoff et al
1
i
Gillespie
1
1
Morrow and Luria
1
1
Baker and Baker
30
4
8
4
1*
3
7
1
3
Total
78
6
32
10
2
4
8
10
4
3
* This infant was also premature and is listed again in the “premature” column.
Will the pregnant poliomyelitis patient go to
term and if so, what are her chances for a normal
delivery ? The various investigators are quite well
agreed on the answer to this question. Blair et al6
found that deliveries were normal despite paraly-
sis. Brahdy and Lenarsky7 take the stand that
uncomplicated poliomyelitis (exclusive of respira-
tory paralysis) is no indication for interruption
of pregnancy. Harmon and Hoyne10 conclude
that “a normal issue assisted by a minimum of
operative intervention which is of the same type
as required in nonparalyzed gravid patients” may
be expected. Kleinberg and Horwitz12 summarize
sixteen cases from the literature and thirteen
hitherto unreported cases and conclude that “not-
withstanding severe paralysis involving the abdo-
minal and extremity muscles, and occurring dur-
ing gestation, a normal course of pregnancy and
labor, and normal offspring may be anticipated.”
They further state that there is the same propor-
tion of complications and of indications for opera-
tive interference as for those who do not have
poliomyelitis, and that cesarean section is not in-
dicated because of poliomyelitis alone. McGoo-
gan13 states that poliomyelitis has no effect on
pregnancy and that normal spontaneous delivery
may be expected. Fox and Sennett8 also observed
that poliomyelitis in the mother did not hamper
spontaneous delivery. Spishakoff et al,15 on the
other hand, attribute their case of premature de-
livery to poliomyelitis. Gillespie9 likewise de-
scribes a case in which cesarean section was per-
formed after a three-day labor left the patient
July, 1947
tions, respectively, seemed to feel that the proce-
dures had not actually been indicated.) Our study
showed that 30.4 per cent of the pregnant polio-
myelitis patients aborted at periods varying from
six weeks to six months. According to Allen,1
18 per cent of all pregnant women abort. This
would seem to indicate that pregnant poliomy-
elitis patients have an excessive tendency to abort.
Of the nineteen surviving poliomyelitis patients
who did not abort, we were able to follow sixteen.
Of these, twelve had normal spontaneous deliv-
eries, or low forceps extractions at term. There
were one cesarean section and three premature de-
liveries (one of these being a breech extraction).
There was no evidence that the effects of polio-
myelitis influenced the type of delivery in any of
these patients, with the exception of one low
forceps extraction on a patient in a respirator.
There is no convincing evidence that intra-
uterine transmission of poliomyelitis occurs.
Weaver and Steiner17 examined records from the
literature, of six cases of alleged prenatal infec-
tion of the fetus with anterior poliomyelitis and
expressed the opinion that the data did not
justify such a conclusion. Bierman and Piszczek5
report a case of poliomyelitis in an eleven-day-old
infant, but acknowledge the possibility of other
avenues of infection, including postnatal contact
with the mother who expired on the fourth post-
partum day with bulbar poliomyelitis. Fox and
Sennett,8 after examining two normal offspring
from mothers with poliomyelitis and one fetus in
a dead mother, concluded that poliomyelitis in the
733
POLIOMYELITIS IN PREGNANCY— BAKER AND BAKER
mother did not affect the fetus. Blair et alG found
no evidence of the infection occurring in utero
in four infants examined by them. Brahdy and
Lenarsky7 could find no effect on the newborn
live babies had been delivered by March 15, 1947.
Eight of these deliveries were spontaneous, and
the infants were full-term. One was a cesarean
section ; two were simple low forceps extractions ;
TABLE V. INFANTS BORN OF MOTHERS WHO HAVE HAD ACUTE
POLIOMYELITIS DURING THE PREGNANCY
Author
Number
of
Infants
Normal
Died
Polio
Stillbirth
Abnormal
Un-
known
Biermann and Piszczek
i
i
Fox and Sennett
2
2
Blair et al
5
4
1
Brahdv and Lenarsky
2
2
McGoogan
3
2
1 (prem.)
Harmon and Hoyne
2
1
1 No evi-
dence of
polio
Kleinberg and Horwitz
( Ibserved
12
12
Kleinberg and Horwitz
Literature
15
12
1 (prem.)
1 (prem.)
1 (Bilateral
club feet)
Gillespie
1
1 (prem.)
SpiskakofF
1
1 (prem.)
Baker and Baker
20
1 (prem.)
1 (prem.)
2 (prem.)
1 (Osteo-
3
13
genesis im-
perfecta)
Total
64
49
5
1
4
2
3
which could be attributed to poliomyelitis in the
mother. According to McGoogan,13 “intra-uterine
transmission, if it occurs, is rare.” He seems to
imply that it can occur, but admits that the evi-
dence is inconclusive. Harmon and Hoyne10 also
speak of it as “rare.” They present one case in
which inoculation of a Macacus rhesus monkey
with preserved fetal spinal cord failed to produce
clinical or microscopic evidence of poliomyelitis.
Kleinberg and Horwitz12 have been quoted above
as believing that normal offspring may be ex-
pected from mothers who have had poliomyelitis
during their pregnancy. None of the offspring
of the pregnant poliomyelitis patients who make
up the material of this study has shown any evi-
dence of having acquired the infection. Autopsies
on the one infant and on one of the stillborn were
inconclusive as to poliomyelitis, but showed that
death of the infant was due to anoxemia. There
was no autopsy on the other stillborn which was
a premature infant.
Summary
During the period of July 29 to September
21, 1946, 695 cases of acute anterior poliomyelitis
were admitted to the Minneapolis General Hos-
pital. Of this number, 115 were females in the
child-bearing age of fifteen to forty-five years,
and of these, thirty were pregnant. There were
seven in the first trimester of pregnancy, seven-
teen in the second, and seven in the third. Fifteen
one was carried out by conversion of a brow to
an occiput posterior position and a low forceps
extraction ; one was a breech extraction of a pre-
mature infant with osteogenesis imperfecta; one
was a normal spontaneous delivery of a premature
infant ; and one was a postmortem hysterotomy
which produced an infant of seven lunar months’
gestation which lived only five minutes. Seven
spontaneous abortions and six deaths occurred
among the thirty pregnant patients.
Conclusions
1. Acute anterior poliomyelitis occurs in all
three trimesters of pregnancy. It occurs in the
pregnant woman more frequently than can be
attributed to mere chance.
2. In general, pregnancy has little influence
on the course of poliomyelitis or the extent of
paralysis.
3. There is a relatively high percentage of
abortion (30.4 per cent) among pregnant patients
with poliomyelitis.
4. This study produced no evidence to show
that the fetus can or cannot contract poliomyelitis
in utero.
Bibliography
1. Allen, E. : A report on sequential abortion. Am. J. Obst.
& Gynec., 46:70-77, (July) 1943.
2. Aycoek, W. Lloyd: Acute poliomyelitis in pregnancy. New
England J. Med., 235:5, (Aug. 1) 1946.
3. Aycock, W. Lloyd: The frequency of poliomyelitis in preg-
nancy. New England J. Med., 225:405-408, (Sept.) 1941.
(Continued on Page 758)
734
Minnesota Medicine
A REVIEW OF 174 CASES OF CANCER WITH NECROPSIES
HAROLD H. JOFFE, M.D., and ARTHUR H. WELLS. M.D.
Duluth. Minnesota
qPHIS review of 174 cancer deaths with nec-
■*- ropsies over a five-year period from 1940
through 1944 is divided into two parts. The first
section is a broad statistical study as to incidence
with a comparison to national and state figures.
The second part consists of a more detailed dis-
cussion with reference to the various more com-
mon sites of cancer and their signs and symptoms.
Statistical Review
The United States Census Bureau for 19447
revealed that 171,171 (12.1 per cent) of 1,411-
338 deaths were due to cancer. In Minnesota the
figures released by the Minnesota Department of
Health for 19457 showed 27,336 deaths from all
causes, with 4,096 deaths (14.9 per cent) due to
cancer.
TABLE I. ADMISSION MALIGNANCY DEATH RATE
Year
Admissions*
Number of
Cancer
Deaths**
Necropsy
Number
Malignancy
Percentage
1940
6,786
27
22
.72
1941
6,805
42
36
1.10
1942
7,553
49
49
1 .30
1943
8,155
40
31
.87
1944
8,590
40
36
.89
Total
37,889
198
174
.97
* Admissions exclusive of newborns.
** Deaths due to cancer without confirmation of necropsy.
At St. Luke’s Hospital, Duluth, Minnesota,
0.97 per cent of all admissions (Table I) over a
five-year period resulted in death by cancer. The
important role which cancer deaths play in our
hospitals is further illustrated by Table II in
which 16.49 per cent, or one-sixth, of the nec-
ropsies performed over the five-year period were
diagnosed cancer.
In Minnesota deaths from cancer in 1945, 7
among residents, showed a sex distribution of
1,942 (51.3 per cent) men and 1,843 (48.7 per
cent) women. These were reversed in the nation
as a whole, with 89,781 (52.4 per cent) women
and 81,390 (47.6 per cent) men for the year of
1944.7 Over a five-year period the cases diagnosed
as cancer on necropsy at this hospital totaled 101
From the Department of Pathology, St. Luke’s Hospital, Duluth,
Minnesota.
Clerical assistance by Miss Faith A. Gugler.
July, 1947
TABLE II. PERCENTAGE OF MALIGNANCIES
IN NECROPSIES
Year
Number of
Autopsies
Number of
Malignancies
Percentage
1940
234
22
9.4
1941
251
36
14.3
1942
185
49
26.4
1943
183
31
16.9
1944
202
36
17.8
Total
1055
174
16.49
TABLE III. SEX DISTRIBUTION OF MALIGNANCIES
ON NECROPSY
Year
Number of
Males
Percentage
Number of
Females
Percentage
1940
10
45.5
12
54.5
1941
24
66.6
12
33.3
1942
25
51.0
24
48.9
1943
17
54.8
14
45.0
1944
25
69.4
11
30 6
Total
101
58
73
41 .9
TABLE IV. CANCER DEATHS BY AGE
Age Group
Number of
Malignancies
Percentage
5-10
2
1.10
11-20
3
1.70
21-30
1
.57
31-40
8
4.59
41-50
21
12.06
51-60
47
27 . 00
61-70
38
21 .80
71-80
44
25.00
81-90
9
5.10
91-100
1
.57
(58 per cent) men and 73 (41.9 per cent) wom-
en (Table III).
The age-specific death rate per 100,000 esti-
mated population in the United States in 19405
bears out the fact that cancer becomes an in-
creasing menace from the fifth decade on. In the
State of Minnesota 3,059 (80.8 per cent) of a
total of 3,785 deaths from cancer among residents
in 1945 occurred in the age group between forty to
eighty years. In our series 150 (86 per cent) of
the cancer deaths (Table IV) occurred between
the ages of forty-one to eighty years. The per-
centage of people in the nation reaching the cancer
age group, between forty-five to sixty-four years,
has increased from 11.9 per cent in 1870 to 19.7
per cent in 1940 and from 3.01 per cent to 6.8 per
cent in the age group of sixty-five and over dur-
735
REVIEW OF 174 CASES OF CANCER— JOFFF. AND WELLS
TABLE V. CANCER MORTALITY IN TERMS OF
ORGANS PRIMARILY AFFECTED
System
Five Year
Total
Percentage
Digestive
Esophagus
3
1 70
Stomach
27
15 50
Transverse colon
5
2.80
Ascending colon
2
1 14
Cecum
3
1 . 70
Descending colon
2
1 14
Sigmoid
8
4 58
Recto-sigmoid
3
1 .70
Rectum
8
4.58
Liver
6
3.44
Gall bladder
3
1.70
Pancreas
10
5.60
Total
80
45.90
Reproductive
Breast
12
6 89
Ovaries
5
2.80
Cervix
7
4.59
Uterus
5
2.80
Testes
1
.57
Total
30
17.00
Genito-urinary
Kidney
3
1.70
Bladder
5
2 80
Prostate
18
10 33
Total
26
14.90
Respiratory
Bronchus
10
5.60
Nasopharynx
2
1.14.
Mastoid
1
.57
T otal
13
7.40
Lymphatic and Bene Marrow
Lymphosarcoma
8
4 58
Lymphatic leukemia
4
2.29
Myelogenous leukemia
4
2.29
Hodgkins
1
.57
Multiple myeloma
2
1.14
Total
19
10.90
Nervous
Brain
1
57
Cardiovascular
Heart
1
.57
Endocrine
Thyroid
1
.57
Adrenal cortex
1
.57
Miscellaneous
2
1.14
ing the same period of time.5 The increase in
longevity and the actual increase in population
does not entirely account for the higher national
incidence.
The proportion of deaths from cancer by age
groups is 0.4 per cent under the age of ten, in-
creasing to 14.7 per cent in the age group between
fifty to seventy, and dropping to 4.8 per cent in
the age group of ninety and over.4 In our series
the percentage varied from 1.10 per cent in the
age group under ten to 27 per cent in the age
group between fifty-one and sixty, and dropping
to 0.57 per cent in the age group of ninety and
over ( Table IV) .
In spite of the small number of cases, the five-
year total percentage of cancer mortality at this
736
TABLE VI. MEAN AGE WITH REFERENCE
TO ORGANS AND SYSTEMS
Organ or System
Mean Age
in Years
Kidney
49.6
Lymphatic and bone marrow
52.3
Cervix
54.2
Ovary
54.6
Uterus
58.0
Breast
59 0
Lung
59.9
Pancreas, gall bladder, and liver
63 4
Stomach
63.5
Esophagus
64 0
Colon
66.0
Urinary bladder
71.4
Prostate
71.6
TABLE VII. TIME INTERVAL FROM ONSET
OF SYMPTOMS TO DEATH
System
Time in
Months
Digestive
Esophagus and stomach
11.7
Colon and rectum
7.2
I 'ancreas
5.5
Gall bladder
2.0
Liver
3.5
Reproductive
U terus
33.1
Ovary
30.9
Breast
29.5
Cervix
20.4
Testes
3.2
Genito-urinarv
Prostate
22.5
Bladder
21.8
Kidney
4.9
Respiratory
Bronchogenic
5.6
Lymphatic and Bone Marrow
Multiple myeloma
34.2
Lymphosarcoma
6.5
Lymphatic leukemia
5.0
Hodgkins
4.7
Myelogenous leukemia
3.7
hospital in terms of organs primarily affected
(Table V) closely parallels the figures of the
United States Census of 1942. 5 An attempt to
correlate our figures with those of the State of
Minnesota for 1945 is rather difficult owing to
the difference of classification.
The percentage frequency with reference to
primary sites in each sex is illustrated by Figure
1. The percentages corroborate the national sex
specific cancer mortality of 19425 in that it is
generally higher in males, except in those sites
due to difference in physiology and anatomy. In
our series, the percentage of malignancies of the
lymphatic system and bone marrow were also
higher in males. The mean age with reference to
organs or systems varied from 49.6 years in can-
cer of the kidney to 71.6 years in cancer of the
prostate (Table VI).
The time interval from the onset of symptoms
Minnesota Medicine
REVIEW OF 174 CASES OF CANCER— JOFFE AND WELLS
to death is tabulated in Table VII with short-
est time interval being in the digestive, respira-
tory, and lymphatic systems and also in the bone
marrow. One plausible explanation may be the
as to whether emaciation is due to impaired me-
tabolism or inanition is debatable.
The causes of anemia in malignancies can be
summarized under blood loss, absorption of toxic
Female
Bone Marrow
3.4? 7.5?
Male
Fig. 1. The percentage frequency of primary cancer sites in each sex. The figures below the
lines represent the national percentage in 1942. The figures above the lines represent the per-
centage in the authors’ series. The diagram is from the Minnesota Cancer Bulletin, volume 1.
silent features of malignancies in these sites plus
the comparatively large surface over which to
spread.
Review of Clinical Manifestations
The systemic effect of emaciation as evidenced
by weight loss of 15 pounds or more was en-
countered in a total of sixty-seven cases (38.5
per cent), of which forty-four (65.6 per cent)
occurred with malignancies of the digestive sys-
tem and twenty-three (34.3 per cent) with malig-
nancies in other sites (Table VIII). The question
July, 1947
TABLE VIII. WEIGHT LOSS
Total Number
67
Percentage
38.5%
Number with gastrointestinal malignancies
44
Percentage
65.6%
Number with malignancies in other sites
23
Percentage
34.3%
products, and deficient nutrition. Approximately
one-half of the cases of moderate and one-third
of the cases of severe anemia occurred with
737
REVIEW OF 174 CASES OF CANCER— JOFFE AND WELLS
TABLE IX. ANEMIA TABLE X. STOMACH TWENTY-SEVEN CASES
Moderate*
Total Number
58
Percentage
33.3%
Number with gastrointestina malignancies
30
Percentage
51 .7%
Severe**
Total Number
12
Percentage
6.9%
Number with gastrointestinal malignancies
4
Percentage
33.3%
♦Hemoglobin below 10.5 grams and red cell count below 3,500,000
♦♦Hemoglobin below G.5 grams and red cell count below 2,000,000
malignancies of the digestive tract (Table IX).
This may strengthen the theory of hidden, re-
current bleeding as a causative factor. Although
albuminuria occurs in a high percentage of cancer
patients, the cause is unknown and in our series
occurred in forty-five (28.5 per cent) cases.
Cancer of the stomach is most deadly, causing
about 25, 0(X) deaths every year in the United
States.3 The unfortunate aspect is that 50 per
cent of all gastric cancers metastasize even before
the appearance of initial symptoms.5 Thus, it be-
comes obvious that persistent digestive disturb-
ances in anyone beyond forty years of age should
be thoroughly investigated. Loss of appetite,
belching, and perhaps mild abdominal pain may
be the only signs. However, anorexia is usually
one of the first symptoms, and in our series
(Table X) occurred in twenty-four out of twenty-
seven cases (88 per cent). Anorexia, chronic
dyspepsia, nausea, loss of weight and vomiting
constituted the five outstanding symptoms (Table
X). Achlorhydria, occult blood in the stools,
anemia, weakness, hematemesis, palpable epigas-
tric mass and dysphagia occurred with significant
frequency so as not to be overlooked as possible
symptoms and signs of carcinoma of the stomach.
Dysphagia may be a relatively early sign of cancer
involving the cardiac end of the stomachy Accord-
ing to Wangensteen and associates,2 the absence
of free hydrochloric acid in the stomach may be
a good screening test for detection of cancer of
the stomach. Unfortunately, in our series of
twenty-seven cases, gastric analysis was done only
ill nine cases, all of which showed an achlorhydria.
Carcinoma has been known to respond to ulcer
therapy and here may lie the danger of confusing
a malignancy with that of peptic ulcer. The dif-
ficulties encountered in early detection of cancer
of the stomach are many and well known. Even
Symptoms
Number
Percentage
Anorexia
24
88.0
Chronic dyspepsia
21
77.7
Nausea
19
70 0
Loss of weight
16
59.0
Vomiting
13
47.7
Achylia
9*
Occult blood in stool
8
29.6
Anemia
8
29.6
Weakness
7
25,9
Hematemesis
5
18.5
Palpable epigastric mass
4
14.8
Dysphagia
2
7.4
♦Gastric analysis done only in nine cases
TABLE XI. RIGHT HALF OF COLON
TEN CASES
Symptoms
Number
Percentage
Anemia
8
80
Loss of weight
6
60
Vomiting
4
40
Nausea
4
40
Anorexia
3
30
Fullness
3
30
after application of all available diagnostic means
at our disposal, the results are often disappointing.
As Rigler states,2 “It is easy to detect a change
on x-ray examination, but the nature of such
may be difficult to determine.”
A large percentage of cancer of the intestines
occurs in the sigmoid and rectum which in our
series (Table V) constituted nineteen cases (61.0
per cent) of thirty-one cases involving the colon.
It has been estimated that approximately 50,000
persons in the United States harbor cancer of the
colon or rectum in the presymptomatic state.5 The
great majority (90 to 95 per cent) of cancers in
the sigmoid and rectum are within easy reach of
the examining finger or instruments.5 In spite of
the accessibility of these lesions for early diag-
nosis and the fact that they metastasize rather late,
about 10 per cent of all cancer deaths annually
are attributable to cancer in these locations.5 The
symptoms of fatigue, weight loss, increasing con-
stipation, change in bowel habits, vague indiges-
tion and anemia are all important warning signs.
Cancer in the right half of the colon may give no
symptoms ; and, since these tumors bleed easily,
the first symptoms may be those resulting from
anemia.3 In our series of ten cases of carcinoma
involving the right half of the colon, anemia oc-
curred in eight (80 per cent) (Table XI). Car-
cinoma of the left half of the colon usually pro-
duces colicky lower abdominal pain due to a
slowly developing obstruction.3 However, blood
738
Minnesota Medicine
REVIEW OF 174 CASES OF CANCER— JOFFE AND WELLS
TABLE XII. LEFT HALF OF COLON —
TWENTY-ONE CASES
Symptom
Number
Percentage
Occult blood in stool
12
57.1
Colicky abdominal pain
11
52.3
Change in bowel habits
10
47.6
Weight loss
8
38.0
Anemia
7
33.3
TABLE XIII. PANCREAS — TEN CASES
Symptom
Number
Percentage
Epigastric pain radiating to back
7
70
Jaundice
6
60
Weight loss
6
60
Palpable tumor mass
4
40
Anemia
3
30
and mucus are commonly found in the stools. In
our series (Table XII), the three outstanding
symptoms in order of frequency were: occult
blood in the stools (57.1 per cent), colicky abdo-
minal pains (52.3 per cent), and change in bowel
habits (47.6 per cent). Since 90 to 95 per cent of
cancers in the sigmoid and rectum are within
reach of the finger or instruments, the routine
procedure of rectal examination will undoubtedly
uncover many more early lesions.
There are usually no physical findings in the
early stage of carcinoma of the pancreas.5 The
complaint of epigastric pain radiating to the back
is a common early sign and occurred in seven (70
per cent) of our cases. The presence of a pal-
pable mass is a late manifestation. The tradi-
tional symptom of painless jaundice occurred in
six (60 per cent) of our cases (Table XIII). The
law of Courvoisier applies here also, according to
which the presence of obstructive jaundice and
distention of the gall bladder is likely to be due
to carcinoma. Weight loss was encountered in 50
per cent, palpable tumor mass in 40 per cent, and
anemia in 30 per cent of these cases.
Early cancer of the prostate is only usually
discovered as an incidental finding in routine
rectal examinations.5 Unfortunately, the cancer
is usually far advanced before symptoms are dis-
tressing enough for the patient to seek medical at-
tention. The first symptoms, though unfortunately
not early, are usually frequency and burning. In
our series (Table XIV) nocturia occurred in
fifteen out of eighteen cases (83.3 per cent) with
frequency and burning occurring in 72.2 and 55.5
per cent, respectively. The diagnosis of early can-
cer of the prostate by digital examination should
be confirmed by microscopic studies. The failure
TABLE XIV. PROSTATE EIGHTEEN CASES
Symptom
Number
Percentage
Nocturia
15
83.3
Frequency
13
72.2
Burning on urination
10
55 . 5
Dribbling on urination
9
50.0
Weight loss
7
38.8
Difficulty in starting stream
7
38.8
Anemia
5
27.7
TABLE XV. BREAST TWELVE CASES
System
Number
Percentage
Single lump
ii
91.6
Serous discharge
5
41.5
Bloody discharge
4
33.3
Nodes in axilla
4
33.3
Anemia
3
25.0
Loss of weight
3
25.0
Retraction of nipple
2
16.6
Dimpling of skin
2
16.6
to do a cystoscopic examination is often the rea-
son for missing carcinoma of the urinary bladder.
The elevation of alkaline phosphatase is non-
specific, but the additional finding of an elevated
acid phosphatase above 10 King- Armstrong units
establishes the diagnosis of bony metastases. In
our series, only seven out of eighteen cases had
an acid phosphatase determination, four of which
had elevated levels ranging from 24.8 up to 205
King-Armstrong units, and all had bony metas-
tases as evidenced by x-ray examinations.
In 1945, of the total cancer deaths, 85,000 were
women and 15,000 of these died of cancer of the
breast.1 The percentage of malignancy of the
breast closely parallels the full maturity of the
organ, and therefore the highest incidence occurs
in the age group of forty-five to fifty-five. There
are many diagnostic signs of breast cancer, of
which pain, discharge, lump, retraction of nipple,
puckering of the skin, and palpable lymph nodes
are the outstanding. Pain usually indicates a
benign lesion, especially if it increases in severity
at the menstrual period. However, its nature
should be carefully scrutinized. Retraction of the
nipple may be an early or late sign. A bloody,
serous or white fluid discharge is suggestive ; a
single lump should always be considered cancer
until proved otherwise by biopsy.
In our series (Table XV), the presence of a
single lump occurred in 91.6 per cent, serous dis-
charge in 41.5 per cent, nodes in the axilla and
bloody discharge in 33.3 per cent each. The
presence of anemia and weight loss occurred in
25 per cent each, with signs of retraction of the
July, 1947
739
REVIEW OF 174 CASES OF CANCER— JOFFE AND WELLS
TABLE XVI. OVARY FIVE CASES
Symptom
Number
Percentage
Abdominal discomfort
3
60
Palpable tumor
3
60
Backache
2
40
Loss of weight
2
40
Ascites
2
40
Abnormal menstruation
2
40
Anemia
1
20
TABLE XVII. CERVIX — SEVEN CASES
Symptom
Number
Percentage
Irregular bleeding
5
71 .4
Leukorrhea
4
57.1
Loss of weight
2
28.5
Anemia
1
14.2
TABLE XVIII. UTERUS FIVE CASES
Symptom
Number
Percentage
Postmenopausal bleeding
4
80 0
Anemia
2
40 0
Loss of weight
2
40 0
Burning on urination
1
20 0
Nocturia
1
20 0
Frequency
1
20 0
nipple and dimpling of the skin in 16.6 per cent
each.
Unfortunately, cancer of the ovary is symptom-
less in its early stage. Backache which is a rather
common complaint of women occurred in 40 per
cent of the cases and should arouse suspicion for
a thorough examination. Abdominal discomfort
and a palpable tumor mass occurred in 60 per
cent each and were the two outstanding symptoms
(Table XVI). Peritoneoscopy with biopsy may
eventually prove of great value in the diagnosis
of cancer involving many of the abdominal or-
gans. The most reliable signs are still : ( 1 ) a pal-
pable abdominal mass or enlargement of an ovary
and (2) visible increase in the size of the abdo-
men with or without ascites. Unfortunately, the
foregoing are late signs and may explain why
ovarian cancer is not diagnosed early and is often
an incidental finding during a surgical exploration
of the pelvis.
A biopsy of the cervix which is usually an office
procedure should make early diagnosis the rule.
However, the early symptoms of irregular bleed-
ing and leukorrhea are usually lightly regarded
by women, and early diagnosis is the exception
rather than the rule. In about one third of the
cases, abnormal bleeding is a late symptom. Biopsy
should be done routinely on all cervices showing
a small erosion or cervicitis. In our series (Table
XVII), irregular bleeding and leukorrhea were
TABLE XIX. LUNG TEN CASES
Symptom
Number
Percentage
Pain in chest
8
80
Blood tinged cough
6
60
Pleural exudate
6
60
Loss of weight
5
50
Wheezing
3
30
Anemia
2
20
encountered in 71.4 and 57.1 per cent, respec-
tively.
Irregular bleeding, during or after menopause,
should be considered as due to cancer of the
uterus unless proven otherwise by microscopic
examination. Here again, by a relatively simple
procedure, we are able to make an early diagnosis.
In our series (Table XVIII), post menopausal
bleeding occurred in 80 per cent of the cases.
Tii our series, cancer of the lung accounted for
ten out of 174 patients (5.6 per cent). There
appears to be a definite predilection for males
(Fig. 1), and whether this is due to smoking
habits is debatable.5 The most common symptom
is cough which may he persistent or may occur
in paroxysms and is usually associated with blood
tinged, mucoid or purulent expectoration. Pain
is not a constant symptom, the location depending
upon the part of the pleura involved. However,
in our series (Table XIX) pain in the chest oc-
curred in eight (80 per cent) with blood-tinged
cough in six (60 per cent). Pleural exudation
per se is not a diagnostic sign of cancer and oc-
curred in six (60 per cent) of our cases. All
had examination of the pleural fluid, and four
(66.6 per cent) revealed cancer cells. This brings
up the efficacy of routine examination of all fluid
accumulations for the presence of carcinoma cells.
This procedure in the hands of an experienced
pathologist is undoubtedly a reliable adjunct and
often makes the diagnosis in obscure cases. The
importance of x-ray examinations cannot be over-
emphasized. Fluoroscopy and chest films in vari-
ous positions as well as at the height of inspira-
tion and expiration is of importance.2 A localized
area of atelectasis or emphysema should make one
suspicious of carcinoma. In addition, bronchos-
copy and biopsy are important adjuncts.
Conclusions
1. Approximately 1 per cent of all admissions
to this hospital over a five-year period resulted in
death by cancer.
740
Minnesota Medicine
REVIEW OF 174 CASES OF CANCER— JOFFE AND WELLS
2. Over one-sixth of the necropsies performed
over a five-year period were diagnosed cancer.
3. The sex percentage was 58 per cent men
and 41.9 per cent women.
4. With reference to age groups, out of 174
cases, 12 per cent occurred in the age group
forty-one to fifty, 27 per cent in fifty-one to
sixty, 21.8 per cent in sixty-one to seventy, and
25 per cent in seventy-one to eighty. A total of
150 out of 174 cases (86 per cent) occurred in
the age group between forty-one to eighty.
5. In terms of organs primarily affected, the
digestive tract accounted for a total of 45.9 per
cent; the reproductive system, 17.0 per cent; the
genito-urinary system, 14.9 per cent ; the lymphat-
ic system and bone marrow, 10.9 per cent; and
the respiratory system, 7.4 per cent, of which
5.6 per cent occurred in the bronchi.
6. The sex specific cancer mortality with ref-
erence to primary sites was generally higher in
males, except in the reproductive system.
7. The average mean age with reference to
organs varied from 49.6 years with cancer of the
kidney to 71.6 years with cancer of the prostate.
8. The total average time interval in months
from the onset of symptoms to death was 5.98
with cancer of the digestive tract; 5.6 in the
bronchi ; 10.8 in the lymphatic system and bone
marrow ; 16.4 in the genito-urinary system ; and
29.4 in the reproductive system.
9. The systemic effect of emaciation occurred
in a total of sixty-seven (38.5 per cent) of the
cases, in which group forty-four (65.6 per cent)
occurred with malignancies of the digestive tract.
10. Approximately one-half of the cases of
moderate anemia and one-third of those with
severe anemia occurred with malignancies of the
digestive tract.
11. Albuminuria occurred in forty-five (25.8
per cent) of the cases.
12. The five outstanding symptoms of can-
cer of the stomach were : anorexia in 88 per cent,
chronic dyspepsia in 77.7 per cent, nausea in 70
per cent, loss of weight in 51.8 per cent, and
vomiting in 47.7 per cent.
13. Gastric analysis was done only in nine
out of twenty-seven cases of cancer of the stom-
ach, and all showed an achlorhydria.
14. In our series, 61 per cent of cancer involv-
ing the colon occurred in the sigmoid and rectum.
15. Anemia which is usually a prominent
symptom of cancer of the right half of the colon
occurred in 80 per cent of our cases in this half
of the colon.
16. Colicky abdominal pain which is usually
a prominent symptom of cancer of the left half
of the colon occurred in 52.3 per cent of these
cases.
17. In our series, only seven out of eighteen
cases of cancer of the prostate had acid phospha-
tase determination, four of which showed ele-
vated levels and evidence of bony metastases by
x-ray.
18. A single lump in the breast was the out-
standing finding in eleven out of twelve cases of
cancer of the breast.
19. Irregular bleeding occurred in 71.4 per
cent of cancer of the cervix and postmenopausal
bleeding in 80 per cent of cancer of the fundus
of the uterus.
20. Examination of pleural fluid for cancer
cells was done on all cases of bronchogenic car-
cinoma with pleural effusion, and was positive
in four (66.6 per cent) of the cases.
References
1. American Cancer Society: Cancer of the Breast. 1946.
2. Cancer Continuation Course: Continuation Center, Univer-
sity of Minnesota, (Jan. 2-4) 1947.
3. Creedon, John J. : Cancer of the digestive tract. American
Cancer Society, 1946.
4. Little, Clarence C. : Proportion of deaths from cancer by
age groups. Public Affairs Pamphlet No. 38, 1939.
5. Minnesota Cancer Bulletin, volume 1.
6. Minnesota Cancer Society, Inc.: Cancer. A study outline
for secondary schools. 1946.
7. Minnesota Cancer Society, Inc.: How your doctor detects
cancer. 1945.
TONSILLECTOMY AND POLIOMYELITIS
The mode of transmission and the portal of entry of
the virus of poliomyelitis remain unknown. Without
this knowledge we are forced to theorize on the relation-
ship between tonsillectomy and poliomyelitis.
A statistical survey indicates that poliomyelitis is
relatively infrequent following tonsillectomy. The study
carried out at Manhattan Eye, Ear and, Throat Hospi-
tal on 11,204 tonsillectomy patients over a seven-year
Tuly, 1947
period revealed but four cases of poliomyelitis follow-
ing tonsillectomy. None was of the bulbar type.
The widespread alarm on the part of the public,
shared by doctors in some communities, is unfounded on
the basis of our statistics.
Cunning, Daniel S,: Tonsillectomy and Poliomyelitis. Ann.
Otol., Rhin. & Laryng., 55:583-591, (Sept.) 1946.
741
GENERAL PRINCIPLES IN THE TREATMENT OF PEPTIC ULCER
JOSEPH M. RYAN. M.D.
Saint Paul, Minnesota
T)EPTIC ulcer is perhaps one of the greatest
obstacles in our efforts to practice medicine
scientifically. It readily fits into a category occu-
pied by hypertension and arthritis, so placed be-
cause of the cloud of confusion that is associated
with them.
The little substantial information that we have
has been given to us by the physiologist who, thus
far, has done the most practical investigative stud-
ies. Even that is insufficient knowledge to enable
the clinician to treat the individual who has a
peptic ulcer with anything but symptomatic man-
agement.
Although the etiology of peptic ulcer is not
known, the pathogenesis should be discussed.
Konjetzny demonstrated that an ulcer begins in
the mucosa and has a penetrative tendency. Mann
and others have shown that the experimental
ulcer in animals also tends to penetrate and is
identical in pathological appearance and in be-
havior with peptic ulcer as seen in human beings.
It has been proved satisfactorily that the pro-
duction of these ulcers is impossible unless acid
gastric juice is present. Cade, Varco, Wangen-
steen and coworkers were able to produce typical
chronic peptic ulcer in the dog and other animals
by inducing a continued hypersecretion of gas-
tric juice by the injection of a slowly absorbable
mixture of histamine and beeswax. Mann pro-
duced experimental ulcer by allowing hydro-
chloric acid to drip continuously into the stomach.
Peptic ulcer occurs only in those portions of
the human digestive tract exposed to the action of
acid gastric juice, i.e., the lower esophagus, the
stomach, the first and second portions of the
duodenum and stomal areas after gastroenteros-
tomy. The observation of Brown and Pember-
ton, that a primary ulcer of Meckel’s diverticulum
occurred adjacent to aberrant acid-secreting gas-
tric mucosa, stresses the importance of acid in
the production of peptic ulcer.
In 2,500 cases of peptic ulcer, Palmer was
unable to find a single case of active chronic pep-
tic ulcer hi the presence of complete and per-
Presented on January 23, 1946, at a meeting of the Oak Ridge
Anderson County, Roane County, Knox County and Campbell
County Medical Societies at Oak Ridge, Tennessee. At the
time of presentation Dr. Ryan was chief of the Medical Service
at Oak Ridge Hospital, Oak Ridge, Tennessee.
manent anacidity. The importance of acid in the
duodenum, or the lack of neutralization of the
duodenal acid, in the formation of ulcer is sug-
gested indirectly by the work of Berk, Rehfuss
and Thomas. They pointed out that normal peo-
ple exhibit a neutralizing ability in the first part
of the duodenum which is inferior to that of nor-
mal dogs. These animals are notoriously resistant
to peptic duodenal ulcer.
Other phenomena as hypermotility, hyperperi-
stalsis, hypertonicity and hypersecretion play defi-
nite roles in the pathogenesis of peptic ulcer.
These conditions obviously indicate that there
is an increase in activity above normal.
Although the various treatments of peptic ul-
cer are far from ideal, it must be remembered
that the chief principle to be followed is pat-
terned by physiological changes in secretion oc-
curring in this condition. Many of us fail to
note this. In other words, individualization of
treatment based on fundamental physiological
facts should be our pattern of therapy.
There should be a thorough evaluation of the
patient before a method of treatment is decided
upon. The x-ray appearance of the ulcer will
only aid in the plan of action to be used. The
individual’s nervous make-up is perhaps the great-
est stumbling block in the management of most
cases. We all recognize the fact that tension due
to fear or anxiety will cause a quiescent ulcer to
manifest symptoms. This is not only a charac-
teristic of military personnel during the past war,
but it is also true of civilians. If emotional
forces are capable of producing symptoms, they
must be dealt with accordingly. When this con-
trol is difficult, although the ulcer is an uncom-
plicated one, the phrase “intractable ulcer” creeps
into our thoughts, and we may prematurely con-
sider surgery as the treatment of choice. Here a
psychiatric study of the patient should be made
by the physician in most cases, but occasionally
it will be necessary to have him consult a psy-
chiatrist. At this point, good doctor-patient rela-
tionship is extremely important, in that it is ab-
solutely necessary to allay the emotional factors
present.
Dietotherapy is perhaps the most valuable
742
Minnesota Medicine
TREATMENT OF PEPTIC ULCER— RYAN
means we have to control the acidity of gastric
secretion. Food in the stomach is much more
comforting to the patient with a peptic ulcer than
is an alkali medicament in the greater number
of cases. Here again we should evaluate the pa-
tient as to the type of diet he requires, and in-
dividualization will be necessary. Diet with rest,
provided the rest can be obtained without undue
worry, really is the treatment to be strived for
in the management of the uncomplicated duodenal
ulcer. Less than three weeks of rest is seldom
beneficial. I have had under my care patients
whose discomfort was exaggerated by strict ad-
herence to the Sippy diet. These same patients
improved markedly when the diet was decreased
in amount or the feedings were spaced differently.
In dietary management one should not overlook
the caloric requirement of the individual. This
principle is especially true in care subsequent to
hemorrhage. Bockus lists the principles upon
which dietary management may be based : The
diet should contain sufficient calories, absence of
gastric secretagogues, absence of cellulose and
meat fiber because of the danger of trauma to
the ulcer site, and the diet should be liquid or
semiliquid.
Alkalies are valuable adjuncts in the treatment
of the uncomplicated peptic ulcer. However, they
serve only a secondary purpose. Their use is per-
haps more efficient in the treatment of the ambu-
latory patient who is unable to neutralize the
gastric contents with frequent feedings. The
proponents of various alkaline substances have
succeeded in placing a cloak of mystery over the
underlying principles of neutralization. Some in-
dividuals will respond to sodium bicarbonate and
others are more comfortable while taking colloid-
al aluminum hydroxide. Even in the use of
alkalies good judgment is needed. A serious ill
effect of large doses of soluble alkalies is the
systemic alkalization which may occur. This is
especially true in the older patient with arterio-
sclerosis and renal changes, whose function of
urea clearance may be disturbed. Colloidal alu-
minum hydroxide is less likely to produce such
changes, as there is very little absorption of the
drug. Investigators have shown that it has no
effect on the evacuating time of the stomach when
fed in large amounts to animals. Komarov points
out that aluminum hydroxide aids in diminishing
peptic digestion.
The advisability of using belladonna in at-
tempt to block out impulses over vagal routes is
very questionable. Gastric motility may be di-
minshed by using doses large enough to produce
the side effects of blurring of vision and dry-
ness of the mouth. In the majority of cases of
uncomplicated ulcer, relief of symptoms with
progress in healing can be attained without it.
Mild sedation is necessary, especially in the pa-
tient who has emotional upsets. Sedation is of
great value in treating the ambulatory patient,
whereas in the hospital, rest and relaxation are
more easily obtained. Phenobarbital is the seda-
tive of choice and can be given in doses ranging
from to 1 grain three times daily.
The use of tobacco must be stopped at the
onset of treatment. Patients are more likely to
have earlier relief of pain when smoking has
been discontinued. In our experience here, best
results were obtained when alcohol was also elim-
inated.
Another more recent treatment of peptic ulcer
deals with the hormone, enterogastrone, which
was originally isolated by Kosaka and Linn, and
has been purified by Ivy and his associates. They
have now reported its use in fifteen clinical cases,
with good response.
The internist and the surgeon should not disa-
gree as to the management of the individual who
has an ulcer. There should be close co-operation
between them, and the time at which the patient
should be transferred to surgery can be deter-
mined by the internist. There should be no
procrastination nor should there be any attempt
to get rid of the patient prematurely because he
does not respond to medical treatment.
The indications for surgical care resolve them-
selves into the following classification :
1. Repeated hemorrhage.
2. Perforation of an ulcer.
3. Stenosis resulting in obstruction.
4. Ulcers on the greater curvature of the stom-
ach, and a gastric ulcer that does not dis-
appear completely in six weeks on adequate
medical treatment without a resulting scar.
5. Intractable duodenal ulcer.
The term “intractable” is widely and loosely
used. There is always the question of the time
at which this term can be applied to the ulcer.
The ideal management consists of proper rest,
diet, and alkalization over a period not less than
July, 1947
743
TREATMENT OF PEPTIC ULCER— RYAN
three months. By proper rest I mean hospitaliza-
tion or satisfactory bed rest in the home. Every
factor that might stimulate the ulcer symptoms
should be investigated thoroughly before any
thought should be given to surgical treatment.
Of course there are many patients who cannot
undergo strict management because of their tem-
perament. There are also patients who will re-
fuse to abstain from tobacco, and they will gladly
submit to surgery rather than follow a strict
regime. The financial question also enters into
the picture. This is especially true of an individ-
ual who has a responsible position. It is difficult
to explain to him why he should not have surgi-
cal treatment so that he can return to his employ-
ment at an earlier date. Many of us fail to dis-
cuss openly the possible results of operations for
ulcer. An individual who has an intractable ulcer
should be told of the possibilities of incomplete
cure following surgical methods of treatment.
Honest opinions given at this time will prevent
much unnecessary explanation several years later.
The patient often undergoes surgical treatment
believing that his troubles will be over completely.
This is not only the fault of the internist but of
the surgeon as well. I have heard many sur-
geons tell their patients after leaving the hospital,
following surgical gastric resection, that they
would be able to eat everything and lead per-
fectly normal lives, only to have them return
to the internist later for further management.
Excluding the acute emergencies, such as per-
foration, persistent bleeding, et cetera, the surgi-
cal treatment of peptic ulcer has now been nar-
rowed to one popular procedure — resection of from
two-thirds to three-quarters of the stomach in an
attempt to diminish or to entirely abolish acid
secretion. This operation has been more success-
ful than gastroenterostomy or any other proce-
dure used in the past. The basic principle is to
abolish acid secretion. Because of the advances in
anesthesia and physiological control of fluid bal-
ance, this operation carries a much lower mor-
tality rate than it did several years ago.
Another surgical procedure that may become
popular within the next few years is that of re-
section of the vagi in an attempt to reduce gastric
secretion. Dragstedt has reported several cases
with very satisfactory results. We have had un-
der our observation here one case upon which this
method of treatment was used with apparently
good results. This case is not to be reported
now as sufficient time has not elapsed since oper-
ation. However, the outstanding result noted so
far has been the marked decrease in nocturnal
gastric secretion.
The surgical treatment and the type of opera-
tion to be used should be left to the surgeon who
is to operate. The internist should always bear
in mind that the surgeon who does gastrointesti-
nal surgery should be one who has had sufficient
training and experience to take the responsibility
of removing healthy tissue in order to bring about
a good functional result. Again we may thank
the physiologist for the advances he has achieved
in the study of fluid balance, and the pharmacolo-
gist because he has furnished the surgeon with
new anesthetics that permit better operative tech-
nique and a lower mortality.
Summary
The treatment of peptic ulcer resolves itself
into a principle of “common sense.” The patient
should be treated as an individual and the ulcer
should be remembered as being the property of
that individual — not the individual the property of
the ulcer. There has been little advancement in
our knowledge of peptic ulcer within the past ten
years. The methods and principles of treatment
have remained practically at a standstill. This
is, of course, the consequence of not knowing the
etiology of the disease. Perhaps routine gastro-
intestinal studies on a series of normal individuals
in the late teen ages will enable us to get some
idea of the early formation of an ulcer in an
individual who is susceptible to it.
References
1. Apperly, F. L., and Crabtree, M. G. : Relation of gastric
function to chemical composition of blood. J. Physiol., 73:
331-343, 1931.
2. Berk, J. E. ; Rehfuss, M. E., and Thomas, J. E.: Duodenal
bulb (“ulcer bearing area”) acidity in fasting normal people.
J. Lab. & Clin. Med., 27:1501-1510, 1942.
3. Bockus, H. L. : Gastro-enterology. Vol. I, p. 446. Phil-
adelphia: W. B. Saunders Co., 1943/46.
4. Brown, P. W., and Pemberton, J. de J.: Solitary ulcer of
ileum and ulcer of Meckel's diverticulum. Ann. Int. Med.,
9:1684, 1936.
5. Dragstedt, L. R. ; Palmer, W. L. ; Schafer, P. W., and
Hodges, P. C. : Supra-diaphragmatic section of the vagus
nerves in the treatment of duodenal and gastric ulcers.
Gastroenterology, 3:450-462, 1944.
6. Edkins, J. S.: The chemical mechanism of gastric secre-
tion. J. Physiol., 34:133-144, 1906.
7. Herriott, R. M.: Isolation, crystallization and properties
of swine pepsinogen. J. Gen. Physiol., 21:501-540, 1938.
8. Ivy, A. G. : Some recent developments in the physiology
of the stomach and intestine which pertain to the manage-
ment of ulcer. Bull. New York Acaa. Med., 20:5-14, 1944.
9. Komarov, S. A., and Komarov, O. : Precipitability of pep-
sin by colloidal aluminum hydroxide. Am. J. Digest. Dis.,
7:166, 1940.
10. Konjetzny, G. : Die entziindliche Grundlage der typischen
Geschwtirsbildung im Magen und Duodenum. P. 80. Berlin:
Julius Springer, 1930.
11. Kosaka, T., and Linn, R. K. S.: Demonstration of the
humoral agent in fat inhibition of gastric secretion. Proc.
Soc. Exper. Biol. & Med., 27:890-91, 1930.
(Continued on Page 779)
744
Minnesota Medicine
CONGENITAL DIAPHRAGM OF THE DUODENUM
Case Report with Preoperative X-Ray Studies
WALLACE I. NELSON. M.D., F.A.C.S.
Minneapolis, Minnesota
CONGENITAL diaphragm of the duodenum
is a developmental anomaly in which a mem-
brane, formed by an infolding of the mucosa and
submucosa, extends across the lumen of the duo-
denum. The diaphragm may be complete or it
may present an aperture. It is to be differen-
tiated from stenosis and atresia (Fig. 1). In
the former, there is a marked local narrowing of
the lumen, due to thickening and approximation
of the walls. In the latter, there is a complete
obliteration of the lumen, due to fusion of the
walls. In reviewing the literature one finds these
terms used interchangeably so that it is necessary
to cover many irrelevant articles in order to
be sure to include all cases of congenital dia-
phragm.
Those cases of a duodenal diaphragm without
an aperture are, of course, instances of congeni-
tal high intestinal obstruction. Unless they are
recognized and successfully operated upon, they
die during the first few days of life. Those pre-
senting small apertures in the diaphragm may
have no symptoms, but they are, in fact, instances
of chronic partial obstruction, and, as such, they
are potential candidates for complete obstruction.
Incidence
No case is recorded in over 43,000 autopsies
at the Department of Pathology, University of
Minnesota. A review of the literature reveals
thirty-five reported cases of congenital duodenal
diaphragm. According to Krieg,8 Robert Boyd,
in 1845, was the first to report a case of obstruc-
tion of the duodenum due to a diaphragm (Table
I).
Between 1845 and 1913 seventeen cases of con-
genital diaphragm of the duodenum were re-
ported in the literature. None of these were
operated upon, but all were discovered at autopsy.
Then in 1916 Terry and Kilgore21 operated upon
a young adult in whom they found an obstruction
of the duodenum and established a posterior gas-
troenterostomy. There was leakage from the
suture line and the patient died on the fifth day.
Presented at a meeting of the Minneapolis Surgical Society,
March 6, 1947.
July, 1947
It was not until the autopsy that the true cause
of the obstruction was discovered. However,
this was the first reported case in which correc-
tive surgery was attempted. Four of the next
seven cases were operated upon, but it was only
Fig. 1. Sketches to illustrate the fundamental differences
between diaphragm, stenosis and atresia.
at the autopsy that the duodenal diaphragms were
discovered.
In 1925, Seidlin,18 in describing his case, wrote,
“Such a membrane, if diagnosed intra vitam,
might be amenable to surgical treatment.”
In 1933, Ladd9 discovered a duodenal dia-
phragm while operating on an eight-year-old child
and performed a duodeno-jej unostomy which re-
sulted in the first surgical cure. In 1935, Mor-
ton13 operated on his second case and was the
first to remove such a diaphragm.
Krieg’s case8 had been missed by others at
two previous explorations.
In Braun’s second case2 the x-ray showed an
enlarged duodenum with obstruction in the third
portion which was erroneously interpreted as an
ileus due to mesenteric thrombosis, and no opera-
tion was done.
In Saunders and Lindner’s case,16 the true
pathologic condition was missed at the first oper-
ation when the patient was fifteen months of age,
but was recognized and successfully corrected
at a second operation when the child was seven
years of age.
745
CONGENITAL DIAPHRAGM OF THE DUODENUM— NELSON
■' r'
TABLE I. REPORTED CASES OF CONGENITAL DUODENAL DIAPHRAGM
Author
Date
Age
Operation
Recognition
Proximal
Dilation
Ring
Con-
stric-
tion
Aperture
Result
Remarks
Boyd, R.
1845
Stillborn
None
Autopsy
*
None
Death
Buchanan, G.
1861
18 mo.
None
Autopsy
Yes
2.5 mm.
Death
Moore, N.
1884
40 vrs.
None
Autopsy
10-15 mm.
Death
Accidental death
Silcock
1885
34 vrs.
None
Autopsy
15 mm.
Death
Resembled finger of
glove.
Galton, J.
1803
1 Vi days
None
Autopsy
None
Death
C. Hampneys
and Power
1897
5 days
None
Autopsy
None
Death
Wvss, M. O.
1900
1 3-2 days
None
Autopsy
Yes
None
Death
Shaw and
Baldorf
1907
13 days
None
Autopsy
Small
Death
Weber
1910
10 days
None
Autopsy
None
Death
Keith
1910
9 mo.
None
Autopsy
None (?)
Death
Keith, A.
1910
Adult
None
Autopsy
Yes
5x3 mm.
Death
Diaphragm ballooned
distally.
Roe and Shaw
1911
5 days
None
Autopsy
None
Death
Spriggs
1912
9 mo.
None
Autopsy
?
Death
Spriggs
1912
14 days
None
Autopsy
Yes
1-3 mm.
Death
Wilkie
1913
Adult
None
Autopsy
Yes
Yes
Yes
Death
Proximal diverticulum.
Wilkie
1913
Adult
None
Autopsy
Yes
Yes
Yes
Deat h
Wilkie
1913
Adult
None
Autopsy
Yes
Yes
Yes
Death
Terry and
Kilgore
1916
24 vrs.
Posterior
Obstruction
Yes
Yes
Yes
Death on
First attempt at correc-
gastro-
recognized at
fifth day
tive surgery. Leakage at
enterostomy
operation but
suture line. Real patho-
cause not
logic condition dis-
recognized
covered at autopsy.
Schroder, C.
1921
14 wks.
Exploratory
Autopsy
3 mm.
Death
and jej unostomy
Morton, J. J.
1923
1 dav
Release
Autopsy
None
Death
First case
paraduodenal
hernia
Nagel, G.
1925
70 vrs.
Exploratory
Autopsy
Yes
No
8 mm.
Death
X-rav showed dilated
stomach. At operation
found intussception of
f
stomach into espohagus.
Seidlin, S.
1925
2 y2 yrs.
None
Autopsy
Yes
Yes
7 mm.
Death
Septum uome-shaped.
Obstruction precipitated
bv eating canned corn.
Thorndike, A.
1927
17 days
Exploratory and
Autopsy
1 mm.
Death
jej unostomy
Garvin, J.
1928
5 days
None
Autopsy
None
Death
Cannon and
1929
8 yrs.
None
Autopsy
Yes
4 mm.
Death
Rupture of stomach
Hal pert
after several enemas.
Ladd
1933
8 yrs.
Duodeno-
At operation
Yes
Cured
jej unostomy
Morton, J. J.
1935
5 days
Electro-
At operation
None
Cured
Second case
desiccation
Kreig, E.
1936
32 vrs.
Posterior
Missed at two
8 mm.
Cured
Had operations in 1917
gastro
previous opera-
and 1927, and not
enterostomy
tions, discovered
recognized.
at third
operation
Braun, H.
1938
2 yrs.
None
Autopsy
Yes
?
8 mm.
Death
Braun, H.
1938
49 vrs.
None
Autopsy. X-ray
Yes
?
6 mm.
Death
X-rav showed megaduo-
revealed an
denum and stenosis in
obstruction in
lower third of duodenum.
dist al duodenum
Suspected ileus due to
but cause was
mesenteric thrombosis.
not recognized
Nagel, C. E.
1939
1 yr.
Duodeno-
By finger ex-
Yes
?
Admitted
Death
No autopsy.
jej unostomy
ploration
tip of
through duo-
little
denotomy at
finger
operation
Saunders and
f 15 mo.
Not noticed at
Missed at first
Not
Missed
Preoperative diagnosis
Lindner
first
operation
recorded
Size not
was congenital stenosis
stated
of second and third por-
tion.
1940
7 Vi vrs.
Excision
X-ray predicted
Yes
Yes
Cured
At, 7 V2 vrs., x-ray in-
obstruction.
dicated obstructed sec-
Recognized at
ond and third portion.
operation
Brody
1940
Newborn
None
Autopsy
Yes
?
None
Death
Ruptured diverticulum
of stomach.
White and
1941
1 mo.
Gastro-
Obstruction
Yes
Yes
Death
Collins
jej unost omy
recognized at
operation but
only at autopsy
was true nature
discovered.
Sumner and
1945
5 days
Posterior gastro-
Operation and
Probable
None
Cured
X-ray showed complete
Morris
enterostomy
x-ray
obstruction.
1944
26 vrs.
Duodenotomv
Operation
Yes
Yes
10 mm.
Cured
Diagnosis predicted on
and excision
basis of preoperative
x-ray.
7Y,
Minnesota Medicine
CONGENITAL DIAPHRAGM OF THE DUODENUM— NELSON
Of the thirty-five cases reported in the litera-
ture (Table I) twelve were operated upon. In
only six cases (8, 9, 13, 14, 16, 20) of the entire
series zms the true nature of the lesion discovered
during life. Of the six, only one was an adult.
Five patients were cured by operation.
This paper is presented so as to call the atten-
tion of the profession again to this anomaly and
to emphasize certain aids in diagnosis. In addi-
tion a case is reported herein which is believed
to be the first in the literature in which preopera-
tive x-ray studies revealed the presence of a con-
genital duodenal diaphragm.
Embryology
Most articles on this subject refer to Tandler’s
paper, published in 1900, which stated that the
lumen of the duodenum became obliterated at
about the fifth week of fetal life by the ingrowth
of epithelial cells. He also stated that the lumen
was re-established about the twelfth week by a
process of vacuolization. According to his theory
a diaphragm formed when a portion of the epi-
thelial cord was not absorbed. According to Boy-
den1 this explanation is erroneous. The lumen
of the duodenum does not form and then become
obliterated. Instead there are two rows of vacu-
oles which form in the region which is to be-
come the duodenum. One row forms along the
lesser curvature side and one along the greater
curvature side. These vacuoles coalesce to form
a lumen. Failure of complete coalescence can
result in a variety of anomalies, including longi-
tudinal or transverse septa. Transverse mem-
branes occur most frequently in the region of
the ampulla of Vater (Fig. 2).
Anatomy
The diaphragm is what its name implies, only
a thin membrane stretching across the lumen of
the duodenum. It varies in thickness from 0.5
mm. to 4 mm. In several instances it was
stretched so as to project distalward in the lumen
with its aboral surface convex. Silcock,19 in
1885, wrote as follows in describing his case :
“In the duodenum, six inches below the pylorus,
is a congenital septum which barely admitted the
tip of the little finger. A pouch formed of mu-
cous and submucous tissue projects downward
into the lumen of the gut and roughly may be
likened in size and shape to the thumb of a glove.”
In eight of the cases definite mention was made
at operation or autopsy of a ring of constriction
visible on the duodenum at the level of the dia-
phragm. In eighteen cases it was stated that the
duodenum proximal to the lesion was dilated and
Fig. 2. Illustration from an
article by R. A. Schwegler and
E. A. Boyden in the Anatomical
Record, volume 67, page 459.
Note the two rows of va:uoles
which are to become the duode-
nal lumen.
hypertrophied. In several cases the stomach,
pylorus, and proximal duodenum were dilated
and hypertrophied. In a few of these a moderate
relative narrowing at the pylorus gave the im-
pression of an hour-glass stomach. Several re-
ported that the stomach and duodenum were
normal on external appearance.
Histologically the diaphragm is made up of two
layers of otherwise normal duodenal mucous
membrane with some intervening submucosa. In
Brody’s case3 some aberrant pancreatic tissue was
found at the base and extending out between the
layers of the diaphragm.
Although the membrane may be at any level of
the duodenum, in the great majority of reported
cases the diaphragm was found at or near the
level of the ampulla of Vater. Both the common
bile duct and the pancreatic duct have been re-
ported traversing the diaphragm, and either or
both ducts may empty into the bowel through
either surface of the diaphragm (Fig. 3). This
is to be borne in mind in planning the surgical
management of such a case.
As is often the case, when one congenital anom-
July, 1947
747
CONGENITAL DIAPHRAGM OF THE DUODENUM— NELSON
aly is present, other anomalies may be present.
This occurred in several of the reported cases
and, by distracting the surgeon’s attention, con-
tributed to the failure to recognize the true path-
Fig. 3. Seidlin’s case. Note the dome-shaped diaphragm witli
a central aperture, the proximal dilatation of the duodenum, and
the relationship of the common bile duct to the diaphragm.
Upper sketch: Esophagus, stomach and duodenum opened after
fixation in formalin. Lower sketch: Duodenal lumen with sep-
tum shown from jejunal side. Drawing in upper left corner:
Diagrammatic representation of the course of the biliary and
pancreatic ducts in relation , to the duodenal septum, its surfaces
and orifice.
ologic condition in the duodenum. Among the
associated anomalies may be mentioned such con-
ditions as incomplete rotation, internal congenital
hernia, abnormal fixation, diverticulum of the
stomach, et cetera.
Clinical Manifestations
In cases of complete membrane without aper-
ture, of course the obstruction is total. Per-
sistent and recurrent vomiting appears in the
first few days of life. Visible peristalsis and
upper abdominal distention may be present. These
patients all die unless the obstruction is recog-
nized and relieved.
The age of onset and the severity of symptoms
vary with the size of the aperture. These pa-
tients tolerate liquid nourishment, but begin to
show obstructive symptoms when soft or solid
foods are added to the diet. This is to be ex-
pected since the aperture in the group up to eight
years of age did not exceed 8 millimeters (Table
I) and could easily be blocked by food particles.
Vegetables, with their high cellulose content, have
been the most frequent cause of converting an
incomplete chronic obstruction to an acute and
complete obstruction. This is what occurred in
Seidlin’s case18 (Fig. 3). In a few cases, acute
obstructive symptoms did not appear but the
nutrition was greatly impaired.
Morlock and Gray11 stated that regardless of
how long the first appearance of symptoms is de-
layed, these infants do not attain the develop-
ment of normal children. However, in several
cases there was no history of obstructive symp-
toms until adult life, and no mention was made
of underdevelopment.
Right upper abdominal pain or discomfort was
complained of by several nonobstructed patients.
In a few cases the discovery of the condition was
entirely accidental.
There was an equal distribution in the two
sexes.
Referring to Table I, it is seen that the cases
readily fall into three age groups. The first group
includes fifteen infants under one month of age.
Of these, eleven had no aperture in the dia-
phragm, while four did have a small aper-
ture. Since complete obstruction is incompatible
with life, those with an imperforate diaphragm
came to be operated upon or died very early in
life. Of the group under one month of age,
all died except two,13’20 both of whom were
cured by operation on the fifth day of life. The
second group of ten includes those from one
month to eight years of age. The third group
includes eleven adults.
Diagnosis
The most important factor in diagnosis is the
ability to recognize the presence of an obstruction
when it exists. Since the obstruction in these
cases is high, there is no generalized abdominal
distention. Visible peristalsis may be present in
the epigastrium. If the vomitus contains bile,
the obstruction is beyond the pylorus and the
entrance of the common bile duct. Congenital
7-W
Minnesota Medicine
CONGENITAL DIAPHRAGM OF THE DUODENUM— NELSON
pyloric stenosis does not have bile in the vomitus
and is also more prone to appear about the third
week of life. If the vomitus contains bile and the
stools are acholic, then the obstruction is likely
due to a congenital anomaly involving the duo-
denum. If the common duct is double, then one
opening may be above and the other below the
diaphragm. In such a case bile could be present
in the vomitus and the stools and yet the obstruc-
tion could be complete.
The actual differential diagnosis between the
various extrinsic and intrinsic causes of obstruc-
tion will often have to be made at operation.
According to Morlock and Gray11 the extrinsic
factors to be considered are abnormal fixation of
the duodenum, persistence of the hepatico-duode-
nal ligament, annular pancreas, and vascular
anomalies. Intrinsic factors include atresia, steno-
sis, and congenital diaphragm. It is believed that
more cases of the latter condition will be recog-
nized as more doctors become aware of it as a
possibility.
The literature gave no accurate study of the
comparative blood laboratory tests in these cases.
It is assumed that they would be the findings of
any high intestinal obstruction.
In a few instances x-ray studies with and with-
out contrast material were made. In Braun’s
case2 the x-ray showed an enlarged duodenum
with obstruction in the third portion which was
erroneously interpreted as an ileus due to mesen-
teric thrombosis, and no operation was done. In
Saunders and Lindner’s case16 a diagnosis of ob-
struction in the duodenum was made by x-ray.
In G. W. Nagel’s case15 the x-ray showed a di-
lated stomach but no lesion. White and Collins22
recognized an obstruction to the barium in the
duodenum. As far as could be determined no re-
corded case was found in the literature where a
preoperative diagnosis of congenital duodenal dia-
phragm was made by x-ray studies. In the ab-
sence of obstruction the symptoms and clinical
findings are not diagnostic, so that such cases
would only be diagnosed by x-ray or at operation.
Attention is called to the x-ray findings in the case
here reported so that both roentgenologists and
clinicians will be conditioned to recognize this
possibility.
At operation there may be a ring of constric-
tion about the duodenum. At first this may sug-
gest an adhesive band, but an attempt to remove
or divide the “band,” reveals that the constrict-
ing ring extends deeply into and is an integral
part of the wall of the duodenum at this level.
There may be dilatation and hypertrophy of the
duodenum proximal to the constricting ring. The
duodenum may have the general appearance of
a portion of the stomach. The dilatation may
also involve the pylorus and stomach. Although
greatly enlarged, these parts may be flaccid and
show no distention if there is no obstruction pres-
ent at the time.
It is believed that these findings (a constrict-
ing ring on the duodenum, and dilatation and hy-
pertrophy of the proximal duodenum), when
present, are so suggestive as to indicate the need
for a meticulous examination of the mobilized
duodenum for the presence of a congenital dia-
phragm within the lumen. Duodenotomy may be
necessary to make the diagnosis, and should be
done if there is a reasonable suspicion that a
diaphragm exists.
Preoperative Management
Cases with acute obstruction present the same
problems as other patients with high intestinal
obstruction, namely, dehydration, hypoproteine-
mia, loss of chlorides, et cetera. Corrective ther-
apy should be instituted at once, but as White
and Collins22 have pointed out, if the patient is
an infant, too much time cannot be spent in at-
tempting to completely restore the body fluids
and chemistry before operation.
In the absence of acute obstruction the opera-
tion can be done at a time of election, and more
time can be given to preparing the patient for
operation. Likewise at operation more time can
be used to explore carefully for other anomalies
and evaluate properly their relative clinical im-
portance.
Management at Operation
Granted that a patient suspected of having a
diaphragm in the duodenum is being operated
upon, what shall the surgical procedure be ? Short-
circuiting operations such as gastro-jej unostomy
and duodeno-jejunostomy have been employed.
These procedures relieve the obstruction and at
times may be the procedure of choice ; however,
they are not physiological. Mobilization of the
duodenum, duodenotomy, and direct removal of
the diaphragm is, however, the procedure which
I would advocate wherever possible. Such a
procedure requires a single short suture line and
July, 1947
749
CONGENITAL DIAPHRAGM OF THE DUODENUM— NELSON
entails no greater risk than one of the short-cir-
cuiting procedures.
Attention is again directed to the fact that the
bile or pancreatic ducts may open onto or traverse
Fig. 4 (above) Author’s case. X-ray shows narrowing in the
second portion of the duodenum. Otherwise there is insufficient
evidence in this film to warrant the diagnosis of duodenal dia-
phragm.
Fig. 5. (below) Author’s case. Lateral view shows the third
portion of the duodenum in cross section. There te a large
mass of contrast material surrounded by a narrow band of
barium, with a thin area of radiolucency intervening. This
demonstrates that the larger accumulation is entirely within
the lumen of the bowel and therefore not a diverticulum.
the diaphragm. Therefore, the diaphragm should
be carefully examined by palpation and by
transillumination so that if a duct is found it can
be preserved during the excision of the dia-
phragm. There is no great harm done if a duct
traversing the diaphragm be severed accidentally,
but care must be taken so as not to occlude the
750
duct in suturing the raw mucosal edges. Closure
of the duodenum should include one row of fine
nonabsorbable sutures.
Case Report
A twenty-six-year-old army nurse first noticed symp-
toms of her illness in March, 1944. There had been
no feeding problem in infancy. A ruptured appendix
had been removed in 1929. There was no history of
any other gastrointestinal symptoms at any time.
In 1942 she had sinusitis, joint pains, fever, and an
increase in blood sedimentation rate, necessitating bed
rest for six weeks.
While she was being treated in an army hospital for
a severe sinus infection, she developed pain in the
right flank with tenderness below the right costal
margin, anteriorly and posteriorly. Pus in the urine
disappeared after the administration of sulfonamides.
Pain persisted, however, and she was transferred to
an army general hospital where the right kidney was
explored surgically on May 10, 1944. The only abnormal
finding was' a slight ptosis which the surgeon corrected.
Pain in the right flank continued, and gradually pain
in the right upper quadrant of the abdomen became
more severe. In June, 1944, cholecystography indicated
a normal gall bladder, and gastrointestinal x-rays showed
an accumulation of barium in relation to the second
and third portions of the duodeum which was diagnosed
as a diverticulum.
In September, 1944, when the writer first saw her, the
patient complained of persistent deep discomfort in
the right upper abdomen and the right flank. There
was no relation to food or meals ; her appetite was fair.
There was no vomiting. Bowel function was normal.
She was taking as much as 90 grains of aspirin a day
in order to obtain relief from the discomfort in the
right upper abdomen. Physical examination at that
time was negative, except for persistent tenderness in
the right upper quadrant of the abdomen, with no
muscle rigidity. The scars of the previous appendec-
tomy and recent nephropexy were well healed. Labora-
tory studies of blood and urine were entirely normal
except for blood sedimentation rate of 25 mm. per hour.
Between June and September a number of gastro-
intestinal x-ray studies were made (Fig. 4). The ear-
lier diagnosis of large duodenal diverticulum was later
changed to intussusception of the duodenum. A lateral
film (Fig. 5) showed a profile of the third portion of
the duodenum with a dense barium shadow surrounded
by a narrow ring of barium (Figs. 6, 7 and 8). This
proved conclusively that the accumulation was intralu-
menal and that we were not dealing with a diverticulum
in the usual sense. The writer, having once seen a case
with two diaphragms in the proximal jejunum and
having read some of the literature at that time, was
conditioned to include congenital diaphragm in the
differential diagnosis, and went on record that the x-ray
findings could be explained by a congenital diaphragm.
On September 26, 1944, the abdomen was explored.
The entire duodenum and pyloric antrum of the stom-
ach were dilated. In the second portion of the duo-
Minnesota Medicine
CONGENITAL DIAPHRAGM OF THE DUODENUM^NELSON
Figs. 6, 7 and 8. These views show a moderate dilatation of the entire duodenum with a zone of narrowing <jf the second
portion of the duodenum. There is a thin area of radiolucency, within the confines of which there is an accumulation of barium.
Surrounding this, mostly on the antimesenteric margin, there is a smaller amount of barium outlining the mucosal folds of the
duodenum.
denum there was a fine ring-like indentation or infold-
ing of the wall. The portion of the duodenum proximal
to the ring was also thickened and redundant, so that
at first sight, it resembled the pyloric antrum of the
stomach. The entire descending duodenum was mo-
bilized and turned medially to demonstrate that there
was no diverticulum originating from the duodenum.
A mobile thickening was palpable within the lumen
of the second and third portions of the duodenum, re-
sembling in feeling a soft, pedunclated polyp, attached
in the region of the ring-like indentation previously men-
tioned.
The duodenum was opened by a linear incision, ex-
tending distally from the level of the constricting ring,
exposing the inferior surface of a congenital diaphragm
attached around the entire circumference of the duo-
denum at the level of the constriction (Fig. 9). Near
the lateral or antimesenteric margin of the diaphragm,
there was an eccentric aperture about 10 mm. in diam-
eter. The mesial portion of the diaphragm was greatly
stretched and formed a sac which extended distally
within the lumen of the duodenum from its origin.
The entire diaphragm and sac were covered with mucous
membrane on both surfaces.
The sacculation was incised longitudinally to permit
careful palpation and transillumination, and the dia-
phragm was excised at its base around the circumfer-
ence of the lumen of the bowel. This was necessary
in order to avoid injury to the common bile duct or
pancreatic duct which often traverse a portion of such
a diaphragm (Fig. 3). In this case, the papilla of
Vater was found about one centimeter proximal to
the diaphragm, on the posterior wall of the duodenum
(Fig. 9). The cut edge of the diaphragm was sutured
with fine chromic catgut. After closure of the duo-
denum by transverse suture, the lumen was adequate.
With the exception of a mild atelectasis which re-
sponded to therapy, the postoperative course was un-
eventful. The patient was relieved entirely of pain in
the right upper quadrant and flank, and has had no
recurrence of symptoms. Roentgenograms made in
May, 1945, showed no abnormality of the duodenum
except a slight enlargement of the cap.
PYLORUS
DILATED
DUODENUM
PAPILLA
APERTURE
DIAPHRAGM
SACCULATION
Fig. 9. Semi-diagrammatic sketch of the operative findings
in the author’s patient. Note the diaphragm forming a saccu-
lation within the lumen of the duodenum, and the position of
the papilla of Vater just proximal to the diaphragm. Barium
or food entering the sac had no way of escape except by being
ejected back into the duodenum proximal to the diaphragm
and then passing through the aperture in the diaphragm.
Summary
1. Thirty-five cases of congenital diaphragm
of the duodenum have been reported in the litera-
ture, only six of which were recognized during
life ; of these, five were cured.
2. One case is reported here of a twenty-six
year-old woman in whom the x-ray studies per-
mitted the preoperative diagnosis to be made.
This patient has been cured by resection of the
duodenal diaphragm.
3. Dilatation of the proximal duodenum de-
monstrable by x-ray has been reported in this con-
dition by others. The x-rays of the case here re-
ported clearly showed a congenital diaphragm
forming a sacculation within the duodenum.
4. Duodenotomy and excision of the membrane
is advocated rather than short-circuiting proce-
dures.
July, 1947
751
CONGENITAL DIAPHRAGM OF THE DUODENUM— NELSON
5. The importance of making the correct diag-
nosis lies in the simplicity of the surgical proce-
dure recommended and in the high mortality of
untreated cases.
6. It is hoped that this demonstration of the
x-ray appearance of a sacculated duodenal dia-
phragm will condition both surgeons and roent-
genologists so that a higher percentage of cases
will be recognized before or at operation.
References
1. Boyden, E. A.: Personal interview.
2. Braun, H.: Congenital stenosis in a child two years old
and in a man forty-five years old. Virchow’s Arch, of
Path., 302:618-626, 1938.
3. Brody, Henry: Ruptured diverticulum of the stomach in
a newborn infant, associated with congenital membrane oc-
cluding the duodenum. Arch. Path.. 29:125-128, 1940.
4. Buchanan: Malformations of duodenum in a child. Tr.
Path. Soc., London, 12:121, 1861.
5. Cannon, P. R., and Halpert, B.: Congenital stenosis of
the third portion of the duodenum with acute occlusion and
rupture of the stomach. Arch. Path., 8:611-621, 1929.
6. Farrell, J. T., Jr.: Duodenum, roentgenography, deformities,
other than those due to ulcer. Pennsylvania M. J., 46:
1149-52, 1943.
7. Garvin, J. A.: Congenital occlusion of the duodenum by
a complete diaphragm. Am. J. Dis. Child., 35:109-112, 1928.
8. Krieg, Earl G. : Duodenal diaphragm. Ann. Surg., 106:
33-41, 1937.
9. Ladd. William G. : Congenital obstruction of the small
intestines. J.A.M.A., 101:1453, 1933.
10. Moore, N.: Multiple diverticula of the small intestine with
congenital stricture of the rectum. Tr. Path. Soc. London,
35:202-04, 1884.
11. Morlock and Gray: Congenital duodenal obstruction. Ann.
Surg.. 118:372-376, 1943.
12. Morton, J. J. : Atresia of the duodenum and right internal
hernia. Am. J. Dis. Child., 25:371-378, 1923.
13. Morton, J. J.: Surgical care of patients in the extremes
of life. Am. J. Surg., 30:92, 1935.
14. Nagel, C. E. : Duodenal diaphragm as a cause of intes-
tinal obstruction. J. Internat. Coll. Surgeons, 2:315-327,
1939.
15. Nagel, G. W. : Unusual conditions in the duodenum and
their significance. Arch. Surg., 11:529-549, 1925.
16. Saunders, John B., and Lindner, H. H.: Congenital anoma-
lies of the duodenum. Ann. Surg., 1 12:321-338. 1940.
17. Schwegler, Raymond Allen, Jr., and Boyden, Edward Allen:
The development of the pars intestinalis of the common
bile duct in the human fetus, with special reference to the
origin of the ampulla of Vater and the sphincter of Oddi.
Anat. Rec., 67:No. 4; 68:Nos. 1 and 2, 1937.
18. Seidlin, S. N.: Congenital duodenal septum with obstruc-
tion. Bull. Johns Hopkins Hosp., 37:328-339, 1925.
19. Silcock, A. Q. : Epithelioma of ascending colon: entero-
colitis, congenital duodenal septum with internal diverticu-
lum. Tr. Path. Soc. London, 36:207, 1885.
20. Sumner and Morris: Duodenal atresia in the newborn.
Am. J. Surg., 68:120-123, 1945.
21. Terry and Kilgore: Congenital stenosis of the duodenum
in an adult. J.A.M.A., 66:1774-76, 1916.
22. White, Charles S., and Collins, J. Lloyd: Congenital
duodenal obstruction. Arch. Surg., 43:858-865, 1941.
23. Wilkie, D. P. : Duplicature of the duodenal wall. Edin-
burgh M. J., 11:221, 1913.
Discussion
Tague C. Chishoi.m : It was a pleasure for me to
listen to Dr. Nelson’s presentation of this subject. It
was a scholarly presentation as well as an excellent case
report. The subject is quite close to my heart, as we
see more stenoses with diaphragms of the duodenum in
children than in adults. By children I am referring to
the newborn period because we encounter this condition
not a few times within the first few days or weeks
of life with intestinal obstruction. I am sure this con-
dition must occur more frequently in adults than is
suggested by reports in the literature. Dr. Nelson’s
suggestion for treatment by local excision and suturing
the cut mucous membrane is a good one. The problem
presented in infants in the newborn period is a little
different. At the Children’s Hospital in Boston, Ladd
and Gross have reported a number of cases. In the next
edition of their book, a few more will no doubt be
added. They have had more success with a side-track-
ing procedure than by local excision. I believe that it
is probably more physiologically correct to excise the
diaphragm, but the frequent involvement of the pan-
creatic and bile duct together with collapsed distal bow-
el in babies increases the technical problems in patients
a few days old.
Another thought on the method of embryological de-
velopment of these diaphragms is that it is associated
with a faulty rotation of the head of the pancreas.
During development, the dorsal and ventral anlage of
the pancreas rotate to the medial and final position,
but sometimes the orifices of the ducts do not rotate
with them and form a constriction which may contrib-
ute to formation of such diaphragms in the duodenum.
I
John R. Paine: I would like to know why Dr. Chis-
holm thinks that in infants it would be more difficult
technically to do as Dr. Nelson does than to make a
short-circuit operation? I think this is the most unusual
diaphragm of the duodenum that I have ever seen.
Tague C. Chisholm : My reasons for stating that
Dr. Nelson’s procedure is more difficult in the newborn
period are the following. Probably in adults there usual-
ly is a fairly wide opening in the diaphragm, enabling
such patients to reach adult life. In newborn babies,
only pinpoint apertures are present, and flat films of
the abdomen show practically no gas going beyond the
diaphragm into the distal bowel. The distal bowel
virtually is in a state of atresia. The distal bowel is
smaller than the diameter of a cigarette while the
proximate bowel is several centimeters in diameter.
With these dimensions, technically it is usually more
difficult to do a satisfactory excision with avoidance
of the pancreatic and bile ducts than in adults.
Wallace I. Nelson : I have nothing to add except
that I appreciate Dr. Chisholm’s remarks. My experi-
ence on this didn’t take me into pediatrics.
One other thing to be considered is the presence of
other anomalies. I found two cases where patients who
had congenital diaphragms died from ruptured diverticu-
lum of the stomach. The cause of death was rupture
of the diverticulum in the stomach, associated with
obstruction of the diaphragm.
752
Minnesota Medicine
THE MINNESOTA MULTIPHASIC PERSONALITY INVENTORY
An Evaluation of Its Use in Private Practice
A. E. WALCH. M.D. and ROBERT A. SCHNEIDER, M.D.
Minneapolis, Minnesota
TT7 0RLD WAR II has focused even more
* ’ sharply the physician’s attention on the
widespread incidence of neurotic and psychoso-
matic illness. Both specialists and general prac-
titioners realize that such cases are commonly
neglected or given cursory treatment. They also
realize that such cases cause more incapacitation
and lost man-hours than does any other single
group. Physicians agree that 50 per cent or more
of their patients present psychogenic problems of
varying magnitude, and that the general “aging”
of the population will increase this percentage.
Unfortunately, the average physician, already
overburdened, rarely finds sufficient time to develop
an adequate psychiatric evaluation of his patients.
In recent years, many personality tests have
been devised, each aiming to evaluate the per-
sonality characteristics of the patient. These
tests include the Rorschach Test,7 the Cornell
Index,8 the Minnesota Multiphasic Personality In-
ventory1"5 and several others. Each has advantages
and limitations. The Rorschach Test is subjective
in its analysis, time consuming, and requires the
interpretation of a skilled psychologist or spe-
cially trained physician. The Cornell Index is
chiefly concerned with the detection of borderline
clinical states (the so-called psychosomatic dis-
orders), and is less effective in screening hysteria,
the pre-psychotic and early psychotic states. The
Minnesota Multiphasic Personality Inventory has
advantages not only for the psychiatrist, but for
physicians in all fields of medicine : it covers a
wide range of personality traits including the
major psychoses; it may be graded and inter-
preted by the physician who has not had special
training in psychiatry ; it can be taken by patients
of average intelligence ; and it yields reproduci-
ble results.
In the course of studying this group of pa-
tients, the authors, whose practice is limited to
internal medicine, have been able to investigate
rather thoroughly the use of the Minnesota Multi-
phasic Personality Inventory as a means of eval-
George E. Fahr, M.D., Donald R. Hastings, M.D., and Starke
R. Hathaway, Ph.D., rendered valuable aid in the. preparation
of this paper.
July, 1947
uating further these cases. It is the purpose of
this paper to describe briefly the procedure used
and to illustrate the use of this test with several
case studies. To date, this test has been applied
to a total of 550 cases where, further psychiatric
evaluation seemed indicated.
The Minnesota Multiphasic Personality Inven-
tory (hereafter referred to in this paper as the
“MMPI”) was originated at the University of
Minnesota seven years ago by J. C. McKinley,
M.D. (Division of Nervous and Mental Diseases)
and S. R. Hathaway, Ph.D. (Department of Psy-
chology). Its authors have attempted to identify
and to measure the multiple phases of the subject’s
personality by using a series of statements to
which the testee responds “true,” “false,” or
“don’t know.” It is not the purpose of this paper
to describe how the inventory was developed or
to discuss its statistical validity. This information
has been published in detail elsewhere by the
authors of the test.1'5
The MMPI consists of a group of 550 simply
worded positive statements, usually in the first
person, of which the first 366 statements are
routinely used. The test has been published in two
forms.* The first form consists of 550 cards,
each containing a statement. The patient takes
the test by sorting out the cards and filing them
into one of three boxes marked “true,” “false,”
and “can’t say.” We have used only the second
form of the test, in which the statements appear
in a bound booklet (the so-called “group form”).
Using a pencil or pen, the patient fills in the ap-
propriate squares (“true” or “false”) after each
number representing the corresponding state-
ment in the booklet. This is done on a separate
answer sheet. If the patient is unable to decide
“true” or “false,” he leaves blank the correspond-
ing number on the answer sheet. The average pa-
tient requires about ninety minutes to complete
the test. Scoring can be done by either the phy-
sician or one of his office workers, and requires
eight to ten minutes. Scoring is accomplished by
*The test materials for both forms of the inventory are pub-
lished by The Psychological Corporation, 522 Fifth Avenue, New
York 18, N. Y.
753
MULTIPHASIC PERSONALITY INVENTORY— WALCH AND SCHNEIDER
making use of nine cardboard templates, one for
each personality trait tested. The “raw scores”
thus obtained are listed under the appropriate
headings on a convenient permanent record card
W score' SOE3 30 4ESQ±L43 4E44:4£4E‘LL
raw sconeOX 3. j! 22, L£L 1L U- A- lO. JL. IQ- — —
? = * LEFT BLANK Pj = PSYCHOPATHIC DEVIATE
L = LIE SCOPE = MAS CULINITY FEMININITY
F = VALIDiry Pol=PARANO/A
Hs= HYPOCHONDRIASIS Pt = PSYCH A S THEN I A
D= DEPRESSION ^ = SCH I Z OPH R E N /A
Hy= HYSTERIA = HYPO M A N / A
Fig. 1. A normal personality profile together with a key to the
symbols used.
(size 5x8 in.). By making use of a series of
tables in an accompanying instruction booklet, the
examiner determines and records “standard
scores.” The standard scores are then charted
graphically on the patient’s record card. Figure 1
illustrates the appearance of “a normal” person-
ality profile. The vertical co-ordinate in Figure 1
is made up of the standard score values, and the
horizontal co-ordinate the personality traits eval-
uated. The average standard score values of each
item in the profile is considered to be 50. Scores
greater than 50 indicate deviation toward the ab-
normal, with a score of 70 taken as borderline.
The first three scores on the horizontal co-
ordinate beginning at the left (Fig. 1) are vali-
dating scores designed to indicate the reliability
of the record. Should any one of the first three
scores exceed 70, the validity of the patient’s
record should be questioned. Based on these
criteria, the reliability of our series of profiles
was approximately 90 per cent. The key to the
symbols used in the test is shown in Figure 1.
Report of Cases
To illustrate the usefulness of the MMPI in
private office practice, we present a series of case
summaries with accompanying profiles, each case
tending to point out the value of the inventory
in the interpretation of a particular type of
patient.
? L K F H. D HT Pd M, Pa P, Se Ma
+ ■« +.« + IK + 1K +.2K
jianuaiu _ _
(T) Score SO S3 S$E77£4Z'll3*323&4S
Raw Score QK 3 1 Q_ 2-3Q33./Q.3&1Q.S.J-13.
Fig. 2. (Case 1) The personality profile shows hysteria in a
patient with essential hypertension and anginal syndrome.
Caise 1. — Probably as important as any type of psycho-
genic problem seen by the practitioner is that of a patient
with a definite pathologic condition (such as cardio-
vascular or gastrointestinal disease) in whom the symp-
toms are multiplied or accentuated by an added neurosis.
A married woman, aged forty-seven, was first seen
on December 14, 1944. At that time her complaints in-
cluded nervousness, a chronic nonproductive cough,
fatigue, frontal headaches, and urinary frequency. Her
past history included pulmonary tuberculosis in 1929,
requiring eight months of bed rest, appendectomy in 1932,
cholecystectomy in 1937, a right nephrectomy in 1940
because of hydronephrosis secondary to a kidney stone,
and hysterectomy in 1943 for myomata with hemorrhage.
Physical examination at that time showed a blood pres-
sure of 210 mm. Hg systolic, 120 mm. Hg diastolic.
X-ray studies showed definite left ventricular enlarge-
ment and healed fibroid tuberculosis of the right upper
lobe and of the left apex. An electrocardiogram showed
only left axis deviation. The pelvic floor was moderately
relaxed. Sputum examinations and gastric washings
for guinea pig inoculation were all negative for tuber-
culosis. The blood Wassermann reaction was negative.
The impression at that time was one of old healed
fibroid tuberculosis of the lung and essential hyperten-
sion. During November, 1946, following a period of
emotional stress and anxiety over family problems, the
patient developed several attacks characterized by syn-
cope, marked agitation, fear of suffocation, and pre-
cordial pain. A series of electrocardiograms showed left
axis deviation but no other significant changes over
previous tracings. There were no measureable changes
in the patient’s previous cardiac status.
754
Minnesota Medicine
MULTIPHASIC PERSONALITY INVENTORY— WALCH AND SCHNEIDER
An MMPI was scored by the patient on January 14,
1947 (Fig. 2). This clearly showed hysteria (score 75)
and a tendency toward symptomatic depression (score
68). The patient was reassured regarding her cardio-
vascular status, and the functional problem of hysteria
? L K F H, D Hr Pj M, P„ P, Sc M„
+ .SK +.« + is + IS +.2S
f-Tscore SOSO— 60 mi21SZOS76ZZ4-338*
Raw Score OKS.— JL ZL£§3Q2Z&M2T3S&
Fig. 3. (Case 2) A grossly abnormal personality curve in a
young patient complaining of chronic backache.
was explained to her. The relationship was pointed out
to her between her personal problems at home and her
resultant anxiety and hysteria. The patient developed
relatively good insight, and when she was seen on
February 11 and again on April 1, 1947, she had been
doing very well and had had no further attacks.
Case 2.— By far the most frequently encountered
situation is that of a patient with multiple complaints
for which no organic basis can be found after a careful
physical examination and appropriate laboratory and
x-ray studies. Aside from an apparent hypochondriasis,
other factors in the personality may escape the physician’s
attention. In such cases, the patient’s MMPI profile may
reveal valuable information which can then be used as
a guide to further interview.
A boy, seventeen years old, was referred on February
5, 1947, for an evaluation of a chronic back complaint.
He complained of “locking and catching” of the lower
back and other vague symptoms referable to the entire
spine. These symptoms began two years ago after the
patient sustained a back strain while lifting a heavy
object. He reported that his father had always had re-
current backaches. A previous diagnosis of spinal injury
with subsequent manipulative treatment had been given
by a nonmedical practitioner. Examination of this patient
showed a tall, asthenic type of individual in whom no
abnormalities of a physical nature could be found after
a complete physical and neurologic examination and after
pertinent x-ray and laboratory studies. An orthopedist,
in consultation, confirmed the absence of physical find-
ings in this patient. It was felt that this patient’s symp-
toms were on a psychogenic basis, and the patient was
asked to take an MMPI test.
The curve shown in Figure 3 indicated that the patient
was not only suffering from hypochondriasis, but was
hysterical and depressed. Because of the unexpected
high scores for schizophrenia (score 83) and for hypo-
mania (score 84), both of which were verified on subse-
? L K F H. D H, Pd M, Pa P, Se M„
+ .SK +.« +.1J + IS +.2K
(T) Score 5£>SO SO Sfi /O! 86 S3 (S3 62 67 65 54
Raw Score QiS -J. — 12-
Fig. 4. (Case 3) A patient’s personality profile which shows
marked depression. The symptom was not obvious clinically.
quent interview, this patient was referred to a psy-
chiatrist for treatment.
Case 3. — On occasion an obviously neurotic patient is
seen with excessive fatigue and multiple complaints
but whose general affect is not that of depression. Such
patients may actually be severly depressed (so-called
“similing depression”) and may be contemplating suicide.
Not infrequently a routine history fails to elicit a state
of depression which the MMPI may make obvious.
A thirty-eight-year-old man, a college graduate, was
seen for the first time on May 6, 1946. His complaints
were those of fatigue, nervousness, and palpitation. He
was decidedly underweight and was troubled with what
he called a “strain of the right groin.” A complete
physical examination and laboratory work were negative.
He was placed on a high caloric diet and was advised
to take additional periods of rest. He was seen again
about eight months later on January 21, 1947. He had
failed to gain weight, and showed no general improve-
ment. The patient took an MMPI test (Fig. 4) at this
time. A marked depression (score 101), which had been
overlooked entirely clinically, was evident.
However, on questioning this patient in more detail,
the depression became very apparent and was freely
admitted. It may be further pointed out that this pa-
tient’s MMPI record shows the “neurotic triad” of
hypochondriasis, hysteria, and symptomatic depression
which has been encountered frequently in other patients.
This patient was referred to a psychiatrist for intensive
psychotherapy. The psychiatrist has since reported con-
siderable improvement in the patient’s condition.
July. 1947
755
MULTIPHASIC PERSONALITY INVENTORY— WALCH AND SCHNEIDER
Case 4. — The “Test-Retest” technique has been used
frequently for various reasons. For example, a patient
having central nervous system syphilis can be studied
in so far as the psychoneurotic and possible psychotic
picture is concerned. Following therapy, such a patient
? L K F H. D H, Pa M, P. P, S, M„
+ .5K +.41 +11 + IK +.21
oianaara . _ _
(T)Sco 6533572S5BZ2ZZ14-±L
RawScor 1S33232A321B3A30M2
Fig. 5. (Case 4) The personality profile of a patient with
paresis, prior to malaria therapy (solid-line curve) and two
months after malaria therapy (broken-line curve).
emotional problem. It is instructive to note the marked
psychic relief in such a patient after a change in the
organic situation is brought about.
A twenty-six-year-old salesman was seen on October
17, 1946, complaining of abdominal cramps, diarrhea,
oiunaara .
(T> Score 50 50 81 /OJ69Z5.£3 65'£5£i?66
Raw Sea,. OK 2. _ 2. 1B.11B212A2Z13l3532.2X
Fig. 6. (Case 5) The personality profile of a patient with
regional ileitis, prior to surgical treatment (solid-line curve) and
after operation (broken-line curve).
can be rechecked with an MMPI test and any changes
in the personality makeup noted. Thus the physician is
aided in evaluating the efficacy of therapy.
A forty-year-old housewife had asymptomatic paresis.
She had received a two-year course of bismuth and
mapharsen and had received 5,000,000 units of penicillin.
Subsequently she had been given a total of 100 grams
of tryparsamide. She was seen on October 8, 1946, at
which time a neurologic examination was negative. A
short time before she had been seen by a neuropsy-
chiatrist and was pronounced normal except for a mod-
erately severe anxiety state. Her symptoms and com-
plaints at this time were largely those of depression and
anxiety. An MMPI test was administered to the patient.
The profile (Fig. 5, solid-line curve) showed a high
score of 88 for depression, a tendency toward psycho-
pathic deviation, together with the picture of paranoid,
schizoid, and psychasthenic traits. In view of the pa-
tient’s symptoms and the findings on the MMPI test, a
course of induced malarial fever was decided upon.
The patient was inoculated with malaria and sub-
sequently experienced fourteen paroxysms of fever in
excess of 103 degrees. Two months after completion
of the fever therapy, the patient was seen again. At this
time she stated that she felt much improved both physi-
cally and mentally. The MMPI test was repeated and
it showed an essentially normal profile (Fig. 5, broken-
line curve) save for a borderline tendency to depres-
sion. The psychotic features in the patient’s personality
were no longer evident in the MMPI profile.
Case 5. — A second example of the “Test-Retest” tech-
nique is that of testing before and after operation in a
patient with organic disease complicated by a definite
and low-grade temperature elevations over a year’s
time. Physical examination and x-ray studies of the
gastrointestinal tract revealed a classic picture of pro-
gressive regional ileitis with a palpable mass in the right
lower quadrant. The patient was an overly conscientious,
worrisome type of individual. He became extremely
apprehensive when the situation was explained and opera-
tion advised. Prior to surgical treatment, the patient
was asked to take an MMPI test (Fig. 6, solid-line
curve).
The profile before treatment showed a score of 101
for depression, a score of 80 for hypochondriasis, to-
gether with psychasthenic and schizoid tendencies of a
moderate degree. A resection of the lower ileum and
part of the cecum was successfully carried out two
days later, and the postoperative course was uneventful.
However, during his hospital stay, special precautions
were used to avoid all possible emotional trauma. The
patient was carefully followed, and when seen again on
February 3, 1947, he stated he felt well, had gained
weight, and his physical and mental symptoms had all
but disappeared. The MMPI test was repeated at this
time (Fig. 6, broken-line curve) and it showed an en-
tirely normal profile.
Case 6. — Tire group of chronic alcoholics presents a
problem in elevation. The differentiation between a
“depressed” drinker and one who has an underlying
psychopathic personality appears to be important.
A thirty-six-year-old man was first seen on February
25, 1947. He complained of intermittent localized pre-
cordial pain, marked tenseness, and nervousness. The
patient freely admitted being an alcoholic of long
standing. He had been known to disappear completely
756
Minnesota Medicine
MULTIPHASIC PERSONALITY INVENTORY— WALCH AND SCHNEIDER
from home periodically. He had been a member of
Alcoholics Anonymous for a period of six months but
had given up the program. He had been successful in
business, but would always “crack up” because of his
alcohol habit. Further history revealed that the patient
? L K F H. D HT Pd M, Pa P, Sc M,
+ .SK + .4K +11 + IK +.2K
(T) Score 15 2Z5626ZS6153636Z86
Haw Score QK J. 12 25 J2.362Sa62-J2.223G
Fig. 7. (Case 6) The personality profile of a chronic alcoholic
shows an underlying psychopathic deviation.
had been divorced and had remarried. His father had
been a chronic alcoholic and was separated from the
patient’s mother. His mother had remarried. There was
considerable hostility between the patient and both his
mother and his stepfather. Physical examination and
laboratory studies were normal. An electrocardiogram
was negative. However the patient showed such motor
overactivity as to suggest hypomania.
The MMPI (Fig. 7) showed not only hysteria (score
86), hypochondriasis (score 97), but also a definite
indication of psychopathic deviation (“psychopathic per-
sonality”) (score 78) together with the anticipated hypo-
mania (86). The patient was referred to a psychiatrist.
He subsequently has rejoined the “AA” program.
Case 7. — On occasion, the physician is consulted by a
patient who has “made the rounds” of many practitioners.
That the patient seems to be a bit “odd” may be obvious,
but the possibility of there being an underlying major
psychiatric disorder is not always immediately evident.
The patient may be treated symptomatically, and the
true fundamental condition could be overlooked. An
MMPI could be quickly administered, and this in turn
might clarify the problem in such a case.
A thirty-five-year-old saleslady was first seen on No-
vember 8, 1946, as a hospital patient. Her complaints
were vague and multiple. She was troubled with back-
aches, indigestion, constipation, restlessness, and marked
insomnia. She admitted the frequent use of sedative
drugs. Her past history was significant. About eighteen
months previously, she had fallen at her place of em-
ployment and had suffered a back injury. Much litiga-
tion had followed. She had been attended by no less
than a dozen physicians in another city over a period
of a year and a half, chiefly for complaints about the
back, and for nervousness and insomnia. Apparently
the possibility of a major psychiatric disorder had not
been seriously entertained by the attending physicians.
At this time, a complete physical examination, together
? L K F H. D Ht Pd M, Pa P, S„ M,
+-5K + .4K + IK + IK +.2K
(T) Score 52 22 _ 22 45 Z2 56 26 45 35 6S Z5 4S
Raw Score QJJ j3 15. 2- 34- 22 33 39 30 27 3! A3
Fig. 8. (Case 7) The personality profile of a woman with a
major psychosis which had been previously overlooked.
with x-ray and laboratory studies, was negative, save for
a transient glycosuria but with a normal fasting blood
sugar. The patient was greatly agitated, depressed,
and showed a ready tendency to weep. Careful question-
ing, together with an interview of the relatives, dis-
closed paranoid delusions, mendacious tendencies, and
possible drug addiction. The patient was asked to take
the MAI PI test (Fig. 8) ; this she did without undue
urging.
Although the reliability of the test was borderline,
it readily confirmed the clinical impressions by showing
depression (score 78), psychopathic deviation (score 96),
paranoia (score 85), and schizophrenia (score 75). The
patient is now under the care of a psychiatrist in a
private sanitarium.
Comment
The Minnesota Multiphasic Personaltiy Inven-
tory has proved to be a valuable aid in identifying
and measuring personality deviations. Although
the need for somatic treatment of the patient
may be perfectly obvious, the need for psychiatric
therapy is not always so apparent. Through the
use of such a test, the physician is better able to
know the relative needs of the patient for psycho-
therapy. Thus by making use of the balanced
approach to the patient’s problems, the physi-
cian is able to secure results. Oftentimes the test
results will aid in the decision as to the need
for referral of the patient to a psychiatrist.
Certain patients seem to derive benefit by
July, 1947
757
MULTIPHASIC PERSONALITY INVENTORY— WALCH AND SCHNEIDER
merely going through the mechanics of taking
the test. The finished profile can be shown to
selected patients. The problem of explaining to
the patient the relationship between symptoms and
personality can be placed on a more concrete basis.
Patients are often relieved to see that their scores
are on the right-hand side of the profile (the
major psychoses) are within normal limits.
It cannot be too strongly stressed that one
must not go ahead on score findings alone. A
complete physical examination together with the
necessary laboratory aids is obviously important.
The patient’s background, from both a hereditary
and a constitutional standpoint, must be consid-
ered. One must gain an impression of the pa-
tient’s environment and of the patient’s reaction
to that environment. The careful elicitation of
the medical and psychosomatic history is still of
first importance. There is no shortcut for these
time-consuming procedures.
As has been indicated, the booklet form of the
inventory has been used exclusively by the authors
of this paper, largely because of the greater ease
of administration and scoring. The authors of
the inventory point out that “for college, high
school, or professional people, who are used to
reading and writing, the results obtained by use
of the booklet form are probably almost identical
with those of the card form.”0 They strongly
urge the use of the card form in testing older
persons, disturbed or hospitalized patients, or
those of low educational or intelligence levels.
For the most part, patients have no objection
to taking the test when it is explained to them
that it is merely a measurement of personality
traits, that it is not a mental or intelligence test,
and that the examiner is not interested in the
answers to individual questions. While taking the
test, the patient should be comfortably seated and
should be alone if possible.
Summary
1. The Minnesota Multiphasic Personality In-
ventory has been administered by the authors to
550 patients selected from an internal medical
practice.
2. The technique of giving and scoring the in-
ventory is described in detail.
3. Seven case histories with accompanying
profiles are included as a means of illustrating
the use of the procedure.
4. The advantages of this procedure as a means
of evaluating the psychogenic aspect of the pa-
tient’s illness are discussed.
5. It is to be re-emphasized that this inventory
is designed to supplement and not to replace a
careful physical examination, laboratory workup,
and a rather detailed medical and psychosomatic
history.
References
1. Hathaway, S. R., and McKinley, J. C. : A multiphasic
schedule (Minnesota) : I. Construction of the schedule.
J. Psychol., 10:249-254, (Oct;.) 1940.
2. Hathaway, S. R., and McKinley, J. C. : III. The measure-
ment of symptomatic depression. J. Psychol., 14:73-84,
(July) 1942.
3. McKinley, J. C., and Hathaway, S. R. : II. A differential
study of hypochondriasis. J. Psychol., 10:255-269, (Oct.)
1940.
4. McKinley, J. C., and Hathaway, S. R.: IV. Psychasthenia.
J. Appl. Psychol., 26:614-624, (Oct.) 1942.
5. McKinley, J. C., and Hathaway, S. R.: V. Hysteria, hypo-
mania, and psychopathic deviate. J. Appl. Psychol., 28:153-
174, (April) 1944.
6. McKinley, J. C., and Hathaway, S. R. : Supplementary
Manual for the Minnesota Multiphasic Personality Inventory,
Part II. New York: The Psychological Corporation, 1946.
7. Sadler, W. S.: Modern Psychiatry. St. Louis: C. V. Mosby
Co., 1945.
8. Weider, Arthur; Brodman, Keeve; Mittelmann, Bela; Wechs-
ler, David; and Wolff, Harold G. : The Cornell index.
Psychosom. Med., 8:411-413, (Nov. -Dec.) 1946.
ACUTE POLIOMYELITIS IN PREGNANCY
(Continued from Page 734)
4. Berg, Roland H.: The Challenge of Polio. New York: Dial
Press, 1946.
5. Biermann, A. H., and Piszczek, E. A.: A case of polio-
myelitis in a newborn infant. J.A.M.A., 124:296-297, (Jan.
29) 1944.
6. Blair, Murray, and Robertson, C. E.: Anterior poliomyelitis
in pregnancy. Canad. M. A. J., 51:552-552, (Dec.) 1944.
7. Brahdy, M. Bernard, and Lenarsky, Maurice: Acute epidemic
poliomyelitis complicating pregnancy. J.A.M.A., 101:195-198,
(July 15) 1933.
8. Fox, Max J., and Sennett, Louis: Poliomyelitis in pregnancy.
Am. J. M. Sc., 209:382-387, (March) 1945.
9. Gillespie, C. F. : Cesarean section in respiratory paralysis
due to acute poliomyelitis. Quart. Bull. Indiana Univ. M.
Center, 3:22-23, (Jan.) 1941.
10. Harmon, Paul H., and Hoyne, Archibald: Poliomyelitis and
pregnancy. J.A.M.A., 123:185-187, (Sept. 25) 1943.
11. International Committee for Study of Infantile Paralysis,
758
(Milbank, Jeremiah): Poliomyelitis. Baltimore: Williams
and Wilkins Co., 1932.
12. Kleinberg, Samuel, and Horwitz, Thomas: The obstetric
experiences of women paralyzed by acute anterior polio-
myelitis. Surg., Gynec. & Obst., 72:58-69, (Jan.) 1941.
13. McGoogan, Leon S. : Acute anterior poliomyelitis complicat-
ing pregnancy. Am. J. Obst. & Gynec., 24:215-223, 1932.
14. Morrow, J. R., and Luria, Sanford, A.: Pregnancy com-
plicated by acute anterior poliomyelitis. J.A.M.A., 113:
1561-1563, (Oct.) 1939.
15. Spishakoff, Nathan M.; Golenternek, Dan, and Bower, Albert
G. : Premature obstetric delivery due to poliomyelitis. Cali-
fornia & West. Med., 54:121-123. (March) 1941.
16. United States Census Bureau: Statistical Abstract, No. 67,
i946.
17. Weaver, H. M., and Steiner, Gabriel: Acute anterior polio-
myelitis during pregnancy. Am. J. Obst & Gynec., 47:495-505,
(April) 1944.
Minnesota Medicine
RECONSTRUCTION OF THE EXTRAHEPATIC BILE DUCT
A Modification of the Allen Method
CHARLES E, REA, M.D.
Saint Paul, Minnesota
GIVEN a patient with a history of a previous cholecys-
tectomy, recurrent or persistent attacks of chol-
angitis or jaundice, the diagnosis of stricture of the
common bile duct should be considered. All surgeons
agree that the best way to prevent these strictures is
care in the performance of cholecystectomy, so that the
extrahepatic bile duct is not injured.
In the treatment of strictures of the common bile
duct, most surgeons try to anastomose the two cut ends
-of the common bile duct over a rubber T-tube. The
use of vitallium or lucite tubes has to date provided no
special advantage over the rubber tube. If the above
procedure is not possible, due to difficulty in locating
the distal portion of the duct or bringing the ends of
the ducts together, a choledochoduodenostomy or choledo-
chojej unostomy (preferably the latter) is usually per-
formed.
In 1945, Allen described a method of anastamosing
the open distal end of the transected jejunum to the
liver around a tube placed in the short segment of the
hepatic duct in the liver sulcus. The jejunum is tran-
sected approximately 30 cm. from the ligament of
Treitz, and the intestinal continuity is re-established by
implanting the proximal segment of the jejunum into
the distal segment after the method of Roux. This
results in a mechanical arrangement whereby the intes-
tinal current is directed away from the liver. Cotton
-or silk sutures hold the end of the jejunum securely in
the liver sulcus since the scar tissue around the duct
opening is very firm and reliable. By inverting the end
of the jejunum for a distance of 1.5 cm., two surfaces
are placed in apposition which theoretically, at least,
have healing properties. The use of the bell end of the
rubber catheter is to lead all bile through such a tube
and thus produce a water tight anastomosis. By making
a vent in that segment of the catheter remaining for a
time within the lumen of the gut, a complete external
fistula can be prevented for as long as the catheter is
left in place. The majority of tubes were removed at
the end of twenty-one days.
The first patient treated by the author by Allen’s
method developed signs of cholangitis three days after
■operation, which subsided upon withdrawing the catheter
on the seventh postoperative day. In Allen’s own series
three patients had one or two mild, transient episodes
of pain, jaundice, chills and fever. At best, a rubber
tube acts as an irritant in the bile duct, and it may
he questioned if removing such a tube at the end of
twenty-one days (or a longer interval) does much to
prevent further stricture.
Accordingly, the following modification was used in
the treatment of the next two patients with stricture of
the common duct.
1. The cut end of the distal jejunum was anastamosed
to the capsule of the liver around the proximal end of
the common duct to act as a funnel to receive the bile.
2. No rubber tube was used in making the anastomosis.
The patients were explored through a right subcostal
incision. In both instances the proximal end of the
duct was a bulbous segment flush with the liver substance.
This finding is not unusual in the more complete stric-
tures occurring high in the common duct. Also, the
amount of fibroserositis on the capsule of the liver in
the region of the upper end of the duct is considerable
and lends itself admirably for the placement of sutures.
The cut distal end of the jejunum was sutured to the
liver so as to form a funnel or cup over the upper
end of the common duct. No rubber tubing was placed
in the duct, as it was felt that even though this dilated
duct should contract somewhat, there still would be no
obstruction to the flow of bile. Interrupted sutures of
No. 000 silk were used to make the anastmosis. The
cut end of the jejunum was inverted by a mattress
suture, so there was a small serosal cuff inside the
lumen. Only two rows of silk sutures were used to
make the anastamosis. A penrose drain was left in the
subhepatic space of Morrison and brought out through
a stab wound inferior to the incision. This was re-
moved on the eighth postoperative day.
These two patients have been followed eight months
and one year respectively since operation and have been
well. In neither have there been jaundice or symptoms
suggestive of cholangitis.
Summary
A modification of the Allen method for reconstruc-
tion of the common bile duct is presented. The cut end
of the jejunum is sutured to the liver capsule to form
a funnel over the upper end of the common duct. No
tubes are used in making the anastamosis. Two patients
so treated have been well eight months and one year
since operation.
References
1. Allen, A. W. : A method of re-establishing continuity be-
tween the bile duct and the gastrointestinal tract. Ann.
Surg., 121:412, 1945.
Probably no greater mental trauma is ever inflicted
by a physician than when he first tells a patient that he
or she has tuberculosis. Material and social problems
combined with the psychological problems of separation
from family, complete change of living routine, sudden
July, 1947
cessation of all activity, ignorance of the disease and
what it will mean to him and an unknown future is likely
to create in the patient a mental turmoil which is a
known detriment to his eventual recovery and return to
a useful life. — C. J. Stringer, Hospitals, (Aug.) 1946.
759
CLINICAL-PATHOLOGICAL CONFERENCE
PARATHYROID ADENOMA
A Diagnostic Case Study
HAROLD H. JOFFE, M.D., F. H. MAGNEY, M.D.. and ARTHUR H. WELLS, M.D.
Duluth, Minnesota
Dr. F. H. Magney : This fifty-one-year-old white
female (Case No. 30757) was first admitted to this hos-
pital on July 21, 1939, for a trigeminal neuralgia on the
left side which was somewhat relieved by an alcohol
injection. Shortly thereafter she underwent an opera-
tion on the Gasserian ganglion at the Mayo Clinic where,
in addition, a cystic lesion of the right os calcis was
curetted and a diagnosis of a giant cell tumor was made.
The cyst was packed with bone chips from the left tibia.
The patient was readmitted on October 16, 1941, with
a history of having been well since the operation two
years before, except for a loss of sensation on the left
side of the face. At this time she had noted intermittent
pain for the past three months in the posterior aspect
of the right lower thigh, especially when bending the
knee. There had also been some occasional pain in the
right heel. On the day of admission she stumbled down
a step, falling and landing on the right knee. Her physi-
cal examination was essentially normal except for muscle
spasm and swelling above the right knee. X-ray examina-
tion revealed a fracture of the lower end of the right
femur with angulation, and at the same time a cystic
lesion suggestive of a giant cell tumor of the bone was
discovered at the site of the fracture. The patient was
treated by extension, manipulation, and application of a
plaster cast.
The chief complaint on the third admission (August
9, 1946) was a dull continuous pain in the left knee
since the spring of that year. It had been getting prog-
ressively worse and was aggravated by weight bearing,
but not relieved by rest. X-ray examination at this
time revealed small calculi in the right kidney and areas
of decreased density throughout the lumbar spine, pelvis,
and ribs with cystic areas in the right ninth rib in the
anterior axillary line and the left tenth rib in its' posterior
portion. There was also a cystic area in the left patella
(Fig. 1), in the superior ramus of the right pubic bone,
and in the left acetabulum. The alkaline phosphatase
was 27.8 King-Armstrong units. The left patella was
excised with the aid of Dr. M. H. Tibbetts. A diagnosis
of benign giant cell tumor or osteitis fibrosa cystica was
made by Dr. A. H. Wells who recommended serum cal-
cium and phosphorus determinations to rule out hyper-
parathyroidism. Two serum calcium determinations re-
vealed 15.02 and 16.62 mg. per 100 c.c., respectively.
The serum phosphorus was normal. Apparently because
of the many previous surgical procedures, including
From the Department of Pathology, St. Luke’s Hospital, Duluth,
Minn., Arthur H. Wells, M.D., Pathologist.
Fig. 1. Cyst in patella.
(1) tonsillectomy and adenoidectomy, (2) appendectomy,
(3) perineorrhaphy, (4) drainage of a breast abscess,
(5) hysterectomy, (6) resection of the Gasserian gang-
lion on the left side, (7) curettement of the right os
calcis for supposedly a giant cell tumor and (8) treat-
ment for a pathologic fracture of the lower end of the
right femur, the patient refused an exploration for a
parathyroid adenoma.
She was readmitted to this hospital for the fourth
time on March 21, 1947. A parathyroid adenoma, the
size of a large olive, was removed from the left superior
parathyroid gland. Gross examination revealed an en-
capsulated mass measuring 3.5 by 2.5 by 1.7 cm. The cut
surface had patchy yellowish gray mottling with an area
of cystic degeneration and hemorrhage measuring 2 by
1.5 by 1.4 cm. (Fig. 2). Microscopically the tumor was
encapsuplated and was made up of solid masses and
cords of rather large, uniformly shaped epithelial cells
with small rounded nuclei and abundance of clear
cytoplasm with a well defined outer wall (Fig. 3). There
was no evidence of malignancy and a diagnosis of
parathyroid adenoma was made.
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Fig. 2. Sectioned adenoma of parathyroid.
Following surgery, symptoms suggestive of tetany
were relieved by the intravenous use of calcium. Post-
operatively, the serum phosphorous was 2.61 mg. per
100 c.c. and the serum calcium on two occasions was
7.6 and 6.5 mg. per 100 c.c.
Incidence
Dr. H. H. Joffe: The alertness of the profession in
recognizing the symptoms of hyperparathyroidism is the
major reason for the increase in frequency of the dis-
ease. In recent collective review23 96.3 per cent of the
twenty-seven reported cases in the literature between
1903 to 1925 were diagnosed at autopsy examinations,
as compared to 3.7 per cent diagnosed at operations.
During the period 1936 to 1945, of the 174 cases re-
ported, 87.4 per cent were diagnosed at operations and
only 12.6 per cent at necropsy examinations. The in-
creasing diagnostic accurracy is further exemplified by
the fact that twenty-four cases had been proved at opera-
tions at the Mayo Clinic from September 30, 1942, to
January 30, 1945, in contrast to fourteen cases observed
during the preceding fourteen years.
Norris,23 in reviewing 322 cases of parathyroid adeno-
mas reported in the literature, found that the location
was specified in only 251 cases. The right side of the
neck accounted for 132 (52.6 per cent) and the left side
for 119 (47.4 per cent). The more specific location
was defined in only 197 cases, with 42.7 per cent occur-
ring in the right lower gland and 41.1 per cent in the
left lower gland. The right upper and left upper glands
accounted for 9.1 and 7.1 per cent respectively. Single
adenomas in aberrant positions were recorded in thirty
(10.7 per cent) of 281 cases, with nineteen (63.3 per
cent) occurring in the mediastinum, nine (30 per cent)
within the thyroid gland and two (6.7 per cent) behind
the esophagus. Of 322 cases, more than one adenoma
was found in twenty (6.2 per cent) of cases.
The age group between thirty to sixty years accounted
for 70 per cent of 316 tabulated cases.23 The incidence
was found to be 3 to 1 in women for single adenomas
and 4 to 1 in the group of multiple adenomas. The
maximum incidence in men occurred a decade earlier
than in women. The latter are divided into two phases
Fig. 3. High power view of parathyroid adenoma illustrating
the water-clear type of cell.
which extended through and correspond to the child-bear-
ing period, reaching a peak at forty-five years of age.
Pathologic Physiology
The parathyroid hormone acts to increase the excretion
of calcium, and if insufficient amount of calcium is being
absorbed from the intestines, or if the output is greater
than the intake, the chief reservoirs of calcium, namely
the bones, are depleted.23’30 Why generalized osteoporosis
predominates in some patients and osteitis fibrosa cystica
is most prominent in others is not clearly understood,
but it has been postulated that the latter apparently
develops in those in whom loss of calcium is more rapid.23
The terminal results of hyperparathyroidism are well
known, but the mode of action still remains one of
conjecture. At present the mechanism of action is
thought to be initiated only by chemical or hormonal
stimuli.27 Prolonged stimulation of the sympathetic
nerves to the glands failed to produce any change in the
blood calcium.27 The endocrine relationship to the pitui-
tary gland is open to question. However, Perlman25
reported a dog having an atypical eosinophilic adenoma
of the pituitary gland and at postmortem examination
was found to have a coincidental adenomatous hyper-
plasia of the parathyroid and severe chronic nephritis,
together with fibrous osteopathy without brown cysts.
Collip23>27 feels that the chief action of the parathyroid
hormone is directly on solution of calcium salts from
bone, while Albright3*23’27 contends that its chief action
is in promoting the renal excretion of phosphate. Recent
experiments show that the hormone may act on both
simultaneously.27
The parathyroids regulate the level of blood calcium,
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determine the rate of movement from the great calcium
deposits, the bones, into the blood stream and tissues,
and thence out into the urine.8 Injection of parathormone
causes excretion of phosphorous and calcium in the
urine which is usually followed by an increase in the
blood calcium with removal of calcium from the bones.6
Collip showed that excess doses of parathormone in dogs
resulted in death in a few days and was preceded by
anuria and retention of nitrogenous products.3 Hueper
showed that such dogs dying of acute parathyroid
poisoning had calcium deposits in the thyroid gland,
mucous membrane of the stomach, lungs, and kidney.3
It is, therefore, felt that the kidney lesions are only a
part of a more generalized process.
The calcium is precipitated out as phosphate salt in
alkaline urine or as calcium oxalate in acid urine. Calculi
may form in any part of the urinary tract from the
renal tubules to the bladder. Calcium may also be
deposited in the renal parenchyma as well as the lungs
and arteries. With progressive renal calcification or
nephritis due to ascending sepsis, the kidney fails to
excrete the excess calcium with which it is burdened
by the overactive gland. The excess is excreted by the
large bowel and the blood level of calcium remains as
before.23 Retention of phosphate, chlorides and nitrog-
enous products occurs with renal impairment.23’24’27
Phosphatase which is an important enzyme in regen-
eration of bone is also elevated in hyperparathyroidism
because nature makes an attempt to form new bone
where old bone is being removed.29
The order of events in the pathologic physiology of
hyperparathyroidism may be briefly summarized as fol-
lows :22 (1) excessive activity of the parathyroid, (2)
extraction of minerals from soft tissues and their excre-
tion, (3) mobilization and withdrawal of not only cal-
cium, but earthy alkaline substances from bone, (4)
proliferation of osteoclasts to phagocytize the decalcified
matrix and proliferation of fibrous tissue to replace the
bone.
Primary hyperplasia of the parathyroid glands is the
result of adenoma with secretion of excessive amounts
of parathormone and depletion of the calcium stores,
resulting in generalized osteoporosis or osteitis fibrosa
cystica. Secondary hyperplasia is a compensatory me-
chanism and can be due to such underlying conditions
as:13’20 chronic renal insufficency, severe rickets, osteo-
malacia, osteitis deformans, fragilitas ossium, multiple
myeloma, metatstatic carcinoma of bones and nephro-
lithiasis.
The exact mechanism of parathyroid hyperplasia in
chronic renal insufficiency or renal rickets is debatable ;
however, retention of phosphate is generally admitted
to be the initial stimulus.2’11’24 Drake, Albright and Cas-
tleman were able to produce parathyroid hyperplasia in
rabbits by repeated injection of a neutral buffered iso-
tonic solution of sodium phosphate.11 In renal insuffi-
ciency the plasma phosphates tend to be high because
the kidney cannot excrete them readily. The high phos-
phate level lowers the plasma calcium which acts as a
stimulus to the parathyroids.6
Histology
The normal gland is generally considered to have three
types of cells ; the chief, water-clear and oxyphil cells.
The first two are probably the same except for degree
of maturation. Based on size and structure of the proto-
plasm, these cells are divided into four types ; dark,
clear, vesicular and water-clear.6 The chief cells are
small and possess dense cytoplasm in contradistinction to
the water-clear cells which are large with vacuolated
cytoplasm. The other cell types are considered transi-
tional with the great majority of the cells belonging to
the intermediate type, thus giving the impression of a
progressive development from the dark chief cells
through the intermediate types to the water-clear cells.6
The oxyphil cells possess a dense acidophilic cytoplasm.
Welsh in 1898, in a study of normal glands from forty
human autopsies, was the first to distinguish the oxyphil
cell from the predominate chief cells and derivatives.10
He believed that the least specialized cell was what is
now called the “water-clear” or “wasserhelle” cell. The
arrangement of both the oxyphil and chief cells varied
from masses to anastomosing and branching columns
and finally cords of a single cell width. True acini
formation were only rarely found.
Histologic studies confirm the monophyletic theory
of the origin of the various cells.6’10 Surprisingly enough,
little of fundamental importance has been added since
the original description of Welsh. Kurokawa,10 in study-
ing 815 glands removed from 240 necropsies, ranging in
age from a seven-month-old fetus up to eighty years of
age, found that up to puberty the cells are all water-
clear cells containing glycogen but no fat. At puberty
these cells begin to decrease and the dark chief and
oxyphil cells gradually appear. The dark chief cells
contain fat but no glycogen and the oxyphil cell con-
tains neither fat nor glycogen. When the cytoplasm in
the chief cell is entirely absent (complete vacuolization)
the cell is called “water-clear” or “wasserhelle” cell. At
puberty or soon afterwards the pale oxyphil cells gradu-
ally appear, at first singly and then in pairs, increasing
in number with advancing age, forming large islands
after forty to fifty years of age. The dark oxyphil
cells occur singly, are not present before puberty, and
likewise do not contain fat or glycogen.10
Histologically the parathyroid neoplasias usually con-
tain all of the types of cells common to the normal
gland.19 Castleman and Mallory10 did not find pure
tumors of either the oxyphil or water-clear type in their
series of neoplasias. Numerous transition forms can
always be demonstrated. They believe that the chief
cell is the basic fundamental cell with the other cells
regarded as degrees of differentiation or as involution
forms. Hyperplasis of the parathyroid is characterized
by diffuse involvement of all the glandular tissue and
occurs in two forms, a more common water-clear cell
type and a much rarer chief cell type.10
The cells may show a considerable degree of pleomor-
phism with mitosis, which has often led to an erro-
neous diagnosis of carcinoma. It is generally agreed that
the great majority are clinically benign, rarely recur,
invade or metastasize.10’13’19’23 Burke8 reported a case
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of recurrent adenoma apparently due to a transplanted
fragment between the muscles of the neck.
Clinical Manifestations
Hyperparathyroidism is pleomorphic in its clinical
manifestations. It may be suspected most often in three
principal ways: (1) through its bone lesions, (2) its
kidney complications and (3) its general somatic effects.
There are two types of bone lesions, a cystic form,
osteitis fibrosa cystica, and a diffuse decalcification. Al-
though osteitis fibrosa cystica is the classical form of the
disease it is not as common as the form associated with
urological symptoms.^2’13’27 Over a ten-year period in
sixty-seven cases of hyperparathyroidism, Albright and
associates12 found the ^classical picture of osteitis fibrosa
cystica in only one-third of the cases. Another one-third
showed mild and often insignificant degrees of skeletal
involvement, and the remainder showed no osseous dis-
ease. Norris23 in a collective review of 322 cases found
osteitis fibrosa generalisata in 191 (59.3 per cent). The
symptoms resulting from involvement of the osseous
system varies from vague aches of pains in the extremi-
ties and back, to a truly disabling condition with
pathologic fractures, cysts, tumors and deformities.19’20’23
The renal complications are three : a diffuse calcinosis,
calculus formation, and pyelonephritis complicating the
calculi. Norris23 found associated skeletal and renal
lesions in 101 out of 322 cases (31.4 per cent) and renal
lithiasis and or renal calcification alone in seventeen
(5.3 per cent). Approximately 10 to 15 per cent of all
patients with renal calculi have the calculi as a compli-
cation of primary hyperparathyroidism. The complica-
tion of renal calcification occurs in over 65 per cent of
cases of hyperparathyroidism.27 Keating and Cook19
found renal calculi in eighteen out of twenty-four cases
with bilateral calculi in seven cases. Fourteen of these
cases had previously undergone a total of twenty surgi-
cal procedures for renal calculi.
The more general somatic symptoms as, a result of
biochemical changes in the blood and urine are too com-
monly present in other diseases to be of much diagnostic
aid. They include : muscular atony, weakness, fatigue,
constipation, anorexia, loss of weight, nausea, and
vomiting, polyuria and polydpsia. The latter two occurred
in eleven (46 per cent) of twenty-four cases.19
Diagnosis
The biochemical and roentgenologic studies and biopsy
of the bone lesions are principal aids in the establish-
ment of the diagnosis of hyperparathyroidism.
The demonstration of the biochemical changes is con-
cerned with (1) an increased serum calcium, (2) a re-
duction of inorganic serum phosphorus, and (3) hyper-
calcinuria. To the foregoing may be added an increased
alkaline phosphatase.
An elevated serum calcium above the normal of 9 to
11 mg. per 100 c.c. may be very slight, and repeated
determinations may be necessary in order to establish
a definite diagnosis. In twelve out of twenty-four cases
at the Mayo Clinic,19 the average concentration was less
than 12.5 mg. per 100 c.c. The values were generally
higher in those cases with classical bony changes.
The total calcium is made up of two fractions, calcium
proteinate in which the calcium is bound to serum protein
and ionic calcium. The former varies with changes in
the protein concentration apd is not primarily affected
by the parathyroid hormone, whereas the ionic calcium
is affected by parathormone.19’21 It is therefore plausible
that with a lowered serum protein and a normal total
calcium, one may actually have an elevated ionic cal-
cium19-21 Neither of the calcium fractions can be meas-
ured directly; however, both apparently can be estimated
from the concentration of total calcium, and total protein
by the use of the nomogram of McLean and Hastings'.21
Certain conditions such as multiple myeloma and sar-
cordosis are frequently accompanied by an increased total
serum protein and by hypercalcemia secondary to the
elevated protein. However, in the experience at the
Mayo Clinic,19 a reduction in serum protein to sufficiently
mask hypercalcemia was rarely encountered as a diag-
nostic problem in hyperparathyroidism. Conversely an
elevated total serum protein was a relatively frequent
means of avoiding an erroneous diagnosis of parathyroid
disease.
The reduction of inorganic serum phosphorus from
the normal of 3 to 4 mg. per 100 c.c. is usually slight.
In 25 per cent of cases, one or more determinations fell
within the normal range, and 17 per cent of cases the
level was at the lower limit of normal.19
Hypercalcinuria was demonstrated in fourteen of
fifteen patients with renal lithiasis in whom hyperpara-
thyroidism was excluded.26 In 50 per cent of these cases
there was evidence of renal damage which may demon-
strate that moderately diseased kidneys may excrete
calcium in the urine in the absence of other explainable
causes. A low level of calcium in the urine, in a con-
centrated specimen, in the absence of renal disease, as
indicated by the Sulkowitch test, practically rules out
hyperparathyroidism.19
An elevated alkaline phosphatase does occur with
hyperparathyroidism and is more commonly seen in the
group with classical bone changes. It is believed to be
the result of osteoblastic activity and therefore, not
pathognomonic of the disease itself. 4’19>23’29
Roentgenologic examination of the bones in the early
stages reveals the trabeculae to be thin and delicate with
the cortex so thin that the bone has a ground glass
appearance.23’30 This is best seen in the flat bones such
as the calvarium. In advanced cases there is wide spread
demineralization with multiple cysts, pathologic frac-
tures,19’30 expanding tumors and a variety of skeletal de-
formities. The common sites of the cystic lesions are
the jaw, pelvis, long bones, ribs, metatarsal and meta-
carpal bones.30 Strock,28 in reporting the dental roent-
genologic findings in forty-five out of fifty-one cases,
found that one-half of the cases showed cystic-like cavi-
ties in the jaw, malocculsion, osteoporosis and absence
of lamina dura.
The diagnosis of giant cell tumor of bone on biopsy
or x-ray without further laboratory and metabolic studies
should be made with reservation. Goldman16 reported
a brother and sister erroneously diagnosed as giant cell
tumors by x-ray in one and by biopsy in the other.
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Both were treated successfully by surgical removal of
parathyroid adenomata. At present we do not feel that
giant cell tumor of bone can be histologically differ-
entiated from osteitis fibrosa cystica.
In summary, the possibility of hyperparathyroidism
should be considered in: (1) all cases of neophrolithiasis
or nephrocalcinosis, (2) all cases in which there is x-ray
evidence of generalized demineralization, (3) all cases
of cysts or bone tumors, (4) all cases of giant cell
tumors so diagnosed by biopsy, (5) all cases in which
there are symptoms referable to the skeleton, especially
pathologic fractures.1’19’23
The secondary or compensatory hyperplasia of the
parathyroids due to some underlying disease must be
differentiated from primary hyperplasia (adenoma) of
the parathyroid gland. In the former, surgical removal
will not cure the underlying pathologic process.
Treatment
The treatment of primary hyperplasia is surgical exci-
sion, and it may occasionally challenge the ingenuity of
the surgeon to locate the erring gland or glands. Fol-
lowing surgical removal, the serum calcium falls rapidly
to normal in a day or two with the inorganic phosphorous
returning to normal more gradually.19 Postoperative
tetany is usually not so severe that it cannot be con-
trolled by the usual means.19 However, Albright2 stated
that severe tetany usually only occurred in patients in
whom the level of alkaline phosphatase exceeded 20
Bodansky units before operation.
The removal of a hyperfunctioning parathyroid may
invite immediate chemical changes with resultant acidosis.
Couch15 reported a case of acidosis with a carbon
dioxide combining power of 19 volumes per cent which
was treated with dramatic results by intravenous sodium
bicarbonate.
The explanation for the production of acidosis is
that the acid radicals, phosphates, sulphates and chlorides
tend to be retained in the blood stream while base sodium
is freely excreted by the kidneys and the base calcium
is retained in the bones.
Summary
We have presented a case of hyperparathyroidism due
to an adenoma. This patient presented all of the prin-
cipal diagnostic features of this syndrome, including
(1) multiple bone cysts, (2) spontaneous fracture of
bone, (3) generalized decalcification of bone, (4) renal
calculi, (5) hypercalcemia, and (6) increased alkaline
phosphatase.
In spite of the study of the case by several physicians,
including at least one pathologist, an orthopedist, two
roentgenologists, a surgeon, and two general practitioners,
the diagnosis was not established over a six-year period.
Physicians should always consider primary hyper-
parathyroidism in cases presenting (1) bone cysts, (2)
pathologic fractures, (3) renal calculi, (4) “giant cell”
tumor of bone, and (5) generalized decalcification of
bone.
An incomplete review of the literature has been pre-
sented.
References
1. Aegerter, E. E. : Giant cell tumors of bone. Am. J. Path.,
23:283-297, (March) 1947.
2. Albright, F. : The parathyroids — physiology and therapeutics.
J.A.M.A., 117:527-533, (Aug. 16) 1941.
3. Albright, F. ; Baird, P. C. ; Cope, O., and Bloomberg, E. :
Studies on the physiology of the parathyroid glands: IV,
Renal complications of hyperparathyroidism. Am. J. M. Sc..
187:49-65, (Jan.) 1934.
4. Albright, F. ; Sulkovvitsch, II. W., and Bloomberg, E. :
Further experience in the diagnosis of hyperparathyroidism.
Including a discussion of cases with a minimal degree of
hyperparathyroidism. Am. J. M. Sc., 193:800-812, (June)
1937.
5. Baumgartner, C. J. : Hyperparathyroidism-normal chemistry-
rapid recalcification following removal of large parathyroid
adenoma. West. J. Surg., 48 :324-327, (May) 1940.
6. Bell, E. T. : Textbook of Pathology. P. 752-754. Philadelphia:
Lea and Febiger Co., 1944.
7. Beilin, D. E., and Gershwin, B. S.: Hyperparathyroidism
due to parathyroid adenoma. Am. J. M. Sc., 190:519-529,
(Oct.) 1935.
8. Boyd, W. : Textbook of Pathology. P. 777-781. Philadelphia:
Lea and Febiger Co., 1934.
9. Burk, L. B.: Recurrent parathyroid adenoma. Surgery,
21:95-101, (Jan.) 1947.
10. Castleman, B., and Mallory, T. B.: The pathology of the
parathyroid gland in hyperparathyroidism. Am. J. Path.,
11:1-72, (Jan.) 1935.
11. Castleman, B., and Mallory, T. B. : Parathyroid hyperplasia
in chronic renal insufficiency. Am. J. Path., 13:553-574,
(July) 1937.
12. Cook, E. N., and Keating, F. R. Jr.: Renal calculi asso-
ciated with hyperparathyroidism. J. Urol., 54:525-529, (Dec.)
1945.
13. Cope, O.: Hyperparathyroidism. The significance of gener-
alized hyperplasia. Clinics, 1:1168-1177, (Feb.) 1943.
14. Cope, O. : Hyperparathyroidism: Sixty-seven cases in ten
years. J. Missouri M. A., 39:273-278, (Sept.) 1942.
15. Couch, J. H., and Robertson, II. F. : Occurrence of post-
operative acidosis and pagetoid bone changes in hyperpara-
thyroidism. Surg., Gynec. & Obst., 73:165-174, (Aug.) 1941.
16. Goldman, L., and Smyth, F. S.: Hyperparathyroidism in
siblings. Ann. Surg., 104:971-981, (Dec.) 1936.
17. Howard, R. M.: Hyperparathyroidism. South. M. J., 33:123-
127, (Feb.) 1940.
18. Keating, F. R., Jr.: The diagnosis of primary hyperpara-
thyroidism. M. Clin. North America, 1019-1033, (July) 1945.
19. Keating, F. R., Jr., and Cook, E. N.: The recognition of
primary hyperparathyroidism, (analysis of 24 cases), J.A.-
M.A., 129:994-1002, (Dec. 8) 1945.
20. Kolmer, J. A. : Clinical Diagnosis by Laboratory Examina-
tion. P. 912-915. New York: D. Appleton-Century Co., 1944.
21. McLean, F. C., and Hastings, A. B.: Clinical estimation
and significance of calcium-ion concentrations in the blood.
Am. J. M. Sc., 189:601-612, (May) 1935.
22. Moore, R. A.: A Textbook of Pathology. P. 1101-1103.
Philadelphia: W. B. Saunders Co.
23. Norris, E. H.: The parathyroid adenoma: study of 322 cases.
Internat. Abs. Surg., 84:1-41, (Jan.) 1947.
24. Nutting, R. E., and Wells, A. H.: Renal rickets. Minnesota
Med., 28:458-641, (June) 1945.
25. Perlman, R. M.: Parathyro-pituitary syndrome. Arch. Path.,
38:20-27, (July) 1944.
26. Riegel, C. ; Royster, H. P. ; Gislason, G. J., and Hughes,
P. B. : Chemical studies in hyperparathyroidism and uro-
lithiasis. J. Urol., 57:192-195, (Jan.) 1947.
27. Royster, H. P., and Riegel, C. : Pathologic physiology of
hyperparathyroidism. Clin. North America, 1462-1469, (Dec.)
1946.
28. Strock, M. S. : The mouth in hyperparathyroidism. New Eng-
land J. Med., 224:1019-1023, (June 12) 1941.
29. Vance, T.; Rogde, J., and Breck, L. W. : Parathyroid osteosis.
South. M. J., 33:128-135, (Feb.) 1940.
30. Yater, W. M.: Fundamentals of Internal Medicine. P. 537-
541. New York: D. Appleton-Century Co., 1944.
\
It has been estimated that nearly four per cent of all
persons who visit physicians’ offices are coughing or ex-
pectorating. The alert physician will insist upon a sputum
examination of all such patients. Such practice will be
rewarded by the discovery of tubercle bacilli in three or
four of every 100 specimens examined. The country doc-
tor will often be astonished to discover that a patient
with slowly resolving pneumonia has an acid-fast reason
for prolonged convalescence. — Pub. Health Rep., Dec. 6,
1946.
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CASE FOR DIAGNOSIS
A. J. HERTZOG, M.D., and JULIAN SETHER. M.D.
Minneapolis, Minnesota
Dr. Julian Sether: This case (A-46-2461) was that
of a sixty-six-year-old woman who was admitted to the
Minneapolis General Hospital at 11:00 P.M. on No-
vember 30, 1946, with a two-hour history of severe sud-
den nonradiating pain in both lower abdominal quad-
rants. The pain was associated with nausea, vomiting,
and several loose bowel movements. Melena or hema-
temesis was not noted. The pain was colicky, sharp,
and stabbing.
The patient was first seen in this hospital in July, 1938,
complaining of polydipsia, polyuria, and dysuria of one
year’s duration. Blood pressure at this time was 145/82.
The diagnosis of diabetes mellitus was established. She
was discharged on insulin therapy. She was again
admitted in March, 1940, because of some swelling of
her ankles. Blood pressure was 150/90. An electro-
cardiogram showed left axis deviation. The left optic
lens was removed in 1941 because of a cataract. In 1942,
a cystocele and rectocele were repaired. In March of
1943, auricular fibrillation was present and she was
digitalized. In 1945, a midthigh amputation was per-
formed for gangerene of the left foot. The blood pres-
sure was 230/88. The heart showed numerous extra-
systoles and a late diastolic murmur at the apex. She
continued to take insulin and her diabetes appeared well
controlled.
Physical examination on this last and final admission
showed her temperature to be 98 degrees ; pulse, 58 per
minute; respiration, 24 per minute; and blood pressure,
210/90. She was slightly obese and was complaining of
severe lower abdominal cramps. The lungs were clear. The
heart was enlarged to the left. An early and late mid-
diastolic low-pitched blowing murmur was present at
the apex of the heart. The second pulmonic sound was
slightly accentuated. The abdomen showed a minimal
tenderness in the right upper and left lower quadrants.
Minimal tenderness was present over the left costo-
vertebral angle. The left mid-thigh amputation was
healed.
Hemoglobin was 86 per cent (Sahli). Leukocyte count
was 26,900 with 96 per cent neutrophiles and 4 per cent
lymphocytes. Urinalysis revealed two plus sugar and
numerous pus cells. The blood sugar was 515 mg. per
cent and the carbon dioxide combining power of the
blood was 62 volumes per cent. An electrocardiogram
showed auricular fibrillation and low voltage in all three
leads.
The pain persisted. On the second hospital day, she
developed a complete anuria. The blood sugar dropped
to 65 mg. per cent. The blood urea nitrogen rose from
79 mg. per cent on the third hospital day to 104 mg.
per cent on the day of death. The anuria persisted. She
became stuporous and had a convulsive seizure on the
From the Department of Pathology-, Minneapolis General Hos-
pital, A. J. Hertzog, M.D., Pathologist.
July, 1947
Fig. 1. (above) Marked atrophy of right kidney.
Fig. 2. (below) Infarction of left kidney with thrombosis of
left renal artery.
seventh hospital day. She expired a few minutes after
the convulsion.
Dr. Hertzog : This case represents a diagnostic prob-
lem. The patient was a sixty-six-year-old diabetic who
expired seven days after the onset of severe lower ab-
dominal pain. Within forty-eight hours after the onset
of pain, she developed anuria. Death was apparently the
result of uremia. Does anyone wish to make a diagnosis?
Dr. F. Gouze : We know the patient had severe arterio-
sclerosis and hypertension as well as her diabetes. The
left leg was amputated in 1945 for arteriosclerotic gan-
grene of the left foot. One naturally thinks of some
complication of arteriosclerosis such as mesenteric
thrombosis. Her heart was fibrillating so there is also
the basis for an embolic phenomenon. The cardiac
murmur suggests a mitral stenosis. The left ventricular
enlargement could be explained on the hypertension.
765
CLINICAL-PATHOLOGICAL CONFERENCES
Dr. Hertzog : The clinical picture was not that of a
mesenteric thrombosis, as she was never distended nor
showed signs of an ileus. A diabetic can develop chronic
uremia on the basis of arteriosclerosis of the kidneys.
In this case, the anuria and uremia were of sudden
onset associated with severe lower abdominal pain. Does
any one else wish to make a diagnosis?
Students : Dissecting aneurysm of the aorta. Throm-
bosis of a renal artery.
Dr. Hertzog : I think both of these are excellent sug-
gestions in view of what we found at autopsy. How are
we going to explain the anuria? Thrombosis of one
renal artery would not give you an anuria. A dissecting
aneurysm would likewise have to interrupt the blood
supply to both kidneys. She never developed the picture
of a shock. Dr. Sether will give the findings at autopsy.
Autopsy
Dr. Sether : We were naturally interested in the kid-
neys in this case. The right kidney was small and
atrophic (Fig. 1). It weighed only 20 grams. The
right renal artery showed approximately 80 per cent
reduction of its lumen by atherosclerosis. The atrophy
of the right kidney appeared to be due to arteriosclerosis
of this renal artery. However, w'e cannot completely
exclude a secondary atrophy associated with an old
pyelonephritis. The left kidney weighed 140 grams. It
had a swollen purplish red appearance. The left renal
artery was completely occluded by a thrombus which
began at the opening into the aorta. The appearance was
that of a thrombus rather than an embolus (Fig. 2). On
section of the kidney, it was completely infarcted. The
heart weighed 350 grams. There was an old rheumatic
mitral valve defect as found in mitral stenosis of a
moderate degree. A mural thrombus was found in
the left auricle. There was severe coronary sclerosis.
The abdominal aorta, as seen in the illustrations, showed
severe atherosclerosis. The pancreas showed hyaliniza-
tion of the islands of Langerhans are found in diabetes
mellitus.
The anatomical diagnosis was (1) thrombosis of left
renal artery with acute infarction of left kidney; (2)
renal arteriosclerosis with contraction and atrophy of
right kidney; (3) uremia; (4) diabetes mellitus; (5)
old rheumatic mitral valve defect; (6) mural thrombosis
of left auricle; (7) generalized arteriosclerosis; and
(8) ancient amputation of left leg.
Dr. Hertzog : The clinical picture is now explained
when we know that from a functional standpoint the
patient possessed only one kidney. When this remaining
kidney became infarcted as a result of thrombosis of
the left renal artery, she developed the pain and anuria.
DECAY OF THE FAMILY?
It is alleged that the institution of the family in
Western civilization is going on the rocks. Life maga-
zinef discusses the question editorially, pointing out that
according to Dr. Carl Zimmerman, Harvard sociologist,
“the Western family has collapsed twice before, in
Greece about 300 B.C. and in Rome about 300 A.D.,
in each case marking the decline of those states.”
Decay of the family in Greece and Rome was marked
by corruption, vanishing birth rate, demigration of par-
ents, juvenile and adult delinquency, says Life.
Certainly, accumulating statistical evidence seems to
lend weight to the warnings from many sources that
something is happening to the modern family. Such a
state of affairs should be of the gravest concern to
doctors of medicine. It is probably inevitable that as
civilizations evolve from their simpler, more rudimentary
forms to their complex maturity the diseases of indus-
trial middle age and early atomic-age senescence invade
their cells destructively. Oswald Spengler elaborated the
thesis in his Decline of the West some time ago.
If the family decays, what then becomes of the family
doctor? The ready answer would be that he becomes
the decayed-family doctor. How near to that status is
he now? If the decay of the family is marked by the
tMarch 24, 1947, p. 36.
symptoms recited in our first paragraph, should not
medical educators, medical societies, and others inter-
ested in the future of medicine, give thought to the fact
that a falling birthrate will necessitate fewer obstetricians
and pediatricians, but probably more gynecologists,
genito-urinary practitioners, and psychiatrists? The de-
cayed-family practitioner could conceivably be a combi-
nation in one person of formerly separate specialties
best calculated to make of him a decayed-family friend
and counselor. His premedical curriculum could in-
clude law, sociology, the rudiments of police work, phi-
losophy with special emphasis on Spencer and Spengler,
abnormal psychology, the rudiments of statism, with
possibly some attention to English composition.
The medical curriculum could well omit any attention
to all but a certain few infectious diseases, substitute
nuclear physics and diseases of irradiation, which may
be reasonably expected to increase as more and more
radio-active gases and other substances are released.
There you have the ideal, shortened course to produce
the decayed-family practitioner. Medicine should be
ever on the alert to be functional in its service to hu-
manity, wherever that may lead, even to the establish-
ment of the qualifications and training of decayed-family
doctors, if need be. — New York State J. Med., July 15,
1947.
766
Minnesota Medicine
Case Report
THE SURGICAL HISTORY OF A CENTENARIAN
DANIEL J. MOOS, M.D., and JOHN V. FARKAS, M.D.
Minneapolis, Minnesota
THE patient, J.F.D., aged ninety-eight years, was
first admitted .to the Minneapolis General Hospital on
August 24, 1941, with the diagnosis of strangulated right
inguinal hernia. He complained of severe pain in the
right lower abdomen of approximately twelve hours’
duration. There had been no nausea or vomiting. The
patient’s past history indicated that he had worn a truss
for bilateral inguinal hernias for many years. Two
years before admission he had suffered a mild heart at-
tack but otherwise had been in good health.
Physical examination disclosed a well-developed, well-
nourished, elderly white man suffering from severe pain
in the right groin. His teeth were in an excellent state
of preservation. The heart was enlarged to the left.
The abdomen was not distended, but there was a very
tender small mass in the right lower abdominal quadrant
over the internal inguinal ring. Considerable excoria-
tion of the skin was present in this region, due to me-
chanical irritation from a truss. The blood pressure
was 168 mm. of mercury, systolic, and 72 mm., diastolic.
The only other abnormal physical findings were a small
inguinal hernia on the left side and a hydrocele on
the right. On the day of admission the hernia was
reduced by gentle taxis without anesthesia (DJM).
The patient was observed in the hospital for a period
of three days. During this time the dermatitis of the
groin was treated locally and gradually improved.
On August 27, 1941, the patient was sent home feeling
well.
Second Admission — Age 99
The admission diagnosis one year later, on August 16,
1942, was strangulated right inguinal hernia.
The history obtained from relatives of the patient re-
vealed that the man had complained of pain in the right
side of his abdomen for four days, bad had anorexia
for several days, with no bowel movements during that
time, and had had intermittent vomiting for thirty-six
hours. Generalized abdominal tenderness, most marked
in the right lower quadrant, severe abdominal distention,
and a tender firm mass, 5 cm. in diameter, in the right
inguinal region, were noted on physical examination. His
temperature was 99° F. Laboratory studies, including
blood and urine examinations, were within normal lim-
its, save for signs of dehydration. A diagnosis of
small bowel obstruction due to strangulated right in-
guinal hernia was made, and surgical treatment was ad-
vised. With an ilio-inguinal nerve block for anesthesia
(1 per cent procaine solution), a right inguinal herniot-
omy was performed (DJM), revealing a strangulation
at the internal inguinal ring. The sac contents included
necrotic omentum, a large amount of dark serosanguin-
ous fluid, and a loop of strangulated small intestine, 14
cm. long, which on further examination proved to be
ileum. _ This was very dark in color, lacking in lustre
and without visible peristalsis. There was a subserosal
hematoma encircling the constricted portion of the intes-
tine.
The internal inguinal ring was incised to allow return
of circulation to the compromised portion of the bowel.
From the surgical service of the Minneapolis Genera! Hospital.
July, 1947
The necrotic omentum was resected. The loop of ileum
was wrapped in warm saline packs for ten minutes,
after which it began to resume a more normal appear-
ance, except for one portion, 3 cm. long and 2 cm.
wide, which improved in color but through which peri-
stalsis passed very poorly. The viability of this area
was questionable ; however, because of the extreme age
and poor condition of the patient, it was decided not to
resect the damaged bowel. As an alternate procedure
a portion of peritoneum from the hernial sac was used
as a free graft to cover the area, the peritoneum being
attached to the intestine with interrupted cotton sutures.
A modified Bassini-type repair was effected, using in-
terrupted sutures of 35 gauge stainless steel wire.
Postoperatively the patient was quite ill. His course
was complicated by marked ileus which was treated by
duodenal suction and by restoration and maintenance
of a normal fluid and electrolytic balance. On the
second postoperative day, and daily thereafter, he was
allowed to be out of bed in a chair. Signs of mild
bronchopuneumonia developed on the third day. The
temperature varied between 99° F. and 103° F. for the
first ten days following surgery, then gradually re-
turned to normal. A slight amount of purulent mate-
rial drained from the operative wound, but the incision
was completely healed at the time the patient was dis-
charged from the hospital on October 6, 1942.
Third Admission — Age 100
The admission diagnosis, seven months later, on March
15, 1943, was a possible head injury with lacerations of
the scalp.
According to the history obtained from relatives of
the patient, he had been found lying in the street in a
somewhat dazed condition, apparently having fallen on
the icy pavement. Physical examination on admission
revealed an elderly white man who had sustained a scalp
laceration 3.5 inches long in the left parietal region.
He was somewhat irrational but not unconscious. Fur-
ther examination showed a well-healed right inguinal
operative scar. The blood pressure was 148 mm. of
mercury, systolic, and 100 mm., diastolic. The pulse rate
was 100 beats per minute. Neurological examination
was negative except for signs of mild confusion. The
laceration of the scalp was cleansed and repaired under
local anesthesia (1 per cent procaine solution) with
several silk sutures. On March 18, 1943, a lumbar punc-
ture was performed. The spinal fluid was clear, color-
less, and under no increased pressure. The cell count
was normal. Roentgenograms of the skull showed no
evidence of fracture. The patient was allowed to be
ambulatory, and his clinical course appeared to be sat-
isfactory until March 20 when he complained of pain
in the left groin. Examination at that time disclosed
a tender mass, 7 cm. in diameter, in the left inguinal
region which clinically appeared to be a direct inguinal
hernia. This was irreducible using gentle taxis ; there-
fore, an emergency herniotomy was performed (JVF).
One per cent procaine solution was used for local
anesthesia. A strangulated sliding type of hernia, form-
ing a mass 6 by 8 cm., was found. The hernial sac
contained several cubic centimeters of clear yellow
767
CASE REPORT
fluid. The sliding portion of the hernia was formed by
a part of the sigmoid colon. After incision of the
constricting band at the neck of the sac, no impairment
of circulation of either the large bowel or the mesocolon
persisted. The neck of the sac was reconstructed, ligat-
ed, and the redundant portion amputated. Orchidectomy
was performed in order to obtain a more firm repair.
Interrupted cotton sutures were used throughout.
The patient was permitted to be out of bed on the
first postoperative day. On the fourth day following
surgery his temperature suddenly rose to 104° F. and
signs of left pulmonary atelectasis appeared. This was
treated by inhalation of 20 per cent concentration of
carbon dioxide gas, combined with manual chest com-
pression over the left side of the thorax. The patient
expectorated a large amount of grayish mucus, follow-
ing which his condition steadily improved and his tem-
perature receded to normal. He was allowed to be
up each day. The skin clips were removed on the
sixth postoperative day and the wound was found to
be healing by primary intention. At the time of dis-
charge on May 3, 1943, the patient was in good health.
He had no complaints, and his operative wounds were
well healed.
Fourth Admission — Age 102
The patient was admitted on October 7, 1943, to the
neurological service with a diagnosis of cerebral apo-
plexy. Physical examination revealed an elderly white
man in an unconscious state. His entire left side ex-
hibited flaccid paralysis. The blood pressure was 190/80.
Laboratory studies indicated normal blood and urine
findings. Examination of the abdomen showed bilateral,
well-healed herniorrhaphy scars, with no recurrence of
hernia. The right hydrocele was again noted.
The patient was in poor general condition during his
entire hospital stay, and his prognosis was grave. De-
spite the administration of 620,000 units of penicillin
between October 15 and October 20, for treatment of
pneumonia which had developed, his course was down-
hill, and he expired on November 27, 1945. Permission
for autopsy was not obtained. The causes of death
were: (1) encephalomalacia, right internal capsule due
to thrombosis; (2) generalized arteriosclerosis, and (3)
senility.
Summary
1. There is presented the case of a man requiring
emergency operation for strangulated inguinal hernia
on two occasions, one at the age of ninety-nine years,
the other at the age of 100.
2. Local anesthesia was the anesthetic of choice for
both procedures.
3. Early ambulation was allowed following each
herniorrhaphy.
4. Pulmonary complications followed both operations
despite early ambulation.
5. Wound healing was satisfactory.
6. The patient was observed over a period of two
years, during which time no recurrence of either hernia
was noted.
ARMY ENGINEERS TO BUILD MEDICAL CENTER
What is planned to be the greatest medical research
center in the world will be built at Forest Glen, Mary-
land, by the Corps of Engineers for the Office of The
Surgeon General, according to a recent announcement
made by Major General Raymond W. Bliss, The Sur-
geon General. In keeping with technological advances
in all fields, based on experiences in the late war, the
center will be equipped to anticipate and meet the
medical problems of the future as well as to cope with
those of the present. The initial cost is estimated at
approximately $40,000,000. Construction will be super-
vised by the District Engineer, Washington, D. C.
Engineer District.
Officially designated as the “Army Medical Research
and Graduate Teaching Center,” the project will consist
of a 1,000-bed general hospital, capable of expansion to
1,500 beds; the Army Institute of Pathology building;
the Army Medical Museum and Center Administration
building; Central Laboratory Group buildings; and the
Army Institute of Medicine and Surgery. A working
library, animal farm, quarters for the staff and other
buildings, are included in the plans.
Located just outside of Washington, the new Army
Medical Center will have the advantage of close relation-
ship to the Walter Reed General Hospital, the Naval
Medical Center, the medical schools of the District and
the proposed new Washington Medical Center, with all
of whom ideas can be interchanged. In addition, mem-
bers of the District of Columbia Medical Society, among
them some of the finest specialists in the world, and
medical experts from other Government departments,
will be available for consultation. The Center will also
co-operate with the National Bureau of Standards, the
National Institute of Health and the National Research
Council.
BIRTHS EXCEED ONE AND ONE-HALF MILLION
Births in May, 1947, are estimated to have numbered
302,000 in the United States, according to figures re-
leased by the National Office of Vital Statistics, U. S.
Public Health Service. This is 29 per cent more than the
estimate for May of last year and it brings the total for
the first five months of this year to 1,572,000.
Although the birth rate of 26.4 per 1,000 population
including the armed forces overseas for the five-month
period, January to May, 1947, was nearly 40 per cent
higher than the provisional rate of 19.1 for the cor-
responding period of 1946, the birth rate has been lower
this year than it was in the last four months of 1946
when it reached record-breaking heights. The decrease
has taken place in spite of the fact that publications
of this Office show that the number of marriages re-
768
ported ten to twelve months ago and throughout 1946
were unusually large. It is possible that the peak in
the birth rate in the latter months of 1946 was due not
only to first births to newly married couples, but also
to births to families who already had children and first
births to couples married before or during the war.
The fact that the birth rate has decreased while mar-
riages remained high suggests that now second and
third births to established families and first births to
persons married more than one year are adding less to
the birth rate than they did at the end of last year.
The estimated numbers of births in each of the forty-
six states reporting monthly and the District of Colum-
bia appear in the Monthly Vital Statistics Bulletin re-
leased by the National Office on July 9, 1947.
Minnesota Medicine
History of Medicine In Minnesota
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester, Minnesota
(Continued, from June issue )
D. N. Morse, born in New York in 1826, arrived in Chatfield in 1856 ac-
companied by his wife, Phoebe Morse, who was a native of Ohio, born in 1834.
Their son, Travers, who in 1860 was three years old, according to a census re-
port, was one of the first children born in Chatfield.
Physician and dentist, Dr. Morse was one of the earliest practitioners in Chat-
field and certainly was one of the first of any profession to place a card in the
recently established newspapers of the village, the Republican and the Democrat,
both of which printed their initial editions early in the autumn of 1856.
In the Chatfield Republican of November 22, 1856, Dr. D. N. Morse, dentist,
announced that he was one mile east of Chatfield on the La Crosse Road. In a
later issue he elaborated as follows :
D. N. Morse, Physician and Dentist, will be found at all hours except when absent on
professional business, at his office one mile from town on the La Crosse Road. Particular
attention paid to all branches of the profession of medicine and dentistry.
After 1857 Dr. Morse’s cards did not appear in either of the newspapers. His
name has not been noted in any of the available early business and professional
directories, beginning in 1865.
“Dr. Murray, President,” was the name appended to an announcement of a
meeting of the Fillmore County Eclectic Medical Society to be held on July 31,
1869, which appeared in the Preston Republican of July 23, 1869. Inasmuch as
this is the only mention of a Dr. Murray in Fillmore County that has been seen
by the writer and inasmuch as Dr. J. J . Morey (and the name in the transactions
of the society was spelled “Morrey”) was a charter member and an early officer
of the group, it is assumed that Dr. Mor(r)ey may have been the signer of the
notice ; furthermore, the two names never appeared in the same notice. The
assumption seems justified when it is remembered that in those days material sub-
mitted to the local editor probably was written in longhand, which is easily subject
to misinterpretation.
Hildus Augustinus O. Nass was born on January 8, 1872, in Winnesheik
County, Iowa, the son of H. O. Nass and Anna Nass, both of whom were natives
of Norway; his father was a farmer and storekeeper.
Hildus Nass was a pupil in the public schools of Waukon, Iowa, received
July, 1947
769
HISTORY OF MEDICINE IN MINNESOTA
his premedical instruction at the Preparatorial Department of Luther College, at
Decorah, and his medical training at the State University of Iowa, at Iowa City,
from which he was graduated on March 30, 1898. On the advice of friends who
knew the needs of the locality and the opportunities it offered, in the summer
following his graduation he settled in the village of Mabel, Fillmore County, taking
up his residence there on July 19, 1898; a month earlier, on June 16, he had ob-
tained his license to practice medicine in Minnesota. In the early days of his prac-
tice discouragement sometimes was near ; he was young and looked especially
young in comparison with the senior physicians of the vicinity, who were elderly
men ; and besides, as he had said, he was just starting and was not well known.
As it happened, when Hildus Nass was a senior medical student, he had the
privilege of assisting in the office of Dr. Walter Bierring, who was then Pro-
fessor of Pathology and Bacteriology in the medical department of the university.
Diphtheria antitoxin had been discovered and was beginning to come into use, and
Dr. Bierring recognized its merits and informed his classes. In the second autumn
after Dr. Nass had settled in Mabel, an epidemic of virulent diphtheria broke
out in the community, taking several lives. The disease struck, among others,
a family of eight children who lived southeast of Hesper, Iowa, which is just
across the state line and not far from Mabel; two of the children had died and
the remaining six were desperately ill when Dr. Nass finally was called in. To
quote him :
I immediately sent to my old friend, Dr. Walter Bierring, for diphtheria antitoxin, for it
was new and could not be picked up at any corner drug store, as now. I used the antitoxin
in all six cases and the patients all made a happy recovery. As far as I know, I was the
first to use diphtheria antitoxin in this community, and from then on I used it in other cases
with satisfactory results, not having a death from the dreaded disease.
This experience established the young physician’s name in the community and
turned the tide of practice. For forty-five years, increasingly esteemed and trusted,
Dr. Nass followed his profession in the locality of his original choice. In the
later years of his practice his own suffering from a cardiac condition influenced
him to make a specialty of the diagnosis and treatment of diseases of the heart.
He long was a member of the Fillmore County Medical Society and affiliated
county groups, the Southern Minnesota Medical Association, the Minnesota State
Medical Association and the American Medical Association.
Early in his career Hildus Nass was married to Maymie Nassie, a native of
Fillmore County, who aided him in his useful life. Dr. and Mrs. Nass were
members of the Lutheran Church of Mabel.
Dr. Nass died in Mabel on March 27, 1944, at the age of seventy-two years;
there were no surviving relatives.
D. F. O’Brien was a physician and surgeon, office one door north of the
post office, in Canton, Fillmore County, for a few months in 1883.
On April 26 the National Republican of Preston, often quoted in this series
of sketches, carried the following barbed announcement — the barb for a physician
unnamed :
Dr. D. F. O’Brien has opened an office in the village of Canton. He deserves a large
practice. He will never neglect a patient or disgrace his profession by mal practice such as
deprived Commissioner M — of the use of an arm. Dr. O’Brien’s card appears in our columns.
Call and make his acquaintance.
By August 30, 1883, Dr. O’Brien had departed to practice medicine in Ross-
ville, Allamakee County, Iowa.
770
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
Christen K. Onsgard, who was born at the farm home of his parents in
Spring Grove Township, Houston County, on April 10, 1863, was one of the
eight children of Knute Onsgard and Bergit Larson Onsgard. His sisters and
brothers were Karli, Guro, Bella, Marie, Ingeborg, Lewis and Martin. The
father and mother were natives of Hallingdahl, Norway, who had come into
Houston County in the early fifties.
In the biographical dictionary appended to notes on medical history in Houston
County (Guthrey) a sketch of Dr. Lewis K. Onsgard contains information rela-
tive to the Onsgard family and other data common to the two physician brothers
that need not be repeated in detail here.
Christen Onsgard, like his younger brother Lewis, was a pupil at the public
and parochial schools of Spring Grove and helped on the home farm. The broth-
ers, encouraged by Dr. Thore E. Jensen, of Spring Grove, who was married to
their sister Ingeborg, decided to become physicians and in 1884 they enrolled at
the Eclectic Medical Institute of Cincinnati, Ohio, the school where Dr. Jensen
had received his training. In 1887 they were graduated in the same class and
when, on June 22, 1887, they were licensed to practice in Minnesota, they re-
ceived consecutivelv numbered certificates, Christen, No. 1460 and Lewis, No.
1461.
On receiving his degree, Dr. Christen K. Onsgard returned at once to Spring
Grove to begin his medical practice. After five successful years during which
he met cheerfully the hazards of country practice of the period, he moved to
Halstad, Norman County, Minnesota. On his return to southern Minnesota six
years later, in 1899, he settled in Rushford, Fillmore County, there to practice
medicine actively for twenty-one years as an able and progressive physician and
to play his part as a responsible citizen. In 1920 he moved once more to Halstad
and there followed his profession until failing health forced his retirement in 1929.
Early in his career Christen K. Onsgard was married to Emma Louise Dokken,
an American girl of Norwegian descent, who was born in Spring Grove. Mrs.
Onsgard died in 1925 and when, in 1929, Dr. Onsgard was obliged to give up
his work, he returned to Rushford to make his home with his daughter Benora
(Mrs. Elvin Humble). Of Dr. and Mrs. Onsgard’s five children only one,
Lloyd, was living in 1942, in Halstad. Clifford died in 1906, Verna in 1912,
Vernon in 1924 and Benora in 1936.
Dr. Onsgard died in Rushford on October 21, 1929, from nephritis. He was
a faithful member of the Lutheran Church, was active in the local Masonic lodge
(A. F. and A. M.), and was identified with medical organizations: the Houston-
Fillmore County Medical Society, the Minnesota State Medical Association and
the American Medical Association.
Lewis K. Onsgard (1866-1938), for forty-six years a practicing physician
of the village of Houston, in Houston County, spent the first five years, from
1887 to 1892, of his professional life in Harmony, Fillmore County. As stated
earlier, a detailed biographical sketch of Dr. Onsgard is included in notes on the
history of medicine in Houston County.
Of Wellington Daniel Parker, Esq., who came into southern Minnesota from
the East, probably toward the end of the eighties, there has been little information
available. There is record, however, that he belonged to the regular school of
medicine, that he was licensed in the state on June 30, 1887, receiving certificate »
No. 1503 (R), which he filed in Fillmore County on December 13, 1887. For
a time he was in Spring Valley and by 1890 he was in Lanesboro. It has been
July, 1947
771
HISTORY OF MEDICINE IN MINNESOTA
recalled by an elderly resident of Lanesboro that in the middle nineties Dr.
Parker died in that village while still a young man and that during his terminal
illness his mother came from the East to see him.
James Henry Phillips, the son of parents who were natives of Tyrone County,
in the North of Ireland, was born at St. John’s, New Brunswick, on February
28, 1852. Five years later the family moved to Chicago, Illinois, where James
Henry grew up and received his education ; at one period he was employed as an
engraver. Of the other members of the family little information has been available ;
his brother William, became a big-league baseball player with the Cleveland and
Brooklyn teams between 1880 and 1890.
In 1878, immediately after his graduation from Rush Medical College, young
Dr. Phillips practiced medicine in Chicago for a short time, but in June of that
year he was establishing himself in Fillmore County, Minnesota, in the village of
Wykoff, Fillmore Township, and in the following August he went briefly to
Chicago to be married to Alice Van Osdel, of that city. Dr. and Mrs. Phillips
had two children, John and Lucia, who were born in Wykoff.
Wykoff, in the seventies and early eighties, was a thriving, incorporated village,
on the Southern Minnesota Railroad and connected by tri-weekly and weekly
stages with the settlement of Fillmore and Watson Creek, respectively. There
were mills of various sorts, hotels, wagon shops and machine shops, a German
newspaper, two churches and several stores. Dr. Phillips, in addition to practicing
medicine, operated a drug store, at first in association with Mr. Jorris and later
with Dr. Calvin H. Robbins, with whom he had entered partnership in medical
practice. Dr. Robbins, twelve years older than Dr. Phillips, had been in the county,
boy and man, since 1859, in medical practice since 1866, and in Wykoff since 1875.
By late 1884 Dr. Phillips had moved from Wykoff to Preston, because of
better opportunity, and in that village he spent the next eighteen years. There
his chief medical contemporaries before the turn of the century were George A.
Love, Henry Jones and Lyman Viall ; in 1900 and 1901 came William D. M.
Beadie and Wendell B. Grinnell.
Throughout his residence in the county Dr. Phillips shared in medical affairs.
Beginning in January, 1880, he was county coroner for seven successive years,
and from 1892 to 1895 he again held the office. After the “Diploma Law” of
1883 was passed, he received license No. 551 (R), given on December 31, 1883.
In 1886 he was a member, with Dr. Love and Dr. Robbins, of the newly created
medical examining board of the Bureau of Pensions of Fillmore County. At the
annual meeting of the Minnesota State Medical Association, at St. Paul on June
19, 1890, he was elected to membership and there is record of his attendance at
meetings thereafter and of his serving on the Committee on Necrology in 1893.
In 1904 his name appeared on the roster of the new Houston-Fillmore County
Medical Society.
As a public servant in civic capacity he played a useful role as well, serving
several terms as mayor of Preston and many years as a member of the board of
education. In 1887 he was a member of the village council. In 1889 he was
a representative from his district to the state legislature. He was a member of the
Presbyterian Church and of various fraternal organizations, among them the
Masons (A. F. and A. M.) and the Benevolent and Protective Order of Elks.
In the early eighties Alice Van Osdel Phillips died, and in 1888 Dr. Phillips
was married to Carrie Conkey, of Preston. Of this marriage there were three
children : Delia, who died in infancy, William Conkey and Elizabeth.
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A capable and honest physician — his son William has described him as being
too honest and too articulate to be very popular — James H. Phillips was also
a man of cultural background and formed literary taste, as reflected by his ex-
cellent and extensive library. The son, before he had finished high school, had
read most of his college English courses from the books on his father’s shelves.
From Preston Dr. Phillips moved in 1912 to Westlock, Alberta, Canada, where
he carried on an arduous practice; members of his family have said that his death,
on August 21, 1921, was the result of overwork. In 1943 there were living of the
family : Mrs. Phillips, making her home with the daughter, Elizabeth Phillips
(Mrs. L. M.) Pernell, in Dubuque, Iowa, and the son, William Conkey Phillips,
of International Falls, Minnesota. John and Lucia, children of the first marriage,
had died many years previously, as had the members of the original family group
in Chicago.
Horace W. Pickett, a son of David Pickett, was born on July 5, 1822, in
Washington County, New York, as were his older brothers, William, Edwin and
Joseph. When the sons were young men they moved from New York with their
father to become pioneer settlers near South Bend, Indiana.
Horace Pickett obtained his medical education at Utica, Oneida County, New
York, where his uncle, Daniel Pickett, was a professor. In 1855 or perhaps a
year later, then a practicing physician, he came from New York into Minnesota
with his wife, Christiana L. Pickett, to the village of Carimona, Carimona Town-
ship, Fillmore County, following by several years his father and his brothers,
William, Edwin, Joseph and, probably, Philo and Alonzo and his sisters, Nancy
and Lorissa. The Picketts were the first settlers of Carimona ; indeed, it was Dr.
William C. Pickett who platted the settlement and founded it on his own land.
Of the little colony Edwin Pickett returned to Indiana before 1862 but later
came back to Minnesota to live, a fact which the following paragraph in the
Preston Republican of June 28, 1862, gave presage: “An early settler, Edwin
Pickett, Esq., one of the first settlers of this county, called on us the other day.
He was looking well. At the present time he resides at South Bend, Indiana.
He informs us that he prefers Minnesota to that state as a place of residence.
He was a good citizen when here and his loss was felt when he left.”
In Carimona and the surrounding community, Dr. Horace W. Pickett for
many years practiced medicine and took part in civic and educational affairs of
the community. An able and progressive physician, he was one of the charter
members of the Fillmore County Medical Society, in 1866, and he otherwise con-
tributed to the improvement of medical practice in spite of the fact that he was,
as one of his nephews has said, so decided in his opinions that he antagonized
people and lost their patronage. On an occasion when he had been, called on a
confinement case and arrived to find a midwife trying to make an instrumental
delivery by means of a long pair of scissors, it would seem that a decided opinion
was justified.
In the late winter of 1883 and 1884 Dr. and Mrs. Pickett disposed of their
home in Carimona and removed to Welsh, Louisiana, in order to be near their
only child, Lillie, who recently had been married to W. B. St. John of that place.
Seventeen years later Mrs. Pickett died in Louisiana. Wishing to be once more
with those of his father’s name, Dr. Pickett, in the spring of 1901, old and frail
though he was, traveled alone to Minnesota. He became ill en route, and on the
day after his arrival in his pioneer home his death occurred. He was buried in
Carimona Cemetery where are the graves of his old friends and of his own people:
his father and mother, a sister and four brothers.
July, 1947
773
HISTORY OF MEDICINE IN MINNESOTA
William Cowan Pickett, born on November 28, 1818, in Washington County,
New York, was the son of Mr. and Mrs. David Pickett and the brother of Edwin,
Joseph, Horace, Philo and Alonzo, and Nancy and Lorissa Pickett. Where he
obtained his medical training has not been learned, but inasmuch as his brother
Horace W. Pickett, studied at Utica, New York, where Daniel Pickett, an uncle
of the brothers, was on a teaching staff, perhaps William C. Pickett also was a
medical student there.
When he was a young man and already a qualified physician, William Pickett
emigrated with the family from New York to Indiana and settled with them near
South Bend. On the outbreak of the War with Mexico (1846-1848) he enlisted
for military service and was appointed a surgeon in the United States Army.
After the war, bound on a new venture in pioneering, in the autumn of 1852
he traveled from South Bend by ox wagon with two of his brothers, Edwin and
Joseph, and another young man into southeastern Minnesota Territory. They
came with the view of making permanent homes, and in what was soon to be
Fillmore County (March 5, 1853) they found conditions to their liking. When in
a few weeks they returned to Indiana, it was to spend the winter disposing of
their local property and completing preparations for their trek to Minnesota in
the following spring. “On June 1, 1853, conditions being right for the maintenance
of their stock on the long trip across the prairies,” one of Dr. Pickett’s nieces
has written, “ a company of four of the Pickett families (the households of David,
Edwin, Joseph and William) who wished to remain together came back to the
place where the three brothers had set their stakes the fall before.” They were
three weeks on the way.
William Pickett was accompanied by his young wife, Phoebe Means Pickett.
On July 4, 1853, in the new settlement in Fillmore County, Dorso Leon Pickett
was born, their first son and the first white child born in the community. In the
next few years Dr. and Mrs. Pickett became the parents of two more children,
Ida, born in 1854, and Ives, in 1859.
As soon as the land was opened for pre-emption, Dr. Pickett took a claim
with his brother Edwin and laid out the village of Wahpeton. He evidenced his
confidence in the site and the prospects by building as soon as he could a roomy,
comfortable stone house as a home for his family. Owing to a clerical error the
name of the post office was recorded as “Warpeton the settlers rejected this
misnomer and chose still another Indian name, that of Chief Carimona (translated,
The Walking Turtle), which duly was recorded. Before the change was made,
however, W. C. Pickett served as sheriff of “Warpeton Precinct,” in 1854. For
a time at Carimona Dr. Pickett did a flourishing real estate business, in the conduct
of which, being an ethical man and, like his brother Horace, of decided opinions,
he refused to sell a lot to any one who proposed to dispense alcoholic liquor. In
addition to founding a village, he was at the same time efficiently running a saw-
mill, operating a blacksmith shop with Joseph Pickett and a flourmill with H.
Johnson, and was practicing medicine reliably.
Dr. Pickett’s medical practice extended over a wide territory. Settlers were few
and scattered; there were only thirteen families in the county on January 1,
1854, and on that date, it has been noted incidentally, William C. Pickett and
Daniel (David?) Pickett were possessors of land in township 102, range 11;
also that in the spring of 1854 “preaching” was held in the home of David Pickett.
Perhaps the first practicing physician to settle within the borders of the present
Fillmore County, Dr. Pickett certainly was one of the first six physicians, with
Dr. Nelson W. Allen and Dr. Augustus H. Trow, of Chatfield, Dr. J. Early, of
774
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HISTORY OF MEDICINE IN MINNESOTA
Spring Valley, and Dr. Erastus Belden and his son Dr. Wallace P. Belden, of
Hamilton and Spring Valley, all of whom are said to have come in 1853.
A good citizen, versatile and public-spirited, Dr. Pickett was active in civic
affairs and local politics. Although in 1857 he was defeated for the office of
county coroner, he was, in 1858, overseer of the poor and, from January 4,
1858, to January 4, 1860, he served as judge of probate court of Fillmore County
and for the same two years as county sheriff. With regard to one of his less happy
experiences as candidate for sheriff, the friendly Chat field Democrat on October
9, 1858, stated with some bitterness :
The Black Republican Party claim to be “the friends of free discussion,” but have a poor
way of showing it. Dr. W. C. Pickett, our indefatigable and worthy candidate for sheriff,
in a discussion at Spring Valley a few days ago, was hissed and insulted in a manner worthy
only of a crowd of “Negro worshippers,” by Black Republicans present. This is free dis-
cussion with a vengeance.
In the late sixties Dr. Pickett left Carimona and the state. Carimona, his
pride, was not to become the city of his dreams. Once the most promising village
in the county, the county seat from March 20, 1855, to April 26, 1856, a key
point on the thronging stage route from Galena and Dubuque to St. Paul and
famed for its hostelry, the Carimona House, in the late sixties the village was
left a few miles to the south by the Southern Minnesota Railroad. It was then
that Dr. Pickett moved to Illinois, where he spent the remainder of his life.
M. G. Pingree first announced himself in Spring Valley, Fillmore County,
as far as the writer has been able to learn, in the issue of August 11, 1870, of the
local newspaper, Western Progress, and he was then in partnership with Dr. J. J.
Morey, office in the Rogers Drug Store, the notice being dated as of June 22, 1870.
By August 24 of that summer these physicians and surgeons were publishing
separate announcements. Dr. Pingree, still in the Rogers Drug Store, stated that
specialty was made of treatment of diseases of the eye and ear.
On August 25, 1870, there was announced the marriage of Dr. Pingree to
Miss Frances E. Terrill, of Bath, New York, the ceremony having been performed
by the Reverend N. C. Chapin ; the editor, in the manner of country editors of
the day, expressed affable if robust congratulations.
In January, 1871, Dr. Pingree expanded his professional announcement by
informing the public that he was prepared to treat all chronic diseases of the eye
and ear according to the most approved system, three years’ practice in the Phila-
delphia hospitals (he stated) being sufficient guarantee of experience.
Whether or not the position of the space allotted was of significance, these
cards or notices of Dr. Pingree appeared for many months in a different part of
Western Progress from the cards of the other physicians of the village. Finally
his name appeared in the same column as the names of his colleagues, but at the
bottom, and by gradual degrees ascended to the top. By September, 1872, Dr.
Pingree was calling himself an eclectic physician; by March, 1873, his name
ceased to appear.
(To be continued in the August issue)
TUBERCULOSIS IN MINNESOTA
Throughout territorial days and for approximately the first quarter of a century of state-
hood, the climate of Minnesota was widely advertised as possessing curative value for those
who suffered from consumption. Therefore, large numbers of families with one or more
members suffering from tuberculosis migrated to this area. Thus in some .years 15 per cent
or more of deaths from all causes were reported to have been due to tuberculosis. It was
this disease more than any other which caused the Minnesota State Medical Association to
arrange for a State Board of Health in 1872. This was the third such board in the nation.
Early in the present century, moreover, efforts of members of the State Medical Association
brought about construction of sanatoriums in various parts of Minnesota. Minnesota phy-
sicians also supported the veterinarians in control of bovine tuberculosis. In 1895 those who
sold milk in Minneapolis were required to have a license, which was not issued unless all
their cows had been tested with tuberculin. This was the first city in the nation to make
such a requirement. In 1923 the eradication of bovine tuberculosis was placed on a state-
wide basis and Minnesota achieved a modified accredited rating in 1935.
These measures resulted in a decrease of mortality, of morbidity, and of infection attack
rate from year to year. Through the educational campaign of the Minnesota Public Health
Association and its component societies, people became so well informed concerning this dis-
ease that a state-wide attack by the Minnesota State Medical Association became feasible.
Therefore, in 1940, a program was organized by the committee on tuberculosis of the Min-
nesota State Medical Association. Every county and district medical society appointed a
committee on tuberculosis. The physicians of Meeker County were the first as a society,
in the nation, to develop an effective tuberculosis control demonstration. The results of the
work of this society and its allies are reported in the June issue of Minnesota Medicine.
Physicians of McLeod County were second to undertake such a program. Other counties,
such as Dakota and Steele, have conducted extensive chest surveys.
The idea evolved of accrediting whole counties, somewhat after the method of veterinarians,
but on the basis of tuberculosis control among human beings. In 1941, Lincoln County was
the first to be accredited, and now twelve counties are accredited. Next came the idea of
certifying schools with reference to tuberculosis control programs in progress. Approximately
500 schools have already been certified.
The members of the State Committee on Tuberculosis have manifested concern over the
counties within which are the three largest cities of the state; namely, St. Louis, Ramsey
and Hennepin counties, where there is the greatest concentration of tuberculosis in the state.
The physicians of St. Louis County, a few years ago, offered photofluorographic inspection
of the chest to its entire citizenry of slightly more than 200,000. Already more than half
of the citizens have responded. In Hennepin County the Medical Society has received enough
support and aid from the Division of Tuberculosis Control of the United States Public
Health Service to conduct a city-wide chest survey in Minneapolis. This began early in
May, 1947, and 400,000 citizens more than fifteen years of age are being offered photo-
fluorographic inspection of their chests. This is the largest survey of its kind that has ever
been undertaken in the United States. In the June issue of Minnesota Medicine appears a
comprehensive article on such survey work by H. E. Hilleboe, formerly Director of the
Tuberculosis Control Division of the United States Public Health Service, and now Assistant
Surgeon General. A city-wide chest survey is being contemplated in Saint Paul by the Ramsey
County Medical Society.
Tn the August, 1946, issue of Minnesota Medicine, the State Committee on Tuberculosis
published what it considers an ideal program for any county or district medical society. For
many years the ideal program has been in effect in most of the ten counties served by the
Southwestern Minnesota Sanatorium and the four counties in the Riverside Sanatorium dis-
trict. Recently, in the Riverside Sanatorium district, tuberculosis was found to have been
completely eradicated in 219 schools.
The State Board of Health is co-operating splendidly in the program of the State Medical
Association. Any county or district medical society is free to request assistance from the
State Department of Health.
In 1918 there were more than 2,500 deaths from tuberculosis in Minnesota, but only 628
in 1945. Already the Committee on Tuberculosis is about to abandon the word control and
substitute eradication.
President, Minnesota State Medical Association
776
Minnesota Medicine
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
STATE MEETING A SUCCESS
THE ANNUAL MEETING held in Duluth,
June 30 and July 1 and 2 was a great suc-
cess from the standpoint of scientific interest and
attendance.
The Southern Minnesota Medical Association
prize for the best scientific exhibit by individ-
uals went to Dr. Arthur H. Wells and Dr. Har-
old H. Joffe for their pathological anatomy ex-
hibit, with honorable mention going to Dr. Wil-
liam V. Knoll for his kodachrome trasparencies
of pathological specimens. The exhibits by the
Mayo Foundation and Mayo Clinic were out-
standing.
The total registration was 2,494, of which 1,099
were physicians and 333 were Woman’s Auxil-
iary members.
The following officers for 1948 were elected :
President: Archibald E. Cardie, Minneapolis
First Vice President: J. R. Manley, Duluth
Second Vice President: G. I. Badeaux, Brainerd
Secretary: B. B. Souster, Saint Paul (re-elected)
Treasurer: W. H. Condit, Minneapolis (re-elected)
Speaker of the House of Delegates: C. G. Sheppard,
Hutchinson
Vice Speaker: Haddon Carryer, Rochester
Chairman of Council: Frank J. Elias, Duluth
Councilor of Third District: L. G. Smith, Montevi-
deo
Councilor of Sixth District (to fill the unexpired term
of A. E. Cardie): O. J. Campbell, Minneapolis
The 1948 State Medical Association meeting
will be held in Minneapolis.
LABORATORY ABUSE
HE TEACHING of medicine as conducted
today in the average medical school has
brought forth a crop of young physicians who
seem to depend too much on laboratory proce-
dures. Much of the bedside teaching in these
schools has drifted into the dialectics of mechan-
ised and biochemical data. The rapid strides in
biochemical studies, the extension of mechanical
procedures in contrast to the good history and
physical examination, has crowded out clinical
perception arid dulled clinical judgment.
We must- reverse this tendency and insist on a
good analysis of a history and a physical exami-
nation before any laboratory investigations are
done.
Thirty years ago, a wise clinician, noting the
advent of the x-ray, electrocardiography and
biochemical studies as applied to clinical medi-
cine, made the pronouncement that all the aid
of mechanical means and biochemical procedures
has not shortened by one minute the making of
a good clinician. No one decries the value of these
laboratory' methods or their growth. One does
decry their unstinted use, particularly in the
private hospital and office. The tendency of to-
day, by the excessive expense of these laboratory
techniques, is to “kill the goose that laid the
golden egg.” In fact, therein alone lies the only
reasonable justification for those who advocate
some form of the much tossed about shibboleth,
“socialized medicine.” To that thought we might
add, laboratory technology is going to increase
and its clinical application is going to multiply,
which means that the necessity and justification
of endowed laboratories to cushion the expense
is obvious. A practical example of this type of
cushion is the State Board of Health Laborato-
ries.
THE NATIONAL FOUNDATION FOR
INFANTILE PARALYSIS
GAIN during these summer months out-
breaks of poliomyelitis are making their ap-
pearance in many sections of the country. Last
year 25,191 cases occurred in the nation, 2,882
of them in Minnesota. No one can forecast how
many cases will occur this year or how badly the
communities in this area will be affected. Medical
science, unfortunately, cannot as yet prevent an
epidemic or even one case.
Physicians in this area, as well as elsewhere,
are aware of the multitude of problems polio-
myelitis presents. Treatment of the disease is
likely to be prolonged and extremely costly, re-
quiring the services of many specialists. Too
often the patient’s family looks to the physician
July, 1947
777
EDITORIAL
for advice and guidance far beyond the imme-
diate problem of medical care.
In times such as these, it is helpful to physicians
to know that there are others prepared to share
these troublesome burdens. In addition to making
possible epidemic aid, education, and scientific re-
search, the National Foundation for Infantile
Paralysis is pledged to assist financially those
patients who require such help. Through their
generous contributions to the March of Dimes,
the American people have made this possible.
Hospital bills, salaries for physical therapists and
nurses, purchase of special equipment, and the
many other charges which may comprise the es-
sentials of good medical care may be paid for by
the chapters of the National Foundation when
necessary. Local chapters of the National Foun-
dation are scattered throughout the United States.
There is one in or near your own community.
Your local health officer can furnish you with the
address of the chapter nearest you.
Physicians serve on the local chapter’s Medical
Advisory Committee, guiding the chapter in de-
veloping medical care programs and solving allied
problems. Physicians are urged to co-operate
with the nearest National Foundation Chapter.
Notify the chapter when a poliomyelitis patient
comes under your supervision. Make certain that
the family of your patient knows of the chapter’s
existence and willingness to assist. By so doing
you will be performing an essential service to your
patient and relieving yourself of many unneces-
sary burdens. E j. Simons, M.D. '
FOLIC ACID IN PERNICIOUS ANEMIA
TT 7TTH the discovery and synthesis of folic
^ * acid and its availability for the therapeutic
use, the question arises whether the use of liver in
the treatment of pernicious anemia should be
abandoned and folic acid substituted. The answer
is no ; and the reason is that a certain number
of patients suffering from pernicious anemia will
develop neurologic symptoms when treated with
folic acid alone.
Folic acid or pteroyl glutamic acid has been
obtained from yeast and liver and can now be
synthesized. It has been shown to be identical
with liver L casei or norite eluate factor, vitamin
M, and Vitamin Be. These various preparations
were shown to be of value in the prevention and
treatment of anemia in chicks and monkeys.
There is no doubt that folic acid is effective in
producing remissions in pernicious anemia similar
to those obtained by liver. That the folic acid con-
tent of liver preparations is not the sole anti-
anemic factor in liver extract is shown by the
fact that folic acid in the dosage contained in ef-
fective liver extract is not sufficient to cause re-
missions in pernicious anemia. If folic acid is
used in the treatment of pernicious anemia, the
use of liver extract is also advised, or the patient
should be watched closely for the development
of neurologic symptoms. That being the case,
no economy is obtained for the patient through
elimination of professional visits. The main rea-
son, however, for not substituting folic acid for
liver extract is, as was stated, that a certain num-
ber of patients with pernicious anemia will develop
subacute combined sclerosis if treated with folic
acid alone. In the presence of neurologic involve-
ment, folic acid is not effective, whereas liver
extract in large dosage has definite value.
LEMON JUICE AND TEETH
f I 'HE announcement by Stafne and Lovestedt*
that the excessive use of lemon juice may be
harmful to the teeth was undoubtedly a new idea
to most dentists as well as physicians. Accord-
ing to their observations, lemon juice can cause
a distinct loss of enamel structure of the teeth
as shown by a hypersensitivity of the teeth to
thermal changes — absence of stain lines, defects
in the enamel which have usually rounded mar-
gins in contrast to the sharp margins produced by
wear, and the projection of fillings above the tooth
surface. Ordinarily, the tooth and filling wear
down equally so that a projection of a filling sug-
gests tooth destruction beyond nerve wear.
Lemon juice is rich in Vitamin C as everyone
knows, and its value in preventing scurvy among
mariners was early discovered and utilized. It has
been used to some extent in reducing diets, for
rheumatism, constipation, and colds where its
value is open to considerable question. Children
frequently suck lemons, and the authors have
observed individuals who have suffered defects
in the labial surfaces of tbe upper teeth as a re-
sult of this habit.
The observation that excessive use of lemon
juice can be detrimental to tbe teeth — perhaps
*Stafne, Edward C., and Lovestedt, Stanley A. : Dissolution
of substance of teeth by lemon juice. Proc. Staff Meetings
Mayo Clinic, 22:81, (March 5) 1947.
778
Minnesota Medicine
EDITORIAL
more often in individuals who have less buffer
action in the saliva — is one that should be borne
in mind and doubtless can be confirmed. Because
lemon juice in excess may be injurious to the
teeth is, of course, no reason for eliminating it
from the diet and thus sacrificing its valuable con-
tent of Vitamin C.
THE MAYO MEMORIAL
T HE increased cost of construction has made
necessary a substantial increase in the goal
set for the construction of the proposed Mayo
Memorial on the University of Minnesota medi-
cal campus, bringing the total to $3,000,000.
The State Legislature appropriated $750,000 in
1945 for the Memorial, an an additional $1,160,-
000 had been subscribed by corporations and in-
dividuals. In view of increased cost of construc-
tion, the last Legislature made a second ap-
propriation of $750,000 contingent upon the rais-
ing of a like amount by private subscription.
This meant that the Mayo Memorial Committee
had to raise an additional $340,000, if the original
undertaking was to be carried through. Some
$90,000 of this $340,000 had been raised by the
middle of July.
For clarity’s sake, it might be mentioned that
the original Memorial has been enlarged to in-
clude the School of Public Health, the Medical
Library, and the Cancer Research Institute, funds
for all of which are being provided from other
sources. This unification in one building will
effect eventual economy in operation.
It would be unfortunate if the original scope
of the Memorial would have to be curtailed be-
cause of lack of funds. The committee in charge
is making every effort to raise the last $250,000
needed and is asking non-contributors for assist-
ance in addition to requesting increases from
those who have already contributed, wherever
possible.
Checks should be made payable to the Mayo
Memorial Fund and should be sent to 63 South
Robert Street, Saint Paul 1, Minnesota.
BOND-A-MONTH PLAN
HP HE Treasury Department has devised an
easy savings plan which in its simplicity should
appeal to the physician. All he does is to sign
a card at his bank authorizing the bank to pur-
chase each month a Savings Bond for $37.50,
$75, $150 or $300 and deduct the corresponding
amount from his bank balance. He receives the
bond each month and all he has to do after sign-
ing the card is to place the bond in his safety
deposit box. It is rather surprising how much
can be saved in ten years by this method. A $37.50
bond purchased each month will amount to $4,998
in ten years; a $300 bond a month, $39,984 in
the same period.
The U. S. Department of Commerce has con-
ducted studies of physicians’ incomes and has
shown that, on the average, the age period from
thirty-five to fifty-four is the money-making pe-
riod in the physician’s career. The peak is reached
in the early fifties and begins to decline at the age
of fifty-four. Few physicians have the time to
study investments, and even professional advice
on the subject is notoriously unreliable. This
bond-a-month plan furnishes a 30 per cent in-
crease in the savings over the ten-year period in
as guilt-edge securities as are obtainable. Phy-
sicians are not covered by social security nor
other retirement plans and so are forced to pro-
vide for their own needs in their declining years.
The bond-a-month plan recommends itself.
POLIOMYELITIS VIRUS IN SECRETIONS
OF NOSE AND THROAT
Poliomyelitis virus has been demonstrated in material
expelled from the mouth (or nose) of two patients out
of nineteen studied. This was achieved by having patients
blow or spit into cloth masks from which virus was ex-
tracted. Virus was also detected in nasal swabs of the
first patient and pharyngeal swabs of the second patient
shown to have eliminated virus from the nose or mouth.
Certain implications of these findings have been discussed.
It is to be emphasized that their epidemiological signifi-
cance or insignificance is yet to be determined.
Ward. Robert, and Walkers, Burrill : The elimination of polio-
myelitis virus from the human mouth and nose. Bull. Johns
Hopkins Hosp., 80:98-106, (J-an.) 1947.
GENERAL PRINCIPLES IN THE
TREATMENT OF PEPTIC ULCER
(Continued from Page 744)
12. Linn, R. K. S., and Ammon, S. E. : “Gastrin” content
of human pyloric mucous membrane. Brit. J. Exper. Path.,
4:27-29 1923.
13. Mann, F. C.: Eusterman, G. A., and Balfour, D. C. : The
Stomach and Duodenum. P. 57. Philadelphia: W. B.
Saunders Co., 1936.
14. Palmer, W. L. : Peptic ulcer and gastric secretion. Arch.
Surg., 44:452-472, 1942.
15. Quigley, J. P. ; Einsel, I. H., and Meschan, I. : Some
effects produced in the normal stomach by the ingestion of
moderate and massive quantities of aluminum hydroxide.
J. Lab. & Clin. Med., 24:485, 1939.
16. Roberts, W. M.: Effect of oils on gastric secretion and
motility. Quart. J. Med., 24:133-152, 1931.
17. Varco, R. L.; Code, C. F. ; Walpole, S. H., and Wangen-
steen, O. H.: Duodenal ulcer formation in the dog by in-
tramuscular injections of a histamine beeswax mixture. Am.
J. Physiol., 133:475, 1941.
18. Walters, W. W., and Butt, H. R.: Management of ulcers
among Naval personnel. Ann. Surg., 118:489-498, 1943.
779
July, 1947
DOCTOR CHESLEY HONORED
The following citation was awarded Dr. A. J.
Chesley,, secretary and executive officer of the Minne-
sota State Board of Health since 1921, on the occasion
of the presentation to him of an Honorary Life Mem-
bership by the American Social Hygiene Association.
The citation gives a resume of his busy career.
Dr. Chesley has been largely instrumental in making
the Minnesota State Board of Health one of the most
efficient organizations of its type in the country. His
co-operation at all times with the medical profession of
the state has been outstanding.
Albert J. Chesley, M.D.
One way of measuring a man’s worth is to consider
what the history of his times and the setting of his life
might have become without his influence. This method,
like any other ordinary yardstick which one might try
to apply to the subject of these remarks, will not do in
his case. It is clearly impossible for those who have
known and worked with Dr. Chesley through the years
to visualize the scene without him. It would be even
more preposterous to attempt any speculation as to what
might have happened differently had he not been there.
There is no room for hypothesis. He was always there.
Usually ahead of the rest of us.
For example, take his connections with the State of
Minnesota. He was born in Minnesota (September 12,
1877, say the excellent vital statistic records of that
state) ; he was educated in Minnesota (Doctor of Medi-
cine, University of Minnesota, 1907) ; he got his first job
in Minnesota with the State Board of Health (assistant
bacteriologist was the first full-time assignment, but he
had worked in the state laboratory all the way through
medical school, from 1902) ; he has worked for the same
boss ever since, having been secretary and executive
officer of the State Board since 1921. For twenty years,
from 1925 to 1945, he was professor of public health in
the State University’s Department of Preventive Medi-
cine. He married a Minnesota girl (another M.D.,
Placida Gardner, in 1920), and their daughter Louise is
Minnesota-born and trained.
Nobody could very well think of health in Minnesota’s
last forty years without Chesley there.
Or consider his part in the affairs of the Conference
of State and Provincial Health Authorities of North
America. For more than a third of the history of this
sixty- three-year-old organization, founded in 1884 to
serve as a clearing-house and policy-planning agent for
official public health activities in the United States and
Canada, Dr. Chesley has been the king-pin. He became
Conference president in 1924, served until 1927, and for
the next twenty years was secretary-treasurer, 1946 be-
ing the first year he has succeeded in getting his annual
resignation accepted. It would be hard to picture Con-
ference matters during this quarter-century, which com-
passed the problems of World War I’s postwar period,
a major economic depression, and a second World War —
without Chesley’s hand among those on the helm.
Chesley knew war from first-hand experience. He was
twenty-one when he enlisted in the Thirteenth Minnesota
Volunteer Infantry, which saw service during 1898-99 in
the Spanish-American War and the Philippine Insurrec-
tion. In 1918-19 he went to France as public health
Albert J. Chesley, M.D.
expert for the American Red Cross, and in 1919-20 he
served in Poland as chief of staff for the ARC Com-
mission. In 1940, when Minnesota’s vast park areas
were selected as the scene of the first National Guard
maneuvers in the defense program, Chesley was there
again, planning months ahead of the mobilization date
for the welfare and health protection of the Guardsmen
during their stay in the State of Lakes. Calling on the
American Social Hygiene Association for advice, he
set up a plan which involved patrols by the State Police,
careful inspection by state authorities of applications for
cottage and trailer-camp permits in the camp regions,
and other safeguards against the invasion of camp-
followers and the venereal disease infections they are
prone to spread. The results of this preparation were
summarized in a letter from the Corps Surgeon in
Charge of Medical Services during the maneuvers,
which said, in part : “There was no undue prevalence
of any type of communicable disease; and further, since
the completion of the maneuvers, with the return of
regular Army troops to home stations and the demobili-
zation of the National Guard troops back to civilian
status, there has been no report to this office of venereal
infection . . .”
The Chesley program of planning ahead, seeing the job
through, and measuring results is well-shown by Min-
nesota’s social hygiene work developed under his direc-
tion. Trained in bacteriology, and epidemiology, and
having served in both those departments of the State
Board of Health, he early saw the dangers and the
opportunities in venereal disease control and prevention.
7«0
Minnesota Medicine
METOPON HYDROCHORIDE
In 1914 he was appointed director of the Board’s newly
created Bureau of Preventable Diseases, and in 1917,
when the State of California appropriated funds to set
up a war emergency social hygiene program and bor-
rowed Dr. Harry G. Irvine of Minnesota to direct it,
Dr. Chesley gave every assistance to the development
of the project. In 1917 he secured a Commission in
his own state and arranged for the return of Dr. Irvine
as Minnesota’s State Director of Venereal Disease Con-
trol. Dr. Irvine is still there, and in a characteristic dis-
claimer of personal credit, Dr. Chesley says of the
Minnesota program : “Irvine has been responsible for
it through World Wars I and II, and in the years
between, with emphasis right along on the positive
aspects of social hygiene, education, through courses in
high schools and colleges in anatomy, ethics and sociol-
ogy. A series of teaching units for use in high schools
will be published in 1947.”
Minnesota was one of the states showing the smallest
proportion of venereal disease infections — less than seven
per thousand men — among Selective Service candidates
in World War II, and as in other states having long-
range social hygiene educational programs, it is believed
that this preventive campaign had much to do with this
fine health record.
After assigning due credit to his efficient staff in other
fields as well as in social hygiene, there seems to be
plenty left over for the chief, according to competent
judges. The pioneer American Child Health Association
held him a member of its Board of Directors. The
American Public Health Association, of which he is a
fellow, elected him president in 1930. He has served on
the Board of Scientific Directors of the Rockefeller
Foundation’s International Health Division. He is an
Honorary Fellow of Britain’s Royal Sanitary Institute.
The American Medical Association (he is a Fellow)
values him as a member of its Joint Committee with
the National Education Association on Health Problems
in Education. He is a member of various professional
organizations, including the Hennepin County Medical
Society, the Minnesota State Medical Association, the
Association of Military Surgeons of the United States
and the American Epidemiological Society, and of
groups such as the National Society for Prevention of
Blindness, the Veterans of Foreign Wars, the Order of
Masons, Nu Sigma Nu Fraternity, and the American
Social Hygiene Association. For the latter organization
he has served as 'a member of the Board of Directors,
a vice president, and on various special and standing
committees, being at present a member of the committee
on nominations.
These contributions as they stand could well serve as
a basis for Dr. Chesley’s election by the Association’s
1947 Committee on Awards as an Honorary Life Mem-
ber, and the Committee takes pleasure in setting down
the facts. But quite aside from noting social hygiene
co-operation and achievement, we desire to record here,
on behalf of the many who share his friendship, a warm
affection for and a deep appreciation of a stout-hearted
fellow-worker in whom idealism, humor, common-sense
and wisdom are equally measured and well mixed for
the benefit of all with whom he has to do.
METOPON HYDROCHLORIDE
(MethyldihYdromorphinone Hydrochloride)
In 1929 with the funds provided by the Rockefeller
Foundation, the National Research Council, through its
Committee on Drug Addiction, undertook a co-ordinated
program to study drug addiction and search for a non-
addicting analgesic comparable to morphine. The prin-
cipal participating organizations were the Universities
of Virginia and Michigan, the United States Public
Health Service, the Treasury Department’s Bureau of
Narcotics, and the Health Department of the State of
Massachusetts, which brought together chemical, phar-
macological and clinical facilities for the purposes of the
study. Metopon is one of the many compounds made
and studied in this co-ordinated effort.
Chemically Metopon is a morphine derivative; phar-
macologically it is qualitatively like morphine even to
the properties of tolerance and addiction liability. Chemi-
cally Metopon differs from morphine in three particulars :
one double bond of the phenathrene nucleus has been
reduced by hydrogenation; the alcoholic hydroxyl has
been replaced by oxygen ; and a new substituent, a
methyl group has been attached to the phenanthrene
nucleus. Studies made thus far indicate that pharma-
cologically Metopon differs from morphine quantitatively
in all of its important actions : its analgesic effectiveness
is at least double and its duration of action is about
equal to that of morphine ; it is nearly devoid of emetic
action ; tolerance to it appears to develop more slowly
and to disappear more quickly, and physical dependence
builds up more slowly than with morphine ; therapeutic
analgesic doses produce little or no respiratory depres-
sion and much less mental dullness than does morphine;
and it is relatively highly effective by oral administration.
In addition to animal experiments, these differences
have been established by extensive employment of the
drug in two types of patients : individuals addicted to
morphine, and others (terminal malignancies) needing
prolonged pain relief but without previous narcotic ex-
perience. In morphine addicts, Metopon appears only
partially to prevent the impending signs of physical and
psychical dependence. In terminal malignancy, admin-
istered orally, it gives adequate pain relief, with very
little mental dulling, without nausea or vomiting and
with slow developments of tolerance and dependence.
The high analgesic effectiveness of oral doses (with
the elimination of the disadvantage to the patient of
hypodermic injection), the absence of nausea and vomit-
ing even in patients who' vomit with morphine or other
derivatives, the absence of mental dullness and the slow
development of tolerance and dependence place Metopon
in a class by itself for the treatment of the chronic
July, 1947
781
METOPON HYDROCHORIDE
suffering of malignancies, and it is for that purpose
exclusively that it is being manufactured and marketed.
Metopon will be available only in capsule form for
oral administration. The capsules will be put up in bottles
of 100 and each capsule will contain 3.0 mg. of Metopon
hydrochloride. They may be obtained by physicians
only from Sharp & Dohme or Parke, Davis & Co., on
a regular official Narcotics Order Form, which must be
accompanied by a signed statement supplying informa-
tion as to the number of patients to be treated and the
diagnosis on each. The drug will be distributed for
no other purpose than oral administration for chronic
pain relief in cancer cases.
The dose of Metopon hydrochloride is 6.0 to 9.0 mg.
(2 or 3 capsules), to be repeated only on recurrence of
pain, avoiding regular by-the-clock administration. As
with morphine, it is most desirable to keep the dose at
the lowest level compatible with adequate pain relief.
Therefore, administration should be started with two
capsules per dose, increasing to three only if the analgesic
effect is insufficient.
Tolerance to any narcotic drug develops more rapidly
with excessive dosage and under regular by-the-clock
administration. Also, as a rule, the pain of cancer varies
widely in intensity from time to time. Pain, therefore,
should be the only guide to time of administration and
dosage level. Tolerance to Metopon hydrochloride de-
velops slowly. It can be delayed or interrupted entirely
by withholding the drug occasionally for twelve hours
or for as much of that period as the incidence of pain
will permit.
To each physician will be sent a record card for each
patient to whom Metopon hydrochloride is to be admin-
istered. He will be requested to fill out these cards and
return them in the addressed return envelope. He must
furnish this record of his patient and his use of Metopon
hydrochloride if he wishes to repeat his order for the
drug. The principal object of this detailed report is
to check the satisfactoriness of Metopon hydrochloride
administration in general practice. The physician’s co-
operation in making it as complete as possible is earnestly
solicited.
The limited use of Metopon hydrochloride as described
above has been recommended by the Drug Addiction
Committee of the National Research Council, and the
Committee, with the co-operation of the American Can-
cer Society, will supervise the distribution of the drug.
The committee is composed of Wm. Charles White,
Chairman, Washington, D. C. ; H. J. Anslinger, Com-
missioner of Narcotics, United States Treasury Depart-
ment, Washington, D. C. ; Lyndon F. Small, National
Institute of Health, Washington, D. C. ; and Nathan
B. Eddy, National Institute of Health, Washington,
D. C. Queries and comments on Metopon may be
directed to Dr. Eddy, who will answer them for the
committee.
References
1. Eddy, N. B. : The search for more effective morphinedike
alkaloids. Am. J. M. Sc., 197:464, 1939.
2. Himmelsbach, C. K.: Studies of certain addiction charac-
teristics of (a) dihydromorphine (“Paramorphan”), (b)
dihydrodesoxymorphine-D (“Desomorphine”), (c) dihydro-
desoxycodeine-D (“Desocodeine”), and (dl methyldihydromor-
phinone (“Metopon”). J. Pharmacol. & Exper. Therap.,
67:239, 1939.
3. Lee, L. E. : Medication in the control of pain in terminal
cancer, with reference to the study of newer synthetic
analgesics. J.A.M.A., 116:216, 1941.
4. Lee, I.. E. : Studies of morphine, codeine, and their deriva-
tives. XVI. Clinical studies of morphine, methyldihydro-
morphinone (Metopon) and dihydrodesoxymorphine-D (Deso-
morphine). J. Pharmacol. & Exper. Therap., 75:161, 1942.
5. Small. L., and Fitch, H. M.: U. S. Patent 2,178,010, Oct.
31, 1939.
6. Small, L. ; Fitch, H. M., and Smith, W. E.: The addition
of organomagnesium halides to pseudocodeine types. II.
Preparation of nuclear alkylated morphine derivatives. J. Am.
Chem. Soc., 58:1457, 1936.
7. Small, L. ; Turnbull, S. G., and Fitch, H. M. : The addition
of organomagnesium halides to pseudocodeine types. IV.
Nuclear-substituted morphine derivatives. J. Org. Chem.,
3:204, 1938.
MULTIPLE FOCI OF POLIOMYELITIS IN FATAL CASE
A fatal case of poliomyelitis is described which oc-
curred in a laboratory worker. It is probable, although
not definite, that this man acquired his infection as a
residt of exposure to poliomyelitis virus in the labora-
tory.
Prior to his infection he was working with human
infectious material and with strains of poliomyelitis
virus in their early monkey passage.
Poliomyelitis virus was isolated in this case: from the
throat (during life), and at autopsy from the central
nervous system, the washed wall of the duodenum,
mesenteric lymph nodes and from some of the right
axillary lymph nodes. Attention is called to this last
fact because just prior to his illness, this patient sus-
tained an injury to his skin on the right wrist.
Previous experiences, both published and unpublished,
on the isolation of poliomyelitis virus from lymph nodes
is reviewed and discussed in the light of the findings
of the above case.
Histologic lesions of poliomyelitis were present in one
anterior olfactory nucleus. Extensive lesions were pres-
ent in the midbrain, pons, medulla and spinal cord.
“The portal of entry of the virus was not deter-
mined.”
Wenner, H. A., and Paul, John: Fatal infection with polio-
myelitis virus in a laboratory technician: isolation of virus
from lymph nodes. Am. J. M. Sc., 213:9-18, (Jan.) 1947.
Minnesota Medicine
782
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
Geosge Earl, M.D., Chairman
ADVISORY COMMITTEE FORMED
TO TACKLE NURSE SHORTAGE
The great scarcity of registered nurses which
presents a problem dangerous and tragic to hos-
pitals, physicians and the public, both in urban
and rural areas, is the reason behind the recent
organization of a committee of eighteen members,
known as the Minnesota Advisory Committee on
Nursing.
Nine different organizations are represented on
this committee : the Minnesota State Medical, hos-
pital and Nurses Associations, the State Board of
Examiners of Nurses, the State Board of Health,
the Division of Public Institutions, the Minnesota
Catholic Hospitals, the State Department of Edu-
cation and the Minnesota Farm Bureau Federa-
tion.
This Committee met with the Governor in his
office on May 28 and informed him about exist-
ing conditions resulting from the nurse shortage.
The Governor was very much impressed with the
findings of the Committee and requested that it
continue its activities, suggesting that an executive
committee be selected from the group. This is
now being done.
Rural Hospital Representatives Meet
Hospitals, doctors, nurses and the general
public have been aware of the serious shortage of
nurses for a long time, but no one has made any
workable suggestions as to what should be done
about it. The first concrete step was taken by
Dr. W. L. Burnap of Fergus Falls when he
called a meeting of rural hospital representatives
at that town on September 14, 1946. The response
to this meeting was excellent. Twenty-five hos-
pitals sent representatives ; others wrote assuring
their support.
It was decided to begin attacking the problem
as it affected rural hospitals first because hospitals
in rural areas depend entirely upon city schools
for nurses and because 50 per cent of all patients
July, 1947
hospitalized are in the country, that is, outside
of the Twin Cities, Duluth and Rochester.
At this first meeting it was learned that state
institutions, nearly all of which are outside of the
large cities, suffer also from a lack of nurses.
These institutions cannot turn patients away be-
cause of this lack, and yet they must provide pa-
tients with the best possible care.
At the meeting Dr. W. L. Patterson, super-
intendent of the Fergus Falls State Hospital said :
“In one way or another the state will see that
its patients are taken care of. It must be done, and
if the nursing profession cannot furnish the
nurses, then State Hospitals will have to start
schools.”
Practical Nurse Bill Passed
Although it was a compromise measure, the Bill
for the Licensure of Practical Nurses, which was
passed by the 1947 Legislature, is counted as an
important step toward solving part of the nurse
shortage problem. This law creates a board of
examiners for practical nurses and as soon as
the board is organized and standards and regula-
tions have been set, it is expected that several
practical nursing schools will be established.
It is felt that the present plan of licensing prac-
tical nurses will help to a certain extent, but it
does not meet the great need for more graduate
nurses. There is a solution to the pressing prob-
lem, in the committee’s opinion — namely, the estab-
lishment of nurses’ training courses in properly
equipped rural hospitals with one-year affiliation
in a large city hospital. This is the goal of the
present advisory committee, to get as many hos-
pitals in rural areas as are in a position to offer
nurse training courses to establish them, or as the
case may be, to re-open nurse schools which are
now closed.
In order to extend the study of the nursing
situation, a meeting was held on March 21, 1947,
in Saint Paul at which representatives of all hos-
783
MEDICAL ECONOMICS
pitals, large and small, who were interested in the
problem were invited. Also present at this meet-
ing were officials from the Nursing Association,
the Hospital Association, the State Board of
Examiners of Nurses, the League of Nursing
Education and the Farm Bureau. The meeting
was called by Dr. Burnap.
Problem Serious in Both City and Country
At this meeting it was learned that the nursing
problem is just as serious in the city as in the
country. The nursing board reported great dif-
ficulties in establishing nursing schools, particu-
larly in rural hospitals, which have the facilities
and teachers and which meet the minimum stand-
ards.
It was agreed bv the group that in spite of
difficulties it is vitally necessary to establish
more schools in the country, as many well-
qualified girls are found there and the training
given in the small hospital makes an excellent
nurse. It is the opinion of those who have been
studying this problem that rural hospital courses
are successful, first, because they are closer to
the homes of the prospective students and, sec-
ond, the courses are so arranged that the girls
can earn their own way, aside from a few inci-
dentals. Here a poor girl has an equal chance
with those who have the means, the committee
argues.
A special committee of physicians, hospital
officials and nurses, with a representative from
the Farm Bureau and one from the Department
of Education, under the chairmanship of Dr.
Burnap, was appointed to investigate the prob-
lems incident to setting up nursing schools in rural
hospitals and also the qualifications for nurses,
the question of practical nurses, student nurse
recruitment and other phases of the general prob-
lem. This special committee reported to a meet-
ing of the Committee as a whole on April 11, at
which representatives from the State Legislature
were present.
Up to this time the committee was unofficial,
and it was agreed that there should be organized
an official representative body, possessing all au-
thority possible. With this in mind an interview
with the Governor was arranged and his consent
to endorse such a committee was received. The
result was the present Nursing Advisory Com-
mittee.
Questionnaire Sent to Hospitals
In order that the Committee might have facts
to work with, a questionnaire was drafted and
sent to all hospitals in the state soliciting informa-
tion as to present facilities, plans for expansion
and present needs. Returns were excellent, with
75 per cent of the hospitals sending in reports
within ten days, all of which was indicative of the
interest in and importance of the problem.
It was evident from the returns on the survey
that nursing schools in the cities are far from
filled, that if they were filled there is a possibility
that they might supply the nursing needs. This in-
dicates the need for recruitment of more students
of nursing.
The Committee has emphasized the fact that
many well qualified girls will enter a training
school near home who would not go to the city
for training. Therefore, they urge the opening of
rural nursing schools. However, they take note
of the problems involved in setting up and staffing
these schools. It is hoped that these problems
can be worked out and that this state may be
several steps nearer an adequate solution to the
problem of the shortage of nurses as a result of
the work done by the Nursing Advisory Com-
mittee.
It has been shown that this committee can be
of service in continuing to clarify the nursing
situation and as a liaison between the nursing
board and the hospitals wishing to establish
schools for practical nurses or those who offer
courses leading to the degree of registered nurse.
The State Medical Association has contributed
financially to the study of this problem and it
stands ready to support any constructive efforts
which will help solve it.
HEARINGS BEING HELD ON
NATIONAL HEALTH BILL
Hearings in Congress on S.545, the National
Health Bill of 1947, began Wednesday, May 21,
before the Committee on Labor and Public Wel-
fare of the Senate, re-opening the verbal contest
between those who believe Americans should be
“helped to help themselves” and those who con-
tend that compulsion is the only means whereby
the health of this country can be maintained.
Developed along lines suggested by the Ameri-
can Medical Association and other allied health
784
Minnesota Medicine
MEDICAL ECONOMICS
organizations, S.545, briefly, provides a plan and
a means to permit broadest variation of health
programs at local levels and meets the needs of
low income groups without an expensive system
of regimentation and the inevitable destruction
of quality and medical service.
Senator Taft, one of the sponsors of the bill,
opened the discussions briefly outlining his meas-
ure. Said Senator Taft: “Compulsory National
Health insurance is nothing more than taxation
to provide free medical care for all the people.
. . . When you proceed to provide free care for
people who are perfectly able to pay for it them-
selves, you socialize the field.” Senator Taft
pointed out that it would be better if the govern-
ment just help states to provide free medical care
for persons who cannot afford it.
Senator Taft maintained further that socialized
medicine would make every physician the employe
of the federal government. Freedom to choose
a doctor, he said, is a major part of our system
of free enterprise.
Denies Bill Provides Charity
Answering charges of Senator Murray and
others that the Taft Bill is merely a “magnificent
promise” and that it “pretends to assure medical
care to all people,” whereas it “only makes limited
medical services available and these only to those
willing to accept public charity,” Senator Taft
commented that for the state to help people pay
their debts is not charity.
It was brought out at the hearings that the
Taft Bill acknowledges the problem of the uneven
distribution of health and medical services in
many parts of our land. In contrast to the Wag-
ner-Murray-Dingell Bill, it encourages the gradu-
al development of local and statewide medical
insurance programs. Provisions are made for
the organization of newer and better forms of
medical practice to meet the new conditions
created by the spread of prepayment plans.
General provisions of the 1947 Health Bill
include a grant of $200,000,000 a year to states
on a population basis for medical care, chiefly
to low-income patients (Minnesota’s allotment
would be $4,119,800) ; establishment of an inde-
pendent national health agency to handle all the
federal government’s health activities ; and grants
to states for dental care, cancer control and
periodical medical examinations for all school
children.
AMA Representatives Appear in Behalf of Bill
Dr. R. L. Sensenich, Chairman of the AMA
Board of Trustees, appeared early in the hearings
in behalf of Taft’s National Health Bill. Having
observed the standards and methods of distribu-
tion of medical care in other nations, and on the
basis of experience and advice of investigators
trained in health activities, he declared that he
feels it evident that social legislation containing
compulsions cannot be enacted without infring-
ing upon the basic quality of American freedom.
Government administration, said Dr. Sensenich,
is too far removed to be applicable to local com-
munity and individual needs. Therefore, to attain
a broad and effective approach to the problem, a
health program must rest on voluntary effort
with legislation providing assistance.
S.545 more nearly approximates the health pro-
gram set forth by the AMA, Dr. Sensenich
pointed out, since the provisions of this bill are
well planned and provide a sensible approach
to meet the needs of the whole nation.
Dr. E. J. McCormick, Chairman of the Council
on Medical Service, called attention to the fact
that better health for the citizens of the nation
is not a single problem, nor merely a financial
problem, but that it embraces several problems.
The provision for assistance to states in making
surveys of medical care preparatory to the for-
mation of a plan for extending such care is there-
fore a very sound one, he maintained.
Hospital Representatives Testify
Referring to the Taft Bill ,as “plunging boldly
and courageously” into the problem of co-ordinat-
ing federal health activities, the president of the
Catholic Hospital Association, Reverend Alphonse
M. Schwitalla, S.J., said that the reorganization
planned would be conducive to greater effective-
ness and economy. He gave three main reasons
for his endorsement of the bill as follows: (1)
The measure undertakes to provide health care
to those most in need. (2) Co-operation between
private and public agencies providing such health
care is assured. (3) While health care is a na-
tional problem, the bill gives full consideration
to local differences and individual rights.
The American Hospital Association sent both
its president and executive secretary to offer
their support of the measure. They added their
appreciation of the features of the bill which
(Continued on Page 797)
July, 1947
785
Minnesota Academy of Medicine
Meeting of February 12, 1947
The regular monthly meeting of the Minnesota Acad-
emy of Medicine was held at the Town and Country
Club on Wednesday evening, February 12, 1947. Dinner
was served at 7 o’clock, and the meeting was called to
order at 8: 10 by the president, Dr. E. M. Hammes.
There were fifty-three members and six guests present.
Minutes of the January meeting were read and
approved.
The scientific program followed. Dr. Charles F. Rea,
Saint Paul, and Dr. Wallace P. Ritchie, Saint Paul, each
read an inaugural thesis.
PRESENT-DAY CONCEPTS IN THE
TREATMENT OF HYPERTHYROIDISM
CHARLES E. REA. M.D.
Saint Paul, Minnesota
In this paper, four phases of the present-day treatment
of hyperthyroidism will be discussed: (1) the use of
thiouracil ; (2) the use of radioactive iodine; (3) the
use of spinal anesthesia for operation and for post-
operative treatment; and (4) the handling of patients
who have a persistently" high basal metabolic rate in spite
of apparent adequate medical and surgical treatment.
Thiouracil. — The introduction of the use of thiouracil
is the greatest advance in the treatment of hyperthyroid-
ism since that of iodine. It is well known that certain
substances, like urea and the sulfonamides, cause a de-
crease in thyroid activity and enlargement of the gland.
It was only natural that the effect of other substances
such as thiouracil should have been tried. Its physiologic
action is to inhibit the iodine uptake of the thyroid
gland. As a result, the pituitary gland becomes sensi-
tive to the lack of thyroxin in the circulating blood and
hypertrophies to produce more thyrotropic hormone.
Under the stimulation of this hormone, the thyroid gland
hypertrophies, but since the iodine uptake is blocked,
no excess thyroxin is formed. Accordingly, there is a
decrease in body metabolism.
Thiouracil is said to be effective against all types of
hyperthyroidism and acute thyroiditis. In my own ex-
perience with three cases of acute thyroiditis treated
with thiouracil, the results were not too impressive. At
least, it took the patients as long to recover from the
disease as others not treated by this drug. The dose of
the drug is 0.6 gm. daily, given in fouri doses. Giving
thiouracil in divided doses seems to be more effective
than in one single dose. The response to this medication
is not seen for several weeks and if iodine has been
given previously, the time response is longer.
In collected reviews, it is said that about 10 to 15 per
cent of all patients treated with thiouracil have some
Inaugural thesis.
reaction to the drug. The reactions are related more to
drug sensitivity than to dosage. In the first large series,
death due to the drug was said to have occurred in 0.5
per cent of cases. This figure is undoubtedly high, as
experience with the drug has been gained. Leukopenia
occurs in 3 to 4 per cent and agranulocytosis in 1.5 to 2.5
per cent. The death rate from agranulocytosis is 26 per
cent. When agranulocytosis occurs, the drug should be
stopped, and penicillin and transfusions given. Fever,
lymphadenopathy and skin rashes have also been reported
as complications. As prophylaxis against these reactions,
the patient should have his leukocyte count checked
weekly and should report to his doctor immediately if
signs of sore throat, coryza, malaise, skin rash, et cetera,
develop. Even after the drug has been discontinued, the
patient may develop toxic reactions and accordingly
should be watched for at least three to four weeks after
stopping the medication.
The question arises as to whether thiouracil can be
used as the sole treatment of hyperthyroidism. The
consensus of opinion seems to be that the drug should
be used chiefly in the preoperative preparation of moder-
ately and severely thyrotoxic patients and that it is risky
to use it as the sole therapy in such cases. Some doctors
have used the drug in the treatment of mildly toxic
hyperthyroid patients over a period of six to eight months
with no untoward effects. Such therapy is not without
its dangers, however, and should be reserved for very
selected cases.
The patient receiving thiouracil before thyroidectomy
should have the drug stopped two weeks before operation
and be given Lugol’s solution, 10 drops three times a day.
Under such conditions, the thyroid gland will be firmer
and less vascular at operation.
The use of iodine and thiouracil gives us some insight
as to the action of iodine in the hyperplastic goiter.
Giving thiouracil to the hyperplastic thyroid gland makes
it even more hyperplastic. While thiouracil prevents the
utilization of iodine by the thyroid, notwithstanding this
block, the addition of iodine as in Lugol’s solution
causes resolution of the thyroid gland in Graves’ disease.
Therefore, it is concluded that iodine exerts two actions
upon the thyroid gland in hyperplastic goiter, an iodinat-
ing action and an involuting action, and that these two
actions can be separated one from the other by means
of thiouracil.
Radioactwe Iodine. — Induced radioactivity was dis-
covered in 1934 and that year Fermi and his co-workers
in Italy prepared radioactive isotropes of iodine. In
1938 Hertz and his associates in Boston prepared radio-
active iodine by exposing ethyl-iodide to radium mixed
with beryllium. The activated iodine was injected into
rabbits. When the various organs of the recipient rabbit
were removed, minced, and spread on a mesh on a plate
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MINNESOTA ACADEMY OF MEDICINE
and exposed to standard detection techniques, it was
found that the normal thyroid gland had picked up
eighty times as much iodine, prepared by the cyclotion
method, as is utilized by a hyperplastic goiter in man.
Radioactive iodine is obtained at present by the deutron
bombardment of tellurium. The result consists of a mix-
ture of radioactive isotropes of iodine. The principal
isotropes are I130 which has a half-life of 12.6 hours
and I131 with a half-life of eight days. One me. of
12 hour iodine per gram of thyroid tissue delivers 12.3
r/min., so with a 40 to 50 gm. thyroid a sizable dose
of irradiation may be given.
The effect of the radioactive iodine is checked by
(1) the urinary secretion; (2) measurement by external
gamma ray counter (Geiger counter) ; (3) the basal
metabolic rate; (4) involution of the thyroid gland; and
(5) clinical improvement of the patient.
Radioactive iodine is given by mouth, and tastes like
stale, distilled water. The dosage given is 0.5 to 1.0
me. of 12 hour iodine per gram of thyroid tissue. The
total doses average 40 to 50 me. although as high as 79
me. in a single dose has been given.
The advantages of administration and selective absorp-
tion of internal irradiation therapy as compared to exter-
nal irradiation are apparent. Internal irradiation is not
without its toxic reactions, however. Acute roentgen ray
sickness may occur ; hypometabolism, even to the degree
of myxedema have been reported. The question of
anemia and malignancy in such cases had not been
answered although in the cases observed to date (and
some for a period of almost ten years), the last two
possible complications have not been observed.
In 1923 Means and his co-workers reported that in
the treatment of hyperthyroidism by roentgen therapy,
about one-third of the patients were cured, another third
improved, and another third not affected. Radioactive
iodine in selected series to date has been effective as a
cure for hyperplastic goiter in 80 per cent of cases.
It should be stated that sufficient experiments have
not been done to establish the limits of safety of the
use of radioactive iodine in the treatment of thyroid
disorders. At least, however, an advance in the treatment
of thyroid disease has been made by this agent.
Spinal Anesthesia. — The importance of proper prepara-
tion before operation of patients with hyperthyroidism is
well recognized. The patient is treated by high caloric
(high protein-high carbohydrate) diet, physical and
mental rest, Lugol’s solution, sedation, et cetera. When
the basal metabolic rate and pulse have been lowered to
normal levels, the patient is considered ready for opera-
tion. More important than the decrease in the basal
metabolic rate is the weight gain by the patient. It is
much more important to have a patient gain weight
even though the basal metabolic rate remains stationary,
than to have the basal metabolic rate lowered- but the
patient lose weight.
The whole rationale of thyroidectomy in hyperthyroid-
ism is to change the patient from a hyper to a hypo
state of metabolism, hoping to hit a normal level. A
bilateral subtotal lobectomy in one stage is the ideal
procedure. About four-fifths of each lobe should be
removed. Sometimes the patient is so very toxic that
a stage procedure must be carried out.
In very severely hyperthyroid patients, it has been
found that a one-stage bilateral lobectomy of the thyroid
can be performed if a spinal anesthesia is given with the
idea of inhibiting the nerve impulses to the adrenals.
An anesthetic level to the fourth dorsal vertebra must
be obtained if the splanchnic nerves to the adrenal are
to be inhibited.
The procedure is as follows : the patient is “sneaked”
under sodium pentothal anesthesia to the operating room,
and 100 to 150 mg. of novocaine crystals are given intra-
spinallv between the third and fourth lumbar vertebrae.
The anesthesia level is checked by noting at what level
the patient winces when pricked by a pin. Local or
inhalation anesthesia is used for the neck incision. Twen-
ty-five patients with very toxic goiters have been treated
in this manner to date, and the results have been very
gratifying. Especially impressive has been the smooth
operative and postoperative course. Bilateral subtotal
lobectomies have been performed in one stage on these
patients, whereas otherwise only stage procedures would
have been attempted. Also, five patients in “thyroid
storm” have been treated to date by spinal anesthesia.
Fortunately all the patients have responded to this
therapy and there have been no deaths.
The rationale of this procedure is based on the prin-
ciple that the adrenals play an important part in thyroid
metabolism. Adrenalin has been used to flare up latent
hyperthyroidism (Goetch test). Also, increase in adrena-
lin or sympathetic-like symptoms has been stated to
occur in hyperthyroidism. Unfortunately the test used
(Whitehorn test) to determine the amount of adrenalin
in the blood is not too specific. Further study is neces-
sary to determine how rational the premise is that
adrenalin is a factor in thyroid storm. Clinically, how-
ever, spinal anesthesia in the operative and postoperative
treatment of severe hyperthyroidism has proven to be
a helpful procedure.
Management of patients with persistently high basal
metabolic rates in spite of apparently adequate medical
and surgical treatment. — Some patients with thyrotoxic
goiters, in spite of excellent medical and seemingly ade-
quate surgical treatment still have a persistently high
basal metabolic rate. If the patient with hyperthyroidism
has had a bilateral, subtotal lobectomy and has a high
basal metabolic rate after operation, it is usually thought
that there has been a recurrence or persistence of goiter
to cause the difficulty. However, if the patient has had
two or three operations on the neck, has had repeated
series of medical management and even a course of deep
x-ray therapy, the problem of how to treat such a pa-
tient with a high basal metabolic rate is quite difficult.
Fortunately, the above symptom complex does not
occur very often. During the past eight years, however,
six such patients have been seen by the author. They
have had the following items in common : Each had had
at least two explorations of the neck for thyroid tissue
after the first thyroidectomy ; in none was the basal
metabolic rate lower than plus 30 per cent. Four had
received a series of radiation therapy. All had a tachy-
July, 1947
787
MINNESOTA ACADEMY OF MEDICINE
cardia. Two patients have had repeated electrocardio-
grams over a period of four years and nothing besides
the tachycardia has been found. One patient was treated
with thiouracil, and while the basal metabolic rate was
lowered from plus 35 to plus 7 per cent, the patient
felt no better, and so the drug was discontinued after
a four months’ trial.
The author has felt in the management of these cases
that as long as the patients feel well and the pulse does
not go over 100 per minute, nothing should be done.
It will be interesting to note any cardiac damage that
may result from a persistent tachycardia. Also, it would
be interesting to note what effect radioactive iodine
would have on these patients. It is possible that they
may have aberrant hyperactive thyroid tissue somewhere
else in the neck or thorax, but none of them wishes
further operation. One of the patients has worked
regularly in a department store over a period of six
years. Needless to say, these patients are being care-
fully followed, and it is hoped that informative data
will be accumulated over the years.
Summary
Some present-day concepts in the management of
hyperthyroidism have been reviewed.
1. The use of thiouracil in the treatment of the
thyrotoxic patient has been the greatest advance in
therapy since the advent of iodine.
2. The use of radioactive iodine may prove to be the
therapy of choice in certain forms of hyperthyroidism.
3. In twenty-five severely toxic patients, the use of
spinal anesthesia as part of the operative treatment made
possible a single stage bilateral subtotal lobectomy when
otherwise only a several-stage operation would have been
ventured. Spinal anesthesia had been used on five occa-
sions in the treatment of “thyroid storm” with beneficial
results.
4. Of six patients, followed over several years, with
persistently high basal metabolic rates after seemingly
adequate medical and surgical treatment, the author
has adopted a policy of watchful waiting. As long as
the patient feels well and does not have too high a
tachycardia, no treatment of such patients is indicated.
Bibliography
1. Chapman, E. M., and Evans, R. D.: The treatment of hyper-
thyroidism with radioactive iodine. J.A.M.A., 131:86-91.
(May 11) 1946.
2. Hertz, S., and Roberts, A.: Radioactive iodine in the study
of thyroid physiology. T.A.M.A., 131:81-86, (May 11) 1946.
3. Rawson, R. W., and McArthur, J. W. : What has thiouracil
taught us about the pathologic physiology of Graves’ disease.
Western J. Surg., 55:27-37, 1947.
4. Rea, C. £. : Unsolved problems in the pre and postoperative
care of patients with hyperthyroidism. J. Tennessee M. A .
37:10-14, 1944.
5. Rea, C. E. : A new plan in the operative treatment of patients
with severe hyperthyroidism. The use of spinal anesthesia
as an adjunct to new preoperative care. Surgery, 16:731-738,
1944.
6. Rea, C. E. : Some problems in the pre and postoperative care
of patients with hyperthyroidism. Minnesota Med., 26:570-
576, 1943.
7. Seidlin, S. M.; Marinelli, L. D., and Ashry, E. : Radioactive
iodine therapy. J.A.M.A., 132:838-846, (Dec. 7) 1946.
Discussion
Dr. Martin Nordland, Minneapolis : I enjoyed listen-
ing to Dr. Rea in the presentation of this subject. He
has made it very clear that hyperthyroidism is a disturb-
ance strictly calling for special treatment. The term
788
“goiter,” like the word “rheumatism” covers too much
territory. It would be fortunate if a more clear-cut
distinction would be made in the minds of the profession
between the functional disturbance of the thyroid, such
as true hyperthyroidism, and the other disturbances of
the gland such as the nodular and inflammatory changes.
It is only in true hyperthyroidism that the new drugs
will help. Thyroidectomy has been very successful in the
treatment of all types of “goiters” with the exception of
true hyperthyroidism. In true hyperthyroidism, statistics
reveal that in about 27 per cent of those treated by opera-
tion, the results have not been satisfactory. Several years
ago, Dr. William O’Brien, of the University of Min-
nesota, discussed the “Future of Medicine” before the
Hennepin County Medical Society. In this discussion,
he pointed out that anatomy, pathology, and even surgical
technique, was relatively standard. He prophesied that
new developments and progress would come through
chemistry, biochemistry and allied fields.
We all know what penicillin and sulfa drugs have done
for surgery. In time, no doubt, a drug such as thiouracil
may eliminate surgery entirely in this disturbance of the
thyroid. At this time, however, thiouracil is not the drug.
Early reports seem to have been too optimistic in their
evaluation of the thio drugs, and to have overlooked
the toxicity likely to occur from large initial doses.
Thiouracil may be a potent weapon for the control of
thyrotoxicosis in many cases when used wisely, with full
understanding of its possibilities and dangers. Long
continuous observation is necessary. Serious complica-
tions have been observed long after discontinuance of
the drug. I only wish to emphasize the fact that it is a
dangerous drug, and that its use at the present time
should be limited to the extremely toxic case in a large
clinic or teaching institution where the patient can be
observed very closely so that the severe complications,
such as leukopenia and agranulocytosis do not develop.
Even the most enthusiastic do not claim that this drug
brings about a cure.
I cannot refrain at this time from discussing one of
the important points in the diagnosis of hyperthyroidism.
Too much emphasis has been placed upon the basal
metabolic rate. The basal metabolic rate should never
be taken as a criterion for surgery, or for the use of
thiouracil. It is a recognized fact that the persistently
rapid pulse comes first in importance. The rapid pulse
with weight loss, together with the other cardinal symp-
toms of hyperthyroidism are much more important than
the basal metabolic rate. This observation (basal meta-
bolic rate) is only confirmatory.
I have had no experience with radioactive iodine and
therefore cannot discuss this phase of treatment. This
may be something well worth while in the near future.
Those of us who have seen a severe postoperative crisis
in hyperthyroidism will welcome any additional method
for the management of this problem. Spinal anesthesia,
as Dr. Rea described it, may develop into an excellent
weapon for the treatment of these patients. Fortunately,
the severely toxic patients are seen less often than pre-
viously ; and, in most of our toxic cases, the post-
operative crisis can be avoided by proper preoperative
preparation.
I want to congratulate Dr. Rea for his excellent pres-
entation. I am very happy to have had the privilege
of listening to him and to have had the opportunity of
discussing his paper.
Dr. J. A. Lepak, Saint Paul : Dr. Rea ought to be
congratulated for bringing to our attention such a timely
subject as the recent advances in the treatment of hyper-
thyroidism. Anyone who wants to use thiouracil ought
to be not only a good clinician but also employ a good
laboratory. Some time ago I listened to a discussion of
the action of thiouracil by a member of the Mayo Clinic.
The more the drug was used, the more cautious was
everyone in prescribing it. Where Lugol’s solution sufficed
to prepare the patient for operation, thiouracil was never
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
employed. Certainly the mortality rate from thiouracil
is all out of proportion to its benefits when compared
with the harmlessness of Lugol’s solution.
The clinical manifestations of hyperthyroidism do not
run parallel with basal metabolic readings. Sometimes
the clinical manifestations of hyperthyroidism are all out
of proportion to the basal metabolic readings. We have
to wait, therefore, for a considerable time for the proper
evaluation of the benefits of thiouracil in the treatment
of hyperthyroidism.
Personally, on account of the relatively high mortality
rate of thiouracil at the present time in the treatment
of hyperthyroidism, I favor the administration of Lugol’s
solution and the operative procedure. Dr. Rea has
brought out a very controversial subject and I hesitate
to accept it without further studies, controls and obser-
vations.
Dr. C. N. Hensel, Saint Paul : I do not like to let such
a splendid presentation pass with nothing but “cold
water” thrown on it by a surgeon and by an internist.
I have had experience with the use of thiouracil in
the treatment of thyrotoxicosis in but one case ; but, in
that case, the results were so satisfactory and lacking in
hazard that I am planning to use it again.
The case is that of a nineteen-year-old unmarried
woman who had been nervous since puberty and whose
symptoms of hyperthyroidism dated back about two
years but were not recognized as such until February,
1945, when her metabolic rate was plus 48 per cent.
In May of 1945 she was examined at the Mayo Clinic
where her metabolic rate was reported as plus 51 per
cent. She was kept in bed, in the hospital at the Mayo
Clinic, on sedatives and Lugol’s and the standard pre-
operative management for a period of six weeks. She
was then sent home as unsuitable for surgery.
On September 10, 1945, she entered the Miller Hospital
as a patient of Dr. Jones to be prepared for thyroidec-
tomy. She was put to bed on sedatives and Lugol’s, 15
drops t.i.d. (the use of iodine had been haphazard in
the previous weeks), and on a full diet.
Her metabolic rate was plus 54 per cent, heart rate
120 beats per minute, and blood pressure 180/100. After
a week on such a regime, there was absolutely no im-
provement in her condition.
At this juncture, I was called in and found a patient
with a severe thyrotoxicosis, exophthalmos, cardiac pal-
pitation, bodily restlessness, tremor, quadriceps weakness,
emotional instability, and insomnia. The thyroid gland
was diffusely enlarged, smooth in outline, and firm in
consistency. The heart was enlarged” and slamming in
action and there was a systolic murmur over the apex.
The standard treatment was obviously not effective in
this case, so we decided to try thiouracil which was then
on the reserve list and could only be obtained from the
manufacturer.
We read the available literature on this new drug,
familiarized ourselves with its dangers and precautions,
and on September 22, 1945, commenced treatment with
thiouracil 0.2 gram t.i.d., with 10 grains of soda bicar-
bonate added to each dose, and ordered leukocyte counts
and differential smears made every day.
Within the first week there was an initial drop in
leukocytes from 10,000 to 5,000 and then the count rose
to 8,000 and remained in that vicinity. The polymor-
phonuclear cells ranged from 58 to 68 per cent.
By October 30, 1945, thirty-eight days after starting
thiouracil, the patient was showing lessening of the
thyroid drive, the metabolic rate was plus 33 per cent
and the pulse rate was 80 beats per minute.
On November 1, 1945, the patient had an acute psy-
chotic episode, left the hospital (unobserved) for two
hours and on her return was in a state of shock and
near collapse. Psychiatric consultation was obtained and
July, 1947
treatment instituted on the basis of a schizophrenia. The
patient was placed in bed, in restraints, put on seda-
tives and tube feeding. But the thiouracil was continued
three times a day in a dose of 0.2 gram.
On November 21, 1945, the metabolic rate was plus
12 per cent and the pulse rate was 52 beats per minute.
Because of the complicating psychosis and suggestions
in the literature that long administration of thiouracil
might effect a permanent cure of hyperthyroidism, we
continued to give thiouracil 0.2 gram three times a day.
On November 27, 1945, shock treatments were started
with insulin therapy.
On December 14, 1945, the metabolic rate was plus 7
per cent, pulse rate 62 beats per minute, and leukocyte
count 12,400. Thiouracil was continued at 0.2 gram
twice daily.
On December 20, 1945, the dose of insulin, which had
reached 160 units a day, was stopped because of the
presence of severe anginal pains and general debility.
Papaverine hydrochloride, grains 1J4, were used four
times a day for the anginal pains. Believing that thioura-
cil might also be having some deleterious effect on the
heart, the dose was reduced to 0.2 gram once daily and
continued at that level. With the cessation of the insulin
therapy, the patient soon revived, and it was evident
that she would always be a schizophrenic at a childish
level with a fanciful outlook on life. The hyperthyroid-
ism was controlled and we hope to keep it so, for surely
this individual was a most unsatisfactory candidate for
goiter surgery.
She was discharged from the hospital on January 1,
1946, with instructions to continue thiouracil 0.2 gram
once daily. At that time her hemoglobin was 90 per cent,
leukocytes 7,600, polymorphonuclear cells 61 per cent
and red blood cells normal. Fasting blood sugar was
105 mg., cholesterol 362 mg., blood pressure 114/60,
and pulse rate 80 beats per minute.
By the persistent use of thiouracil for 100 days, we
had carried this patient through a violent psychotic
episode and brought a “flaming” thyrotoxicosis under
control without hazard, when nothing else could have
accomplished these results.
On February 2, 1946, thiouracil was stopped for one
week because of joint pains and chilly sensation and then
resumed in a dosage of 0.1 gram daily.
On April 3, 1946, the patient was examined at the
office. Her eyes were no longer prominent. There was
no vasomotor blotching of the skin ; body nutrition was
improved, and heart action was irritable, but quieted on
held breath. The metabolic rate was plus 3 per cent,
pulse 88, temperature 97.8°, and blood pressure 130/80.
Cholesterol was 347 mg. and sedimentation rate 8 mm.
in one hour. Hemoglobin was 89 per cent, red blood
cells 4,620,000, and white blood cells 6,400. She was
continued on thiouracil, 0.1 gram a day.
In June, 1946, she was seen by Dr. Jones after a
bruising auto accident. He found clinical evidence of
reactivation of the hyperthyroidism.
The dose of thiouracil was increased to 0.1 gram three
times a day, without any amelioration in symptoms. It
was now obvious that our only recourse was surgical
removal of the thyroid gland and that promptly. So, on
June 27, 1946, thiouracil was stopped, and Lugol’s solu-
tion 15 drops three times a day was started and seda-
tives prescribed.
On July 10, 1946, the patient re-entered the Miller Hos-
pital and on July 11 Dr. Jones performed a bilateral
partial thyroidectomy with no undue bleeding or compli-
cations.
The microscopic diagnosis of removed tissue was
“hyperplastic goiter, lugolized.” The patient was out of
bed on the third postoperative day, walked on the fifth
day and went home on the ninth day.
A month later her metabolic rate was minus 11 per
cent, pulse 66 to 70, temperature 98.6°, leukocytes,
8,300, and cholesterol 278 mg.
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MINNESOTA ACADEMY OF MEDICINE
Dr. M. B. Visscher, University of Minnesota: I want
to congratulate Dr. Rea on his studies with the use of
spinal anesthesia in the attempt to eliminate some of
the hazards in thyrotoxicosis. There is a very good
physiological rationale for the type of procedure he is
using. I think he would he the first to admit that only
the future will tell what practical significance this inno-
vation may have in the treatment. I feel sure he will add
something to our knowledge about the thyroid gland
and I want to urge him to carry on these studies on the
thyroid gland. I think he is doing a very good job.
Dr. Rea, in closing: I wish to thank those who
discussed this paper. I believe that thiouracil should
be used only in the more severely toxic cases of goiter.
The slightly toxic cases can he prepared adequately by
iodine therapy without thiouracil.
I am glad the question of evaluating the basal meta-
bolic rate was brought out in the discussion. It should
be remembered that the basal metabolic rate is a labora-
tory test and is subject to error. Personally, I put more
emphasis on whether or not the patient is gaining weight,
rather than the lowering of the basal metabolic rate in
determining the progress of the thyrotoxic patient under
therapy. A thyrotoxic patient with a basal metabolic
rate of plus 50 per cent that goes down to a plus 20
per cent, but who is losing weight, is a poorer risk than
a similar patient whose basal metabolic rate remains
stationary but who is gaining weight.
EXPERIENCES IN THE TREATMENT OF
HYDROCEPHALUS IN INFANTS
WALLACE P. RITCHIE, M.D.
Saint Paul, Minnesota
The birth of a hydrocephalic infant has usually been
faced with despair by the obstetrician, pediatrician and
the family from the earliest ages. Only in the last ten
years has there been an honest hope that the child will
be one of the few which will either recover spontaneously
or be a candidate for surgical amelioration of his
condition.
This discussion is limited to hydrocephalus occurring
in early infancy. It is a discussion of internal hydro-
cephalus in which the fluid is within the ventricular
system. External hydrocephalus, caused by an excess
of fluid in the subarachnoid space, or by subdural hema-
toma or hygroma, is a rare occurrence and is only men-
tioned in passing. Hydrocephalus occurring after infancy
is due, in 95 per cent of cases4, to tumors or cysts and
will not be included.
There are no thorough studies of any large group of
hydrocephalics as regards etiology and prognosis. The
incidence is suggested by several authors. Dott and
Levin11 found sixty cases of hydrocephalus not caused
by tumor in 700 cases of verified tumor. Wilder and
Moldavalsy27 record eight cases in 6,000 deliveries, while
Putnam19 states that according to Murphy there were
found eighty-eight cases of hydrocephalus alone or
associated with spina bifida in approximately 130,000
births. Putnam considers, however, that there are prob-
ably twice as many, as reported, as a large number do
Inaugural thesis.
not develop until weeks or months after birth. Haynes16
states that in 183,044 admissions to the Children’s Hos-
pital, there were 334 cases of hydrocephalus. These
figures are certainly not satisfying. It is very important
to know the percentage chance that any infant with
hydrocephalus has of spontaneous recovery or of recov-
ery by conservative means before subjecting it to a
procedure with a rather high mortality. This would
necessitate a careful evaluation of a large number of
cases and such a study apparently has not been made.
In all probability there are numerous mild cases which
go unrecognized, but when a child has sufficient hydro-
cephalus to cause recognition and any concern, the
chances of its spontaneous correction are apparently not
small, according to Bucy3 and Penfield,18 although Put-
nam19 states he has never seen a spontaneous recov-
ery. It is our impression that if an infant has such
a degree of hydrocephalus that the family or pediatrician
is concerned, the chances are very great against recov-
ery without treatment.
The cerebrospinal fluid and tbe subarachnoid spaces
were first described by Cottugno12 in 1784. According
to Fraser and Dott14 the cerebrospinal fluid is probably
not produced before the fifth month of intra-uterine life
as it is only after this time that the foramina of Luschka
and Magendie appear as perforations in the tela choro-
idea. Their reasoning is by implication for if the fluid
was secreted before this time it could not be absorbed
and hydrocephalus would always result due to the as yet
unpatent foramina. It is possible, however, that cerebro-
spinal fluid may have other avenues of exit in intra-
uterine life. Browning2 states that in fetal life there are
spinal afferent vessels, possibly similar to lymphatics,
which lead out through the spinal nerves as shown by
Key and Retzius. This is the exit for cerebrospinal
fluid in most animals and possibly is an avenue of exit
in fetal and early infant life. If Fraser and Dott are
correct, however, a congenital hydrocephalus would begin
at the earliest after the fifth month of intra-uterine life.
The origin of the cerebrospinal fluid in the choroid
plexus, its circulation through the aqueduct of Sylvus
to the fourth ventricle and to the basal cisternae by
way of the foramina of Luschka and Magendie, and
thence to the arachnoid villi where it is absorbed, is
quite well established. Hassin15 is one of the few who
question the fact that the cerebrospinal fluid is a product
of the choroid plexus. He cites numerous cases of
marked hydrocephalus with an atrophic, sclerosed
choroid plexus which is imbedded in the brain and which
could not secrete fluid. There may be some secretion of
cerebrospinal fluid, however, i'n tbe perivascular spaces.
Penfield18 states that there is probably some absorption
of cerebrospinal fluid by the ventricles themselves.
Foley13-1-13"2 has demonstrated a reversibility of flow
through the choroid plexus. The spontaneous arrest of
hydrocephalus may possibly be explained by some such
process.
The surgical treatment of infantile hydrocephalus,
however, is based on the well-established evidence of
the production of the cerebrospinal fluid by the choroid
plexus and its absorption over tbe surface of the brain.
790
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
There are two types of infantile internal hydrocephalus,
obstructive and non-obstructive or communicating. In
the first instance there is an obstructive mechanism so
that fluid is unable to reach the spinal subarachnoid
space due to an obstruction somewhere from the choroid
plexus down to and including the foramina of Luschka
and Magendie. Sachs,23 reporting the largest series of
operated cases in the literature (ninety-eight in all),
states that fifty-four (60 per cent) were communicating
types and forty-two (46 per cent) were obstructive in
nature. Fraser and Dott14 found that six cases out of
twenty-one' were communicating. In seven of their
cases there was a definite history of birth trauma. The
common causes of obstructive hydrocephalus are con-
genital artresias, ependymitis or arachnoiditis caused by
toxins, infection or hemorrhage. Obstructive hydro-
cephalus frequently accompanies spina bifida du6 to the
Arnold-Chiari deformity. Russell and Donald-2 describe
the Arnold-Chiari deformity, first reported by Arnold
in 1894 and shortly thereafter by Chiari, as primarily a.
deformity of the cerebellum. The fourth ventricle is
elongated. The foramina of Luschka and Magendie lie
below the foramen magnum and, because of the lack of
space, fluid is unable to enter the basal cisternae. I shall
further discuss this important syndrome under the sub-
ject of treatment.
In the communicating type of hydrocephalus, fluid is
able to leave the fourth ventricle but the mechanism of
absorption in the subarachnoid spaces is faulty, due to
either failure of development of the subarachnoid spaces,
arachnoiditis, ependymitis caused by toxins, infections
or hemorrhage. Internal hydrocephalus is rarely if ever
caused by hypersecretion of cerebrospinal fluid.
Toxoplasmosis,1 a protozoan infection, which Cowen
and Page1 in 1939 showed could be transmitted to man
is also a frequent cause of hydrocephalus.
Hydrocephalus may be congenital or acquired after
birth.
Penfield studied twenty-seven cases and of these,
seventeen were present at birth and seven developed
after birth. In at least five cases he states that an inflam-
matory process started in ntero. In twenty-six cases
treated by Putnam,21 fifteen were congenital. Dandy
and Blackfan found in fifty-four cases of obstructive
hydrocephalus, 21 per cent were congenital, while
Bucy3 found about 50 per cent of forty-five cases of
communicating hydrocephalus were congenital.
Probably over half of the cases of infantile hydro-
cephalus are present at birth. In some instances there is
such an aplasia of brain substance that either the hydro-
cephalus must have been present for many months or
there was a congenital absence of brain tissue. In either
event the prognosis is extremely poor no matter what
procedure is attempted.
The pathological findings depend upon whether the
hydrocephalus is communicating or obstructive. The
white matter is stretched and is destroyed long before
there is destruction of the gray matter. It is surprising
to note the extent of damage in some individuals in
whom there still remains a high degree of intelligence
and function. Of course, the basal nucleii are little
affected until late; therefore, a tairly normal function
is possible even with a tremendous hydrocephalus. Cases
have been recorded in which there has been a definite
return of cortical thickness after relief from hydro-
cephalus. However, it is conceded by all that if the
cortex is less than 1 cm. in thickness, efforts to treat the
child should be abandoned, as only an imbecile will
result.
Diagnosis
The determination of the presence of hydrocephalus is
not always easy, particularly in the early stages. When
one considers that diagnostic procedures such as spinal
puncture, communication tests and air studies carry a
definite risk, one must be quite certain that a hydro-
cephalus is developing before subjecting the infant to
these procedures. If there are doubts, it will do no
great harm to observe the size of the head over a
period of several weeks before undertaking more active
diagnostic measures.
If there is evidence that the size of the head is in-
creasing out of proportion to the normal, the first proce-
dure is a diagnostic ventricular tap, to rule out subdural
collection of fluid. The next consideration in diagnosis
is the determination of whether the hydrocephalus is
communicating or obstructive. At the same time the
severity of the hydrocephalus can be determined. The
most satisfactory test to determine the type is the com-
munication test. One c.c. of phenosulphopthalein is in-
jected into a lateral ventricle and a spinal puncture done
twenty to thirty minutes later. If there is an_. obstruc-
tive hydrocephalus there will be no dye recovered in the
spinal fluid. Pressure readings of both ventricular and
spinal fluid should be taken.
The width of the cortex should be noted, as a cortex
of less than 1 cm. in thickness prognosticates a poor
result.
Encephalography is of some value but encephalography
carries some risk, and as a rule one has ample evidence
of the type of hydrocephalus and the adequacy of the
cortex without this procedure.
Other diagnostic procedures are secondary. One at-
tempts to determine the cause of the obstructive or com-
municating hydrocephalus, whether it be toxoplasmosis,
syphilis, Arnold-Chiari deformity, congenital aplasia or
nonspecific infection. Tumor as a cause of early hydro-
cephalus is extremely rare.
Treatment
There is no doubt that there are spontaneously
averted cases. There are no records of what this per-
centage is. It must, however, be small.
The excellent historical review by Davidoff8 in 1939
and by Haynes16 demonstrates the wide variety of surgi-
cal methods used in the treatment of infantile hydro-
cephalus.
Almost every means imaginable for draining the
cerebrospinal fluid has been used. The drainage of spinal
fluid outside the ventricles is as old as the hills. It was
tried by Hippocrates and Celsus, and was resurrected by
Von Bergman, Kocher, Lane and many others. All met
with failure.
July, 1947
791
MINNESOTA ACADEMY OF MEDICINE
Drainage into the subcutaneous tissues, peritoneum
and dural sinuses have all been attempted with poor re-
sults. Perhaps the best of these procedures is that
described by Torquildsen25 whereby he drains the lateral
Fig. 1. Drawing to demonstrate the lamina terminalis and the
point of puncture. From Stookey and Scarff: Bull. Neurol.
Inst. New York, 5:367, (Aug.) 1936.
ventricles into the cisterna magna by means of a tube
buried subcutaneously.
The three methods which have brought the best
results in the treatment of infantile hydrocephalus are
(1) the so-called “puncture” operations by means of
which fluid is let out of the closed ventricular space into
the subarachnoid spaces where it may be absorbed; (2)
the operations directed against the choroid plexus itself
in which either coagulation or extirpation is performed;
and (3) the operation of the decompression of the
foramen magnum in cases of Arnold-Chiari deformity.
The earliest so-called puncture operations were de-
scribed first by Anton and Bramman in 1908. They
recommend puncture of the corpus callosum, the so-
called Balkenstitch procedure. This procedure has grad-
ually been discarded because of failure of the puncture
opening to remain patent. However, as late as 1927
Jennings17 reported nineteen cases, with five deaths and
only three good results.
Dandy5 first advocated a puncture operation which has
been successful in many cases, i.e., puncture of the lamina
terminalis into the anterior wall of the third ventricle
(Fig. 1). The two cases presented in detail in this
paper were treated in this manner. Dandy modified his
procedure by a temporal approach and so that the drain-
age was from the third ventricle into the cisterna inter-
peduncularis. White26 does not believe this is necessary
and gives good evidence that the puncture in the lamina
terminalis remains open.
In obstructive hydrocephalus in infants, the puncture
of the lamina terminalis is a rational procedure which
has given satisfactory results in our hands.
Shunting operations are satisfactory for obstructive
types of hydrocephalus, but in communicating hydro-
cephalus where absorption is faulty and there are no
obstructed passages, the most successful operations have
been in attempts to decrease the output of cerebro-
spinal fluid. Dandy6 made the first attack in 1918 when
he extirpated the choroid plexus in four cases. This
method has been replaced by cauterization of the choroid
Fig. 2. (A) Size of anterior fontanelle before cauterization
of the choroid plexus. (B) Size of anterior fontanelle one month
following cauterization of the choroid plexus on one side.
plexus, although there are some neuro-surgeons who are
again attempting extirpation.
Putnam20 in 1935 first reported twenty-two patients
in whom he had cauterized the choroid plexus by a
bipolar endoscope. Only nine survived a period of four
to fifteen months but five of these were well and normal,
two were improved and two unimproved. In 1938 he
reported a 21 per cent mortality with only two deaths
in his last sixteen cases. Scarff24 almost simultaneously
reported similar results.
This method has given satisfactory results. It con-
sists of bilateral occipital trephine with opening into
the ventricles and cauterization of the choroid plexus
of the lateral ventricle either by direct vision or by endo-
scopic methods. The two sides are cauterized at different
operations. The technical aspects of the operation will
not be discussed here. Suffice it to say there is ample
evidence that cauterization of the choroid plexus is a
very satisfactory method of decreasing the cerebrospinal
fluid production (Fig. 2, a and b).
The third method of treating hydrocephalus is only
applicable in those individuals who have an Arnold-
Chiari deformity. D’Errico9 first recommended unroofing
the foramen magnum in such cases. He reported six
cases with three satisfactory results. In 1942 he re-
ported10 a mortality of 12.5 per cent. In hydrocephalus
associated with spina bifida, the Arnold-Chiari deformity
is usually present and a cerebellar decompression is in-
dicated. In some instances the choroid plexus may also
have to be cauterized.
Results
If one recognizes that infantile hydrocephalus is pres-
ent at birth in probably one-half of the cases, and the
many of these are far advanced or there is a definite
aplasia of the brain, the prognosis is discouraging at
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MINNESOTA ACADEMY OF MEDICINE
the outset. Nevertheless one successful result out of
many cases cannot be forgotten or cast aside. The re-
mark is heard so often : “What is the use, they will
only grow up to be imbeciles?” That is true to some
extent but it reflects our failure to recognize the infant
who will be imbecilic if saved by operation, and should
not be a reflection on the operation in the properly
selected case.
Thirteen of the cases which have been studied are
collected cases from the neurosurgical service at the
University Hospital, and four are from the authors’
series in Saint Paul.
Five of the seventeen cases were patients with hydro-
cephalus associated with spina bifida and with associated
Arnold-Chiari deformity. One (BH) died postopera-
tively — a mortality of 20 per cent. One (NC) was a
mental defective four years after operation, in whom
operation was originally carried out at the insistence of
the family, as the prognosis was admittedly poor. One
(PB) living four years after is in fair condition, a
cauterization of the choroid plexus having been per-
formed following decompression. One (CY) was living
and well one year after operation and was apparently nor-
mal. One (BB) was living and apparently normal five
months after operation.
Thus in two of five cases the operation appeared to
have produced a satisfactory result. When one realizes
that this condition is secondary to another serious defect,
a meningocele, a satisfactory recovery in 40 per cent is
encouraging.
There were eight cases in which the etiology was
undetermined. Two of these cases (TS) and (JS)
were obstructive and were treated by puncture of the
lamina terminalis. Both are living and normal thirteen
and seven months after operation. Six were treated
by cauterization of the choroid plexus. Two died post-
operatively, and the remaining four are discouraging.
Although the hydrocephalus was averted, not one has
developed properly. This is the most discouraging group.
The hydrocephalus has been averted but the child’s
development has been subnormal. The majority of these
patients probably had their hydrocephalus in utero and as
evidenced at operation had extremely thin cortices. The
only positive statement that one can make about these
cases is that hydrocephalus can be controlled by cau-
terization of the choroid plexus. Failure is due to lack of
recognition of the chance of normal development rather
than to the operation.
Two infants with congenital mal-development of the
cerebellum were operated upon — one by puncture of the
lamina terminalis and one by cerebellar decompression.
Both died.
Only two cases of hydrocephalus caused by proven
toxoplasmosis are included in this series. One (TH)
has developed normally after cauterization of only one
side. One (RLH) is progressing normally after six
months.
In recapitulation, seventeen cases have been operated
upon. Five operative deaths are recorded — a mortality
of 29 per cent over all.
There are six patients who are developing properly.
Satisfactory results in 35 per cent of these cases is not
a remarkable record. But if one could be able to deter-
mine the prognosis for each case and refuse operation
Fig. 3. (Case 1) Occipital view of the skull shows a marked
separation of the sutures.
for those with a poor prognosis, operation will cure 35
per cent of these children with hydrocephalus who would
otherwise live only a few years.
Case Reports
Case 1. — T.S. was first admitted to the Children’s Hos-
pital as a patient of Dr. Fred Ouellette on October 15,
1945. He was thirteen months old. His birth had been
normal. His past history was negative except that at
the age of ten months he developed chicken pox. Since
that time he had been irritable and disliked any distur-
bance such as noise or movement. Although he had
vomited before his chicken pox the vomiting had be-
come almost continuous the week before admission. He
could no longer walk.
Physical examination revealed a well-nourished child,
not acutely ill but very irritable. The general examina-
tion was negative but the neurological examination (Dr.
Gordon Kamman) revealed optic atrophy, right; left
knee jerk increased on the right. Spinal fluid: colloidal
gold negative, protein 112 mg., cell count 2, chloride 710
mg., sugar 70 mg. X-rays revealed slight enlargement
of the skull with separation of the sutures (Fig. 3). He
remained in the hospital six days, during which time he
was very restless and irritable. He was readmitted four-
teen days later. At this time he was much more irri-
table, did not like bright light and there was some
bulging of the fontanelle. There was a right sixth
cranial nerve paresis, optic atrophy on the right and
a 3 diopter choked disc on the left. On November 6,
1945, communication tests revealed no dye appearing in
the spinal canal after insertion into the ventricle. Be-
cause the symptoms seemed to have been definitely a
sequela of chicken pox, an obstructive hydrocephalus
due to encephalitis rather than to a tumor was con-
July, 1947
793
MINNESOTA ACADEMY OF MEDICINE
sidered to be the most likely etiology. Consequently, on
the same day a puncture of the lamina terminales was
performed and a free flow of fluid obtained, colored by
the dye.
Postoperatively fluid collected beneath the skin flap,
Fig. 4. (Case 1) One year after the lamina terminalis had
been punctured.
and frequent aspirations were necessary. Because the
fluid did not seem to be absorbing, an attempt to cauterize
the choroid plexus was made but the ventricles were
collapsed. The brain appeared of fairly normal thick-
ness. After about three weeks the fluid collecting beneath
the scalp suddenly ceased and the patient was discharged
after thirty-six days. The patient appeared to have only
light perception. He remained irritable for three or four
weeks, then suddenly improved and appeared to notice
his surroundings.
Shortly thereafter he began to sit up, to walk and to
develop normally. He developed poliomyelitis in July,
1946, but is recovering and according to all examina-
tions is a normally developing child (Fig. 4).
Case 2.— J. S. was admitted to the Children’s Hos-
pital by Dr. Ray Shannon on May 25, 1946. She was
five months old. She was a full-term baby and was
delivered spontaneously. She appeared absolutely nor-
mal to the mother, and as a result medical care was not
sought until a neighbor called the mother’s attention to
the fact that the baby’s head was larger than normal.
On admission, the findings were essentially negative
except that the anterior fontanelle measured 14 by 10
cm. and the circumference of the head was 4-8 cm.,
which was approximately 6 cm. larger than normal.
Puncture through the anterior fontanelle revealed the
cortex to be approximately 1 cm. thick on the left and
2 cm. thick on the right. A communication test revealed
a block, as no dye was recovered in the spinal fluid.
The cell count, protein, colloidal gold curve and Kahn
test were normal.
On May 31, 1946, a puncture of the lamina terminales
was performed. Her postoperative course was uneventful
except for a fever up to 103° for a few days.
The child now has a head 52 cm. in diameter. The
fontanelles are sunken. She looks like a normal child
and is beginning to stand up. Her mother thinks she
is further developed than her other children were at
the same age.
References
1. Adams, F. H.: Toxoplasmosis. Staff Meet. Bull., Univ.
Minnesota, 17:41-50, (Oct. 19) 1945.
2. Browning, W. : The anatomical cause and the frequency of
hydrocephalus in childhood. M. Rec., 89:959, (May 27)
1916.
3. Bucy, Paul C. : Hydrocephalus. In Brenneman: Practice of
Pediatrics, vol. 4, chap. 3. Baltimore: W. F. Prior Co.
4. Dandy, W. E. : Diagnosis and treatment of strictures of the
Aqueduct of Sylvius (causing hydrocephalus). Arch. Surg.,
51:1-15, (July) 1945.
5. Dandy, W. E. : The diagnosis and treatment of hydrocephalus
resulting from stricture of the Aqueduct of Sylvius. Surg.,
Gynec. & Obst., 31:340-358, (Oct.) 1920.
6. Dandy, W. E. : Extirpation of the choroid plexus of the
lateral ventricles in communicating hydrocephalus. Ann.
Surg., 68:569-79, (Dec.) 1918.
7. Dandy, W. E., and Blackfan, K. D. : Internal hydrocephalus.
Am. J. Dis. Child., 14:424-443, (Dec.) 1917.
8. Davidoff, L. M. : Treatment of hydrocephalus; historical re-
view and description of a new method. Arch. Surg., 18:1737-
62. (April) 1929.
9. D’Errico, Albert: A surgical procedure for hydrocephalus
associated with spina bifida. Surgery, 4:856-866, (Dec.) 1938.
10. D’Errico, Albert: The present status of operative treatment
for hydrocephalus. South. M. J., 35:247-252, (March) 1942.
11. Dott, N. M., and Levin, E. : Chronic progressive hydro-
cephalus. Tr. Med. Chir. Soc. Edinburgh, in Edinburgh M.
J., pp. 113-128, (Aug.) 1936.
12. Elsberg, C. H.: Chronic internal hydrocephalus; the newer
methods of its recognition and treatment. Interstate M. J.,
24:1114, (Dec.) 1917.
13-1. Foley, F. E. B. : Alterations in currents and absorption of
cerebro-spinal fluid following salt administration. Arch.
Surg., 6 :587-604, (March) 1923.
13-2. Foley, F. E. B.: Clinical uses of salt solution in conditibns
of increased intracranial tension. Surg., Gynec. & Obst..
33:126-136, 1921.
14. Fraser, J., and Dott, N. M.: Hydrocephalus. Brit. I. Surg.,
10:165-191, (Sept.) 1922.
15. Hassin, G. B.: Hydrocephalus; report of a case in an infant
with vestiges of a choroid plexus in the fourth ventricle only.
Arch. Neurol. & Psychiat., 27:406-419, (Feb.) 1932.
16. Haynes, I. S. : Congenital hydrocephalus; its treatment by
drainage of the cisterna magna into the cranial sinuses.
Ann. Surg., 57:449-484, 1913.
17. Jennings, J. E. : Hydrocephalus in infancy. S. Clin. North
America, 7:901-8, (Aug.) 1927.
18. Penfield, Wilder: Hydrocephalus and spina bifida. Surg.,
Gynec. & Obst., 60:363-369, (Feb.) 1935.
19. Putnam, Tracy J.: The surgical treatment of infantile hydro-
cephalus. Surg., Gynec. & Obst., 76:171-182, (Feb.) 1943.
20. Putnam, T. J.: Results of the treatment of hydrocephalus by
endoscopic coagulation of the choroid plexus. Arch. Pediat.,
52:676-685, (Oct.) 1935.
21. Putnam, T. J.: Mentality of infants relieved of hydrocephalus
by a coagulation of choroid plexuses. Am. J. Dis. Child.,
55:990-999, (May) 1938.
22. Russell, D. S., and Donald, C. : The mechanism of lateral
hydrocephalus in spina bifida. Brain, 58:203-215, (June)
1935.
23. Sachs, Ernest: Hydrocephalus; an analysis of 98 cases. J.
Mt. Sinai Hosp., 9:767, (Nov. -Dec.) 1942.
24. Scarff, J. E. : Endoscopic treatment of hydrocephalus; descrip-
tion of a ventriculoscope and preliminary report of cases.
Arch. Neurol. & Psychiat., 35:853-861, (April) 1936.
25. Torquildsen, A.: A new palliative operation in cases of
inoperable occlusion of the Sylvian aqueduct. Acta chir.
Scandinav., 82:117-124, 1939.
26. White, J. C., and Michelsen, J. J. : Treatment of obstruc-
tive hydrocephalus in adults. Surg., Gynec. & Obst., 74:
99-109, (Jan.) 1942.
27. Wilder, E. M., and Moldavsky, L. F. : Congenital hydro-
cephalus complicating labor. South. Surgeon, 10:861-873.
(Dec.) 1941.
Discussion
Dr. E. F. Robb, Minneapolis ; All pediatricians see
a number of these cases, which have been most discour-
aging as far as I am concerned. A few have seemed to
cure themselves but most of them have gone on to a
fatal termination. The results from surgery have in my
experience been 100 per cent bad. Dr. Ritchie’s most
excellent paper tonight should give us renewed cour-
age. He is to be congratulated on his fine work.
Dr. Ritchie, in closing: 1 appreciate the discussion.
Regarding the thickness of the cortex, 1 mav have been
somewhat misleading. In estimating the thickness of
the cortex, one must subtract about 1 cm. from the
depth at which ventricular fluid is obtained on punc-
ture through the fontanelle.
Inasmuch as the gray matter is not destroyed until
late, there is a good opportunity for recovery of func-
tion after the hydrocephalus has been relieved.
Although the results are not by any means perfect,
there are a sufficient number of recoveries to warrant
a careful evaluation of all cases of hydrocephalus before
determining that they are hopeless.
The meeting adjourned.
A. E. Cardle, M.D., Secretary
794
Minnesota Medicine
in the severity
of symptoms.
In the dyspnea
AMINOPHYLLIN
Searle Aminophyllin contains
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G. D. Searle & Co., Chicago 80, Illinois
SEARLE
of allergic asthma,
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July, 1947
RESEARCH
IN THE SERVICE
OF MEDICINE
795
♦ Reports and Announcements ♦
MEDICAL BROADCAST FOR JULY
The following radio schedule of talks on medical
and dental subjects by William O’Brien, M.D., Direc-
tor of Postgraduate Medical Education, University of
Minnesota, is sponsored by the Minnesota State Medical
Association, the Minnesota State Dental Association,
the Minnesota Hospital Service Association in co-
operation with the Minnesota Hospital Association and
the Minnesota Nurses Association.
1
9:00 A.M.
WCCO
Blue Cross Enters 14th Year
3
9:00 A.M.
wcco
Minnesota Medicine
8
9.00 A.M.
WCCO
New Field in Nursing
10
9:00 A.M.
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Body Heat and Hot Weather
IS
9:00 A.M.
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Why Hospital Costs Are Rising
17
9:00 A.M.
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Food Infections
22
9:00 A.M.
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Increased Demand for Nurses
24
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Skin Care in Summertime
29
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Costs of One Operation
31
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Getting Ready for School
INTERNATIONAL COLLEGE OF SURGEONS
The International College of Surgeons, United States
Chapter, will hold its twelfth annual Assembly and
Convocation in Chicago, September 28 to October 4,
1947.
The program will include operative and non-operative
clinics, demonstrations, symposia, forums, medical mo-
tion pictures, exhibits and the formal dedication of the
new library and permanent home of the United States
Chapter. All meetings, with the exception of the opera-
tive clinics, will be held in the Palmer House and the
Stevens Hotel.
Copy of the program and detailed information may
be obtained by writing Max Thorek, M.D., Co-chairman,
1516 Lake Shore Drive, Chicago, Illinois.
AMERICAN COLLEGE OF PHYSICIANS
AND SURGEONS
Dr. Julian DuBois, Sauk Centre, has been elected
president of the American College of Physicians and
Surgeons. Other recently elected officers of the organiza-
tion are Dr. C. H. Pierce, Wadena, first vice president ;
Dr. A. E. Ritt, Saint Paul, second vice president ; Dr.
Henry D. Deissner, Minneapolis, third vice president,
and Dr. O. A. Lenz, Minneapolis, secretary-treasurer.
The organization will hold its first annual dinner on
June 29 at the Spalding Hotel in Duluth. Speakers at
the dinner include Dr. Charles A. Dawson, president of
the Wisconsin Medical Society, and Dr. F. G. Benn,
Minneapolis, president of the Minnesota chapter.
MISSISSIPPI VALLEY MEDICAL SOCIETY
The twelfth annual meeting of the Mississippi Valley
Medical Society will be held in Burlington, Iowa, October
1, 2 and 3, 1947. Over twenty-five clinical teachers from
the leading medical schools of the country will conduct
this postgraduate assembly, the entire program having
been planned to appeal to general practitioners. Dr. Ed-
ward L. Bortz, president of the AMA, will be the prin-
cipal speaker at the annual banquet, at which talks will
796
also be given by the presidents of the Illinois, Iowa and
Minnesota Medical Associations.
All ethical physicians are invited to attend, and for the
first time in history no registration fee will be charged.
A program may be obtained from Dr. Harold Swanberg,
Secretary, 209 W. C. U. Building, Quincy, Illinois.
NORTHERN MINNESOTA MEDICAL ASSOCIATION
Announcement has been made that the annual meeting
of the Northern Minnesota Medical Association will be
held on Saturday, September 6, at Breezy Point Lodge,
Pequot Lakes (near Brainerd).
The following program is scheduled for the one-day
meeting.
“Abdominal Hodgkin’s Disease’’ — Dr. W. O. B. Nelson
and Dr. Leonard Dwinnell, Fergus Falls.
“Some Practical Aspects of the Rh Factor” — Dr. A.
H. Wells, Duluth.
“The Diagnosis of Congenital Cardiac Defects Which
Are Amenable to Surgery” — Dr. Thomas J. Dry, Roch-
ester.
“The Management of Lesions of the Rectal Outlet” —
Dr. Louis A. Buie, Rochester.
“Clinical Evaluation of New Developments in Allergy”
— Dr. Albert V. Stoesser, Minneapolis.
“The Psychosomatic Component of Disease” — Dr. O.
L. Norman Nelson, Minneapolis.
“Clinico-Roentgen-Pathological Conference” — Dr. E.
L. Tuohy and associates, Duluth.
The meeting will close with an evening banquet, at
which Governor Luther W. Youngdahl will be the prin-
cipal speaker.
HENNEPIN-RAMSEY COUNTY SOCIETIES
At the first joint scientific meeting of the Hennepin
and Ramsey County Medical Societies, held May 19 in
the auditorium of the University of Minnesota Museum
of Natural History, the principal speakers were Dr.
James D. Bisgard, professor of surgery at the University
of Nebraska, and Dr. Edgar S. Gordon, professor of
medicine at the University of Wisconsin. Dr. Bisgard
spoke on “Intra-thoracic Tumors,” and Dr. Gordon dis-
cussed “Deficiency Diseases.”
SOUTHWESTERN MINNESOTA SOCIETY
At a dinner meeting of the Southwestern Minnesota
Medical Society, held June 3 at the Hotel Thompson in
Worthington, Dr. R. W. Koucky, Minneapolis, spoke on
“The Rh Factor,” and Dr. John Stam, Worthington,
gave a report on the cyanotic condition produced in in-
fants by water heavily impregnated with nitrates.
At a business meeting of the society on May 20, Dr.
Hermanus DeBoer of Edgerton reviewed the history of
the Southwestern Minnesota Medical Society, which was
founded in 1888. Dr. B. O. Mork, Jr., discussed a re-
Minnesota Medicine
REPORTS AND ANNOUNCEMENTS
cent meeting of the state association of county medical
officers.
UPPER MISSISSIPPI SOCIETY
Fifty-four members of the Upper Mississippi Medical
Society, and their wives, were guests of the Bemidji
Medical Society at a meeting held May 24 at the Cyrana
Lodge on Lake Beltrami. Dr. Charles W. Vandersluis
and Dr. Sidney F. Becker, both of Bemidji, were in
charge of arrangements for the meeting, which was
presided over by Dr. Otto F. Ringle, president of the
Upper Mississippi Society.
The major part of the scientific program consisted of
a discussion of low back pains by Dr. M. S. Henderson,
professor of orthopedics at the Mayo Clinic, and by
Dr. William Peyton, professor of surgery at the Uni-
versity of Minnesota.
WASHINGTON COUNTY SOCIETY
The Washington County Medical Society met for din-
ner on the evening of June 24, 1947, to honor one of its
members, Dr. James H. Haines of Stillwater, who has
completed fifty years of medical practice.
Dr. Haines was graduated from Rush Medical College,
Chicago, in 1895 and was licensed to practice medicine in
1897. He went to Stillwater shortly after graduation and
started his medical life as a house physician at the Still-
water Hospital, now known as Lakeview Memorial Hos-
pital. Shortly after that he opened an office for the
general practice of medicine, and he remained in active
practice until January 1, 1947. Since that time he has
been enjoying a much-needed rest.
Following the dinner meeting, the evening was spent in
listening to tales by Dr. Haines and others of the early
years of practice. A gift was presented to Dr. Haines
in memory of the occasion.
MEDICAL ECONOMICS
NATIONAL HEALTH BILL
(Continued front Page 785)
provide federal assistance to states for the estab-
lishment of medical and hospital services for
those whose low income makes it difficult or im-
possible for them to get adequate care. They
further pointed out that health functions of the
federal government are of sufficient importance
to justify their separation into a unit headed by
persons trained and experienced in health work.
They especially favored the provisions of S.545
for local participation and administration, which
would in every case make the community feel
that it is carrying out the program according to
its best judgment.
American Dental Association officials have also
voiced their approval of the philosophy embodied
July, 1947
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in the Taft Bill, as opposed to that motivating
such legislation as the Wagner-Murray-Dingell
Bill. They point to the greater freedom to states
in direction of their own programs and favor
expending dental care to children whose parents
cannot meet the cost of such care, but emphasize
that such a program should be at the community
level.
As the hearings progress, it is clear that the
evidence is piling up in favor of this bill and
that it shows considerable possibility of ultimate
passage through Congress.
797
IN MEMORIAM
1909 1947
Thirty-eight years of success-
ful treatment of rheumatism
under the same manage-
ment. Dr. H. E. Wunder,
M. D., Resident Physician.
Tel. Shakopee 123
U.S. Hwy. 212
anitarium
Cook County
Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY; — Two-week intensive course in Surgical
Technique, starting August 18, September 22, October
20.
Four-week course in General Surgery, starting August
4, September 8, October 6.
Two-week course in Surgical Anatomy & Clinical Surg-
ery, starting July 21, August 18, September 22.
One-week course in Surgery of Colon & Rectum, start-
ing September 15, and November 3.
Two-week course in Surgical Pathology every two
weeks.
FRACTURES & TRAUMATIC SURGERY Two-week
intensive course starting October 6.
GYNECOLOGY — Two-week intensive course starting
September 22, October 20.
One-week course in Vaginal Approach to Pelvic Sur-
gery, starting September 15 and October 13.
OBSTETRICS — Two-week intensive course, starting Sep-
tember 8, October 6.
MEDICINE — Two-week intensive course, starting Oc-
tober 6.
Two-week course in gastro-enterology, starting October
20.
One-week course in Hematology, starting September 29.
One-month course in Electrocardiography & Heart Dis-
ease, starting September 15.
Two-week intensive course in Electrocardiography &
Heart Disease, starting August 4.
DERMATOLOGY & SYPHILOLOGY — Two - week
course starting October 20.
General, Intensive and Special Courses in all Branches
of Medicine, Surgery and the Specialties
TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar, 427 S. Honore St., Chicago 12, 111.
798
In Memoriam
GEORGE RALPH CHRISTIE
Dr. G. R. Christie, a practioner of Long Prairie since
1884, died January 20, 1947, at the age of eighty-nine.
Dr. Christie was born January 19, 1858, in Berlin,
Wisconsin. After teaching for several years, he entered
Rush Medical College from which he graduated in 1882.
He began practice in Montello, Wisconsin, but moved
to Long Prairie in 1884.
On September 1, 1887, he was married in Milwaukee
to Susan West. Four children were born to them, three
sons, and a daughter who passed away at the age of
eight. Dr. Christie was left a widower in 1910. In 1911
he married Ida Lewis Mason who died in 1944.
Dr. Christie took an active interest in his community
and county. He was one of the incorporators of the
Bank of Long Prairie, and was interested in banking
circles in neighboring towns. He was a past president
of the Upper Mississippi Medical Society, president of
the local board of education for upwards of twenty
years, served as president of the village council and was
president of the county pension board for a number of
years.
In 1938, Dr. Christie, along with Dr. B. F. Van Valken-
burg, was honored at a dinner by the Long Prairie
Commercial Club, and tribute was paid to his long
medical service and his contributions to community
development.
A member of the Masonic Lodge, the Upper Missis-
sippi Medical Society, the Minnesota State and American
Medical Associations, the Great Northern Surgeons’ As-
sociation, Dr. Christie gave valuable medical and civic
service to bis community for a long period of time until
his retirement a few years ago. He will long be re-
membered by his many friends.
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Minnesota Medicine
Of General Interest
SOUTHERN MINNESOTA MEDICAL ASSOCIATION
Annual meeting — New Ulm, Minnesota, September
8, 1947.
* * *
In September Dr. G. M. A. Fortier, Little Falls, ex-
pects to move into his new one-story medical office
building, on which construction was begun in June.
* * *
A new member of the More Hospital and Clinic staff,
in Eveleth, is Dr. Adrian W. Davis, who became a resi-
dent of Eveleth during the first week of June.
* * *
Dr. Sheldon Clark Reed of Harvard University has
been appointed director of the Dwight Institute of Human
Genetics, effective in September, 1947.
* * *
Dr. R. G. Tinkham, who is associated with Dr. John
Eiler in Park Rapids, enrolled for a course in ob-
stetrics and gynecology in Chicago during June.
* * *
Medical dean of Crow Wing County with fifty-one
years of practice behind him, Dr. John Thabes, Sr.,
spoke on the progress of medical science at a meeting
of the Brainerd Lions Club on May 14.
Kalman & Company, Inc.
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ST. PAUL MINNEAPOLIS
A week of vacationing in Wisconsin during June cli-
maxed the end of his first year of practice in Glenwood
for Dr. J. T. Gericke of that city.
^ ^
Dr. T. J. Hughes, a member of the Mayo Clinic staff
for four years, is now associated with a group of
physicians in Corona, California, and is specializing in
ear, nose and throat and maxillofacial surgery.
;*c >-c %
Dr. C. K. Maytum, Rochester, spoke on “Functional
Respiratory Disturbance With Hyperventilation as a
Cause of Symptoms” at the meeting of the South Da-
kota State Medical Association in Rapid City on. June 3.
JjJ ^
Dr. S. A. Slater, Worthington, and Dr. Carl How-
son, Los Angeles, were chosen active vice presidents of
the National Tuberculosis Association on June 19 at the
annual meeting of the association in San Francisco.
* * *
Eighty-five year old Dr. A. M. Ridgway, Annandale,
who is still maintaining his medical practice, was honored
by the Annandale Masonic Lodge on June 2 was
presented with a fifty-year jewel.
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Address or telegraph communications or
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$75.00 weekly indemnity, accident Quarterly
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$20,000.00 accidental death $32.00
$100.00 weekly indemnity f accident Quarterly
and sickness
ALSO HOSPITAL EXPENSE FOR MEMBERS
WIVES AND CHILDREN
86c out of each $1.00 gross income used for
members’ benefits
$3,000,000.00 $14,000,000.00
INVESTED ASSETS PAID FOR CLAIMS
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Dr. Catherine Burns, (laughter of the late H. D.
Burns, Albert Lea, recently became associated in medical
practice with Dr. S. A. Whitson and Dr. J. P. Person
in offices at Albert Lea.
* * *
One of the speakers at the annual convention of the
AMA in June was Dr. W. G. Workman, Tracy, who
with Mrs. Workman traveled by plane to Atlantic City
for the meeting.
* * *
New offices for the practice of medicine in the spe-
cialty of eye, ear, nose and throat diseases have been
opened in International Falls by Dr. R. Hugh Monahan,
Jr., of that city.
* * *
Dr. William C. Dodds, a member of the Bratrud
Clinic in Thief River Falls for more than a year, has
entered into partnership with Dr. Donald M. Houston of
Park Rapids and has begun his practice in that city.
* * *
On May 29 Dr. W. W. Brown terminated his practice
in Isle and began a vacation trip to California. Upon
his return he planned to establish his medical practice in
Wilmont.
* * *
Dr. Henry E. Michelson, Minneapolis, was elected
chairman of the Section of Dermatology and Syphilol-
ogy at the recent meeting of the American Medical
Association in Atlantic City.
* * *
At the annual meeting of the North Dakota State
Medical Association, held in Fargo on May 27, Dr.
H. O. McPheeters, Minneapolis, presented a paper en-
titled, “Peripheral Circulatory Disease and the General
Practioner.”
* * *
In the alphabetic roster of members of the Minnesota
State Medical Association, printed in the May issue of
Minnesota Medicine, Dr. Roberta G. Rice’s address
was incorrectly listed as Aitkin. It should have been
Rochester.
* * *
Tracy acquired a new physician in May when Dr.
O. J. Esser, formerly of Gibbon, became an associate of
Dr. A. D. Hoidale and Dr. W. G. Workman in their
clinic in Tracy. Dr. Esser recently completed post-
graduate study in New York City.
* * *
Brazilian surgeon Dr. Paulo P. L. Baptista, who
has been studying chest surgery and tuberculosis at
Glen Lake Sanatorium for two years, recently left the
sanatorium to undertake further study in surgical pathol-
ogy elsewhere.
* * *
Recently elected as first vice chairman of the Min-
nesota Committee on Local Health Services was Dr.
D. A. Dukelow of Minneapolis. The committee is begin-
ning to form plans for resubmitting a new health bill
to the next state legislature.
Minnesota Medicine
OF GENERAL INTEREST
Since January, Dr. Frederick Kottke, Minneapolis, who
has a traveling medical fellowship, has studied in
Rochester, in New York City, and in Warm Springs,
Georgia. His major field of study has been physical
medicine, especially as it concerns poliomyelitis.
* * *
Back at work after a seven-month rest to improve his
health, Dr. I. F. Seeley, Northfield, has resumed his
medical practice. Dr. Seeley spent most of the past
winter in Arizona and returned to Northfield in early
spring.
* * *
Dr. Robert M. Ahrens, son of Dr. and Mrs. Albert
E. Ahrens of Saint Paul, received his degree of doctor
of medicine from New York Medical College on June
11. Dr. Ahrens served his internship at Ancker Hospital,
Saint Paul.
* * *
Dr. Alvin L. Schultz, Minneapolis, was one of forty-
one members of the Ohio State University hospital
staff who received certificates of service at the annual
dinner for medical and dietary interns at Columbus, Ohio,
during June.
Three Rochester physicians, Dr. M. C. Petersen, super-
intendent of the Rochester State Hospital, and Dr. H. P.
Heersema and Dr. Fred Moersch, Mayo Clinic staff mem-
bers, attended the annual meeting of the American
Psychiatric Association held in New York City during
May. Dr. Moersch is a counsellor of the association.
Dr. H. F. Colfer, fellow in medicine in the Mayo
Foundation, Rochester, has been granted the National
Research Council award for study with Professor E.
Adrian, chairman of the Department of Physiology at
Cambridge University in England, and will begin a one-
year fellowship at Cambridge in the fall.
* * *
Formerly of Watertown, South Dakota, Dr. Stephen
Hanten has become associated in medical practice in
Caledonia with Dr. J. J. Ahlfs. A graduate of Creighton
University in Omaha, Nebraska, Dr. Hanten served his
internship at St. Mary’s Hospital in St. Louis, Missouri.
He was in the army for five years during World War II.
* * *
Dr. Mario Fischer, Duluth health director and acting
St. Louis County health officer, was a member of the
Minnesota delegation which attended the forty-third an-
nual meeting of the National Tuberculosis Association
in San Francisco during June. Dr. Fischer is a director
of the association.
% %
Formerly of Kenyon, Dr. Clifford N. Rudie has
opened offices in Staples for the practice of medicine
and surgery. A graduate of the University of Louisville,
Kentucky, Dr. Rudie served his internship at Miller Hos-
pital in Saint Paul. He practiced in southern Minnesota
for a number of years.
* * *
The association of Dr. Henry J. Borge in the practice
of medicine and surgery has been announced by Dr.
Homewood hospital is one of the
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July, 1947
801
OF GENERAL INTEREST
R. C. Radabaugh, Hastings. Dr. Borge, a graduate of
Northwestern University Medical School and a veteran
of four years of army medical service, began his medical
practice with Dr. Radabaugh in May.
* * *
Dr. Albert V. Stoesser, Clinical Professor of Pediat-
rics, Medical School, University of Minnesota, and Di-
rector of Allergy Clinics of the Department of Pe-
diatrics, was elected a member of the Board of Regents
of the American College of Allergists at the annual meet-
ing held in Atlantic City in June.
* * *
Appointment of Dr. M. B. Llewellyn to the position
of pathologist at Asbury Hospital, Minneapolis, has been
announced. Dr. Llewellyn, a graduate of the University
of Minnesota Medical School, has been associated with
the pathology departments of Wayne University and
Henry Ford Hospital, Detroit.
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Dr. F. L. Stutzman, formerly of Newport, now at-
tached to an army preventive medicine section in Ma-
nila, Philippine Islands, has been promoted to the rank
of captain. A graduate of the University of Minnesota
Medical School, Dr. Stutzman entered the army in
April, 1946. He has been stationed in the Philippines
since September, 1946.
* * *
Dr. George B. Eusterman of the Mayo Clinic has been
awarded the Julius Friedenwald medal for outstanding
contributions in his specialty of gastroenterology. The
award was presented at the annual dinner of the Ameri-
can Gastroenterological Association, held at Atlantic
City in conjunction with the AMA meeting in June. Dr.
Eusterman was president of the association twenty-five
years ago.
* * *
At a meeting of the American College of Chest Physi-
cians in Atlantic City in early June, Dr. Lewis S. Jordan,
superintendent of Riverside Sanatorium at Granite Falls,
stated that on the basis of studies carried out in Min-
nesota the eradication of tuberculosis could probably be
accomplished within the life span of the coming genera-
tion.
* * *
Seventy-five year old Dr. A. Cyr of Barnesville had
the honor of pitching the first ball of the season on May
25 when the Barnesville baseball team opened its Red
River League schedule with a game with Downer. In
a brief ceremony which preceded the throwing of the
first ball, Dr. Cyr was presented with an engraved pen
and pencil set.
* * *
Dr. George McGeary, Jr., son of Dr. George McGeary,
Sr., of Minneapolis, has joined Dr. M. I. Hauge in
Clarkfield to form the Clarkfield Clinic.
A graduate of the University of Minnesota Medical
School, Dr. McGeary, Jr., served his internship at Ancker
Hospital in Saint Paul. He was recently discharged
from the army.
* * *
At the recent meeting of the International Congress
on Obstetrics, held in Dublin, Ireland, from July 5 to
12, Dr. Ann Arnold of Minneapolis was a member of
the American delegation. Dr. Arnold, together with her
daughter, Nancy, flew to London in June and planned
to travel extensively in Ireland and Scotland in addition
to attending the seven-day obstetrical meeting.
* * *
Dr. Arlie R. Barnes, Rochester, was elected president
of the American Heart Association at a meeting in At-
lantic City in June at which 100 laymen were admitted
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OF GENERAL INTEREST
to membership in the association. Dr. Barnes succeeds
Dr. Howard F. West of Los Angeles. Election of the
laymen, who included Harold Stassen, Samuel Goldwyn
and Mrs. Clare Booth Luce, was made in accordance
with a newly approved reorganization of the association.
* * *
A modern medical office building was recently opened
in Belle Plaine by Dr. H. M. Juergens of that city.
Architectural features of the offices include the newest
type of fluorescent lighting and a radiant heating sys-
tem, in which the entire floor serves as a radiator. The
building has been under construction since last win-
ter when Dr. Juergens’ old offices were destroyed in a
fire.
* * *
A certificate of merit was awarded to Dr. Karl
Pfuetze, superintendent of Mineral Springs Sanatorium,
and Dr. William H. Feldman and Dr. H. C. Hinssaw,
of the Mayo Foundation, for their exhibit at the AMA
convention in Atlantic City in June. Their exhibit,
which demonstrated the use of streptomycin in the treat-
ment of tuberculosis, was entitled, “Streptomycin : Ex-
perimental and Clinical Observations.”
* * *
Three thousand miles were covered by Dr. and Mrs.
George Friedell, Ivanhoe, during a two-week June va-
cation trip which included attendance at the annual con-
vention of the AMA in Atlantic City. A small family
reunion was staged at the AMA meeting when Dr.
Friedell met with his brother, Dr. Aaron Friedell of
Minneapolis, and his nephews, Dr. H. L. Friedell of
Cleveland and Dr. Morris Friedell of Chicago.
jjt %
Thirteen physicians are co-operating this summer in a
revised health program for 4-H members of Nobles
County. Conducting examinations and determining health
conditions of the 4-H members are Doctors E. A. Kil-
bride, B. O. Mork, Sr., B. 0. Mork, Jr., P. W. Harrison,
C. R. Stanley, F. L. Schade, R. P. Hallin, 0. M. Hei-
berg, all of Worthington; E. W. Arnold, D. E. Nealy,
L. A. Laikila, all of Adrian; D. J. Halpern, Brewster,
and B. M. Stevenson, Fulda.
HC 5}i *
Two brothers are now practicing medicine together in
Holdingford. Dr. E. J. Schmitz has announced that his
brother, Dr. Glenn Schmitz, has joined him in practice
at Holdingford, fulfilling a long-held ambition of both
brothers.
A graduate of St. Louis University Medical School,
Dr. Glenn Schmitz interned at Wheeling Hospital in
West Virginia and then served in the army from 1945
until February of this year.
* * *
In Europe to attend a medical conference, Dr. Hulda
Thelander, Little Falls, writes that living conditions in
Denmark are extremely restricted, that rationing is
severe, and that the Danish people have no heat, very
little butter or meat, and no fresh fruit, coffee, tea or
chocolate. Sweden, on the other hand, has a liberal ra-
tioning system and, judging by meals served and store-
window displays, is a rich country compared with the
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rest of Europe. That, Dr. Thelander writes, does not
help the Danish people, however, for the Danes can take
only $5 with them if they leave Denmark and they cannot
get permission to leave without a good reason.
* * *
Dr. G. B. Ne\y, Rochester, discussed “Nasal Deformi-
ties, Congenital and Acquired: Methods of Treatment”
at the meeting of the Canadian Otolaryngological So-
ciety at Minaki Lodge, Ontario, Canada, during the week
of June 23.
* * *
At a meeting of the Wyoming State Medical Society
during the week of June 23, Dr. J. Grafton Love, Roch-
ester, spoke on “Injuries to the Central Nervous Sys-
tem” and “Spinal Cord Tumors and Protruded Disks
as Causes of Backache and Sciatic Pain.”
* * *
On July 1, Dr. A. L. Koskela, formerly of Grand
Rapids, began an association with Dr. G. A. Miners in
the Deer River Clinic. Since his return from military
service, Dr. Koskela has been associated with Dr. M.
J. McKenna, Dr. F. M. John and Dr. A. V. Grinley of
Grand Rapids.
Dr. H. R. Anderson, a member of the Deer River
Clinic for the past twelve years, has withdrawn from
the clinic and moved to to Arizona.
* * *
Mayo Clinic staff members Dr. P. A. O’Leary and
Dr. C. F. Code of Rochester were on the program of
the Canadian Medical Association meeting in Winnipeg,
Canada, during the week of June 23. Dr. O’Leary spoke
on the subjects, “The Present Status of Penicillin in
the Treatment of Syphilis” and “Xanthomatoses.” Dr.
Code discussed a series of papers on the role of hista-
mine in allergy and also presented a paper entitled, “A
Study of the Action of Antihistamine Drugs in the Skin
of Human Beings.”
* * *
On his fiftieth anniversary as a practicing physician,
Dr. Fred H. Rollins of St. Charles celebrated by attending
a Chicago reunion of former classmates from the class
of 1897 of Rush Medical College.
With the exception of a year at White Rock, South
Dakota, and at West Salem, Wisconsin, Dr. Rollins has
spent his entire medical career at St. Charles. A public-
spirited citizen, he has served the community as mayor
and for the past forty years as a member of the
school board.
* * *
A new physician in Princeton is Dr. W. F. McManus,
formerly of Chicago, who is now associated in the prac-
tice of medicine with Dr. W. R. Blomberg of Prince-
ton. Dr. McManus graduated from the College of
Medicine of Loyola LTniversity in 1938 and then served
his internship at St. Anne’s Hospital, Chicago. After
practicing in Chicago for three years, he entered the
army and served for thirty-nine months, part of the
time as chief of the surgical and laboratory staffs of two
hospitals in Florida.
PALM ORTHOPEDIC
APPLIANCE CO.
Bra ces for the Handicapped
Abdominal and Arch Supports
Elastic Stockings
Sacro Iliac Belts
Expert Truss Fitters
Crutches and Canes
54 W. 4th St. - GArfield 8947
ST. PAUL 2, MINN.
VJL WaL s your (glasses
Glasses produced by us are made with
the precision that only the finest and most
up-to-date equipment makes possible.
Consult an authorized eye doctor . . .
Let us design and make your glasses
Dispensing Opticians
25 W. 6th St. St. Paul
CE. 5797
DANIELSON MEDICAL ARTS PHARMACY, INC
10-14 Arcade, Medical Arts Building urmuc
PHONES: HOURS:
ATLANTIC 3317 825 Nicollet Avenue — Two Entrances — 78 South Ninth Street WEEK DAYS — 8 to 7
ATLANTIC 3318 MINNEAPOLIS SUN. AND HOL— 10 TO 1
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
INSTRUMENTS ■ TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494
804
Minnesota Medicine
OF GENERAL INTEREST
A pre-medical student at the LTniversity of Minnesota,
Jason Aronson of Little Falls is studying socialized
medicine in England this summer. One of forty Uni-
versity students selected by a faculty committee to
study conditions and people in Europe for two months,
Aronson planned to concentrate on government-spon-
sored medical programs, considering advantages and dis-
advantages, gathering information on the attitudes of the
laity and the professional men. Students participating in
the European study program were selected on the basis
of scholarship, leadership and background in their chos-
en field.
* * *
Two University of Minnesota medical scientists, Dr.
Maurice B. Visscher and Dr. John J. Bittner, are tour-
ing Austria and Hungary this summer as members of a
ten-man team of American and Swiss physicians to pro-
mote international exchange of medical and scientific
knowledge.
Dr. Visscher, head of the Department of Physiology
of the University of Minnesota, is chairman of the
group, which is sponsored by the LTnited Nations.
Dr. Bittner, professor of cancer biology at the Uni-
versity of Minnesota, who will tell European physicians
of recent development in cancer research, was chosen as
president of the American Association for Cancer Re-
search at a meeting on June 2.
Main topics to be discussed by members of the ten-
man team at medical meetings in Austria and Hungary
include the latest developments in surgery, poliomyelitis,
cancer, medicine and psychiatric research.
Red Wing physician Dr. L. E. Claydon, who has
circled the globe three times, made seventeen Atlantic
crossing and visited every continent in the world, com-
pleted his fifty-second year in the practice of medicine
on June 12.
A graduate of the University of Minnesota Medical
School, Dr. Claydon began his medical practice with
Dr. M. H. Cremer at Mezeppa in 1895. After seven
years in Mezeppa the two moved to Red Wing and
established their practice there. Since 1900, when he went
to Germany and Norway for additional medical study.
Dr. Claydon has gone on some type of world jaunt every
few years, but has always returned to his practice in
Red Wing. At the present he has no thoughts of re-
tiring.
* * *
Among the speakers at the forty-third annual meet-
ing of the National Tuberculosis Association in San
Francisco in June were Dr. J. A. Myers, professor of
medicine at the University of Minnesota, and Dr. H. C.
Hinshaw of the Mayo Foundation, Rochester. Dr. Myers
participated in a panel discussion on the use of BCG
vaccine in tuberculosis. Dr. Hinshaw, vice president of
the association, spoke on recent research in tuberculosis
and gave an evaluation of the use of streptomycin in the
treatment of tuberculosis. President of the National Tuber-
culosis Association is a former Minnesota man. Dr. Wil-
liam P. Shepard, now of San Francisco, who was former-
ly on the staffs of the Minnesota State Department of
Health and the University of Minnesota School of Public
Health.
' " ' ""
THE VOCATIONAL HOSPITAL
TRAINS PRACTICAL NURSES
Nine months Residence course. Registered Nurses and
Dietitian as Teachers and Supervisors. Certificate from
Miller Vocational High School. VOCATIONAL NURSES
always in demand.
EXCELLENT CARE TO CONVALESCENT AND
CHRONIC PATIENTS
Rates Reasonable. Patients under the care of their own physicians,
who direct the treatment.
5511 Lyndale Ave. So. LO. 0773 Minneapolis, Minn.
\ immmmmi «» hi."""'"' """"""" """ "
REST HOSPITAL
A quiet, ethical hospital with therapeutic facilities
for the diagnosis, care and treatment of Nervous
and Medical cases. Invites cooperation of all
reputable physicians who may supervise the treat-
ment of their patients.
PSYCHIATRISTS IN CHARGE
Dr. Hewitt B. Hannah
Dr. loel C. Hultkrans
2527 2nd Ave. S., Minneapolis, Phone At. 7369
July, 1947
805
iiiiiiiiiiiiiiiiiiiiiiiiiMiiiiiiiiiiiiiiiiiiiiiiiiiiniiiiiiiimiiiiiimiiiiiiiiiiiiiiiiiiiiu^
Vlali/moL PhamumL S&Avke, . . . roB HOSP,TALS-cuT^l»lSrosrncEs
PART TIME — TEMPORARY — PERMANENT
When in need of a PHYSICIAN, DENTIST, OFFICE NURSE, TECHNICIAN, MEDICAL SECRETARY, or
OTHER PERSONNEL for medical and dental offices, clinics, and hospitals contact —
Minneapolis, Minn. — GE. 7839 The Medical Placement Registry st. ^aui^M^n.— GA!n67i8
OLIVE H. KOHNER, Director
Classified Advertising
Replies to advertisements should be mailed in care of
Minnesota Medicine, 2642 University Avenue, Saint
Paul 4, Minn.
FOR SALE — Full set stainless steel surgical instru-
ments, general, orthopedic, neuro, chest. Additional
miscellaneous chrome. Condition excellent. Telephone
Main 6003, or write J. H. Strickler, M.D., 814 S. E.
4th Street, Minneapolis 14, Minnesota.
WANTED — Laboratory technician, B.S. degree or
equivalent experience, general lab work and chemistry.
Good salary, paid vacation and sick leave. Full par-
ticulars first letter. Write Laboratory Director, Glen
Lake Sanatorium, Oak Terrace, Minnesota.
WANTED — A well-qualified physician, preferably one
interested in Internal Medicine and preferably Catho-
lic to assist in general practice in city of 2,000. Ex-
cellent equipment and opportunity for experience and
eventual permanent association. Address E-23, care
Minnesota Medicine.
FOR SALE IMMEDIATELY — Slightly used general
practitioner’s examining room equipment. Good con-
dition. Telephone Regent 7355.
WANTED — Physician for southern Minnesota location.
A small town with a large drawing area of a well-
to-do farming community. Office space available.
Contact M. C. Mattson, President of Vernon Center
Business Men’s Association, Vernon Center, Minn.
FOR RENT — Excellent location for physician in Mid-
way district, Twin Cities. Telephone Dr. M. L. Nor-
man, Midway 2040.
FOR SALE — Used x-ray equipment in good condition.
Placed for quick sale as room is needed for other
purposes. Address E-22, care Minnesota Medicine.
LOCATION OR EQUIPMENT FOR SALE— A gen-
eral practitioner retiring desires to sell equipment at
once. Write E -24, care Minnesota Medicine, or tele-
phone Midway 7054.
TAILORS TO MEN
r,4jjp|P% jjkj',!; J
SINCE 1886
ll
The finest imported and
si
domestic woolens such as
SCHUSLER'S have in stock
are not too fine to match
■:Jy§r • #
the hand tailoring we al-
ways have and always
m
will employ.
■ rv/..
J. T. SCHUSLER co.
j|g||j
379 Robert St. St. Paul
George Dejmek
BORCHERDT
MALT SOUP
EXTRACT
or Constipated Babies)
Borcherdt's Malt Soup Extract is a laxative
modifier of milk. One or two teaspoonfuls in a
single feeding produce a marked change in the
stool. Council Accepted. Send for sample.
BORCHERDT MALT EXTRACT COMPANY, 217 N. Wolcott Ave., Chicago 12,
806
Minnesota Medicine
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
■ INSTRUMENTS • TRUSSES • EQUIPMENT • PHARMACEUTICALS ■ DRUGS
SAVE TIME!
TRY DAHL'S FIRST
Biologicals Dressings
Pharmaceuticals Surgical Instruments
Hypodermic Medications Trusses
7:30 a.m. to 6 p.m.
Holidays, 9 a.m. to 6 p.m.
Joseph E. Dahl Co.
Incorporated
ATlantic 5445 82 So. 9th St.. Mpls.
Radiological and Clinical
Assistance to Physicians
in this territory
MURPHY LABORATORIES
Minneapolis: 612 Wesley Temple Bldg. - - At. 478i
St. Paul: 348 Hamm Bldg. ...... Ce. 7125
If no answer, call Ne. 12S1
Orthopedic Braces and
Appliances
Physicians' specifications
followed precisely.
Scientific manufacture
and fitting.
AUGUST F. KROLL
Manufacturer
230 WEST KELLOGG BLVD.
St. Paul. Minn. CE. 5330
Hall & Anderson
PRESCRIPTION PHARMACY
BIOLOGICALS
PHYSICIANS’ SUPPLIES
SAINT PAUL, MINN.
LOWRY MEDICAL ARTS BUILDING
TELEPHONE: CEDAR 2733
LOW COST- Auto Loans
vj^R'C
V
4 *
Ii you need cash for your
new car — borrow to your
advantage.
The American Way Plan
has served thousands . . .
the same courteous, effi-
cient service is available to
you.
THE AMERICAN NATIONAL BANK
OF SAINT PAUL
Bremer Arcade Robert at 7th CE 6666
Member Federal Deposit Insurance Corporation
^
UNUSUAL LENS GRINDING
CATARACT,
MYO-THIN
and other difficult
and complicated
lenses are ground to
extreme thinness and
accuracy by our
expert workmen.
ORTfKIRpWlLUAPlJ =S
l J
Insurance
at a
Saving
MINNESOTA
Druggists Mutual Insurance Company Pr°mPt
OF IOWA. ALGONA, IOWA LOSS
Fire - Tornado - Automobile Insurance Service
REPRESENTATIVE-S. E. STRUBLE, WYOMING, MINN.
July, 1947
807
WHEN interviewed between platefuls, this 11-months-old
young man emphatically stated: "I have been brought
up on Pablum and still like it, but some days when I’m in the
mood for oatmeal, nothing satisfies me like Pabena!”
Nutritious , quick and easy to prepare ,
both products are for sale at drug stores .
MEAD JOHNSON & COMPANY, EVANSVILLE, IND., U.S.A.
808
Minnesota Medicine
The traditional efforts to escape
from areas of “high pollen count”
by plane/ car, train or ship may
frequently be unnecessary. This
summer many people will be
able to stay at home/ or go
vacationing from preference
rather than from the necessity
of escape. The reason is
BENADRYL* The patient will
appreciate the facility with
which this antihistaminic induces
relief from the symptoms of
allergy. In most cases, from
25 to 50 mg. are sufficient to
produce complete symptomatic
relief.
BENADRYL (diphenhydramine
hydrochloride) is available in
Kapseals® of 50 mg. each, in
capsules of 25 mg. each, and
as a palatable elixir containing
1 0 mg. in each teaspoonful.
\
nadryl
hyd rochlori
de
PARKE. DAVIS 8c COMPANY. DETROIT
3 2 .
MICHIGAN
Your Ability to Earn
is your
Greatest Asset
WHAT WILL BE YOUR EARNINGS TO AGE 60 ASSUM-
ING YOU MAKE $150 PER WEEK?
The figures below will give you the answer.
Age
25 (earnings to age 60) $273,000
30 234,000
35 195,000
40 156,000
45 117,000
(Earnings of $300 per week will double the above figures.)
Don't make your policy part of the hazard of disability.
Protect your earning capacity with long term, non-
cancellable, incontestable disability insurance.
Write or Call
MASSACHUSETTS INDEMNITY INSURANCE COMPANY
Ralph H. Brastad, Agency Manager
1400 RAND TOWER GENEVA 8319
MINNEAPOLIS 2, MINNESOTA
810
Minnesota Medicine
QHmms&k Qflmcine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30
August, 1947
No. 8
Contents
“For Manners Are Not Idle.”
Louis A. Buie, M.D., Rochester, Minnesota 841
Postgraduate Medical Education in a Private
Hospital.
Arthur H. Wells, M.D., Duluth, Minnesota 845
Water-Borne Tularemia.
Abraham Falk, M.D., Minneapolis, Minnesota.. 849
Infection of the Neck After Tonsillectomy.
Clifford F. Lake, M.D., Rochester, Minnesota... 851
Sporotrichosis in Minnesota.
John F. Madden, M.D., Saint Paul, Minnesota. . 854
Tuberculosis Among Residents of Olmsted
County Over the Age of Sixty-five.
F . M. Feldman, M.D., Dr. P. H., Rochester,
Minnesota 856
Metastatic Carcinoma of the Heart.
J. S. Blumenthal, M.D., F.A.C.P., and Herbert
W. Peterson, M.D., Minneapolis, Minnesota... 860
Clinical-Pathological Conference :
Chordoma.
Arthur H. Wells, M.D., Arnold O. Swenson,
M.D., and Harold H. Joffe, M.D., Duluth,
Minnesota 863
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. (Continued from July
issue.)
Nora H. Guthrey, Rochester, Minnesota 867
President’s Letter:
The General Practitioner 877
Editorial :
If You Were Told 878
Associated Medical Care Plans 878
Community Chest 879
Report of AM A Delegates 880
Medical Economics :
Delegates Discuss Health Questions at Duluth
Meet 881
Minnesota Academy of Medicine :
Meeting of March 12, 1947 884
Educational Management in Psychomatic Medicine
with Special Reference to the Gastrointestinal
Tract.
Harvey O. Beek, M.D., Saint Paul, Minnesota. 884
Cogenital Dislocation and Congenital Subluxation
of the Hip.
Vernon L. Hart, M.D., Minneapolis, Minnesota. . 889
Reports and Announcements 898
In Memoriam 903
Of General Interest 906
Book Reviews 910
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918.
August, 1947
811
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
C. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — $3.00 Single Copies — $0.40. Foreign and Canadian Subscriptions — $3.50.
The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
ST. CROIXD ALE ON LAKE ST. CROIX
PRESCOTT. WISCONSIN
MAIN BUILDING— ONE OF THE 8 UNITS IN “COTTAGE PLAN”
A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous and Mental Disorders
Located on beautiful Lake St. Croix, eighteen miles from the Twin Cities, it has the advantages of both
City and Country. Every facility for treatment provided, including recreational activities and occupational
therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
NEUROPSYCHIATRISTS
PRESCOTT OFFICE
Prescott, Wis.
Howard J. Laney, M.D.
Tel. 39 and Res. 76
Hewitt B. Hannah, M.D.
Joel C. Hultkrans, M.D.
Howard J. Laney, M.D.
511 Medical Arts Building
Minneapolis. Minnesota
Tel. MAin 1357
SUPERINTENDENT
Dorothy M. Most, R.N.
Prescott, Wisconsin
Tel. 69
812
Minnesota Medicine
Special, (Policy, fan, OIL Vfl&mbehA,
ACCIDENT AND SICKNESS
INSURANCE
STATE MEDICAL ASSOCIATION MEMBERS
Only,!
• POLICY NON-CANCELLABLE FOR THE INDIVIDUAL.
• CARRIED TO AGE 70.
• PREMIUM NEVER RAISED NOR BENEFITS REDUCED.
• NO HOUSE CONFINEMENT FOR EITHER ACCIDENT OR SICKNESS.
• NO RESTRICTION AS TO THE KIND OF ACCIDENT OR ILLNESS.
• 40% TO 60% SAVING IN PREMIUM DUE TO GROUP PURCHASING
POWER OF YOUR ASSOCIATION.
• NO EXAMINATIONS NECESSARY DURING ENROLLMENT PERIOD.
• MANY OTHER ATTRACTIVE FEATURES.
! - ' /
fomplsdsL (bslailA, ofc, Hua, Plan, wilL bsL Mint io ipiL
within, cl few daijA,
CASWELL-ROSS AGENCY
The Commercial Casualty Insurance Company
1177 Northwestern Bank Bldg. • Minneapolis
MA. 2585
Investigated and Recommended by:
Minneapolis District Dental Society
Minnesota State Dental Society
Minnesota State Pharmaceutical
Minnesota State Bar Association
Hennepin County Bar Association
Ramsey County Bar Association
Stearns-Benton County Medical Society
Hennepin County Medical Society
Ramsey County Medical Society
St. Louis County Medical Society
11th Judicial Bar Association
St. Paul District Dental Society
St. Cloud Dental Society
West Central District Dental Society
August, 1947
813
20%
IMPROVE
FREE OF SEIZURES
32 %
SEIZURES REVUCEV BY
■ •
MORE THAN %
' T
WORSE
UNCHANGED
Improvement In 85%
of Petit Mai Cases
with Tridione
Here’s new evidence that Tridione is effective in petit mal. A recent study
showed that it brought decided improvement in 83% of the patients to
whom it was administered.13 In this study, Tridione was given to 166 pa-
tients suffering from petit mal (pykno-epilepsy), myoclonic jerks or akinetic
seizures. This group, as a whole, had received little or no benefit from other
medicaments. With Tridione, 31% became free of seizures; 32% had fewer
than one-fourth of the previous number of seizures; 20% improved to a
lesser extent; 13% remained unchanged, and only 4% became worse. Thus
83% showed improvement. • Furthermore, in some cases the seizures did not
return when Tridione was discontinued. Studies also showed that Tridione
was beneficial in certain psychomotor cases when given in conjunction
with other antiepileptic drugs.12 Prescription pharmacies everywhere stock
Tridione in 0.3-Gm. capsules or in pleasant-tasting aqueous solution con-
taining 0.15 Gm. per fluidrachm. May we send latest Tridione literature?
[Trimethadione, Abbott)
ITI • V • &
Tridione
llOGftAPHY
1 . Richords, R K , and Everett, G. M
(1944), Analgesic and Anticonvul-
sant Properties of 3.5,5-Trimethyl-
oxazolidme-2.4 -dione (Tridione),
Federation Proc , 3 39, March
S. Goodman, L , and Manuel, C
(1945), The Anticonvulsant Proper-
ties of Dimethyl-N-mefhyl Barbituric
Acid and 3,5,5-Trimethylo*azoli -
dme 2,4-dione (Tridione), Federa
lion Proc , 4 119, Mar 3. Good-
man, L S , Toman, J E P . and
Swmyard, E A (1946), The Anti-
convulsant Properties of Tridione,
Am J Med , 1 213, September
4. Richards, R K , Perlstein, M. A
(1946), Tridione, o New Drug for
the Treatment of Convulsive and
Related Disorders, Arch Neurol
and Psychiat , 55 164, February
5. Lenno*,W G (1945), The Treat-
ment of Epilepsy, Med. Clin North
America, 291114. September.
6. Thorne, F C (1945), The Anticon-
vulsant Action of Tridione Prelimi-
nary Report, Psychiatric Quart , 19
686. Oct 7. Lennox, W G
(1945), Petit Mal Epilepsies
Their Treatment with Tridione, J
Am er Med Assn ,129 1069, Dec 15
8. Lenno*. W G (1946). Newer
Agents in the Treatment of Epilepsy,
J Pediat . 29 356. Sept 9 De
Jong. R N (1946), Effect of Tn-
dione in Control of Psychomotor
Attacks, J Amer Med Assn, 130
565. Mar 2. 10. Perlste.n, M A .
ond Andelman, M B (1946), Tr.
dione Its Use in Convulsive and Re-
lated Disorders, J Pediat , 29 20,
July 1 1 . Lenno*. W G
(1946), Two New Drugs in Epilepsy
Therapy, Am J Psychiat . 103 159,
Sept 12. DeJong. R N (1946),
Further Observations on the Use of
Tridione in the Control of Psycho-
motor Attocks, Am J. Psychiat ,
103 162, Sept 1 3. Lenno*, W. G.
(1947), Tridione in the Treatment
of Epilepsy, J Amer Med Assn ,
134 138, May 10 14. Rickies, N K,
ond Polan, C G (1947), Tridione
Its Use in the Treatment of Epilepsy
ond other Neurologic Disorders,
Northwest Med , 46 375, May
814
Minnesota Medicine
. t on ffl gfo«s *oU 801 H
_ -
Stdiiity
OPERATES ON F.C.C.
ALLOCATED FREQUENCY
ie exclusive L-F WAVEM ASTER frequency control main-
ins operation at the frequency allocated by the Federal
Dmmunications Commission.
EVERY KNOWN METHOD
OF APPLICATION IS AVAILABLE
WITH THE L-F SW-227
dinged Treatment Drum
• Air Spaced Plates
• Condensor Pads
• Inductance Cable
• Orificial Electrodes
ne Hinged Treatment Drum alone is adjustable to fit the
untour of any part of the body to be treated. PLUS Pro-
ict-A-Tube safeguard . . . single-tube design, for remark-
ole economy . . . Voltage Compensator . . . Metering De-
ice . . Adjustable, Counterbalanced Arm . . . and other
latures. Write for L-F Catalog M-847.
DISTRIBUTED BY
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
MINNEAPOLIS
MINNESOTA
£15
August, 1947
WHENEVER NUTRIENT INTAKE
MUST BE AUGMENTED
The occasion frequently arises when
the intake of all essential nutrients
must be increased, as in general under-
nutrition, following recovery from in-
fectious diseases and surgical trauma,
and during periods of anorexia when
food consumption is curtailed.
In the general management of these
conditions, the dietary supplement
made by mixing Ovaltine with milk
can find wide applicability. Delicious
in taste, it is enjoyed by all patients,
young and old. Its low curd tension
and easy digestibility impose no added
gastrointestinal burden on the patient.
This nutritious food drink supplies all
the nutrients considered essential for
a dietary supplement: biologically ade-
quate protein, readily utilized carbo-
hydrate, easily emulsified fat, B-com-
plex and other vitamins including
ascorbic acid, and essential minerals.
The recommended three glassfuls daily
virtually assures normal nutrient intake
when taken in conjunction with even
a fair or average diet.
THE WANDER COMPANY, 360 N. MICHIGAN AVE., CHICAGO 1, ILL.
Three servings daily of Ovaltine, each made of
Zi oz. of Ovaltine and 8 oz. of whole milk,* provide:
CALORIES
669
VITAMIN A
3000 I.U.
PROTEIN
32.1 Gm.
VITAMIN Bi
1.16 mg
FAT
31.5 Gm.
RIBOFLAVIN
2.00 mg.
CARBOHYDRATE
64.8 Gm.
NIACIN
6.8 mg.
CALCIUM
1.12 Gm.
VITAMIN C
30.0 mg.
PHOSPHORUS
0.94 Gm.
VITAMIN D
417 I.U.
IRON
12.0 mg.
COPPER
0.50 mg.
*Based on average reported values for milk.
816
Minnesota Medicine
Comes summer . . . comes hay fever . . . comes
Neo-Synephrine for relief.
Decongestion of nasal and ocular edema occurs
promptly, lasts for hours . . . hypersecretion and
excessive lacrimation are quickly checked . . . days
are more comfortable, nights more restful.
Neo-Synephrine
BRAND OF PHENYLEPHRINE
HYDROCHLORIDE
/lay fetter belief
INDICATED for relief of the nasal and ocular symptoms of hay
fever, sinusitis and summer colds.
FOR INTRANASAL USE: %% in isotonic saline and in isotonic
solution of three chlorides (Ringer's) with aromatics, 1% in saline,
1 fl. oz. bottles; Vi% in water-soluble jelly, % oz. applicator tubes.
FOR OPHTHALMIC USE: '/s% in low surface tension, aqueous
solution,* isotonic with tears, 15 cc. bottles.
FREDERICK STEARNS & COMPANY • DIVISION
DETROIT 31, MICHIGAN • New York • Kansas City * San Francisco • Atlanta
Windsor, Ontario • Sydney, Australia • Auckland, New Zealand
“Contains Aerosol OT 100 (dioctyl ester of sodium sulfosuccinate) 0.001 f/o
Trade-Mark N eo-Synephrine Reg. U. S. Pat. Off..
August, 1947
817
KOROMEX JELLY
ACTIVE INGREDIENTS: Boric acid 2.0%, oxyquinolin benzoate
0.02% and phenylmercuric acetate 0.02% in a base of glycerin,
gum tragacanth, gum acacia, perfume and de-ionized water.
• Fastest Spermicidal Time
measurable under Brown and Gamble technique
• Proper Viscosity
for cervical occlusion
• Stable Over Long Period of Time
pH consistent with that of the normal vagina
and in addition
time-tested clinical record
Prescribe Koromex Jelly with Confidence
, . . send for literature
HOLLAND-RANTOS COMPANY, INC., 551 FIFTH AVENUE, NEW YORK 17, N. Y.
818 Minnesota Medicine
"
.
i
Benzedrine Inhaler, N.N.R.
.. is quite effective in the
clearing of nasal congestion
due to allergy or infection."
* , Feinberg. S. M.: Allergy in Practice, Chicago,
. ♦ . • The Year Book Publishers, Inc., 1944, p. 502.
...
Jour hay fever patients will be grateful ... particularly between
* * * • office visits ... for the relief of nasal
congestion afforded by Benzedrine Inhaler,
N. N. R. The Inhaler may make all the
difference between weeks of acute misery
and weeks of comparative comfort.
Benzedrine Inhaler
•tUlUl »•'
ach Benzedrine Inhaler is packed with racemic amphetamine. $.K F., 250 mg.; menthol, 12.5 mg.; and aromatics.
a better means of nasal medication
Smith, Kline & French Laboratories
Philadelphia, Pa.
.
* .
1 8
|
August, 19-57
819
Prepared originally for infant feeding
now used extensively
for special diet cases
Good food plays a psychologically as well as a
physiologically important part in aiding recovery.
This is one reason so many doctors are now using
Swift’s Strained Meats for patients on high-protein,
low-residue diets containing chemically and physi-
cally non-irritating foods. Swift’s Strained Meats
provide a palatable, natural source of complete,
high-quality proteins, B vitamins and minerals for
patients whose condition prohibits the use of meats
prepared in the ordinary manner. Each of the six
kinds: beef, lamb, pork, veal, liver and heart, offers
a tempting, distinctive meat flavor more readily
accepted by patients, even when normal appetite is
impaired.
Lean meat— strained
fine enough for tube-feeding
Swift’s Strained Meats, developed orig-
inally for feeding to young babies, are
prepared from selected, lean U. S. Gov-
ernment Inspected Meats. They are care-
fully trimmed to reduce fat content to a
minimum. The meats are slightly salted and strained
so fine they will pass through the nipple of a nurs
ing bottle . . . may easily be used in tube-feeding.
Convenient to use— especially for patients at home
—Swift’s Strained Meats are ready to heat and serve!
Each vacuum-sealed tin contains 3V$ ounces of meat.
Swift’s Diced Meats— tender, juicy cubes
For soft, smooth, high-protein and low-residue
diets, these small cubes of lean meat offer new con-
venience and appetizing variety. Swift’s Diced
Meats are tender juicy pieces of meat, easily mashed
into smaller particles if desired. 5 ounces per tin.
We will be glad to send you further informa-
tion about Swift’s Strained and Swift’s Diced
Meats with samples. Write Swift & Com-
pany, Dept. BF, Chicago 9, Illinois.
All nutritional statements made in this
advertisement are accepted by the Council *
on Foods and Nutrition of the American
Medical Association.
820
SWIFT & COMPANY • CHICAGO 9, ILLINOIS
Minnesota Medicine
While sodium estrone sulfate is the principal estrogen in "Premarin," other equine ^
estrogens . . . estradiol, equilin, equilenin, hippulin . . . are also present as water-
soluble sulfates. The water solubility of conjugated estrogens (equine) assures rapid
absorption from the gastrointestinal tract. ***<» KTS'*
for an active
....a “PLUS
The "sense of well-being" so frequently reported by patients following "Premarin"
therapy often means the difference between an active, enjoyable middle age
and a sedentary one. Not only prompt relief from distressing menopausal
symptoms but also a brighter mental outlook which may be translated into a
desire "to be doing things”. ..such are the results which may usually be expected
following "Premarin" administration . . . therapy with a "plus."
August, 1947
"Premarin" provides effective estrogenic therapy through the oral route with
comparative freedom from untoward side effects.
"Premarin" is available as follows:
Tablets of 2.5 mg bottles of 20 and 100.
Tablets of 1.25 mg bottles of 20, 100 and 1000.
Tablets of 0.625 mg bottles of 100 and 1000.
liquid, containing 0.625 mg. in each 4 cc. (1 teaspoonful) bottles of 120 cc.
CONJUGATED ESTROGENS
(equine)
Premarin
AYERST, McKENNA & HARRISON Limited
22 EAST 40lh STREET, NEW YORK IS. N. Y.
•C-
1m If kfc . .
The First Prescription was written in Egypt about 3700 B.C. Later, when the
color of an herb was believed to indicate which planet it was under and for what
disease it should be used, herbs were compounded with long prayers for their success
to Jupiter, largest of the planets. Next, the prayers were condensed, written over the
command "Recipe!” (Take!), and finally shortened to (R plus a vestige of the
old sign of Jupiter).
The First Dental Prescription was Galen’s, about 165 A.D. — a smooth paste for
the cavity of an aching tooth (carrot, anise and parsley seeds, saffron, black pepper
and opium).
Between those prescriptions — about 2030 B.C., in the Code of Hammurabi —
broke the dawn of malpractice law. (" If the doctor has caused a gentleman to die , one
shall cut off his hands ... if he has caused a slave s death , he shall render slave for slave.”')
The First Prescription Today, for most doctors, is the complete protection and
the confidential service provided by a Medical Protective policy.
Professional Protection exclusively. . . since 1899
MINNEAPOLIS Office: Stanley J. Werner, Representative, 816 Medical Arts Building, Telephone Atlantic 5724
822
Minnesota Medicine
"Better Call the Doctor"
A familiar phrase in these United States. Self sacrificing, and
willing to help at all times, the doctor has indeed earned his high place in
our social esteem.
Right now we’re , “calling the doctor.” Physicians and hospitals
across the country are seriously concerned over the shortage of trained nurses
available. We feel that in this case, too — the doctor is best able to solve the
problem. A well trained corps of nurses is vitally necessary to insure the high
standard of medicine as we now know it.
Glenwood Hills Hospital — through its school of nursing — is anxious
to cooperate with you in your effort to increase the number of nurses in your
community. A student from your locality will result in increased nursing as-
sistance to you in the near future. Your help is greatly needed in recruiting
candidates for this profession. For full information write Miss Margaret Chase,
R.N., B.S., Director, School of Nursing.
SCHOOL OF
PSYCHIATRIC
OORSIHG
FALL CLASS
will start in
September
Candidates for the Sep-
tember class should make
reservations at once . . .
School and health record
must be reviewed and
correspondence complet-
ed prior to acceptance.
“Hospital administrators and doctors throughout the country are
seriously concerned over the dangerously inadequate nursing care
available. Results of a recent survey indicate that 55 to 60 per cent
of the required amount is obtainable . . .
“ . . approved hospitals should provide training for such voca-
tional nurses by means of short courses.’
“The doctor is responsible for the care of the patient. In order to
meet this obligation, the medical staff together with the hospital and
nursing administrators, are urged to undertake the development and
execution of this program.”1
“It is time that some of the present-day advantages of a nursing
career be made known to young women.”2
ONE YEAR NURSING COURSE
Glenwood Hills Hospitals are currently offering to qualified
applicants a one year course in psychiatric nursing. All phases
of the subject are skillfully presented by a capable and experi-
enced faculty. TUITION IS FREE. Regular classes begin in
January, June, and September.
enuuooc
MS os
3i a s
ft
3501 Golden Valley Road : Route Seven : Minneapolis/ Minn.
1. Irvin Abell, M.D., Chairman, Bd. of Regents, Am. Col. Surgeons; Am. Jl. of Nursing, March 1947.
2. A. E. Hedback, M.D., Editor, Modern Medicine; Jl.-Lancet, April 1947.
August, 1947 t’2J
PYOKTANIN SURGICAL GUT
Plain and Jemalijed
Manufactured Since 1899 by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia.
• • •
Price Xiit
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE G NONBOILABLE
Sizes 000 — 00 — 0 — 1— 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
Ill
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul. Minnesota
FDR SALE BY SURGICAL DEALERS AND DRUGGISTS
824
Minnesota Medicine
"Dyspepsia” due to hyperchlorhydria is the
most common of all gastric disturbances. . . By
prescribing Creamalin for the control of hy-
peracidity, the physician is assured of prolonged
antacid action without the danger of alkalosis
or acid rebound. Through the formation of a pro-
tective coating and a mild astringent effect,
nonabsorbable Creamalin soothes the irritated
gastric mucosa. Thus it rapidly relieves
gastric pain and heartburn.
[reamalin
Brand of aluminum hydroxide gel
LIQUID IN 8 OZ., 12 OZ., AND 1 PINT BOTTLES
CHEMICAL COMPANY , INC .
New York 13, N. Y. • Windsor, Ont.
825
CREAMALIN, trademark Reg. U.S. Pat. Off. & Canada
August, 1947
Same patient; Sup-
port applied. The
uterus is being held
up and back more
nearly over the sup-
porting joints.
Patient, para IV,
has never worn an
abdominal support
during previous preg-
nancies. Came for
support when seven
months pregnant.
By relieving the forward and downward shift of the enlarged uterus, Camp
prenatal supports take some of the tension from the abdominal muscles and
fasciae, assist in the return of venous blood, prevent many backaches and
give exceptional support to the softened joints of the pelvic girdle.
Experience shows that best results are obtained when prenatal supports are
applied during the fourth month and worn faithfully throughout pregnancy.
S. H. CAMP AND COMPANY • JACKSON, MICHIGAN
World's Largest Manufacturers of Scientific Supports
Offices in New York • Chicago • Windsor; Ontario • London, England
826 Minnesota Medicine
a new advance in
The development of Gelfoam* by the Upjohn research lab-
oratories marks a new advance in hemostasis. Gelfoam is a
readily absorbable, easily cut and molded gelatin sponge
which may be used with or without thrombin and may be
left in situ without fear of tissue reactions. Gelfoam makes
readily available biochemical hemostasis to simplify the
clearing of oozing surfaces, the control of capillary bleeding,
the arrest of trickling from small veins, and the staunching
of annoying hemorrhage from resected tissues. It has a wide
variety of indications in surgery and general practice. Gel-
foam is a unique addition to the surgical armamentarium
for the control of bleeding.
Upjohn
FINE PHARMACEUTICALS SINCE 1886
Gelfoam
'Trademark
is made in sponges 20 x 60 x 7 mm., in size. Four sponges are packed in each jar.
August, 1947
827
t
1— Precoitus. Effective
occlusion of cervical
os by "RAMSES”
Vaginal Jelly.
3 — Four hours post-
coitus. Uterine os re-
mains occluded.
4 — Ten hours postcoi-
tus. Occlusion still
manifest — barring the
passage of sperm.
2 —One hour postcoi-
tus. Barrier action
maintained by film of
jelly.
L
The direct-color photographs shown above establish the prolonged
barrier action of "RAMSES"* Vaginal Jelly. For photographic pur-
poses, the jelly, which has a transparent clarity, was stained with a
nonspermatocidal concentration of methylene blue.
In addition to the barrier action provided by its exclusive gum base
"RAMSES" Vaginal Jelly immobilizes sperm rapidly.
Tests by an accredited independent laboratory, supported by clinical
work of an outstanding research organization, confirm the lack of
irritation and toxicity under continuous use. For dependability in
spermatocidal jelly specify
TRADEMARK REO. US. RAT. Off.
[ .
p|
[■;.
til
E
l
•The word "RAMSES" is a registered trademark of Juliv Schmid, Inc.
Umzts uncmm jeuv
Active ingredients: Dodecaethyleneglycol
monolaurate 5%; Boric Acid 1%; Alcohol 5%.
gynecological division JULIUS
/S83
scumm, me.
423 West 55th St.. New York 19. N. Y.
wm
i
i ^
_■
f — <"-
828
Minnesota Medicine
Formulac Infant Food provides a balanced and flexible formula
basis for general infant feeding — both in normal and difficult
diet cases.
A product of National Dairy research, Formulac is a con-
centrated milk in liquid form, fortified with all vitamins known
to be necessary for proper infant nutrition. No supplementary
vitamin administration is necessary with Formulac. The Vitamin
C content is stabilized, assuring greater safety.
The only carbohydrate in Formulac is the natural lactose
found in cow’s milk— no other carbohydrate has been added. This
permits you to prescribe both the amount and the type of carbo-
hydrate supplementation required.
Formulac is promoted ethically, to the medical profes-
sion only. Clinical testing has proved it satisfactory in promoting
normal infant growth and development. On sale in grocery and
drug stores throughout the country, Formulac is priced within
range of even modest incomes.
Distributed by KRAFT FOODS COMPANY
NATIONAL DAIRY PRODUCTS COMPANY, INC.
NEW YORK, N. Y.
• For further information about
FORMULAC, and for professional
samples, mail a card to National
Dairy Products Company, Inc., 230
Park Avenue, New York 17, N. Y.
jpor-rs
August, 1947
829
m ° series 0f
'importance of ,
gpis£xir~-*.
^-■s£Sr=»
c 'or most
,„» "', ‘d ,U“,ic’u ubont thr r Hr may
Sr/f"” *■ '•••» du« ,„ *,
I dou’" l/tt off,n.r J . Ur&’
ort, your Jr,ar‘y
W'c'm<ut,a,a,Jrr
v'olfm(y S?'“ °f 'mi!,"rd <
rr>^orZayzb'
‘,,c emit hai, ,, d°S l,air’
m die lna, un()<.r
. lira fe share oft
"•S substance. DrZ U”J '
sU,nce fi-i„£ trXjh'' /yr“'‘ ""
°"ce a doctor », r
f°und "Am c
plemcme,||), t "S °r Amor,
hording
//Ma!
' patirnt « a//,r(t
*®ne/ elution ,. 0 a Pot
your casr is ,
hundreds of p0i
can '"ate s„mc
’ **"“••*•« <o 111
r grass ptW/tr
a rug.
"«*»/ M,
cx?racts—.0r .
-“rc "jrcted i„/o u
sensitive to th.
"S V'i/l usually J.
surprising ei,r,iv
pk> however ,i„
nent, or arc « 001 rcsPon
*° mate inoculations ^ <C° "
*™'caldn.gs_devcI^
||, r-_,. •
certain types
roinise. Ti,-..
'"°°d Iu"cl'ror°“ SUff" fr'""
'Anns. your nIl "»• *
S've
°r »oine.
scries of
g>— are
course.
recurring
rashes, or
,n other
)°u more
smodicine,
Prescribed
Physician,
The subject is : Allergy
iri LIFE and other national magazines,
Parke-Davis presents a timely mes-
sage about allergy (shown below), it
appears in full color . . . reaches an
audience of nearly 23 million people.
It is No. 206 in the "See Your Doctor"
series published in behalf of the medi-
cal profession.
The advice, as usual, is
“SEE YOUR DOCTOR’
ParK£, davis
830
Minnesota Medicine
for the approaching school days
IMMUNITY FROM
ALL THREE IN
ONE SOLUTION
When you are planning for the inocula-
tions to be given as school days roll
around again, remember the convenience
and efficacy of National Drug's "D-T-P."
Immunity against these three diseases
THE NATIONAL DRUG COMPANY • Philadelphia 44, Pa.
PHARMACEUTICALS, BIOLOGICALS, BIOCHEMICALS FOR THE MEDICAL PROFESSION
August, 1947 831
Carbohydrate for S#ppl*iBH','®8
°R INFANT FEEDlN'
.^Directed 3j£2& by Phy***0"
- MALTOSE - deXT%°?
pur« starch Pr<^2|<
uniform
"a ^6Sr.,rorn irf,tat'hg impurities .
* m«tic seal of hi#i vacuum
^biespoonfuls equal i fi °*
*20 calories per ft ox-
COlUMOi
PROTEIN SPARER
832
Carbohydrates as protein sparers have
particular significance in infant nu-
trition, which requires a high order
of efficient utilization of protein for
an active metabolism.
CARTOSE* is well tolerated; its
content of dextrins in association with
maltose and dextrose minimizes gas-
trointestinal discomfort due to an
excessive concentration of readily
fermentable sugars in the gastro-
intestinal tract.
CARTOSE is liquid, facilitating
rapid, exact formula preparation. It
is compatible with any formula base
— liquid, evaporated, or dried milk.
SUPPLIED: In clear glass bottles
containing 1 pt. Two tablespoonfuls
( 1 fl. oz.) provide 1 20 calories. Avail-
able through recognized pharmacies
only.
Mixed Carbohydrates
*The word CARTOSE is a registered trademark of H. W.
Kinney & Sons, Inc.
CARTOSE
H. W. KINNEY & SONS, INC.
COLUMBUS, INDIANA
Minnesota Medicine
You Prescribe
We Provide . . .
•'"■-vx' '■•xV-'-i: y
Dorset]
, — - v '
* * 7? -'■— \ ' •" *
f-$ V>-.
DEPENDABLE PHARMACEUTICALS
Like a gem, every case in your daily practice presents
many facets besides the strictly medical ones — constitution,
temperament, environment, AND the reliability of the medica-
tion you prescribe.
Most of these contributing factors are outside your control.
Certainly, in these busy days, you cannot take time to trace
the manufacturing history of every drug you use.
What you can do is to prescribe pharmaceuticals of un-
questioned reliability — drugs you can depend upon.
You can depend upon Dorsey products for unvarying pur-
ity and potency, for they are made under rigidly standard-
ized conditions. Laboratory and manufacturing equipment, per-
sonnel and procedure are constantly protecting your treat-
ment with Dorsey drugs.
THE SMITH-DORSEY COMPANY
LINCOLN, NEBRASKA
Branches ot Dallas and Los Angeles
MANUFACTURERS OF
PURIFIED SOLUTION OF LIVER-DORSEY
SOLUTION OF ESTROGENIC SUBSTANCES-DORSEY
August, 1947
833-
uttotefUt ELECTRO-CARDIOGRAPHY
Portable, rugged, electrically oper-
ated without batteries. Cardiotron Is
available with or without stand.
The first successful
'Detect- ‘Recondwy
Electrocardiograph..*
With more than 1 200 now in use throughout the
world, the Cardiotron has established the principle
of instantaneous recording in general clinical elec-
tro-cardiography.
The Cardiotron is fast, accurate and sensitive. If
makes an immediate black and white cardiogram-
on permanent chart paper. It is free from skin re-
sistance eirors. It reveals more information than any
other electrocardiograph instrument.
IMPORTANT: Factory-supervised installation and service
are available in most parts of the world. Good deliveries
are scheduled. Cardiotron is sensibly priced.
Send for 12-page descriptive booklet
Cahdurthen
ELECTRO-PHYSICAL LABORATORIES, INC., 298 Dyckman St., New York 34, N. Y.
electrocardiographs, electroencephalographs, shock
Oft THERAPY apparatus, and special electronic equipment
Distributed by
C. F. ANDERSON CO., INC
901 MARQUETTE AVENUE MINNEAPOLIS 2. MINN.
834
Minnesota Medicine
Robert Koch ( 1843-1910 ) proved it in bacteriology...
Koch showed in his postulates that he knew the value of experience: Specificity
is demonstrated only when the microorganism (1) is present in all cases of the
disease, (2) can be cultivated in pure culture, (3) produces the disease in
susceptibles on inoculation, and (4) can be recultivated in pure culture.
Yes, and experience is the best teacher in smoking too!
The wartime cigarette shortage was a real experience
for smokers. Millions of people smoked whatever brand
was available — more different brands than they might
ordinarily have tried in years. And from that experience
so many more smokers chose Camel as their cigarette that
today more people are smoking Camels than ever before.
But, no matter how great the demand, we don’t
tamper with Camel quality. Only choice tobaccos,
properly aged, and blended in the time-honored
Camel way, are used in Camels.
rtccore/tug to a recent Nationwide survey'.
More Doctors smoke Camels
t/ian any ot/ier cigarette
R. J. Reynolds Tobacco Company
Wiastcn-Salom. North Carolina
August, 1947
835
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous aHd mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
REST HOSPITAL
A quiet, ethical hospital with therapeutic facilities
for the diagnosis, care and treatment of Nervous
and Medical cases. Invites cooperation of all
reputable physicians who may supervise the treat-
ment of their patients.
PSYCHIATRISTS IN CHARGE
Dr. Hewitt B. Hannah
Dr. |oel C. Hultkrans
2527 2nd Ave. S., Minneapolis, Phone At. 7369
^t•••l•llllllllllllllllllllllllllllllllllllllllllllMlllllllllllllllllllllllllllllllllllllllll|||||||||||•l|||■l|||||||||||||||||||•||||||||||,|||l||||||||||||||||||||||||||||J|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||■lalllllllllllll|||||||||||■l||||||||||||||||••||■|fl■f^
THE VOCATIONAL HOSPITAL
TRAINS PRACTICAL NURSES
Nine months Residence course, Registered Nurses and
Dietitian as Teachers and Supervisors. Certificate from
Miller Vocational High School. VOCATIONAL NURSES
always in demand.
EXCELLENT CARE TO CONVALESCENT AND
CHRONIC PATIENTS
Rates Reasonable. Patients under the care of their own physicians,
who direct the treatment.
5511 Lyndale Ave. So. LO. 0773 Minneapolis, Minn.
836
Minnesota Medicine
Pollen Count
of City Air*
Los Angeles 108
Denver 1126
Washington, D. C. 820
Atlanta 697
Boston 359
Detroit
St. Louis
Chicago
Des Moines
New Orleans 796
Omaha 4159
New York 585
Portland, Oregon 36
Philadelphia 1257
Dallas 2077
•"Allergy in Practice," Feinberg, S. M., Second
Edition: 1946, Year Book Publishers, Chicago
Pyribenzamine
HYDROCHLORIDE
In seasonal hay fever Pyribenzamine has provided effective
symptomatic relief in 82 per cent of patients.* It has also
been successfully employed in urticarial dermatoses, acute
and chronic atopic dermatitis and certain allergic drug
reactions. The comparatively low incidence of side effects
permits adequate doses in cases where other
antihistaminics have not been tolerated.
•Feinberg, J.A.M.A. 132 :702, 1946
PYRIBENZAMINE ® (brand of tripelennamine)
For further information, write Professional Service Division
CIBA PHARMACEUTICAL PRODUCTS, INC., SUMMIT, NEW 1ERSEY
August, 1947
837
UOMEWOOD HOSPITAL is one of the
-L Northwest's outstanding hospitals for the
treatment of Nervous Disorders — equipped
with all the essentials for rendering high-grade
service to patient and physician.
Operated in Connection with
Glenwood Hills Hospitals
HOMEWOOD HOSPITAL
Corner Penn and Plymouth Avenues North
Minneapolis Minnesota
The Birches Sanitarium, Inc.
2391 Woodland Avenue
Duluth 3, Minnesota
A hospital for the care and treatment of
Nervous and Mental disorders. Quiet, cheer-
ful environment. Specially trained personnel
Recreational and occupational therapy
Psychiatrists in Charge
L. R. Gowan, M.D. L. E. Schneider, M.D.
838
Minnesota Medicine
A life may depend on the purity and clarity of the
urographic contrast medium to be injected intra-
venously. NEO-IOPAX, a superior solution
for intravenous pyelography, is triple checked
through every stage of its preparation for exact
composition and sterility, and then inspected re-
peatedly for the presence of extraneous foreign
matter.
Hold your contrast medium up to the light before
injecting it. You will find NEO-IOPAX solutions
sparkling and crystal clear— a good index of the
care with which they have been processed.
Naturally, we take pride in the NEO-IOPAX
safety record, based on hundreds of thousands of
injections.
NEO-IOPAX, stable solution of disodium N-methyl-
3,5-diiodo-chelidamate, is available in water-clear glass
ampules only, in 50 and 75% concentrations.
Trade-Mark NEO-IOPAX-Beg. U.S. Pat. Off.
THE CHICAGO MEDICAL SOCIETY
announces
Postgraduate Courses
To Be Held in Chicago
Leading Teachers from All Over the U. S.
CARDIOVASCULAR DISEASES
OCTOBER 20-25
GASTROENTEROLOGY
OCTOBER 2 7 -NO VEMBER 1
Both Courses Limited to 100 and Open to Physicians in Good
Standing in Their Local Medical Societies. Fee $50.00 per Course.
Send Applications to
DR. WILLARD O. THOMPSON
CHAIRMAN COMMITTEE ON P. G. EDUCATION
CHICAGO MEDICAL SOCIETY, 30 NO. MICHIGAN, CHICAGO 2
lllelrazol - Powerful, Quick Acting Central Stimulant
COUNCIL ACCEPTED
ORALLY - for respiratory and circulatory support
BY INJECTION - for resuscitation in the emergency
INJECT I to 3 cc. Metrazol as a restorative
in circulatory and respiratory failure, in
barbiturate or morphine poisoning and in
asphyxia. PRESCRIBE I to 3 tablets,
or 15 to 45 minims oral solution, as a sus-
taining agent in pneumonia and congestive
heart failure.
AMPULES - I and 3 cc. (each cc. contains lV2 grains.)
TABLETS - l'/2 grains.
ORAL SOLUTION - (io% aqueous solution.)
Metrazol, brand of pentamethylentetrazol. Trade Mark reg. U. S. Pat. Off.
840
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 August. 1947
FOR MANNERS ARE NOT IDLE"
LOUIS A. BUIE. M.D.
Rochester. Minnesota
NOW in this time when all that is human
tends to be regarded as something repre-
hensible, I, myself an erring mortal, have the
temerity to come before you, an association of
physicians, and to offer you, of all things, a
panacea. Nevertheless, bear with me if you can,
for what I hold forth is not a nostrum. It is
nothing, in truth, so satisfyingly concrete as that.
It is rather an abstraction, a matter of behavior,
which, when sterling, has its source in the char-
acter of a man and only when counterfeit is but-
tered upon him.
Yet, out of my sadly incomplete knowledge of
how the centuries have molded the convictions of
men, I venture to say that down through the ages,
this trait, this quality which I have in mind, has
been accorded its place of importance. Otherwise,
springing from the so-called Wisdom Movement
of the Near East, there might not have been pre-
served in the Biblical Book of Proverbs, that
which reads, “A soft answer turneth away wrath."
Later, comparatively recently in fact, since it was
in Elizabethan times, Shakespeare put into the
mouth of no less than the Lord Chamberlain
Polonius, his precepts to his son. Moreover,
whatever people in general may think of Lord
Chesterfield, and whatever Samuel Johnson did
not think of him, men of this age occupy no
height from which to look down upon him. And
who can say that his preoccupation with how
a man should gracefully bear himself with relation
to his fellows had nothing to do with the dis-
Presidential address delivered at the Annual Banquet of the
Minnesota State Medical Association, July 1, 1947, Hotel Duluth,
Duluth, Minnesota.
From the Mayo Clinic, Rochester, Minnesota.
August, 1947
tinguished political service he gave to his coun-
try, including what most administrators have
found impossible, conciliation of the factions in
Ireland? Again, Cardinal Newman, the author
of “Lead, Kindly Light,” whose life was almost
coextensive with the nineteenth century, saw fit
in his discourses “The Idea of a University to
introduce two well-known paragraphs with the
sentence, “Hence it is that it is almost a definition
of a gentleman to say he never inflicts pain.
And to come down to the present time, that cen-
tury which was borne in on so high a tide of
hope but wherein, man is now struggling for
existence in a whirlpool of degradation : can
it not be asked whether in this time hope could
have been renewed if present political opponents
of the United States had read or, having read had
retained, a memory of the works of this great
man?
Therefore I, in my imperfect attempt to follow
after the great men whose thoughts I have just
cited, ask your leave to consider, for a few
moments, how we physicians, in the various roles
we must assume in this modern day, perhaps can
perform our tasks with greater ease and effec-
tiveness than otherwise we could if, in a world
which seems no longer to value consideration for
others, we insist on conducting our affairs with
good manners, with courtesy, with decorum.
Never in the history of our organization have
those within it, and those outside it, needed the or-
ganization more. The association maintains its ef-
fectiveness. Yet these are times of stress. Stress
*Newman, John Henry: The Idea of a University, Discourse
VIII.
841
“FOR MANNERS ARE NOT IDLE”— BUIE
engenders fatigue and fatigue, impatience. Out of
impatience come altercation, enmity and the search,
in unlikely places, for solutions of problems. Per-
haps these are reasons why we physicians find
great obstacles in our path as we set ourselves
to the task of maintaining the standards of our
work, or of elevating them. The nature of these
obstacles is familiar to everyone here. Suf-
fice it to say, there are modem institutions and
organizations, and even large segments of our
population whose interests we seek to defend, who
face with skepticism and even with antagonism
the proposals which we offer as solutions of per-
plexing problems.
Yet I believe that the people of the world not
only are tired of struggle against hunger, illness
and an uncertain future but that they also are
tired of strife. If this is so, it is particularly
desirable now for our association to function with
harmony among its members as well as in its
environment. To this end the physician must
consciously deal gently with his colleagues and
he must exercise extreme caution as he proceeds
with plans for the benefit of those among whom
he dwells. Very easily he can ofifend without
intention. Among those who work for a living
he is accorded, whether he wishes it or not, a
slightly superior position. This he may accept
but the assumption of a superior manner on his
part will not be condoned, particularly by those
of his neighbors whose knowledge of sociology
and economics may be better than his. He will
need constantly to employ his insight into human
nature to get the other’s point of view. From
this exercise of his faculties, he will derive the
habit of tolerance.
Certainly the physician will converse with many
enlightened and competent individuals. Often
they will entertain notions concerning medicine
and the distribution of medical care which they
will advocate with confidence and support with
arguments which are satisfactory to themselves.
Many times, to the physician, with his special
knowledge of his own field, these arguments
may seem worthy of contempt but he must not
reject them with a contemptuous air. He must
try to assume the objective position of an impar-
tial inquirer and to seek some means whereby
he may determine why, or even whether, his op-
ponent is wrong.
Concerning some questions, the further he
searches, the more he may become convinced that
no answer is at hand and that some questions,
if they do not transcend the limits of human
understanding, may at least transcend its pres-
ent resources. He cannot afford to permit him-
self to be discouraged by such experiences. He
must be willing to take the time and to make the
effort to clarify matters for others or to explain,
fully and courteously, that knowledge which
would allow him to answer the question under
consideration is not as yet available.
Such an approach discourages strife and en-
courages amicable discussion. It is through dis-
cussion that experience is analyzed and eventually,
we hope, correctly interpreted. I said “eventual-
ly” because often the correct interpretation is con-
siderably delayed while men in a free society
experiment and discuss. This freedom to try
and to think and to express ourselves, probably
most of us consider among our greatest strengths
and greatest blessings. This freedom, which al-
lows us to take our time, may render us a little
tardy. Nevertheless it allows us to live up to
the precept, “First of all, do no harm.”
Now, if the foregoing advantages lead most
physicians to the conviction that private enter-
prise brings the greatest good to the greatest
number, well and good. Nevertheless, if there
is a dissenter among us who believes that our
concern for the public interest should lead us
to accept a greater measure of public control, is
he less our brother?
Surely there is one community enterprise which
we can afford to strengthen, to revive or to in-
augurate, depending on our belief as to the state
which existed formerly. I refer to a more or
less generally recognized moral standard which,
it seems to me, used to have more force than it
has now in guiding individual and corporate con-
duct.
It may seem that to treat of morals as a sub-
topic under good manners is to interchange the
small for the great. But it is the fact that the
two are related, not the order in which they are
considered, which is important. Tennyson, who
had considerable influence in forming our Anglo-
American culture, expressed the relationship in
words of which I took a part as the title of this
address. He wrote,
“For manners are not idle but the fruit
Of loyal nature and of noble mind.”
842
Minnesota Medicine
“FOR MANNERS ARE NOT IDLE”— BUIE
This is an age of science ; an age of dangerous
science; an age when science is about to outstrip
all other activities. It is important to realize that
science, unrestrained by moral precepts, can de-
stroy man and all that he possesses and inhabits.
Man must learn to live with man and he must
know how to conduct himself in the presence
of his own capacity for destruction.
It should be possible to evolve a system or a
manner of living which, when guided by con-
science and principles of ordinary decency, might
be capable of developing proper human relation-
ships. I insist that this can be done, given the
proper human behavior. In each and every
human being, if the soul has been lost, the soul
must be re-created. A community soul must
be reborn ; a national conscience ; a native Ameri-
can morality. These must be displayed to the
world. At the same time, all must be pre-
pared, with good grace, to accept change in all
values, even these.
Knowledge is the product of great labor and
great sacrifice but it is the advance of ideas by
which progress ultimately is determined. Prog-
ress itself depends on change. Consequently, it is
probable that in the march of ages many differ-
ent creeds, apparently good creeds, which now
exist, are destined to die out and to be succeeded
by some which are better. The world has wit-
nessed the beginning of some of them and there
is no assurance that it will not see their end. All
values which are essential to human progress
must sustain the shock and the vicissitudes of
time.
Moreover, if man adopted only the opinions of
his forebears and contemporaries, he would create
nothing new. The result would be an evident
decay of that vigor of character and that audacity
of conception and execution which paves the way
to achievement. Our duty as physicians is clear.
We shall freshen the fabric of our knowledge. We
shall color anew its various parts and harmonize
its apparent discrepancies. We shall employ every
resource which we possess in an effort to deter-
mine what is best for all and, having arrived at
a sound conclusion, we shall uphold it zealously,
being assured that if it is true, ultimately it will
prevail. In addition, we shall urge it with cour-
tesy that it may more likely be adopted with will-
ingness. Perhaps tolerance, maintained in an at-
mosphere of righteousness, persisting through
change, may develop into esteem and that, in
turn, may broaden into something resembling af-
fection for our fellow men.
The safest and most impregnable ground on
which social advancement can be founded is the
universality of the affections. It is the bond of our
common humanity ; it is the golden link which
joins together and preserves the human species.
It is in the acts prompted by these affections that
the existence of the highest instincts of our na-
ture is revealed. Affection can warm the coldest
temperament and soften the hardest heart. Re-
gardless of how greatly the character of an in-
dividual may be deteriorated and debased, this
spirit is capable of redeeming it. It is a godlike
attribute.
The affections even transcend death and we
feel, in the presence of death, that something re-
mains— something which possibly the eye of
reason cannot discern but which the eye of affec-
tion perceives. If this be a delusion, it is one
which the affections themselves have created and
we are forced to believe that the noblest and
purest elements of our nature conspire to deceive
us. Of all the moral sentiments which adorn and
elevate the human character, the instinct of af-
fection is one of the most vibrant and profound.
It is the choicest of our possessions and bears
upon itself the impression of truth. It is at once
the condition and the consequence of our being.
It flourishes best in an atmosphere of considera-
tion and courtesy.
In fact, there are few fields of human endeavor
wherein attention given to the feelings of others
can be neglected safely. This applies even in the
realm of practical politics, wherein we physicians
have much to learn. We have been censured and
justly so, for our failure to enter into community,
state and national life. We have felt that for us
to enter politics was scarcely consonant with the
principles of medical ethics. We have looked
with lack of esteem on many whose activities have
been confined to political life and we would have
to use stronger language to give our estimate of
the lobbyist. Now it is necessary, however, that
we alter our opinion concerning these matters.
I do not believe that human progress is chiefly
owing to the wisdom of governments. Those who
control government often are the creatures of
the age in which they live and are not its creators.
Often their accomplishments are the result of
August, 1947
843
‘FOR MANNERS ARE NOT IDLE”— BUIE
social progress and not the cause of it. Many
times such men are the accidental and insufficient
representatives of the spirit of their time. They
may discern fallacies and may point out means
to protect by presuming to raise themselves into
positions as supreme judges of national interests.
Great political reform or improvement often is
not originated by such individuals but by bold
and capable thinkers who are outside the govern-
mental establishment. Persons of the latter type
may discern fallacies and may point out means
by which they can be remedied.
Thus, it is no longer advisable for the physi-
cian to confine his activities to the care of the
infirm. Much of the progress which he may effect
will depend on governmental action, energized
not by others, but by himself. It is imperative
now that the physician, with befitting dignity, as-
sume his proper place beside those who determine
the destiny of nations. We have a venerable
precedent in the life of Dr. Benjamin Rush, signer
of the Declaration of Independence. Since his
time, a number of physicians have served effec-
tively in political capacities.
If, in what I have said, my central thought has
ever seemed too tenuous, perhaps I can bind all
together by stating my basic conviction. I agree
with that philosophy which holds that mankind is
more virtuous than vicious and that good acts
are of more frequent occurrence than bad acts.
We know that cruelty is counteracted by benevo-
lence. We know that sympathy is excited by suf-
fering. We know that the injustice of some pro-
vokes the charity of others and we know that new
evils are met by new remedies.
Accordingly, outstanding qualities of estimable
men are these : gentleness and courage, boldness
and prudence, tolerance, reverence, confidence,
stability, humility, wisdom, patience and honesty.
I believe not only that possession of these quali-
ties engenders good manners but that the exercise
of good manners furnishes proper soil for the
cultivation of these qualities. The two elements
working together, not alone, I believe, would do
much to allay those twin dreads of the world to-
day: fear and want.
Finally, we, in our profession, have been reared
well. The code of ethics of our organization
provides that “a physician shall be an upright man,
instructed in the art of healing.” Furthermore, he
“must keep himself pure in character and conform
to a high standard of morals and must be diligent
and conscientious in his studies . . . conducting
himself with propriety in his profession and in all
actions of life.” Perhaps no other group is in
a more favorable position to exemplify the union
of good manners and good faith.
CANCER APPROPRIATIONS
With the passage by Congress of legislation more
than tripling appropriations for research and control of
cancer, and bringing next year’s budget of the National
Cancer Institute in Bethesda, Md., to the all-time high
of $14,000,000, the U. S. Public Health Service an-
nounces plans for an expanded attack on the cancer
problem that will place cancer in the forefront of the
Government’s medical research and control programs.
Under the broad authority provided in Public Health
Service Law and the Appropriation Act, support may
now be extended to universities to assist them in devel-
oping greatly expanded cancer research and training
programs. The law also supports the acquisition of land
and construction of buildings when urgently needed.
Evidence of the over-all desire on the part of the Con-
gress and the President to provide continuity in cancer
research is shown in a provision of the Act, under
which funds for cancer research and training grants
remain available until spent.
Already the National Advisory Cancer Council of
the Institute has recommended greatly increased grants-
in-aid to outside institutions engaged in experiments to
find the cause and cure of cancer. With the passage of
the Appropriations Act a total of forty-six project
grants, involving the expenditure of $594,348, was made
to widely scattered groups. In all. thirty-five institu-
tions in twenty-three states are recipients. At the same
time the Institute is greatly expanding its own research
program at Bethesda, where there will be increased
emphasis on clinical research.
Four million dollars of the increase in NCI’s budget
will go — not to research — but to cancer control, the pro-
gram administered through the States to increase the
effective use of present methods of diagnosing and treat-
ing cancer. It is estimated that while a fourth of can-
cer patients are cured today, another fourth could be
cured if they received early treatment.
The cancer control program will place emphasis on
the improvement of cancer detection, diagnostic and
treatment facilities ; the development of refresher courses
for doctors ; the establishment of adequate statistical
services on cancer ; and the setting up of cancer control
units in State Health Departments.
844
Minnesota Medicine
POSTGRADUATE MEDICAL EDUCATION IN A PRIVATE HOSPITAL
ARTHUR H. WELLS. M.D.
Duluth, Minnesota
rT',HE logical center for the continuation of
■*- medical education in a community is the hos-
pital. There one can find an abundance of ma-
terial and qualified teachers. National, state, and
regional medical meetings, as well as short post-
graduate training courses, should be considered
indispensable adjuncts to the daily local teaching
program. Furthermore, unless the hospital is the
physician’s most productive source of medical
knowledge, then the doctor, his patients, and his
community are missing something of inestimable
importance. Determined steps can change a le-
thargic, procrastinating institution into a dynamic
teaching center equivalent to that found in many
medical schools. This goal has been reached in
two private hospitals in this city of 100,000 popu-
lation.
Any 200-bed or larger general hospital with a
full-time clinical pathologist and roentgenologist
has the basic essentials for the establishment and
the continuous support of such a co-operative edu-
cational program. All that is necessary is the
proper organization of : (1) the truly overwhelm-
ing amount of interesting subject matter in such
an institution; and (2) the qualified, but fre-
quently hidden, teaching talents of its medical
staff.
The tried and proved teaching methods of
medical schools are the key to success. Some of
the basic rules include the following:
1. All departments and all staff members are
expected to contribute their part to a well-rounded
program.
2. Interns and residents present as much as
50 per cent of the teaching material.
3. Lectures, conferences, literature seminars,
medical meetings, patients’ chart reviews, demon-
strations, et cetera, must be scheduled at least one
month in advance.
4. Fixed weekly schedules are mandatory.
5. Someone who is intimately associated with
the institution, its medical staff, and its patients,
and who is willing to give whatever is necessary
for success, must assume a leading role in arrang-
ing much of the program.
From the Department of Pathology, St. Luke's Hospital, Duluth,
Minnesota.
August, 1947
6. Participants must be notified three times :
one month, one week, and one day in advance of
their scheduled activity.
7. Insistence upon a thorough preparation and
a good delivery is essential.
8. The material and methods of presentation
must be varied and have a practical value.
9. As a rule, diagnostic and therapeutic prob-
lems should have been solved before presentation.
10. The limitation of teaching assignments to
a few men is detrimental and is not to be toler-
ated.
11. The long range educational benefit to the
participating physicians is the criterion for selec-
tion of subjects and speakers.
12. The frequent publication in medical jour-
nals of the material covered in the teaching pro-
gram is highly desirable (Table I).
Adherence to these twelve rules results in a
stimulation to greater effort, a spirited interest,
a broader comprehension of medicine, and a
warmer appreciation of one’s colleagues.
The specific assignments of this hospital’s edu-
cational program are arranged during the previous
month to fit into an established weekly schedule
(Table II). All staff members are sent the mimeo-
graphed monthly program (Table III) and are
invited to all presentations, although certain items
are primarily designed for interns and residents.
On each of four days of the week, Tuesday
through Friday, two one-hour medical subjects
are scheduled. A third one-hour session in the
form of a necropsy, with a co-ordinated study of
the clinical aspects of the case, occurs on the
average of almost every day of the week. These
examinations are announced in advance by phone
and on bulletin boards. On Tuesday (Table II)
there is an 8:00 A.M. postgraduate medical con-
ference (P.M.C.). In the afternoon the roentgen-
ologist reviews selected films from the previous
week’s x-ray diagnostic problems (X-ray). On
the first Tuesday of the month the Duluth Pedi-
atric Society has its pediatric-pathologic confer-
ence (P.P.C.). A lecture (Lect.) is scheduled
primarily for the interns and residents on Wed-
nesday, and in the same evening they conduct
an informal medical literature seminar (M.L.S.).
845
POSTGRADUATE MEDICAL EDUCATION— WELLS
TABLE I. PUBLICATIONS EMANATING FROM EDUCATIONAL PROGRAM
1944 1945 1946
1. Toxemia of Pregnancy with Uterine
Exsanguination
2. Congenital Fibrocystic Disease of
Pancreas ,
3. Bilateral Cortical Necrosis of Kidneys
4. Atheromatous Plaque of Renal Artery
with Hypertension
5. Bilateral Adrenal Hemorrhages with
Waterhouse-Friderichsen Syndrome
6. Failure of Surgical Wound Healing
Due to Talc
7. Actinomycosis of the Urinary Bladder
Complicating Madura Foot
8. Malignant Hepatoma in an Infant
9. The Minnesota Coroner System
10. Duodenal Obstruction by Superior
Mesenteric Artery Pressure
11. Volvulus in the Newborn
12. Acute Sulfonamide Myocarditis
1. Rh Tranfusion Reaction and Transfu-
sion Reaction Instructions
2. Epidermolysis Bullosa in a Newborn
3. Congenital Anal Stenosis
4. Congenital Interauricular Septal Defect
5. Renal Rickets
6. Parenteral Fluid Therapy
7. Punch Biopsy of the Liver
8. Chronic Peptic Ulcer of the Esophagus
9. Congenital Atresia of the Biliary Tract
10. Isolated Myocarditis, Probably of Sul-
fonamide Origin
11. Cardiac Amyloidosis with Chronic Con-
gestive Heart Failure in Multiple
Myeloma
12. The Nature of Cancer
13. Adrenal Hemorrhage of the Newborn
1. Cancer Detection Centers and Allied
Cancer Projects
2. Chronic Intradural Hematoma
3. Cancer Research — A Preface
4. Diptheria: A Report of Six Deaths
5. Pulmonary Emphysema
6. Hormonal Dyscrasias of the Breast
7. Periarteritis Nodosa
8. Cancer Research
9. Normal Appendices in 1000 Appendec-
tomies
10. Practical Application of New Develop-
ments in Blood Groups and Types
11. Blood Types in Pregnancy (Questions
and Answers)
12. Air Embolism
TABLE II. BASIC WEEKLY SCHEDULE
Tuesday
Wednesday
Thursday
Friday
A.M.
P.M.
A.M.
P.M.
A.M.
P.M.
A.M.
P.M.
First week
P.M.C.
P.P.C.
Lect.
M.L.S.
Lect.
St.M.S.
St.M.C.
M. Chart
Second week
P.M.C.
X-ray
Lect.
M.L.S.
Lect.
St.L.Co.
St.M.C.
S. Chart
Third week
P.M.C.
X-ray
Lect.
M.L.S.
Lect.
St.L.S.
St.M.C.
P.Chart
Fourth week
P.M.C.
X-ray
Lect.
M.L.S.
Lect.
U.S.S.
St.M.C.
O. Chart
Key: P.M.C. = Postgraduate Medical Conference. P.P.C. = Pediatric Pathologic Conference.
Lect. = Lecture. M.L.S. = Medical Literature Review. St.M.S. = St. Mary’s Hospital Monthly Staff
Meeting. St.L.Co. = St. Louis County Monthly Meeting. St.L.S.=St. Luke’s Hospital Monthly
Staff Meeting. D.S.S.=Duluth Surgical Society Monthly Meeting. St.M.C.=St. Mary’s Hospital
Pathologic Conference. M.Chart=Medical Chart Review. S.Chart=Surgical Chart Review.
P.Chart=Pediatric Chart Review. O.Chart=Obstetric Chart Review.
On Thursday there is a second weekly lecture.
The regular monthly medical meetings occur on
Thursday evenings, including those of the staffs
of the two larger hospitals (St.M.S. and St.L.S.),
the county medical society (St.L.C.) and the
Duluth Surgical Society (D.S.S.). A second
weekly postgraduate medical conference is con-
ducted on Friday in the collaborating neighbor-
ing institution, St. Mary’s Hospital (St.M.C.).
On the same day the chiefs or assistants in the
various departments of medicine (M. Chart), sur-
gery (S. Chart), pediatrics (P. Chart), and obstet-
rics (O. Chart) conduct a review before the in-
terns and residents of selected charts of patients
discharged from the respective departments dur-
ing the preceding thirty days.
The two weekly postgraduate medical confer-
ences play a more important role in medical edu-
cation of our physicians and interns than do
the regular monthly medical meetings. They are
conducted in a manner similar to that of the
clinical pathologic conferences of other medical
institutions, except that a much wider variety of
subjects is covered. An attempt is made to in-
846
elude all practical aspects of the field of medi-
cine, with frequent variations of the subject mat-
ter and method of presentation. The principal
sources of material include the following : post-
mortem examinations, living patient case studies
and demonstrations, out-of-town medical meet-
ings, outstanding articles from the medical litera-
ture, recent advances in special fields, reviews of
selected topics in the basic sciences or clinical
medicine, clinical experimental studies, and col-
lective case reviews. All serious diagnostic and
therapeutic mistakes are routinely discussed with
complete frankness. Even the pathologist admits
his mistakes.
Approximately 100 lectures (Table IV) de-
livered by forty-five physicians are scheduled for
delivery to the house staff during the year. These
informal talks are designed to prepare the stu-
dents for the practical application of medicine in
general practice. The subjects have at times been
selected with the talent of the teacher in mind.
They may not cover the entire field of the general
practitioner; however, upon the request of the
(Continued on Page 848)
Minnesota Medicine
POSTGRADUATE MEDICAL EDUCATION— WELLS
TABLE III. POSTGRADUATE MEDICAL EDUCATIONAL PROGRAM
(Month of February, 1947. Fifty subjects, fifty-three participants)
February
4. St. Luke’s Postgraduate Medical Conference
1. Heparin and Dicoumarol
2. Phlebothrombosis Case Study
3. Diagnostic Case Study
Pediatric-Pathologic Conference
1. Foreign Body in Bronchus
2. A Diagnostic Study
3. A Diagnostic Case Study
4. A Monstrosity (demonstration)
5. Injuries of Hand
Medical Literature Review
6. Medical Legal Topics
St. Mary’s Staff Meeting
1. Presentation of Plaque Honoring
Dr. Malcolm T. MacEachern
2. Presentation of Scroll Honoring
Dr. E. L. Tuohy
3. Hospital and Nursing Falicities in Brazil
Dr. R. H. Wasserburger*
Dr. E. C. Bagley
Dr. R. H. Wasserburger*
Dr. F. H. Dickinson, Jr.
Dr. M. S. Munson*
Dr. R. P. Buckley
Dr. E. E. Barrett
Dr. R. P. Buckley
Dr. H. A. Sincock
Dr. G. C. MacRae
Dr. L. F. Grams*
Mr. John Fee
Sister Olivia, O.S.B.
7. St. Mary’s Pathologic Conference
1. Pathology of Stomach
(1) Case Study
(2) Case Study
2. Physiological Problems
Review of Medical Patient Charts
Dr. John Mayne* •
Dr. P. S. Rudie
Dr. R. D. Workman*
Dr. M. G. Gillespie
Dr. E. L. Tuohy
Dr. F. J. Hirschboeck
11. St. Luke’s Postgraduate Medical Conference
1. Toxemia of Pregnancy and Hypertension
2. Acute Uremia and Peritoneal Irrigation (Case Report)
3. Classification of Skin Tumors
X-ray Review
12. Prenatal Care
Medical Literature Review
13. Abortions, Premature Labor, Hemorrhage
St. Louis County Medical Society Meeting
1. Treatment of Syphilis
2. Treatment of Gonorrhea
3. Reiter’s Disease
14. St. Mary’s Pathologic Conference
1. Acute Abdominal Conditions
(1) Case Study
(2) Case Study
Review of Surgical Charts
18. St. Luke’s Postgraduate Medical Conference
1. Dyspepsia, Ulcer, and Gastric Cancer
2. Diagnostic Case Study
X-ray Review
19. Hospital Literature Review
20. The puerperium
St. Luke’s Staff Meeting
1. Report of Proceedings of American Academy of
Orthopedic Surgeons
2. Oxygen Therapy
21. St. Mary’s Pathologic Conference
1. Acute Intestinal Obstruction
(1) Case Study
(2) Case Study
2. Caloric Requirement of the Working Man
Review of Pediatrics Charts
25. St. Luke’s Postgraduate Medical Conference
Obstetrics and Gynecology Conference
1. Obstetrics and Gynecology Service
Review
2. Identical Twins
3. Hormonal Therapy at Menopause
X-ray Review
26. Pharmacology in Obstetrics
Medical Literature Review
27. Operative Obstetrics — Forceps and Their Use
Duluth Surgical Society Meeting
1. Sarcoma of the Breast
2. Pyometra
3. Sarcoma of the Stomach
28. St. Mary’s Pathologic Conference
1. Ocular Tuberculosis
2. Case for Diagnosis
Dr. E. Zupanc*
Dr. W. H. Pollard
Dr. M. G. Fredricks
Dr. A. L. Abrahams
Dr. R. J. Eckman
Dr. R. J. Goldish*
Dr. E. C. Bagley
Dr. F. T. Becker
Dr. W. E. Hatch
Dr. O. E. Sarff
Dr. Joseph Seitz*
Dr. A. J. Spang
Dr. W. V. Knoll
Dr. W. C. Martin
Dr. A. J. Bianco
Dr. P. S. Rudie
Dr. R. A. MacDonald*
Dr. C. H. Mead
Dr. H. M. St. Cyr*
Dr. A. L. Abrahams
Dr. R. H. Wasserburger*
Dr. H. M. St. Cyr*
Dr. J. R. Manley
Dr. M. H. Tibbetts
Dr. R. J. Dittrich
Dr. S. S. Houkom
Dr. F. J. Jacobson
Dr. John Bartness*
Dr. G. C. MacRae
Dr. John Mayne*
Dr. A. J. Bianco
Dr. E. L. Tuohy
Dr. R. E. Nutting
Dr. E. E. Hunner*
Dr. R. J. Goldish*
Dr. M. O. Wallace
Dr. A. L. Abrahams
Dr. F. H. Magney
Dr. J. P. Tetlie*
Dr. A. O. Swenson
Dr. W. A. Conventry
Dr. E. C. Bagley
Dr. Clarence Jacobson
Dr. F. N. Knapp
Dr. D. W. Wheeler
Dr. Joseph Seitz
Dr. Henry Fisketti
Interns and residents
POSTGRADUATE MEDICAL EDUCATION— WELLS
interns or residents, any additional subjects are
scheduled.
Other factors of importance in the postgraduate
training of the hospital medical staff members
(8) a guarded minimum of laboratory, blood
bank, and parenteral fluid routine duties for in-
terns, with specially trained technicians and
nurses performing the bulk of these tasks ; (9) a
TABLE IV.
Practical Therapeutics (2)
Medical Ethics and the Harrison Act
Pharmacology in Obstetrics
Cardiac Diseases in Practice (2)
Orthopedic Apparatus and Application
Back Pain
Fractures (5)
Thoracic Surgery
Management of Dystocia
The Puerperium
Eye Conditions and General Practitioner
Otitis Media and Mastoiditis
Bookkeeping, Collections, Taxes for Physicians
Anal and Rectal Diseases
General Practitioner’s Bag
Diabetes Mellitus (2)
Peptic Ulcer
Colon Diseases
Esophageal Diseases
Dermatology for General Practitioner (2)
Office Gynecology
Version
Brow, Face, etc., Presentations
Caesarean Sections
Toxemias of Pregnancy
Feeding Infants
Ciliary Action of Upper Respiratory Tract
Immunization
Electroencephalography
The Newborn Infant
Neurologic Examination
Brain Tumor and Abscess
Spinal Fluid Examination
Liver Function Tests
Rh Factor
Anemias
Pulmonary Tuberculosis
Psychoneuroses (2)
HOUSE STAFF LECTURES
Allergy
Medical Economics
Burns
Neck Surgery
Thyroid
Electrocardiogram (6)
Coma
Pulmonary Diseases
Surgical Technique
Pre- and Postoperative Care (2)
Minor Surgery (2)
Hernia
Feet
Evaluation of Disability
Cardiac Murmurs
Hypertensive Disease (2)
Arrhythmias
Pre- and Postnatal Care
Contraction of Pelvis
Uses of X-ray in Obstetrics
Tumors of the Hand
Injuries of the Hand (2)
Decidual and Placental Clinical Pathology
Country Practice
Medical Legal Topics
Chronic Alcoholism
Urogenital Diseases
Abortions
Prenatal Care
Biologic Hormones (2)
Forceps and Their Use
Breech Extraction
Manikin Exercises
Caldwell-Malloy Films and Technique
Analgesics and Premedication Before Delivery
Anesthetics Used in Obstetrics
\ Physiotherapy
are: (1) an informed and progressive hospital
board of directors whose members constantly
anticipate the rapid advances in medical science
and appreciate fully the importance of continuous
collaboration with the medical staff; (2) a com-
munity which has been educated over a long
period by its physicians as to the value of post-
mortem examinations; (3) a flat rate fee for
laboratory tests based upon the time spent in the
hospital and not upon the amount of work per-
formed, thus permitting the equivalent of medical
school laboratory studies without financially bur-
dening the patient; (4) the aid of a full-time
medical anesthesiologist; (5) a medical library of
adequate size; (6) a well-balanced, rotating in-
ternship; (7) properly supervised residencies;
maximum of 700 hospital admissions per intern
per year ; and ten of the greatest importance,
a congenial medical staff alerted to the mutual
benefit derived from a continuous effort at per-
sonally teaching and entertaining interns and
collaborating with medical colleagues in all of
the details of maintaining a high standard of medi-
cal practice in the community.
The great majority of private hospitals of
this country are deficient in their medical educa-
tional program. Inasmuch as this may be due to
the lack of realization of its advantages and feasi-
bility of attainment or a need of methods and
rules of procedure, an ideal postgraduate teaching
center for both private practitioners and resident
physicians has been briefly described.
848
Minnesota Medicine
WATER-BORNE TULAREMIA
ABRAHAM FALK. M.D.
Minneapolis, Minnesota
rT"'HE clinical recognition of tularemia and the
■*- expanding reservoirs of infection for man
among the warm-blooded animals have been re-
ported more frequently. The clarification and
recognition of clinical states of the disease, in-
cluding the important pleuropulmonary manifes-
tations, have resulted in an entity considerably
enlarged from its original description13 in 1911.
With the evident specificity of streptomycin in its
treatment the clinical cycle appears to have been
completed.
The reported sources of infection for man,
however, appear to be increasing. Francis6 in
1937 noted over twenty animal and insect sources,
although the cottontail rabbit, jack rabbit and
snowshoe hare alone were implicated in over 90
per cent of human cases in the United States.
Additional reports since that time have described
transmission of the disease to man by the pheasant,
grouse, horned owl, chicken hawk, beaver, rac-
coon, dog, fox, squirrel, and snapping turtle.
Burroughs4 in 1945, listed all known naturally
infected vertebrates, including five bird species
and twenty-three mammalia in the United States
and six in Canada. The latter area included
species of ground squirrels, mice, rabbits, and
the gull. The evidence of the large animal reser-
voir of infection is impressive. Infection in man,
in most instances, occurred through infected tick,
flea or other insect bites, or direct contact with
the tissues of infected animals. Transmission
from animal to animal and from animal to man is
known, but no instance of transmission from man
to man has been reported.
Human infection through the handling of cold-
blooded animals has been described as incurred
in the skinning of a bull snake,6 and Miller11
described infection from the fin prick of a catfish
caught in a small Kansas river, resulting in a
small wound on the palm of the left hand, with
onset of symptoms five days later. Rabbits with
so-called “rabit fever” had been seen to fall into
the river and drown and numerous rabbit car-
casses were noted in the water. No other similar
From the Department of Medicine, University of Minnesota,
and Veterans Administration Hospital, Minneapolis, Minnesota.
Published with the permission of the Medical Director, Veterans
Administration, who assumes no rsponsibility for the opinions
expressed, or conclusions drawn, by the author.
August, 1947
instances are noted in the literature, although
infection from fish caught with infected rabbit
meat as bait is reported. It is not assumed that
reptiles or fish present reservoirs of infection,
but rather are the inadvertent sources of trauma
to the skin allowing entry of the organism from
the contaminated body surfaces.
Water-borne infection, presumably from con-
tamination with animals, dead or alive, has been
recognized. About 1,000 cases of tularemia re-
ported from Russia in 1928 resulted from the
skinning of water rats for their pelts. Karpoff
and AntonofP in 1936 reported forty-three cases
from Russia in natives who drank unboiled
water from a brook thought to have been con-
taminated by water rats. The presence of the
organisms in the water course was proved ex-
perimentally and bacteriologically, as 100 per
cent of guinea pigs infected with the water died,
and cultures of P. tularense were obtained from
their organs. The stream was not stagnant, but
it was noted to have been good flowing water of
shallow depth.
Parker12 reported tularemic infection in Mon-
tana streams and Jellison8 subsequently reported
infection in beaver in that state with coincidental
contamination of stream water. The associa-
tion of stream infection with epizootics occa-
sionally observed in beavers was suggested. The
dangers of infection from run-off water from rain
and melting snow contaminated with animal car-
casses and later stored in reservoirs for animal
and human use are emphasized by Bow and
Brown3 as possible sources of water-borne tu-
laremia in Western Canada.
A case of tularemia due to infection while
cleaning fish, with successful treatment with strep-
tomycin, is reported.
P. V., aged thirty-nine, white, male, caretaker of a
tourist camp, and resident of a southern Minnesota town,
was admitted on September 3, 1946. On August 27
the patient experienced the onset of malaise, slight nau-
sea, fever and profuse perspiration, followed by shaking
chills during the next two days. He was admitted to
a local hospital on August 29 with continued symptoms
and fever of 101-103° F. Atabrine, penicillin and sev-
eral blood transfusions were given without benefit, and
he was subsequently transferred to this hospital.
Examination revealed a well-developed and well-
nourished white man, perspiring profusely and appear-
849
WATER-BORNE TULAREMIA— FALK
ing acutely ill, with temperature of 100° F. Positive
findings were confined to the left upper extremity. An
irregular deep ulcer with fairly sharp edges and puru-
lent, necrotic base was noted on the dorsal aspect of
the left thumb overlying the interphalangeal joint, with
moderate redness and slight edema of the immediately
surrounding skin. On the dorsal aspect of distal phalanx,
left little finger, was a small, rounded, crusted, healing
ulceration. Moderate enlargement and tenderness of the
left axillary nodes and a few slightly enlarged right
axillary nodes were palpable.
Laboratory studies: Hemoglobin 17.7 Gms., red blood
count 4,350,000, white blood count 6,400 with 50 per cent
neutrophils, 45 per cent lymphocytes, 5 per cent mono-
cytes. Urinalysis, blood Wassermann and repeated mala-
ria smears were negative. Sedimentation rate (West-
ergren) ,46 mm./hr. Admission chest radiograph was
negative.
Careful questioning on many occasions failed to re-
veal any history of the handling of live or dead game
or other animals. There was no history of tick bite. He
never hunted, but did fish almost daily for carp and
catfish in the Minnesota River. He recalled scratching
the dorsum of the left thumb while cleaning fish some-
time during a two-week period prior to onset of his
illness, with the appearance of infection and ulceration
with concomitant pain and enlargement of left axilliary
nodes several days prior to August 27. A small in-
fected, ulcerated area appeared on the left little finger
at about the same time.
Agglutinations for B. abortus and typhoid-paratyphoid
were negative on admission and remained negative. P.
tularense agglutination on September 7 was 1 :80, with
cross agglutination of Proteus OX 19 to 1 : 160. Cultures
from the ulcers on the left hand revealed hemolytic
Staphylococcus aureus. Cultures of material from the
ulcers and blood cultures on cystine media produced
no growth.
Symptoms remained unchanged, with profuse per-
spiration as the most prominent complaint. Temperature
became normal on September 5, then rose sharply to
103.8° F. on September 6, with a subsequent daily spiking
fever of 101.4° to 104° F. Intramuscular penicillin, 40,-
000 units every three hours, was given from September
7 to 12 without response. The lesion on the left thumb
healed rapidly after application of hot, moist com-
presses followed by 5 per cent sulfathiazole ointment,
with gradual subsidence of axillary lymphadenopathy.
On September 8 a small patch of crepitant rales was
heard at the left lung base and chest radiograph re-
vealed a diffuse pneumonitis at the left base and to a
lesser degree in the right upper lobe. Cold agglutinin
titres were negative. Tularemia was considered the most
likely diagnosis at this time and streptomycin was re-
quested for therapy. P. tularense agglutination titre
repeated on September 13 had risen to 1 :2560.
Streptomycin therapy, 0.2 grams intramuscularly
every three hours, was begun on September 13 and con-
tinued until September 20, the patient receiving a total
of 9.9 grams. Subjective improvement with subsidence
of the profuse diaphoresis was noted by the patient on
the second day of treatment. Temperature became
normal on September 17 and remained normal sub-
sequently.
On September 22 there was an episode of severe
pain in the left chest, exacerbated by respiration, relieved
by strapping and sedation. Chest film revealed no ex-
tension of the pneumonitis, there were no abnormal phys-
ical findings and the temperature remained normal. The
symptoms were attributed to pleuritis, and subsided
slowly over a period of ten days. Electrocardiogram on
September 23 was normal. No evidence of pleural ef-
fusion was noted at any time, and final chest radiograph
on October 7 showed only minimal residuals of the
pneumonic consolidations and complete resolution of all
infiltrative lesions.
850
The highest titre of P. tularense agglutination on Sep-
tember 17 was 1 :1280, on September 27, 1 :640, and on
October 5, 1 :1280. Sedimentation rate on October 11 was
27 mm./hr. The white blood count ranged between 6000
and 9000, with moderate lymphocytosis.
At the time of discharge on October 15, 1946, the
patient was ambulant, asymptomatic and without positive
physical findings.
This case of tularemia, with cutaneous and pul-
monary infection, responded rapidly and effec-
tively to treatment with streptomycin. The mor-
tality in pleuropulmonary tularemia has previous-
ly been reported2 as from 30-60 per cent. Stuart
and Pullen14 reported 268 cases from the litera-
ture with a mortality of 39.9 per cent. Hunt7 re-
cently reported twelve cases treated with an av-
erage of 0.5 grams streptomycin daily with one
death occurring in a case with cerebral manifesta-
tions. He recommends a therapeutic trial of the
antibiotic for several days in cases of severe pneu-
monia of undetermined origin in areas of endemic
tularemia, since waiting for confirmatory labora-
tory studies, in some cases, may endanger lives.
Recommended dosage at the time our case was
treated was higher than that now recommended by
the National Research Council,10 the present sug-
gested dosage being 0.5 to 1.0 grams daily for
five to seven days.
The resurgence of hunting and fishing follow-
ing the recent war years, especially in the upper
Midwest, suggests the possibility of increasing
exposure and infection. The relatively wide va-
riety of infected game birds and animals and the
possibility of contamination of fishing waters
should be adequately recognized. The ingestion
of improperly sterilized water from such sources
may also be of significance, as the oral portal of
infection from water has been previously noted.
Amoss and others1’14 have also reported cases due
to the ingestion of partially cooked rabbit meat.
Summary
A second case of tularemia incurred during the
handling of fish, in which the source of infection
was undoubtedly water borne, is presented, to-
gether with some comment on the possibilities of
other human infection from this source.
Bibliography
1. Amoss, H. L., and Sprunt, D. M.: Tularemia: review of
literature of cases contracted by ingestion of rabbit.
106:1078, 1936.
2. Blackford, S. D., and Carey, C. J. : Pleuropulmonary tula-
remia. Arch. Int. Med., 67:43, 1941.
(Continued on Pag.e 880)
Minnesota Medicine
INFECTION OF THE NECK AFTER TONSILLECTOMY
CLIFFORD F. LAKE, M.D.
Rochester, Minnesota
T^ORTUNATELY, infection of the neck after
tonsillectomy is not a common occurrence
among the large number of tonsillectomies per-
formed. However, when such infection does oc-
cur it is dangerous and demands prompt, rational
treatment.
Infections of the neck may be represented by
cervical adenitis, cellulitis of the neck, infection of
a fascial space, thrombophlebitis and septicemia or
any combination of these conditions.
Etiology and Prophylaxis
Obviously infection of the neck after tonsillec-
tomy results from invasion of one of the cervical
structures by pathogenic bacteria. The avenue of
entrance of such bacteria into the neck cannot be
determined definitely. Certain conditions already
present in the patient’s throat and trauma incident
to surgery may predispose to postoperative infec-
tion. The presence of an active infection of the
throat or a common cold may predispose to infec-
tion of the neck after tonsillectomy. Injury to the
superior constrictor muscle, which lies between
the tonsil and the pharyngomaxillary space, con-
ceivably may predispose to infection of this space.
Undue trauma incident to performance of tonsil-
lectomy, especially that caused by dissection of the
lower pole of the tonsil from its rather firm at-
tachment to the superior constrictor muscle, may
produce an avenue of infection to the pharyngo-
maxillary space.
In introducing a local anesthetic agent great
care should be employed to direct the needle prop-
erly, especially in the region of the lower pole of
the tonsil, wherein deep insertion of the needle
might readily cause penetration of the superior
constrictor muscle. At the lower pole, the needle
should be directed into the plica in a direction
horizontal to the palatoglossal muscle in order
to avoid penetration of the superior constrictor
muscle. All injections about the tonsil should be
made into the plane which lies between the ton-
sillar capsule and the aponeurosis of the superior
constrictor muscle ; the needle should be felt to
From the Section on Otolaryngology and Rhinology, Mayo
Clinic, Rochester, Minnesota.
Read at the meeting of the Minnesota Academy of Ophthal-
mology and Otolaryngology, St. Paul, Minnesota, December 13,
1946.
August, 1947
move freely in this plane. The use of unsterile
equipment in administration of injections obvi-
ously may lead to infection of the neck.
Occasionally the styloid process produces a con-
vexity or “tenting effect” in the otherwise con-
cave tonsillar fossa ; if this condition is not recog-
nized, undue trauma to the tonsillar fossa may
result from operation. Obviously, if careful dis-
section is done, injury to the tonsillar fossa should
not occur.
From a bacteriologic standpoint, the virulence
of the invading organism is undoubtedly of great
importance. In 1939 New and Erich2 reviewed
the articles which had appeared in English during
the previous five years on the subject of infections
of the neck. In summarizing the results of the
bacteriologic studies that had been recorded these
authors made the following statement: “It would
appear that many types and strains of organisms
will produce cervical abscess or cellulitis under
favorable conditions. Most frequently encoun-
tered in such suppurative conditions is the hemo-
lytic streptococcus. In many cases the Borrelia
vincentii plays a prominent role. Only infrequent-
ly are such organisms as staphylococci, non-hemo-
lytic streptococci, and pneumococci the primary
cause of the inflammatory process, although they
occur commonly in the mixed type of infec-
tions.”
Such diseases as diabetes, chronic nephritis or
other severe constitutional diseases, although they
may not actually predispose to infection of the
neck, certainly make the patient less resistant once
infection has developed.
Anatomic Considerations
From a pathologic standpoint knowledge of the
anatomy of the neck, especially that of the fascial
planes, is important. It is especially important
that every practitioner of otolaryngology be fa-
miliar with the pharyngomaxillary space, which
lies very near the tonsil. To understand better
the importance of this space one must be familiar
with the anatomy of the deep cervical fascia. This
fascia lies beneath the platysma muscle and invests
the neck. It also forms sheaths for the carotid
vessels and for structures in front of the vertebral
851
INFECTION OF THE NECK— LAKE
column. The investing layer of deep cervical
fascia is attached posteriorly to the ligamentum
nuchae and to the spinous process of the seventh
cervical vertebra. As it passes around the neck,
the fascia invests the trapezius and sternocleido-
mastoid muscles. In the posterior triangle of the
neck the fascia is a rather loose areolar tissue,
while in the anterior triangle it forms a single
fascial lamella which continues anteriorly to the
midline to join with its fellow of the opposite side.
In the midline of the neck anteriorly the fascia
is attached to the hyoid bone and the symphysis
mandibulae.
Above, the fascia is attached to the superior
nuchal line, to the mastoid process and to the
inferior border of the mandible throughout its
length. It ensheathes the parotid gland and ex-
tends upward to attach to the zygomatic arch.
The part that passes medial to the parotid forms
a strong band known as the stylomandibular liga-
ment.
Below, the fascia is attached to the acromion,
the clavicle and the manubrium. Above the
manubrium it splits into two layers to form the
suprasternal space (Burns’ space).
The fascia which covers the deep surface of
the sternocleidomastoid muscle gives off several
processes which form the sheath of the omohyoid
muscle, the carotid sheath and the prevertebral,
buccopharyngeal and pretracheal layers of fascia.
The prevertebral fascia is fixed to the skull
above and continues into the thorax below. The
buccopharyngeal fascia ensheathes the constrictor
muscles of the pharynx and is carried superiorly
onto the buccinator muscle; it is separated from
the prevertebral fascia by loose areolar tissue to
form a space known as the retropharyngeal space.
The pretracheal fascia ensheathes the thyroid
gland. It is fixed above to the hyoid bone and is
extended below beyond the root of the neck to
fuse with the pericardium. It also fuses on either
side with the prevertebral fascia to form a com-
partment for the thyroid gland, trachea, larynx,
pharynx and esophagus.
It should he understood that the pharyngomax-
illary space in the normal neck is merely a po-
tential space and that only as a result of the
formation of an abscess within it or of the intro-
duction of the dissector’s finger or instrument into
it does this potential space become an actual
space or compartment.
The pharyngomaxillary space is pyramidal in
shape ; its base is the skull and its apex is at
the greater cornu of the hyoid bone. The lateral
boundary consists of the parotid space and fascia.
The internal pterygoid muscle and the ascending
ramus of the mandible form the anterior bound-
ary. The superior constrictor muscle separates
the pharyngomaxillary space from the tonsil and
provides the medial boundary of this space. Pos-
teriorly the space is bounded by the stylopharyn-
geal aponeurosis which covers the great vessels
of the neck.
Signs and Symptoms
Deep infections of the neck frequently have
an insidious onset, although those which follow
tonsillectomy may have a rapid onset. The tem-
perature rises daily to peaks, then may level off
and gradually fall. Chills and sweats commonly
occur. Various degrees of toxemia may exist.
Dysphagia and dyspnea may be present. The
patient complains of pain in the throat and neck.
At examination, some evidence of tenderness can
be elicited. In infections of the pharyngomaxil-
lary space trismus, swelling in the region of the
parotid gland and displacement of the tonsillar
fossa and the palate occur. The patient who has
infection of the pharyngomaxillary space should
be observed closely for symptoms and signs of
phlebitis.
Treatment
There are two schools of thought in respect to
treatment of deep infections of the neck: those
of one school favor early opening of the lesion,
while those of the other favor the relatively con-
servative practice of waiting for appearance
of signs of fluctuation or of localization of the
infection before institution of drainage. Use of
hot packs and irradiation may prove beneficial.
The sulfonamide drugs and penicillin are valuable
in combating infections caused by organisms
which are sensitive to the action of these thera-
peutic agents. General supportive measures
should be instituted. If dysphagia is severe a
feeding tube should be inserted. Should involve-
ment of certain structures cause dyspnea, trache-
otomy should be performed. The value of blood
transfusions should not be forgotten.
Incision for opening an infected pharyngomax-
illary space is made from below and behind the
angle of the mandible forward on a line toward
852
Minnesota Medicine
INFECTION OF THE NECK— LAKE
the hyoid bone. The T incision of Mosher1 may
also be used. After the superficial structures have
been separated, the finger is inserted in the space
between the parotid and submaxillary salivary
glands medial to the mandible and pushed along
the inner aspect of the internal pterygoid muscle
into the pharyngomaxillary space. A large rub-
ber-dam type of drain should be inserted deeply
into the space and a suitable dressing applied.
If thrombophlebitis of the internal jugular vein
has taken place the incision should be extended
down over the course of the vein so that ade-
quate exposure of the vessel may be secured to
permit treatment of this complication.
Reports of two cases follow. One case is
that of an uncomplicated infection of the pharyn-
gomaxillary space which followed tonsillectomy ;
the other is that of an infection of the pharyngo-
maxillary space complicated by the occurrence
of thrombophlebitis and the presence of frank
pus in the internal jugular vein.
Report of Cases
Case 1. — A white woman, aged twenty-three years, en-
tered the hospital on August 14, 1946. She stated
that tonsillectomy had been done two weeks previously
and that the right side of her throat had remained sore
ever since. The patient complained of headache and
attacks of nausea, vomiting and dizziness; she said
that in the last three days before admission to the hos-
pital she had noticed, in the right upper cervical region,
swelling which extended up to the cheek. She stated
that she had received penicillin for one week previous
to admission. A culture taken elsewhere was said
to have revealed streptococci.
The patient was given both penicillin and sulfadiazine
for five days; then administration of sulfadiazine was
stopped and use of penicillin alone was continued for
another five days. The amount of penicillin given during
the course of treatment was 1,420,000 units. After
the third day the patient showed marked improvement
and only very slight induration remained in the superior
cervical region. The induration seemed to clear up
shortly thereafter. At no time was there fever of the
spiking type. It was only during the first three days
of treatment that she had fever at all. The highest
temperature recorded was 100.6° F. ; this occurred on
the second day after admission.
After hospitalization for ten days the patient was
dismissed. She got along well for three days, after
which she again noted pain in the right side of the
throat and had difficulty opening her mouth. She re-
turned one week after dismissal. It was difficult to
examine the throat because the patient was unable to
open her mouth satisfactorily. Induration was present
in the right submandibular region. Again the patient
was given penicillin; over a period of eight days 1,040,000
units were administered. Again symptoms disappeared.
A small abscess at the upper pole of the right tonsillar
fossa was opened and the patient was dismissed from
the hospital eight days after admission. At no time
during this second period of hospitalization was there
fever.
Six days after the second dismissal the patient entered
the hospital for the third time. Marked swelling of
the right upper cervical region and cheek was present.
The patient was again given penicillin. The tempera-
ture varied between normal and 99.8° F. Two days
after admission an incision was made below the angle
of the jaw and an abscess in the pharyngomaxillary
space was drained. The abscess also extended to the
submaxillary space. Two ounces of thick yellow pus
were evacuated and a Penrose drain was inserted into
the wound. The patient was dismissed on the fifth
day after drainage of the abscess. The amount of
penicillin given during this period of hospitalization was
640,000 units. The patient has remained well since.
Case 2. — A white man, aged twenty-six years, was
admitted to the hospital on October 16, 1941. The patient
had undergone tonsillectomy one week before admission.
Two days after tonsillectomy the patient felt ill and
began to have severe chills which lasted for an hour.
He noted swelling on the right side of the neck. At
examination the right tonsillar fossa appeared swollen.
There was tenderness in the right superior cervical
region. The patient appeared acutely ill.
On the day of admission, a spiking type of tempera-
ture with a peak of 101.6° F. was observed. Intra-
venous administration of sodium sulfapyridine was
started. On the second day blood transfusion was per-
formed and a pharyngomaxillary abscess was drained.
The infection had caused phlebitis, the site of which
was the internal jugular vein. The vein, when opened,
contained frank pus. There was no bleeding from the
vein when a sucker tip was inserted superiorly or inferi-
orly. Transfusion was performed on the first postopera-
tive day. On the second postoperative day the tempera-
ture rose to 106° F. and continued elevated. On the
third postoperative day the temperature reached 107° F. ;
the patient died a few hours later. Cultures taken from
the throat revealed Diplococcus pneumoniae. Cultures
obtained from the abscess revealed green-producing
streptococci.
Summary and Conclusions
Infection in the neck following tonsillectomy
is dangerous. Tonsillectomy should not be car-
ried out in the presence of acute infection in the
pharynx or mouth. Great care should be em-
ployed in introducing the local anesthetic agent for
tonsillectomy. Familiarity with the anatomy of
the neck is important in carrying out both the
infiltration for anesthesia and the tonsillectomy.
After tonsillectomy all patients should be observed
(Continued on Page 896)
August, 1947
853
SPOROTRICHOSIS IN MINNESOTA
JOHN F. MADDEN. M.D.
Saint Paul. Minnesota
SPOROTRICHOSIS is a rare disease in Min-
nesota. Montgomery3 reported the last case
in this state in a patient seen at the Mayo Clinic
in January, 1937. Gastineau, Spolyar, and
Haynes2 reviewed the literature up to 1941 and
could find only three cases from Minnesota.
The disease is comparatively common in plants
and much more common in animals than in man.
It is believed that man acquires sporotrichosis
from contact with plants, infected animals, or
animals acting as carriers. There is no record of
direct transmission of the infection from man to
man although Foerster1 reported two cases in
which the disease was thought to be contracted
bv handling contaminated dressings from lesions
of sporotrichosis.
Sporotrichosis may appear in several definite
or mixed clinical types. Localized lymphatic
sporotrichosis is the most common type seen in
the United States. Our cases were of this type
and the initial lesion occurred on the usual place,
the hand. The initial lesion is sometimes spoken
of as a “sporotrichotic chancre” and may be
present for days or weeks before other lesions
appear. It was taken for a ‘‘boil” in our cases,
and that is the usual diagnosis. The initial nodule
is round, firm, indolent, and relatively painless.
It later undergoes necrosis, liquefaction and ul-
ceration. Days or weeks later other similar
nodules appear along the lymphatics draining the
initial lesion. They in turn undergo the same
changes. The localized lymphatic type rarely dis-
seminates, although the secondary gummatous le-
sions may remain for months or years.
The disseminated form is seen most frequently
in France. Usually no primary lesion is seen, the
onset is insidious, and the first symptom is mul-
tiple nodules scattered over the skin surface sug-
gesting a blood stream infection. The lesions may
or may not ulcerate. The patients are acutely ill
and deaths occur.
The epidermal form usually is accompanied by
nodular lesions and appears as infiltrated plaques,
areas of folliculitis, or eczematous or verrucous
lesions. It may mimic many other dermatoses.
From the Ancker Hospital, Saint Paul, and the Division of
Dermatology and Syphilology, University of Minnesota, Dr. H.
E. Michelson, director.
In some instances it may be an “id” type of lesions
accompanying the subcutaneous nodular type of
the disease. In both types the constitutional symp-
toms are mild or absent.
Sporotrichosis of the mucous membranes may
be primary or a manifestation of the disseminated
form. The eruption is usually in the nose or
mouth and appears as erythematous, ulcerated or
vegetative lesions simulating more common types
of stomatitis or rhinitis.
Skeletal and visceral sporotrichosis is very
rare but cases have been reported where the
bones, joints, muscles, kidneys, testes, or breasts
have been involved.
A positive diagnosis is made by culture and
identification of the organism. In our cases the
organism, sporotrichum Schencki , grew well on
Sabouraud’s glucose agar slants maintained at
room temperature. In some instances it took
three weeks to obtain a good growth. Examina-
tion of direct smears from pus from the lesions
is unreliable and not considered of diagnostic
value. It is also generally conceded that the causa-
tive organism cannot be identified in microscopic
sections of the diseased tissue.
Case Reports
Case 1 — D. R., a school boy, aged twelve, cut his right
index finger while skinning a rabbit the first of Novem-
ber, 1944. About a week later an abscess appeared on
the dorsum of the right index finger over the first
phalangeal joint at the site of the cut. This was incised
by his local doctor. At intervals of a few days several
marble-sized nodules and abscesses began to appear
and extend up the arm. Some of these ulcerated and
others remained hard, painless and red. On examination
there were two irregular olive-sized fung'ating lesions
on the dorsum of the hand, and several marble- to olive-
sized nodules on the forearm and arm, extending from
the fingers to the shoulder. The lesions were asymp-
tomatic. There was also an olive-sized ulcer on the
lateral surface of the middle third of the left leg. The
patient felt well and his temperature was normal. The
patient had three negative agglutination tests for tulare-
mia, the last one the first week of January, 1945. The
blood Wassermann reaction was negative. The Man-
toux test, 1 : 1000, was negative. Fungi were not found
in fresh preparations made with sodium hydroxide.
S forotrichxvm Schencki were demonstrated from cul-
tures made on Sabouraud’s media. The family doctor
prescribed wet packs to the lesions, the abscesses were
854
Minnesota Medicine
SPOROTRICHOSIS IN MINNESOTA— MADDEN
Fig. 1. Case 1. The initial lesion is on the index finger,
incised and drained, sulfathiazole ointment was applied,
and he was given sulfathiazole by mouth for two months
without improvement. The lesions healed permanently
after the patient took 15 drops of a saturated solution
of potassium iodide by mouth for three weeks.
Case 2. (Dr. H. E. Michelson’s Case) — M. D., a
Mexican, aged forty-one, stated that on September 1,
1945, he injured the third finger of the right hand
while loading corn. The fingers and the back of the
hand became swollen. The lesion on the finger was in-
cised by his local doctor but did not heal. About Sep-
tember 21 the patient noticed a dark, painless streak
extending up his forearm. There were hard nodules at
intervals along the streak. The eruption was painless
and purplish-red color. The patient was admitted to the
University Hospital on November 1, 1945. There was
a dime-sized verrucous granulating lesion on the dorsum
of the third finger of the right hand ; a fluctuant, red-
dish-brown olive-sized mass on the dorsum of the
right hand and a hard cord-like brownish-red streak
extending a little above the elbow. There was bean- to
marble-sized epitrochlear and right axillary lympha-
denitis. The sporothrix was recovered from cultures
made on Sabouraud’s media. All other examinations,
including a roentgenogram of the chest, were negative.
The patient was given 45 grains of potassium iodide
daily, and the eruption healed in seventeen days.
Case 3. (Case of Drs. F. W. Lynch and G. E. Har-
mon)— Mrs. O. L., a farmer’s wife, aged forty-one,
stated that an indolent nodule appeared on the palm
at the base of the right thumb in November, 1945. The
patient did not remember injuring her hand. The lesion
was incised and pus expressed, but it did not heal. In
a few days new lesions appeared. When seen in De-
cember, 1945, about thirty marble- to olive-sized, red,
comparatively painless, subcutaneous nodules or ulcers
extended from the hand to the elbow along the lymphat-
ics draining the initial lesion. There was slight epitroch-
lear and axillary lymphadenitis. The sporothrix was
recovered from cultures made on Sabouraud’s media.
The patient was given 45 grains of potassium iodide a
day by mouth, and the lesions healed within three
weeks. (Note: The patient stated that cattle on her
farm had actinomycosis.)
with ulcers and nodules extending along the lymphatics.
Fig. 2. Case 1. Sporotrichum Schencki from cultures on Sa-
bouraud’s glucose agar, showing hyphae supporting conidio-
phores terminated with a cluster of pyriform conidia.
Potassium iodide is considered specific in the
treatment of sporotrichosis. In our cases it was
specific with rapid cure. The localized lymphatic
type, of which our cases were examples, responds
more favorably and rapidly to treatment than
other types. Roentgen ray therapy may be of
value in some cases. In the first case of ours,
sulfathiazole was of no value even though given
over a comparatively long period.
Summary
Three additional cases of sporotrichosis were
reported from Minnesota, making a total of six
reported up to the present time. They were of
the localized lymphatic type and all responded
rapidly to treatment with potassium iodide.
Bibliography
1. Foerster, H. R. : Sporotrichosis. Am. J. M. Sci., 167:54-
76, (Jan.) 1924.
2. Gastineau, F. M.; Spolyar, L. W., and Haynes, Ed.:
Sporotrichosis; report of six cases among florists. J.A.M.A.,
117:1074-1077, (Sept. 27) 1941.
3. Montgomery, H., and Holman, J. C., Jr.: Pseudo-epithelio-
matous hyperplasia in a case of sporotrichosis. Proc. Staff
Meet., Mayo Clin., 13:465-469, (July 27) 1938.
August, 1947
855
TUBERCULOSIS AMONG RESIDENTS OF OLMSTED COUNTY
OVER THE AGE OF SIXTY-FIVE
Data on Blood Pressure, Hemoglobin and Urine Tests
F. M. FELDMAN, M.D., Dr. P.H.
Rochester, Minnesota
'""PUBERCULOSIS mortality rates in this area
are reaching very low levels. Over the last
five years, only twenty-four deaths in Olmsted
County residents have been recorded as due to
tuberculosis. This is less than five per year. If
we estimate the population at 48,000, the mor-
tality rate would be 10. The rate for the same
period in the whole of Minnesota will approxi-
mate 25.1. More striking is the fact that for the
calendar year 1946, only three residents of this
county died of tuberculosis. It also might be
pointed out that during this same year seventy-
seven residents died of heart disease, forty-six
of intracranial vascular lesions, forty-three of
cancer and eight of accidents. Tuberculosis ac-
counted for only 1 per cent of the 293 deaths.
With these low tuberculosis mortality rates,
we are surprised and pleased to find an average
of twenty-six tuberculosis patients from our coun-
ty under treatment in various institutions. This
is over five per annual death.
Surveys of adult groups of all ages in .this
area indicate that less than 0.2 per cent have
active reinfection-type tuberculosis. This means
that the finding of active cases by any survey
methods covering the whole population is be--
coming increasingly more difficult and expensive.
Another well-marked trend has been the in-
crease in the average age of patients admitted to
sanatoria. Laird1 states that no patients over the
age of fifty were admitted to Nopeming Sana-
torium in 1913. In the years 1923, 1933, and
1943, the respective percentages were 4, 9, and
20. Other sanatorium superintendents have also
noted this shift in age.
In 1940, the highest tuberculosis death rate in
the Registration Area of the United States for
any ten-year age group was 110. This was for the
age group fifty-five to sixty-four inclusive.
Considering the obvious decrease in tuber-
culosis infections and deaths in the general popu-
lation, and the equally obvious shift toward
the older age groups, the officers of the Olmsted
County Public Health Association decided to at-
tempt an x-ray sampling survey of older persons
in the community.
856
Through the Rochester City Health Department
and the Mayo Clinic, arrangements were made for
weekly half-day clinics to be held during the
summer of 1946. As an added inducement for
patients to come to the clinic, blood pressure tests,
hemoglobin tests and urine tests were also of-
fered along with the chest x-ray examinations.
The lower age limit was arbitrarily set at sixty-
five, partly because this happens to be the earliest
age at which persons can participate in the old-
age assistance program of the County Welfare
Board. Expenses of this clinic, except for certain
facilities of the Health Department and the Mayo
Clinic, were borne by funds from the Public
Health Association, obtained through the sale of
Christmas Seals. No charge was made to patients
for these rather limited procedures.
Publicity was obtained through the local news-
papers, the radio, the Welfare Board, and by
various other means. The response varied di-
rectly with the amount of such promotional effort.
In Rochester and Olmsted County there are
approximately 2,500 persons over the age of
sixty-five. Although the total attendance at these
clinics was only 162, or 6.5 per cent, this sample
revealed several things of interest. Figure 1 shows
the age and sex of those who came in.
Since the primary purpose of this project was
the discovery of tuberculosis, the x-ray findings
will be discussed first. Of the 151 who received
chest x-rays, thirteen (8.6 per cent) had definite
evidence of reinfection tuberculosis. Only one
was a previously reported case. So far, we have
been unable to show that any are active cases, but
great difficulty has been encountered in obtaining
adequate follow-up examinations, so it is quite
possible that some may be discharging tubercle
bacilli.
Of the lesions seen, eleven could be classified
as minimal, and two moderately advanced. None
was far advanced. An additional fifteen patients
had some apical fibrosis. Sputum examinations
were made on four of the minimal cases and on
the two moderately advanced cases, but no tub-
ercle bacilli were found. This is consistent with
the x-ray appearances which did not suggest
Minnesota Medicine
TUBERCULOSIS— FELDMAN
activity except in the two moderately advanced
cases.
We will continue our efforts to obtain sputum
examinations and periodic x-rays on some of these
ment was noted in eleven, and one man had a lung
carcinoma from which he has since died.
The other tests, which were offered primarily
to encourage attendance at the clinics, also af-
AGE!
Fig. 1
BLOOD PRCSSURC
-33 100-03 110-13 120-23 130-33 110-13 150-53 IG0-G3 170-73 180-03 130-33 200+
patients, just as we follow other known tuber-
culosis cases. We are hoping to persuade a few
to come in for gastric washings.
As is usual in x-ray surveys, other pathologic
conditions were also uncovered. Heart enlarge-
forded an unusual opportunity for the collection
of some limited but valuable data.
The blood pressure determinations were all
made by one experienced nurse using the stetho-
scope and mercury manometer technique. As
August, 1947
857
TUBERCULOSIS— FELDMAN
shown by Figure 2, and as expected, wide varia- In Figure 3, average blood pressures have been
tions were encountered, with a large proportion tabulated and charted by age and sex. Systolic
BLOOD PRESSURE - AGE AND SEX
Fig. 3.
OCMOCIOBIN
-9.9 10- 10.3 11-113 12-12.9 15-15.9 14-14.9 15-15.3 16-169
GRAMS PLR 100 C.C.
Fig. 4.
having systolic pressures over 150 mm. Diastolic pressures for women were higher than for men
pressures also covered an extensive range. in every age group except in the last two where
858
Minnesota Medicine
TUBERCULOSIS— FELDMAN
the number of observations is too small to be of does not reveal the variations within each age
any significance. Diastolic averages, however, did group. In the seventy-five to seventy-nine age
Fig. 5
not rise with age, particularly in men. This is
consistent with observations on 5,331 men re-
ported by Russek.2 No such extensive studies on
women could be found in recent literature.
Although not shown by this chart, the varia-
tions within each age group were considerable.
For example, the systolic pressure in the group
age eighty to eighty-four ranged from 116 to 222,
with six of the fifteen below 150, and, interest-
ingly enough, all six in men. The significance of
these observations I must leave to the clinicians.
The hemoglobin determinations were done
photoelectrically. Although it is often stated that
a normal person should have 14 grams of hemo-
globin per 100 c.c. of blood, most physicians
would agree that this is a rather high standard.
As can be seen in Figure 4, all except twenty-one
fell below the 14 gram level, and a very consider-
able proportion below 12 grams.
In Figure 5, average hemoglobins are charted
for age and sex. The differences are not great,
but the women are consistently lower than the men
in every age group. Also there is a definite in-
verse correlation with age.
This chart was constructed from averages, and
August, 1947
group the lowest was 10.2 grams and the highest
14.2 grams.
The average for persons receiving old-age as-
sistance was 12.1 grams, and for the others 12.6
grams. Considering the fact that of the 150 per-
sons upon whom hemoglobin determinations were
made, sixty were receiving assistance and ninety
were not, this difference is probably statistically
significant.
Qualitative tests on Urine for albumin and
sugar were made using Exton’s solution for al-
bumin and a commercial compressed tablet for
sugar. Only one was found with excessive
amounts of albumin. He had a systolic blood
pressure of 260 mm. and has since died. One of
the others with a 1 + albumin was later found to
have a large stone in the kidney pelvis.
Three persons had sugar in the urine rated
as 3 + , one rated as 24-, and two rated as 1 + .
Only two of these six would consent to go to their
physicians for further examinations, and no final
diagnoses are available at this time.
Perhaps no great fundamental discoveries were
made through studying this limited sample, par-
( Continued on Page 880)
m
METASTATIC CARCINOMA OF THE HEART
Report of a Sole Metastasis from Carcinoma of the Cecum
Diagnosed Before Death
J. S. BLUMENTHAL. M.D., F.A.C.P. and HERBERT W. PETERSON, M.D.
Minneapolis, Minnesota
HPHE incidence of primary tumor of the heart
is very small: eight cases in 480,331 (.0017
per cent), according to the national autopsy ex-
perience in internship hospitals from 1938 to
1942, as reported in the Journal of the American
Medical Association.10 The frequency of cardiac
invasion in various neoplastic diseases, however,
is reported to be from 2 per cent11 to 10.9 per
cent.15 Ritchie12 at the Wisconsin General Hos-
pital reports 3, (XX) autopsies with sixteen meta-
static tumors of the myocardium. Metastases to
the heart have been reported from neoplasms of
all the main organs. These metastases are usually
generalized but the heart may be the only one
present, though this is infrequent. Burke4 in his
series of fourteen cases noted none. Yater20 in
his extensive review makes no specific observation
on this point. Ritchie12 reports one case, a cancer
of the esophagus, in which the myocardium was
the sole site of remote metastases.
Three routes of invasion are recognized :4,20 ( 1 )
blood stream through the coronaries; (2) lym-
phatics from the mediastinal nodes against the
lymph stream; and (3) direct extension.
Age in the cases reported reveals nothing of
note as it corresponds to the age group in which
the original tumor is apt to be found. Sex is of
no importance. Ritchie12 reports twelve males
in sixteen cases but the autopsy material is
weighted in about the same proportion.
Clinically no signs of involvement of the heart
may be found even when extensive invasion has
taken place. Any impairment and findings can
usually be more easily explained by non-neoplastic
conditions. Ritchie12 reports that none of his
sixteen cases was diagnosed before death. Fish-
bert,5 however, records three cardiac tumors
diagnosed by the presence of auricular fibrillation
in two and auricular flutter in one. In 1934,
Barnes2 reported a case of a sixty-two-year-old
woman in whom a diagnosis of a possible primary
sarcoma of the heart was made during life. The
findings were bloody pericardial effusion, an elec-
trocardiogram showing interference in conduction,
and a biopsy of a node diagnosed as metastatic
sarcoma. At autopsy a tumor was found involving
the right auricle and ventricle. In 1935, Shel-
burne16 reported a primary cardiac tumor diag-
nosed during life in a twenty-four-year-old negro
male by reason of (1) sudden onset of cardiac
decompensation without known cause; (2) rapid
accumulation of bloody pericardial fluid which did
not clot; (3) no evidence of tuberculosis or
syphilis; (4) predominance of lymphocytes in
the pericardial fluid eliminating acute pericarditis,
and (5) heart block. Rosenbaum13 and others
7,8,12,20 pave note(] almost complete replacement of
the heart by metastatic carcinoma in which few
symptoms have been noted.6’9 Precordial pain,
angina, cyanosis, and all other cardiac symptoms
or none at all may be present. The location of the
lesion will of course determine many of the signs
and symptoms noted.
The electrocardiographic findings that occur in
the presence of tumors of the heart are not dis-
tinctive. Here again the location of the tumor is
all important.2’13’15 Right bundle-branch block,
5,1C’19 partial heart block, complete atrio-ventric-
ular block,7 changes in the P waves,18 flutter and
paroxysmal auricular fibrillation,1’5’14’17 small
QRS complex have all been reported. They have
been, in themselves, of little value in diagnosis
as the very same findings may take place in many
other conditions. Rosenbaum13 reports a case of
cancer of the esophagus with metastases to the
heart in which persistent upward displacement of
the RS-T segment occurred. The probable ex-
planation was that the neoplastic infiltration
caused almost continuous injury to the myo-
cardium.
We are here reporting a case of cancer of the
heart. It was metastatic from the colon. It was
the only site found. The diagnosis was made be-
fore death.
Case Report
The patient was admitted to the St. Andrews Hospital
on September 26, 1946, and died on October 10, 1946.
The patient had a questionable history of dyspnea
on exertion for eleven and one-half months and was
told that she had heart trouble only four weeks pre-
860
Minnesota Medicine
CARCINOMA OF THE HEART— BLUMENTHAL AND PETERSON
viously when a murmur was first heard by her local
doctor. There was no history of rheumatic fever. One
week previously she was sent to Dr. H. W. Peterson
with complaints of pain in the right lower quadrant
which had begun fourteen months before and had be-
come more severe in the past month. A barium enema
was done before entrance to the hospital and showed
a neoplasm of the cecum. The patient was sent to the
hospital for operation.
On first examination the patient appeared toxic and
somewhat orthopneic and cyanotic on exertion. Blood
pressure was 121/86, pulse rate 100, respirations 20. The
heart was not enlarged to percussion. There was a loud
systolic murmur at the left of the sternum and no
diastolic murmurs were heard. P2 was equal to the A2.
No other findings of significance were noted. A mass
was noted in the right lower quadrant. Ihere was mod-
erate tenderness in this area.
The electrocardiogram (Fig. 1) showed sinus tachy-
cardia, a flat T wave, diphasic ST2 and ST3, notched
QRS — a definitely abnormal tracing. A flat plate of
the chest showed a normal heart and chest. A diagnosis
of probable neoplastic involvement of the heart was
made.
Laboratory examinations showed a negative Kline
test and Rh positive blood ; hemoglobin 73 per cent, red
blood cell count 4,000,000, white blood cell count 13,300,
with neutrophiles 65 per cent, lymphocytes 34, and mono-
cytes 1. The urine on September 26 was straw colored,
with 1+ albumin and no sugar.
On September 31 at about 3 :00 p.m., the patient passed
about 300 c.c. of blood per rectum, which was followed
by collapse. A gallop rhythm of the heart was noted.
On October 1, neurological examination showed a defi-
nite weakness of the left arm and leg, and it was
thought that the patient had had a cerebral accident
or possibly a metastasis to the brain. The pulse im-
proved and was regular but the patient remained listless
and unresponsive. Throughout her hospital stay she had
a streaking of the stools with blood and a cyanosis of
the lips and fingers. She also had slurred speech and
a dysphagia. From October 1 until her death the patient
remained unresponsive and flailed her arms about a great
deal. She was involuntary from that time on. On
October 9 a urine odor was noted on her breath. She
expired on October 10. Her temperature varied between
97° and 103° during her hospital stay.
The autopsy showed a 161 cm. woman weighing ap-
proximately 105 pounds. She was well developed and
poorly nourished. Rigor was present as well as hypo-
stasis. There was no edema. The fingernails and toenails
were cyanotic. The pupils were 7 mm. and equal. The
right leg and arm appeared smaller than the left. The
right leg measured 24 cm. at the calf and the left 29 cm.
There were small bruises on the right hip and a hemor-
rhage on the left hip. The left upper arm was swollen
and reddened and the veins were very prominent. The
peritoneal cavity was smooth and glistening. No fluid
was present. The appendix was present and normal.
The liver was 11 cm. below the xiphoid process and
3 cm. below the midclavicular line on the right. The
pleural cavities showed no fluid. There was an adhesion
on the base of the right upper lobe. The pericardial
sac contained 50 c.c. of straw colored fluid.
The heart weighed 350 grams and had an enlarged
right auricle. A mural thrombus was present in the
Fig. 1. Electrocardiogram shows sinus tachycardia, a flat Ti,
diphasic ST2 and ST3, and notched QRS.
right auricle. The right ventricle had a tumor filling
the entire chamber, with the point of attachment on the
posterior side. One knob of the tumor extended through
the pulmonary valve. The root of the aorta was nor-
mal. The coronaries were patent and showed no
sclerosis.
The right lung weighed 200 grams and the left 150.
The right lung had many small areas of hemorrhage,
the largest one measuring 3 cm. in diameter. In the left
lung the same small hemorrhagic areas were present.
The spleen weighed 200 grams. It had four hard
whitish areas on its surface, the largest measuring 2 cm.
in diameter.
The liver weighed 1,600 grams. On cut section it had
a pale mottled appearance. The gall bladder was normal
and the bile ducts were patent.
Gastrointestinal tract : There were adhesions of the
omentum over the cecum. A mass was palpable in the
cecum. When the tumor in the cecum was cut, it had
a fungating appearance and measured 6 cm. in diameter.
There were portions of the tumor which contained
cartilage.
The pancreas and adrenals appeared normal. Each
kidney weighed 110 grams. Both kidneys had large
white nodular masses on their surfaces which extended
into the cortex of the kidney and measured 2 by 5 cm.
in diameter. Aside from this the kidney surface was
August, 1947
861
CARCINOMA OF THE HEART— BLUMENTHAL AND PETERSON
smooth. The right ureter was slightly dilated, but the
bladder and genital organs appeared normal.
1 he organs of the neck appeared normal. No enlarged
mesenteric lymph nodes were found.
I hrombi were present in the common iliac veins. An
embolus was found in the portal vein.
Microscopic : '1 he lungs showed areas of infarct and
patchy aieas of atelectasis. A section taken through the
tumor in the cecum showed an adenocarcinoma, with
some sections having a gelatinous appearance.
The kidneys microscopically showed small infarcts;
otherwise the glomeruli and tubules were normal.
Sections through the tumor in the heart showed an
adenocarcinoma.
1 he liver had areas of central lobular necrosis typical
of chronic passive congestion.
1 he spleen had thrombi in its arteries and infarction
of the parenchyma.
1 he brain showed a large necrotic area in the right
occipital lobe 2 cm. in diameter. No tumor cells were
present.
Diagnoses: 1. Adenocarcinoma of the cecum.
2. Large metastasis of adenocarcinoma to the wall
of the right ventricle completely filling the chamber.
3. Thrombosis of the common iliac artery.
4. Infarct of the kidney, spleen, and lungs.
5. Thrombosis of left axillary vein.
6. Infarction of the right occipital lobe of the brain.
7. Chronic passive congestion of the liver.
Comment
Given a case of known cancer with no previous
history of cardiac pathology, with sudden develop-
ment of rapid pulse and cyanosis on exertion, a
loud systolic murmur only recently heard, a nega-
tive history of rheumatic fever, negative findings
or history of syphilis or tuberculosis; and beyond
that a definitely abnormal electrocardiogram in a
young individual — it is quite reasonable to give
strong consideration to neoplastic involvement of
the heart. The findings in this case justified the
diagnosis which autopsy confirmed.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
References
Auerbach. O. ; Epstein, H., and Gold, H.: Metastatic car-
cinoma of the heart; a case presenting auricular flutter
symptoms of coronary thrombosis and congestive heart fail-
ure. Am. Heart J., 12:467, 1936.
Barnes, A R.; Beaver, I). C., and Snell, A. M. : Primary
sarcoma of the heart; report of a case with electrographic
and pathological studies. Am. Heart J., 9:480, 1934.
Borman, P. G.: Primary sarcoma of the pericardium; report
of a case. Ann. Int. Med., 12:258, 1938.
Burke, E. M. : Metastatic tumors of the heart. Am T Can-
cer, 20:33-47, 1934. ’ J
Fishberg, A. M. : Auricular fibrillation and flutter in meta-
static growths of the right auricle. Am. J. M. Sc., 180:629,
nammon, ia.
i>ieiabiauc carcinoma ot the heart.
mu.
J. Cancer, 16:205, 1932.
Lymburner, R. M.: Tumors of the heart. Histopathological
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Morris, E. M.: Metastasis to the heart from malignant
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Napp, O. : Ueber sekundare Herzgeschwiilste. Ztschr. f
Krebsforsch, 3:282, 1905.
Necropsy performance in internship hospitals: TAMA
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Pollia, J. A., and Gogol, L. J.: Some notes on malignancies
of the heart. Am. J. Cancer, 27:329, 1936.
Ritchie, Gorton: Metastatic tumors of the myocardium
Am. J. Path., 172:483, 1941.
Rosenbaum, Francis F. ; Johnston, F. D., and Alzamora,
V. V.: Persistent displacement of the RS-T segment in a
case of metastatic tumor of the heart. Am. Heart J., 27:667,
1944.
Schnitker, M. A., and Barley, O. T. : Metastatic tumor of
the heart. A case diagnosed during life. J.A.M.A., 108-
1787, 1937.
Scott, R. W., and Garvin, C. F. : Tumors of the heart and
pericardium. Am. Heart J., 17:431, 1939.
Shelbourne, S. A.: Primary tumors of the heart with special
reference to certain features which led to a logical and
correct diagnosis before death. Ann. Int. Med., 9:340, 1935.
Smith, IT. S. : Neoplastic involvement of the heart: two cases
diagnosed before death. J.A.M.A., 109:1192, 1937.
Strouse, S. : Primary benign tumor of the heart of forty-
three years duration. Arch. Int. Med., 62:401, 1938.
Willius, F. A., and Amberg, S. : Two cases of secondary
tumor of the heart in children — in one of which a diagnosis
was made during life. M. Clin. North America, 13:1307,
1930.
Yater, W. M.: Tumors of the heart and pericardium — pathol-
ogy, symptomotology, and report of nine cases. Arch. Int.
Med., 48:627, 1931.
The ( following quotation is taken from the U. S.
Senate’s report on a bill providing for the appointment
of a by-partisan commission to streamline the executive
branch of our government as reported by the Council
on Medical Service of the AMA.
“During the past sixteen years, national and inter-
national events have necessitated a constantly expanding
emergency government. In the wake of the prolonged
economic distress of the 1930’s and the four years of
direct participation in World War II, the number of
principal components of the Federal Government have
multiplied from 521, in 1932, to 2,369, in 1947. The
annual pay roll of the executive branch of the Govern-
ment today approximates 6IA billion dollars which is
\y2 billion dollars more than the Government spent for
all purposes in 1933. The executive branch now em-
ploys more people than all the State, city, and county
governments combined. In this sprawling organization
called the Llnited States Government, functions and
services criss-cross and overlap to a degree which has
astounded every student of governmental operation.
For example, there are no less than twenty-nine agencies
lending Government funds, thirty-four engaged in the
862
acquisition of land, sixteen engaged in wildlife preserva-
tion, ten in Government construction, nine in credit and
finance, twelve in home and community planning, ten in
materials and construction, twenty-eight in welfare mat-
ters, four in bank examinations, fourteen in forestry
matters, and sixty-five in gathering statistics. Exclud-
ing the Army and the Navy, there are more Federal
employes on the pay roll today than on V-J day.
“In its annual evaluation of Government budget esti-
mates, the Congress, and its committees are constantly
faced with a well-nigh insoluble dilemma. In striving
to strike an equitable balance between justifiable expendi-
tures and imperative economy, the conscientious search
for the necessary facts more often than not leads up
dead-end paths or becomes enmeshed in a maze of con-
fusion and doubt. There is nobody who can tell us in
detail, and with informed authority, just where we can
consolidate, or where we can eliminate, or where, if nec-
essary, we must expand. This situation forces Congress
to swing the meat ax rather than manipulate the sur-
geon’s scalpel. Efficient economy cannot be predicated
on guesswork, no matter how sincere the effort. Effi-
cient and economical government can be the product only
of painstaking study and authoritative analysis.”
Minnesota Medicine
CLINICAL-PATHOLOGICAL CONFERENCE
CHORDOMA
A Sacrococcygeal Type Case Report
ARTHUR H. WELLS. M.D., ARNOLD O. SWENSON, M.D., and HAROLD H. JOFFE, M.D.
Duluth, Minnesota
Dr. A. H. Wells : Although a rare disease process, about the second sacral nerve to the anus and measuring
chordoma is indeed a most interesting subject for a about a foot in diameter. It was firmly fixed to the
review. pelvis over a large base. There was no bruit or fluc-
Fig. 1. Anterior-posterior view of soft tissue mass and de-
struction of sacrum marked by arrows.
Case Report
Dr. A. O. Swenson : This eighty-seven-year-old re-
tired white male (Case 82963) was admitted on April
31, 1947, complaining primarily of difficulty of having
bowel movements, and secondarily, of a large mass sit-
uated over the sacrum. He sustained a bad bump on
his back in an auto accident twelve years earlier, but
not sufficiently severe to consult a physician. A few
months later, he noticed a small lump over the injured
area (sacrum). This mass slowly grew in size and
caused no trouble until he began having difficulty with
his usual daily bowel movements. There had been no
pain, sphincteric or other sensory disturbances. His
weight and appetite had not changed.
The physical examination revealed the expected usual
senile changes in an eighty-seven-year-old, well-nour-
ished, and fairly well-developed male. There was a
huge, irregularly rounded, firm mass extending from
From the Department of Pathology, St. Luke’s Flospital, Du-
luth, Minnesota, Arthur H. Wells, Pathologist.
August, 1947
Fig. 2. Lateral view of destruction of sacrum.
tuation. The mass could be felt crowding the rectum
from the dorsal aspect but did not infiltrate its walls.
The1 patient stood with a decided foreward tilt above
the hips.
His blood pressure was 23Q/130 mm. of mercury.
Urinalysis, blood counts, and blood urea nitrogen,
sugar, nonprotein nitrogen and creatinine were in a
normal range.
•i -
Dr. A. L. Abraham : Roentgenograms (Figs. 1 and
2) reveal the soft tissue mass inferior and posterior
to the ischial bone. There is destruction of the inferior
portion of the sacrum and coccyx of an osteolytic na-
ture. A chest film reveals a double scoliosis of the
thoracic spine. There is, in addition, a marked curva-
ture of the lumbar spine with its convexity to the left
and hypertrophic changes in the bodies of the vertebrae.
The sacrococcygeal lesion best fits the diagnosis of
a chordoma ; however, some other bone-destroying lesion
cannot be ruled out.
863
CLINICAL-PATHOLOGICAL CONFERENCE
Dr. A. O. Swenson : On April 7, 1947, under pro-
caine spinal, nitrous oxide and ether anesthesia, the large
tumor mass was resected except for fragments invading
the remaining eroded sacrum. The postoperative course
Fig. 3. Dorsal view of the buttocks and the protruding
tumor mass.
was uneventful. A large defect over the rectum had
been packed with gauze. This slowly granulated in
over a period of two months.
Dr. A. H. Wells : The irregularity rounded, relatively
smooth surfaced mass measures 10.5 by 21 by 23.5 centi-
meters. There is a strong opague, fibrous capsule cov-
ering all but about 20 per cent of the outer surface
at the site of attachment to the sacrum. The cut sur-
face (Fig. 4) is made up of numerous irregularly round-
ed, highly refractile spaces filled with tenacious to solid
clear mucoid material. These vary from about 1 mil-
limeter to 2.5 centimeters in diameter and are separated
from each other by strong, clear-cut fibrous septa.
Occasionally clusters of nodules form larger nodules.
Histologically (Figs. 5 and 6) the prominent fibrous
septa separate rounded areas containing what appears
to be badly degenerated and vacuolated neoplastic cells.
There is a predominance of mucoid material inclosed
in delicate fibril-like strands generally arranged in
irregular circles. These, at times, appear to be the
remnants of cell walls for there are transitions be-
tween them and the huge vacuolated or physaliphorus
cells which are present in clusters near the margins of
nodules. Isolated cells with elongated cytoplasm, with
indistinct margins and oval or elongated nuclei, are
scattered through the more mucoid areas. A few
closely related syncytial cells with three to six nuclei
are also found in these areas.
The diagnosis in sacrococcygeal chordoma.
Notochord
The notochord, or corda dorsalis has its origin from
the entoderm about the same time that the ectoderm
gives rise to a similar parallel dorsally placed longitudinal
tube of epithelial cells, the neural tube. It forms the
functioning spiral axis in the amphioxus, a species
representing the connecting link between vertebrates and
invertebrates. In man the structure is generally con-
sidered destined to physiologic and anatomic oblivion
Fig. 4. Cut surface of chordoma.
by the formation of the vertebral axis. However, it
may conceivably have a function in the nucleus pul-
posus into which it has been forced from the bodies of
vertebrae by “tissue growth pressure.” Remnants of
its cells have been described in the semiliquid centers of
the intervertebrae fibrocartilages even in adults. Schmorl
has observed three cases of persistence of the noto-
chordal channel through the centers of the bodies of
vertebrae in adults. Offshoots of the chorda which are
located principally in the saggital plane have been re-
peatedly described.14 Remnants of notochordal cells
have been found on the anterior or dorsal aspects of the
vertebral bodies. At the cephalic end the notochord
passes through the dens and the dentate ligament to the
dorsal surface of the basilar portion of the occipital
bone, thence through this bone to its ventral surface
to lie immediately adjacent to the pharynx. It then
passes back into the basilar bone finally to end up
in the dorsal sellar region of the sphenoid bone. At
the caudal extreme, the regression of the tail vertebrae
results in much coiling and offshoots from the main
stem which finally lie in the bodies of the sacrum and
coccyx.14
Pathology
Chordomas are found at any point along the notochord
and are generally designated as to location. A modifi-
cation8 of Coenen’s topographic classification is as fol-
lows :
I. Cranial
(A) Ecchordosis physalifera
(B) Chordomas
1. Sphenoid
2. Spheno-occipital
3. Nasopharyngeal
4. Dental
864
Minnesota Medicine
CLINICAL-PATHOLOGICAL CONFERENCE
II. Vertebral
(A) Cervical
(B) Thoracic
(C) Lumbar
III. Sacrococcygeal
(A) Antesacral
(B) Central
(C) Retrosacral
•Ecchordosis physalifera has been substituted for Vir-
chow’s original and erroneous term of ecchondrosis
physalifera and is defined as a non-neoplastic and sub-
clinical chordal ectopia occurring on the clivus Blumen-
bachii (the sloping surface between the sella and the
foramen magnum).22 This apparently noninfiltrating
jelly-like mass of notochordal cells ranging up to 3
centimeters in diameter has been an incidental finding
in from 1.5 to 2 per cent of autopsies.23
Although the true chordomas are most often histolog-
ically benign, they are seldom cured because of their
characteristic infiltrative nature and their intimate rela-
tionship to the central nervous system and its bony sup-
port. The tumor cells are occasionally highly em-
bryonic with many tumor giant cells. Metastasis to local
lymphnodes, liver, lungs, pleura, skin, et cetera have
been found at autopsies in eleven cases, all of which
were primarily located in the sacrococcygeal area.12
Of the approximately 250 cases of chordoma1 in the
literature, a little over one-third are intracranial and
all but a few of the remainder are sacrococcygeal in
origin.6’7’10 One study14 of the reported cases up to
194i, revealed eighty-one cranial (33.1 per cent), 135
sacrococcygeal (55.1 per cent) and twenty-nine vertebral
cases. The latter were divided ino cervical, eleven ;
thoracic, six, and lumbar, twelve.
No matter in what part of the axis the tumor is lo-
cated, the main bulk of the neoplasm tends to be in
the saggital plain and ventral, dorsal, or central in ref-
erence to bodies of vertebra or the basilar bone of the
skull.
Of the cranial tumors, approximately 80 per cent are
intracranial and 20 per cent extend into the . naso-
pharynx.2 There are five directions of extension of the
cranial chordomata. The most common is from the
clivus with dorsal extension. There is also an anterior-
cephalic progression from the clivus, an extension into
the sella, a directly anterior growth through the sphenoid
sinus and a protrusion into the pharynx or the nasal
cavities. They are nearly always associated with much
destruction of basilar bone. Frequently intracranial
nerves are engulfed and seldom the tumor invades the
pons, pituitary, or temporal lobes of the cerebrum.
The sacrococcygeal chordomata can be generally classi-
fied as anterior, posterior, or central in location. There
is nearly always much invasion of the sacrum and ex-
tension along its nerves.3’7’15’20''25 The anterior lesions
frequently crowd the pelvic organs and occasionally
invade the rectum.
The histology of chordomata reproduces the ontogeny
of the notochord from the rarely found regular cavities
Fig. 5. (above) Low power view of fibrous septa and adjacent
tumor cells.
Fig. 6. (below) Physaliphorus and polyhedral cells typical of
chordoma adjacent to fibrous septa.
lined by cuboidal epithelium as found in the primitive
tube to the most mature manifestation of stringy atrophic
syncitial cells engulfed in mucus, at times found in the
nucleus pulposus. The two intervening stages progress
from large solid polyhedral epithelial-like cells frequently
in cords to vaculated or physaliferous (physalis bubble)
cells. The latter are characteristically found in prac-
tically all chordomata. The older cells appear to die
in their own secretions similar to the common phenomena
in mucoid carcinoma. The intracytoplasmic vacuoles
stain with glycogen identifying dyes even after the
glycogen should have been dissolved out by the fixita-
tive.7 Intranuclear vacuolization is more rarely noted.
Most chordomata have a coarse capsule and well-defined
globular, fibrous septa enclosing nodules with a more
cellular peripheral zone made up of solid polyhedral
and physaliphorous cells and a poorly cellular central
area with stringy atrophic and syncitial cells with much
extra cellular mucus.7’21
August, 1947
865
CLINICAL-PATHOLOGICAL CONFERENCE
Clinical Manifestations
The signs and symptoms of chordomata are those of
a slowly growing malignant tumor interfering with nerve
function or mechanically pressing on adjacent organs at
some site along the original path of the notochord. The
intercranial lesions generally cause a progression of
unilateral or bilateral palsies especially of the sixth, third,
and fifth nerves. Intracranial pressure symptoms are
next most important, with evidence of interference with
the optic nerves, the pyramidal tract and the cerebellum
of less frequent occurrence. 5’10’24 A characteristic V-
shaped defect is occasionally demonstrated by x-ray
examination of the basilar bone.24 Pneumographic vis-
ualization of a cephalic displacement of the fourth ven-
tricle and aqueduct appears to be more reliable than the
demonstration of bone destruction.2’8 Nasopharyngeal
extensions may mechanically block these passageways
and even invade the paranasal sinuses. None of the find-
ings is pathognomonic except biopsy or aspiration. One
must differentiate cranial chordoma from craniopharyn-
gioma (Rathke’s pouch), parasellar meingioma, pontile
glioma, neurinoma, dermoid cyst, chondroma, myxosar-
coma, hypophsis tumor, metastatic carcinoma and pha-
ryngeal carcinoma.
The sacrococcygeal chordomas are nearly always asso-
ciated with pelvic pain and sometimes sciatic pain.
Tenderness is common. Objective and subjective numb-
ness are frequent. Sphincteric disorders and obstruc-
tion of the rectum are found.7’11’25 Sacrococcygeal
chordomas are almost twice as frequent in males as
females as compared to an almost equal sex occurrence
in the cranial neoplasms.17 The caudal lesions have their
highest incidence in the fifth and sixth decades about
twenty years after the peak occurrence of sphenooccipital
chordomata.17 The neoplasms at either site may be
found at any age.
The digital demonstration of a mass in the hollow
of the sacrum and x-ray evidence of a tumor-like de-
struction of the coccyx and sacrum should always sug-
gest chordoma. This neoplasm must be differentiated
from teratoma, dermoid cyst, ependymoma, giant cell
tumor, neurofibroma, Ewings tumor, myxochondrosar-
coma, metastatic carcinoma, and carcinoma of the rec-
tum.
Treatment
A cure for chordoma in any site nearly always neces-
sitates radical surgery. Temporary amelioration is all
that can be hoped for in the cranial lesions.13’4 For
intercranial lesions a two-stage operation has been de-
vised.24 First, a cerebellar decompression, with re-
section of a large part of the cerebellum on the side of
greater nerve palsies, and tentorial section are performed.
The second operation consists of a piecemeal extirpation
of the mass with sacrifice of the fifth, seventh, and
eighth cranial nerves.
The sacrococcygeal chordomas have a slim but hope-
ful chance of complete removal. With this in mind a
block resection is advised3’18’19 with extirpation of the
coccyx and sacrum up to, but not including, the second
sacral nerve. A two-stage procedure with primary
colostomy may be advisable.18 Those who advise piece-
meal eradication simply hope to prolong life.7 Deep x-ray
therapy is generally considered of little value except
for occasional cases where alleviation of symptoms and
prolongation of life are hoped for.7’16
The duration of life from the onset of symptoms has
been estimated to from two and a half to three and
a half years in cranial chordomata, six and a half to
seven and a half years in sacrococcygeal lesions and one
and a half to two years in the tumors of the lumbar
group.19
Summary
The case of an eighty-year-old male with a sa-
crococcygeal chordoma has been presented. The tumor
had grown slowly beginning shortly after trauma to
the sacral region twelve years ago. Recent interference
with bowel movements was the only complaint. A
recurrence is expected following incomplete excision.
A summary of the literature concerning the notochord,
pathology, clinical manifestations and treatment is in-
cluded.
References
1. Adson, A. W. ; Kernohan, J. W., and Woltman, H. W. :
Cranial and cervical chordomas. Arch. Neurol. & Psychiat.,
33:247-261, (Feb.) 1935.
2. Boldrey, E., and McNally, W. J. : Chordoma of basiocciput
and basisphenoid. Arch. Otolaryng., 33:391, (Mar.) 1941.
3. Brindley, G. V.: Sacral and presacral tumors. Ann. Surg.,
121:721-736, (May) 1945.
4. Carmichael, F. A.; Helwig, F. C., and Wheeler, J. H.:
Cranial chordoma. Am. J. Surg., 55:583-587, (Mar.) 1942.
5. Cautor, M., and Stern, L. D. : Spheno-occipital chordoma.
Arch. Neurol., & Psychiat., 30:612-620, (Sept.) 1933.
6. Faust, D. B. ; Gilmore, H. R., and Mudgett, C. S. : Chor-
domata. Ann. Int. Med., 21:679-698, (Oct.) 1944.
7. Fletcher, E. M. ; Waltman, H. W., and Adson, A. W. : Sa-
crococcygeal chordomas. Arch. Neurol. & Psychiat., 33:283-
299, (Feb.) 1935.
8. Gardner, W. J., and Turner, O. : Cranial chordomas. Arch.
Surg., 42:411-425, (Feb.) 1941.
9. Givner, I.: Ophthalmologic features of intracranial chor-
doma and allied tumors of the clivus. Arch. Ophth., 33:397-
402, (May) 1945.
10. Globus, J. It., and Berman, S.: Suprasellor chordoma. J.
Mt. Sinai Hosp., 13:177-187, (Nov. -Dec.) 1946.
11. Gould, S. E. : Spheno-occipital chordoma. Arch. Otolaryng.,
23:588-592, (May) 1936.
12. Graf, L. : Sacrococcygeal chordoma with metastasis. Arch.
Path., 37:136-139, (Feb.) 1944.
13. Hass, G. M.: Chordomas of the cranium and cervical por-
tion of the spine. Arch. Neurol. & Psychiat., 32:300-327,
(Aug.) 1934.
14. Horwitz, T. : Chordal ectopia and its possible relation to
chordoma. Arch. Path., 31:345-362, (Mar.) 1941.
15. Hutton, A. J., and Young, A.: Chordoma. Report of two
cases; A malignant sacrococcygeal chordoma and chordoma of
the dorsal spine. Surg., Gynec. & Obst., 48:333-344, (Mar.)
1929.
16. Kilby, W. D.: Chordoma. A case report. Bull. School Med.
U. of Maryland, 26:11-16, (July) 1941.
17. Mabray, R. E. : Chordoma. A study of 150 cases. Am. J.
Cancer, 25:501-516, (Nov.) 1935.
18. Mixter, C. G., and Mixter, Wm, J.: Surgical management
of sacrococcygeal and vertebral chordoma. Arch. Surg.,
41 :408-421, (Aug.) 1940.
19. Richards, V., and King, D.: Chordoma. Surgery, 8:409-422,
(Sept.) 1940.
20. Robbins, S. L. : Lumbar vertebral chordoma. Arch. Path.,
40:128-132, 1945.
21. Schwyzer, A.: A case of chordoma will a hitherto unob-
served intraspinal extension. Minn. Med., 20:15-21, (Jan.)
1937.
22. Stewart, M. J., and Burrow, J. le F. : Ecchordosis phys-
aliphora philo occipitalis. J. Neurol. & Psvchiat., 4 :218,
(Nov.) 1923.
23. Stewart, M. T., and Morin, J. E. : Chordoma. A review
with report of a new sacrococcygeal case. J. Path. & Bact.,
29:41-60, (Jan.) 1926.
24. Van Wagenen, W. P. : Chordoblastoma of the basilar plate
of the skull and ecchordosis physaliphora spheno-occipitalis.
Arch. Neurol. & Psychiat., 34:548-561, (Sept.) 1935.
25. Wittaker, L. D., and Pemberton, J. de J.: Tumors ventral
to the sacrum. Ann. Surg., 107:96-106, (Jan.) 1938.
866
Minnesota Medicine
History of Medicine In Minnesota
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester. Minnesota
(Continued from July issue)
Albert Plummer, ninth of the eleven children of Dr. and Mrs. Nathan
Plummer, was born at Auburn, Rockingham County, New Hampshire, on
September 7, 1840. Nathan Plummer, a physician of English descent, was
a native of Londonderry, New Hampshire, and, in 1816, a medical student
at Dartmouth College; his father, also Nathan Plummer, served three years
in the Continental Army during the American Revolution. Albert Plummer’s
mother, Mahitabel Dinsmore Plummer, of Scotch-Irish descent, was, like
her husband, a native of Londonderry, New Hampshire.
Albert Plummer received his early schooling in Auburn and his academic
education at Kimball Union Academy, in Meriden, New Hampshire, from
which he was graduated on April 28, 1862. Lor a few months immediately
afterward he studied medicine under his father’s preceptorship, so that when
he enlisted in August in the Tenth New Hampshire Regiment of Volunteer
Infantry he possessed special knowledge that was to be of value throughout
his military service, to the close of the Civil War, and especially in the last
period, since in August, 1864, he officially was appointed hospital steward
and in Lebruary, 1865, he was promoted to assistant surgeon to his regiment ;
from Lebruary to May, 1865, he was stationed at an army hospital at Old
Point Comfort, Virginia. In the following autumn, on his discharge from
military service, he entered the medical department of Dartmouth College ;
later he transferred to the medical school of Bowdoin College, Brunswick,
Maine, from which he was graduated in 1867, having completed three full
years of medical study. Lor a year or two thereafter Dr. Plummer taught
a rural school, before deciding on the practice of medicine in the Middle
West.
Among the adventures and mishaps incidental to the young physician’s
journey west in 1869, the uncomfortable experience of running out of money
just as he entered Lillmore County, Minnesota, proved to be a disguised
blessing, of lasting influence. Dr. Plummer, as he had planned to do, stopped
in Rushford, in the northeastern corner of the county, to see his half-brother,
Henry Plummer, who was a bookkeeper at Sprague’s Mills in that town,
and to view the prospects for a medical practice. Rushford, he found, already
was well supplied with physicians find surgeons, and Henry Plummer,
having heard that Hamilton, on the western edge of the county, might be a
good location for a doctor, and having a friend who lived there, advised his
brother to look over that settlement. On foot and penniless, not having men-
August, 1947
867
HISTORY OF MEDICINE IN MINNESOTA
tioned his financial predicament, Ur. Plummer set out ; a few miles east of
Hamilton he traded his jackknife, his last piece of portable property, for a
glass of milk. Fortunately, Hamilton was greatly in need of a physician and
surgeon and he started practice almost at once ; Henry Plummer’s friend
lent him a horse to ride on calls in the community. The newcomer had
found his place, and from Hamilton as a center Dr. Plummer followed his
profession for the next twenty-four years.
Hamilton, in the valley of Bear Creek, was platted in 1855 in two parts,
the upper and lower villages, and by 1858 it had a store, a hotel and a Metho-
dist church and was the home of the Bronson Institute, a Methodist “Aca-
demical school of the first class,” which already had eighty pupils; the finan-
cial endowment of the school failed to materialize, however, and the institute
was short-lived. The little settlement, seven miles from Spring Valley and
twenty-five from Preston, was near the Mower County line; in fact, Ham-
ilton was in both Mower and Fillmore Counties, but ultimately the entire
business portion was on the Fillmore side. Because it was in a wheat-growing
section and had excellent water power for grist and flour mills, the village
prospered ; in the sixties and into the seventies it had two mills, five stores,
three churches, machine and blacksmith shops, stage connections with Spring
Valley and Rochester, and “mail three times a week, on Monday, Wednesday
and Friday.” One of the most beautiful and most valued natural features
of the place was the “Hamilton Boiling Spring,” at the western edge of the
village, a never failing source of bubbling clear cold water. With the gradual
absorption of flour milling by the huge mills, such as those of Minneapolis,
and the failure of the Southern Minnesota Railroad to pass through the little
town, Hamilton gradually declined and became by the nineties one of the
phantom villages of Minnesota history; its business interests gravitated to
near-by Racine, in Mower County, which was founded in 1893 on the line
of the Chicago, Great Western Railway.
In Hamilton, in 1869, Dr. Plummer entered into a full life, carrying a heavy
practice, succeeding as he did to the local field of Dr. Wallace P. Belden and
extending it, acting as dentist whenever required, for in those days none of
the small communities had a resident dentist, and serving his community
in ways other than professional. Ethical and progressive, he early became
a member of the Fillmore County Medical Society (organized in 1866) and
of the Minnesota State Medical Society, which was revived and reorganized
in 1869. Further evidence that he was an able and conscientious physician
is the record in the reports of the State Board of Health that he was one
of the eleven physicians of Fillmore County who co-operated with the board
to compile the official report on diphtheria in the county for the period from
November 1, 1879, to November 1, 1880. In 1882 and 1883, temporarily
adding major civic duties to professional, he served in the state legislature
as representative from his district. After the passage of the “Diploma Law”
of 1883 Dr. Plummer was licensed to practice in the state, receiving certificate
No. 738 (R), given on January 15, 1884. In 1895 he was appointed to the
Board of Examining Surgeons for the Bureau of Pensions at Spring Valley.
He attended services at the Congregational and Methodist Churches, was a
Mason (A. F. and A. M.) and an Odd Fellow. Other than in his profes-
sion, his greatest interest and pleasure lay in farming, gardening and raising
flowers and in fishing and hunting, and happily the conditions of his life
were such as to make these' occupations and recreations readily possible.
868
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
Albert Plummer’s marriage to Isabel Steer took place in the village of
Sumner, Fillmore County, on Thursday evening, October 10, 1872 (as
announced in an item in Western Progress, of Spring Valley, on November 6,
1872), at the residence of M. J. Hoag, The Reverend Mr. G. Millet perform-
ing the ceremony. Isabelle Steer Plummer, of Scotch-English descent, a
schoolteacher in Sumner Township before her marriage, was the daughter of
Greenberry Steer, of Adrian, Michigan. Of the four children of Dr. and Mrs.
Plummer, Sadie and Ray died in infancy. Henry Stanley, born in 1874, at
Hamilton, and his brother, William Albert, born in 1883, at Racine, lived
to devote themselves to the practice of medicine.
In 1893, Hamilton having become a hamlet rather than a village, Dr.
Plummer moved to Racine, Mower County, a better center from which to
serve his patients, and there he remained for eighteen active years. In
this place at different times he had as associates three physicians : his son,
Dr. Henry S. Plummer, between 1898 and 1901 ; Dr. Jacob Prinzing, a grad-
uate of the medical department of the University of Minnesota, from 1901
into 1903; and between 1903 and 1910 Dr. E. E. Benedict, also from the Uni-
versity of Minnesota.
The experiences of Dr. Albert Plummer as physician and surgeon, and
equally as guide, philosopher and friend to his patients, were countless and of
all degrees, from funny to solemn. Of the years in Hamilton and Racine
Mrs. Plummer, decades later, used occasionally to reminisce, on request,
to her family and close friends. These recollections, always kindly, told
by a true raconteur in her own inimitable style, were a delight to the few who
were privileged to hear them. One story concerned a family of many children
whose parents, not blessed with mental lucidity, never could agree as to the
number of the progeny that had been born to them ; Dr. Plummer was
called frequently to settle the quarrel, for it was a quarrel, and time after
time at great inconvenience to himself he responded and with characteristic
patience recounted the number of the children, their names, the dates of
their birth (and of death, of some of them) and the conditions of each event.
In 1911 Dr. and Mrs. Plummer moved from Racine to make their home in
Rochester. Dr. Plummer was then in failing health ; his death occurred on
March 20, 1912, in his seventy-second year. Mrs. Plummer lived twenty-four
years longer and died in Rochester on January 15, 1936, little less than a year
before the death, on December 31, 1936, of her older son, Dr. Henry S.
Plummer, of Rochester, of whose household she had long been a member.
Dr. William A. Plummer, the second son, survives (1947).
Graduated in medicine from Northwestern ETniversity in 1910, Dr. W. A.
Plummer in June of that year entered the Mayo group as a member of the
staff. He is head of a section in medicine in the Clinic and associate pro-
fessor of medicine, Mayo Foundation for Medical Education and Research,
Graduate School, University of Minnesota.
A brief note on the life and work of Dr. Henry S. Plummer is included
here for the reason that, although he began to practice medicine when a
resident of Mower County, he was, with his father, active professionally in
Fillmore County.
Henry Stanley Plummer, one of the four children of Dr. and Mrs. Albert
Plummer, was born on March 3, 1874, at Hamilton, Fillmore County, Minne-
sota. He grew up in the village, went to the local schools, and early felt
August, 1947
869
HISTORY OF MEDICINE IN MINNESOTA
the interest in a medical career that was to last all his life. He often accom-
panied his father on professional calls and helped him in many ways, so
that to some extent, even as a youth, he was associated with medicine in
Fillmore County. When Henry Plummer was a boy of sixteen a case of
thyroid tumor in his father’s practice so interested him that from that time
he gave thought to goiter; in his years at the Medical School of North-
western University he followed with special care the cases of thyroid
disease, medical and surgical, and in the dissecting room and the experimental
laboratories, to learn all that he could about them.
In 1898 Henry S. Plummer received the degree of doctor of medicine from
Northwestern University and returned to Racine, where Dr. Albert Plummer
had settled in 1893, to join his father in the practice of medicine in a com-
munity which extended into Fillmore County and into Olmsted County
as well. He remained in the village three years, at the end of which he
joined the staff of the Drs. Mayo, Stinchfield and Graham, in Rochester. Let
Dr. William J. Mayo, whose lasting pride and satisfaction it was that it had
been his privilege to recognize the unusual intelligence and ability of Henry S.
Plummer, tell the story :*
It was in the latter part of the year 1900 that I was called in consultation to see a pa-
tient by Dr. Albert Plummer, a well-known practitioner of Racine, Minnesota. Dr.
Plummer had two sons, Henry the elder and William the junior.
I drove out the twenty miles from Rochester to Racine, to find that Dr. Plummer was
ill in bed with a cold, but he said that his son Henry, who recently had been graduated
in Medicine at Northwestern University, was in practice with him and would be glad to go
with me to see the patient. It was arranged that I should leave my team of horses and
ride the seven miles with Henry, who came out carrying a microscope in a case in his hand.
We got into a little buckboard behind a gray horse and started on an hour’s drive to see
the patient. During this ride Henry talked to me about the blood, of which I did not
know any too much. He had an extraordinary amount of information about the composi-
tion of the blood, its characteristics and function, much of which I realized was not to be
found at that time in print.
The case we were to see was one of leukemia, of the type with a diminution rather
than an excess of the white cells ; at that time it was called aleukemic leukemia ; it is now
designated leukopenic leukemia. Henry took a drop of blood from the ear of the patient,
put it under the microscope and demonstrated the findings to me. He called in the hired
man and a member of the family and took blood from each of them and under the micro-
scope contrasted it with the blood of the patient foe my information. On the way back
he continued to talk about the blood ; I continued to listen, and I learned much. He also
spoke of interest in the thyroid gland, to which subject my brother, Dr. Charles H. Mayo,
was devoting a great deal of study.
When I got home that night, I told my brother, “Dr. Plummer has a son in Racine
who certainly knows more about the blood, at least, than any one I have ever met. I
think he is really an extraordinary young man, and I believe we had better try to bring him
here and add him to the staff to bring our laboratories up to date.” At that time our
laboratory equipment and routine were fairly good, about that commonly found in general
practice, but largely confined to surgical needs. I wrote young Dr. Plummer and asked
him to come up to talk with us. He came, we went over the situation, and he came on
the permanent staff early in the year 1901, thirty-seven years ago.
Dr. Plummer remained with the Mayo Clinic the rest of his life, making
contributions of almost incalculable value to the institution and in many
fields of medical science. Wherever modern medicine is known, there is
knowledge of his work on the blood, on esophageal stenosis, on bronchoscopy
‘Excerpt from Dr. Mayo’s article “The Work of Dr. Henry S. Plummer,” published in the Proceedings
of the Staff Meetings of the Mayo Clinic, 13:417-422 (July 6), 1938; reprinted in the Collected Papers
of the Mayo Clinic, 30:928-934, 1938.
870
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
and, especially, on the diagnosis and treatment of diseases of the thyroid
gland. He was a master in mechanical detail also ; the Mayo Clinic buildings,
the first in 1912, the second, adjoining, in 1929, are monuments to his genius,
marvels of efficiency for the performance and correlation of scientific work.
Henry S. Plummer was married on October 4, 1904, to Daisy Berkman,
of Rochester. He died at his home in Rochester on December 31, 1936, at
the age of sixty-two.
Inasmuch as the greater part of Dr. Plummer’s distinguished scientific
career was identified with the Mayo Clinic, a detailed biographical account
will be given in the story of the growth of medical practice in Olmsted County.
David Frank Powell, a graduate of the Medical College of Louisville,
Kentucky, was a successful and popular physician who practiced medicine in
Lanesboro, Fillmore County, in the seventies and into the eighties.
When Dr. Powell came to Lanesboro, he was accompanied by his brothers,
George and William, also practitioners, both of whom subsequently studied
•at medical schools in Burlington and Keokuk, Iowa, from which they are
said to have emerged as full-fledged doctors of medicine. The three brothers,
David Frank Powell especially, were picturesque figures, tall and large,
wearing their long hair flowing to their shoulders in the manner of “Buffalo
Bill” Cody; in fact, Buffalo Bill (William Frederick Cody, a native of Scott
County, Iowa, who lived from 1846 to 1917), was their admired and good
friend. In 1880, on the occasion of a celebration in Lanesboro, Colonel Cody
came to the village in order to be present at a powwow and to visit the
Powells, and at that time he enlisted Dr. Powell’s help in Cody’s Wild West
Show, which came into full flower in 1883. Dr. Powell stayed with the
show for a while during its modest beginning but later returned to medical
practice.
Sometime in the seventies Dr. Powell, who apparently had unusually sym-
pathetic understanding of the Indians, received from a Siouan tribe farther
west in the state the name “White Beaver,” and this endorsement of him
by their kinsmen brought him the friendship and acceptance of the local
Winnebago Indians, with whom he evidently was on the best of terms, for
in December, 1879, a band of Winnebagos in Lanesboro “got up an exhibi-
tion under the patronage of Dr. Powell and realized almost $50.” On
occasion, furthermore, they would rally to his defense : At time's Dr. Powell,
uplifted by liquor, so ran a reminiscent account, would don a beautiful suit
of buckskins, no doubt the gift of his Indian friends, get on his horse and
tear up and down the streets of the village yelling and shooting off revolvers,
one in each hand, to such effect that the Indians near town, fearing that he
was in trouble, would hurry to the rescue, only to be assured by White
Beaver that he was all right and that they might return to camp.
Mr. C. A. Ward, long a resident of Lanesboro, has described these scenes
of Dr. Powell’s revelry and has given other vignettes of this physician who
must have been a source of interest to his more staid fellow citizens. A
crack shot, Dr. Powell delighted in displaying his marksmanship, a pastime
in which he was encouraged by his boon companions, Frank Bergey, who
was Mr. Ward’s brother-in-law, and John Rogers. Mr. Bergey, in particular,
had such confidence in White Beaver that he often and cheerfully would
support a potato or an apple on his head as a target for his friend who for
the moment fancied the role of William Tell. When Mr. Ward was a youth
August, 1947
871
HISTORY OF MEDICINE IN MINNESOTA
he had trouble with his eyes: Dr. Powell treated him for the disorder, kept
him in a dark room a week or ten days, and the eyes were cured “slick
as a whistle,” and evidently remained in that condition for they were func-
tioning without the aid of glasses, except for reading, when Mr. Ward, in
1941, was eighty -iseven. Also, while Dr. Powell was still in Lanesboro, he
performed “the first appendectomy on record,” on a farmer living three miles
southeast of Whalan, and it is said that Minneapolis newspaper in recent
years published an article about it; this reference has not been susceptible of
confirmation by the writer. On one occasion Dr. Powell himself was the
patient, when in August, 1877, he was bitten by a rattlesnake; as has been
told, Dr. Luke Miller, then of Lanesboro, formerly of Chatfield, “prescribed
R. spiritus frumenti, ad lib.”
Reminiscent comments on Dr. Powell’s professional courage and skill are
substantiated by various editorial notes of praise in county newspapers, among
them the Lanesboro Journal and the Rochester City Post. In 1879 Dr.
Powell’s “Lanesboro Sanitarium,” about which unfortunately, details are not
known, was in full operation. Late in that year it was stated that Dr. D. F.
Powell, “Lanesboro’s skillful physician and surgeon, has been driven to
the curtailment of his general practice in order to meet the demands of his
special practice in surgery and the treatment of female diseases. From five
to a dozen different ladies from neighboring towns and cities are constantly
under his care at the Sanitarium and his success is bringing him customers
for miles around.” And early in 1880' it was stated that in the past fifteen
months Dr. Powell had performed sixty-one operations for cross eyes and
that every operation had been successful.
In 1880 Dr. Powell removed to La Crosse, Wisconsin, where in a broader
sphere he continued his colorful career, practicing medicine and taking an
active part in local and civic affairs ; for many years he was mayor of La
Crosse. After the passage of the “Diploma Law” in Minnesota, in 1883,
Dr. Powell was licensed to practice in this state and received certificate No.
42 (R), given on October 11, 1883.
In the early eighties the White Beaver Medical and Surgical Institute of
Saint Paul and La Crosse was in operation, by Dr. Powell. In 1883 there
appeared among advertisements of medicines and appliances in the
Northwestern Lancet of September 15 an endorsement by Dr. D. F. Powell of
Celerina, The Nerve Tonic: “I believe that Celerina is the best nerve tonic in use.
In one case (in which no other remedy was of benefit) a cure was effected. My
patient was grateful and so was I.”
And in the Chatfield Democrat of February 16, 1884, Dr. Powell had a full
column advertisement for “Cough Cream made only by Dr. Frank Powell, Medi-
cine Chief of the Winnebago Indians.” To this the editor added: “Dr. Frank
is having a lively tussle with the state medical board and is coming out on
top. He has the reputation of being a first-class physician. We know he is a
good advertiser, and what is more, does not pay for it grudgingly.”
When, in May, 1906, Dr. David Frank Powell died, the Journal of the Min-
nesota State Medical Association and Northwestern Lancet stated, “Dr. D. R. F.
Powell, known as White Beaver,’ died last month. Dr. Powell was a man
of no mean attainment, in medicine and other lines, and lived a life of use-
fulness.”
George Powell, brother of Drs. David Frank Powell and William A.
Powell, was a practitioner of medicine in Lanesboro. He and his brother
872
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HISTORY OF MEDICINE IN MINNESOTA
William in^the winter of 1881-1882 spent a few months, according to the
National Republican of Preston, in attendance upon medical lectures and in other
preparation for a more thorough practice of medicine, and on their return to
Lanesboro late in March, 1882, opened an office in the village for resumption of
their professional work.
William A. Powell, as stated, was the brother of Drs. David Frank Powell
and George Powell. Little has been learned about him except that he
was well liked, as were his brothers, and that when he and Dr. George
Powell returned in March, 1882, from additional study at medical schools,
presumably in Burlington and Keokuk, Iowa, they renewed their medical
practice “among old friends” in Lanesboro.*
Albert Wentworth Powers was born on March 31, 1850, at New Castle,
Ontario, Canada West, the son and one of the five children of Calvin Siscoe
Powers and Mary Ann Bailey Powers; the other children were Hartwell
and Helen, older than Albert, and Martha and Frederick, who were younger.
His parents both were primarily of English descent and natives of Canada ;
Mary Ann Bailey was born in Canada East.
The recorded genealogy of the Powers family in America dates from
1639 with the birth of Walter, who with his wife early immigrated to this
country. Of Calvin Siscoe Powers’ great uncles, eight fought throughout
the American Revolution. Representatives of the Bailey family came from
England around 1630; among their descendants one was an officer in the
Revolution ; many others have been clergymen. Members of the present
generations of the Powers family have stated that a distant cousin of Albert
Wentworth Powers was the Hart for whom Hartford, Connecticut, was
named ; another cousin married a McDougal, governor of Massachusetts ; a
third was descended directly from the wife of Millard Fillmore, onetime President
of the United States.
Calvin Siscoe Powers, father of Albert Wentworth, Harley, Frederick,
Helen and Martha, was a man of originality and force of character. Himself
a native of Canada, his father was born in Vermont and his mother in
Ireland. Leaving Canada in 1860, he brought his family to Waukokee, near
Carimona, in Fillmore County in the period when Indian uprisings were
imminent in Minnesota; his grandchildren have recalled stories, told them
by their parents, of the frequent warnings and scares. A member of a
family that had produced artists in various lines, Calvin Powers’ tastes and
talents ran to the study of general science, to sculpture, but chiefly to
literature, public speaking and politics. He had been the editor of a literary
paper in Canada ; in 1878, in Minnesota, he was editing the Dollar Weekly at
Wykoff in the interest of the Greenback Party; the following year he became
editor of the Fillmore County Radical; in the same general period, of the Fountain
Radical, and in April, 1881, he began the publication, at Rochester, in Olmsted
County, of the Rochester National, also a Greenback paper and a large one, of
eight columns, well executed and “edited with much spirit;” after six months,
however, he returned to Fountain. In 1879 and in 1881 he represented the district
in the state senate. In most of these enterprises his son, Albert Wentworth
Powers, by 1872 a physician, was his associate.
*Information has been received in the archives of the Wisconsin State Historical Society there are
numerous letters written by Dr. Powell and his physician brothers, all of whom practiced in Wisconsin
after leaving Lanesboro, Fillmore County, Minnesota.
August, 1947
873
HISTORY OF MEDICINE IN MINNESOTA
Albert W. Powers went to district school at Waukokee and in due time
studied high school subjects under tutors. In 1869 he entered the office of
Dr. Lafayette Redmon, at Preston, as a student to learn what he could
of medicine and surgery before going to Chicago to enroll at Rush Medical
College. The course of 1871-1872 at Rush was interrupted by the great fire
of October 8 and 9, in which the college buildings were reduced to piles of
brick and twisted iron and half melted apparatus. Among the students in
the city who became part of the huge army of homeless citizens was Albert
Powers, who lost most of his personal property in the fire and narrowly
escaped with his life. The faculty members of Rush in a few days reas-
sembled classes; the Cook County Hospital had offered the use of a clinical
amphitheater for a lecture room and the Chicago Medical College the use
of a dissecting room ; both aids were accepted and the students of Rush Medi-
cal College were enabled to continue their work.
From Chicago Dr. Powers returned in February, 1872, to his home town
of Fountain to begin his medical practice, and for a year or two immediately
thereafter he was in partnership with Dr. John A. Ross; Dr. Powers was in
Fountain, Dr. Ross retained his residence in Preston. By 1874 this associa-
tion had been dissolved, and Dr. Powers and his father, Professor Powers
were putting up the stone building that was to be occupied by them as
drug store and residence. In later years the doctor’s consulting rooms and his
medical library were in his separate residence ; after his death the books were
placed in the drug store, where they have remained (1943).
The year after the completion of his medical course, Albert Wentworth
Powers was married, on February 21, 1873, to Amanda Justina Bickford,
of English descent, born near Rochester, New Hampshire, a daughter of Ira
Bickford. Dr. and Mrs. Powers were the parents of five children, Elsie,
Albert, Frederick, Alta and Glenn.
Dr. Powers was a good citizen, sharing the life of the community as
civil servant, businessman and general medical and surgical practitioner.
At one time or another in the nearly fifty years of his adult life there, he
held almost every town and village office and county and state office in addi-
tion. He was justice of the peace, mayor, councilman, a member of the
school board, and in 1912 he was rounding out thirty years as town clerk.
When his father was state senator from the district, Dr. Powers went along
on appointment as clerk for the senate.
In his capacity as physician he carried on a heavy practice, was local
health officer, co-operating with the State Board of Health, county coroner
from 1895 to 1896, and for a time he served, with Dr. W. W. Mayo, of
Rochester, on the pension board for veterans of the Civil War. During
most of his professional life prior to 1900 he was the only physician in the
village; for a year or so in 1885 and 1886 Dr. Ole T. Hoftoe, newly graduated
from Rush Medical College, was in Fountain before going on to Lanesboro
and, in 1888, to Abercrombie, North Dakota. Under the medical practice acts
of 1883 and 1887 Dr. Powers was authorized to practice in the state, in
official registers of physicians of Minnesota he is listed as the holder of an
exemption certificate. Part of the record, as embodied in the following
letter, is of interest in connection with methods of licensure:
874
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
State of Minnesota, State Board of Medical Examiners
Seven Corners, St. Paul, Minnesota, June 3, 1899.
Dr. W. A. Powers
Fountain, Minnesota.
Dear Doctor :
I have received your affidavit of practice prior to the law of 1887. This will be placed
on file in the office of the Secretary of the State Board of Medical Examiners. This gives
you the legal right to practice medicine in the state of Minnesota. No other certificate
is provided by law.
Sincerely yours,
(signed) John B. Brimhall,
Secretary
This letter duly was filed and recorded in the office of the Clerk of the
Court of Fillmore County.
To his patients Dr. Powers was friend, confidant and adviser as well as
physician. His fellow practitioners who came into the county soon after the
turn of the century have spoken of Dr. Powers as an interesting character,
a pleasing personality. He liked good stories, that is, funny stories, to hear
and to tell, and some of his favorites still are quoted. He was a supporter
of the Baptist Church of Fountain and, when this denomination was super-
seded in the villege by the Methodist Church, he lent his support to the
latter. In sympathy with fraternal organizations, he was a member of several,
among them the Masonic Lodge (A. F. and A. M.) and the Royal Neighbors
of America. A very dark brunet, with black eyes, when he still was a young
man he began to wear a black flowing beard ; as the years whitened his hair
and beard and added to his weight he became in appearance so much the
conventional figure of Saint Nicholas that children who did not know him
addressed him as “Santa Claus.”
Dr. Powers died of heart disease at Fountain on May 30, 1921. Of his
five children three survived him ; Frederick of Kansas City, Missouri ; Alta
(Mrs. Gilbert) Kolstad, of Spring Valley, Fillmore County, who before her
marriage had been a teacher in Houston, Rushford and Lindstrom, and a
teacher and assistant principal of the Fountain grammar school ; and Glenn,
formerly principal of the high schools of Ely and Gilbert, Minnesota, of
later years a photographic artist. On November 8, 1943, Mr. Glenn Powers
died suddenly from cardiac disease at his home in Virginia, Minnesota. Of
the original family, his brother and his sister were living.
Donald Bannerman Pritchard (1865-1931), a native of Fort Garry (Winni-
peg), Canada, became one of the distinguished physicians of Minnesota.
On graduation in medicine and surgery from the University of Edinburgh,
Scotland, in 1887, Dr. Pritchard returned to America, and in April, 1887,
having received Minnesota state license No. 1370-1 (R), he began his career
as a physician in the village of Rushford, Fillmore County. In 1889 Dr.
Pritchard moved from Rushford to Winona, Winona County, where he spent
the remaining forty-two years of his useful life.*
Charles Wilbur (sometimes spelled Wilbor) Ray, born in 1856, was a grad-
uate of the Bennett College of Eclectic Medicine and Surgery, of Chicago,
in 1885. Two years later he was licensed to practice medicine in Minnesota,
*When the History of Medicine in Winona County appeared in Minnesota Medicine, in 1941, because
of an unfortunate inadvertence it lacked a biographical note on Dr. Pritchard. A detailed sketch of Dr.
Pritchard, originally prepared by the present writer as part of the story of medicine in Fillmore County,
will appear separately in due time and ultimately will be included with material on the physicians of
Winona County.
August, 1947
875
HISTORY OF MEDICINE IN MINNESOTA
receiving state certificate No. 1414 (E), given on May 26, 1887, and in the
next twenty-two years he followed his profession in various localities in the
state. In 1890 and presumably for a year or two previously he was in St.
Clair, Blue Earth County; in 1893 he was practicing in Owatonna, Steel
County; and in 1894 and 1895 he was resident in the village of Canton, Fill-
more County.
In Canton Dr. Ray had his home and office together in a house “back of
the Presbyterian Church, facing on the opposite street.” From conversations
of her elders in the village it has been recalled by an early citizen, who was
then a child, that Dr. Ray in his preferred specialty of obstetrics advocated
the use of a mysterious “twilight sleep,” and that in addition to his general
medical practice he on occasion undertook surgical operations. His profes-
sional contemporaries in Canton were Dr. Henry H. Haskins and Dr. Robert
A. Sturgeon.
Dr. Ray has been described in Canton as tall and dark, of medium weight,
a man of social aptitude and of artistic and dramatic ability that found expres-
sion in home talent plays, which he coached and for which he designed
and painted the scenery. These extraprofessional activities were not regarded
with favor by certain of the residents, who in consequence called him
visionary. It was Dr. Ray who, one evening in March, 1895, when the Modern
Woodmen of America in Canton were holding a meeting, initiated another
organization; by prearranged plans with the ladies of the village who were
eligible to become members of the Royal Neighbors of America, Dr. Ray
brought this group into the meeting hall during recess and then and there
organized the Surprise Camp of the Royal Neighbors.
On leaving Canton in 1896, Dr. Ray moved with his wife and children to
the village of Nicollet, in Nicollet County, succeeding to the practice of the
late Dr. Joseph Wicke, whose stock of drugs and medicines he bought from
Mrs. Wicke. For part of 1896 Dr. Ray was the editor of the Nicollet Leader.
At this period of his life he was a member of the Minnesota State Eclectic
Medical Association and for some years its secretary. It has been said
that the summer of 1899 he spent in Boston and other eastern cities visiting
hospitals and that in 1900 he moved with his family to California; and record
exists that in 1901 he was licensed to practice medicine in California.
Within the memory of a citizen of Nicollet who in 1941 was fifty years old,
Dr. Ray at two different, unspecified periods practiced medicine in that village.
It seems probable that after a relatively short time in California he returned
to Nicollet, for in 1907, then a member of the American Medical Association,
he was living in the village, and he remained that at least into 1909. By 1912
he again was in California, in Los Angeles, where his death occurred in the
following year. Mrs. Ray and the children in 1941 were said to be living
in Los Angeles; attempts to communicate with them for the purpose of this
sketch have not been successful.
(To be continued in September issue )
876
Minnesota Medicine
THE GENERAL PRACTITIONER
IN an effort to uphold the prestige of the general practitioner and to encourage him to
provide his patients with the kind of medical care which he is peculiarly qualified to
furnish, the Council on Medical Education and Hospitals of the American Medical
Association submitted a significant supplementary report to the House of Delegates of
the American Medical Association at its recent meeting in Atlantic City.
Attention was called to the fact that a Section on the General Practice of Medicine was
established in 1945 and that almost a thousand physicians had registered in this section at
the 1946 Scientific Assembly. Also, it was recalled that the House of Delegates had ex-
pressed its approval of the organization of sections on general practice in state and county
medical societies. “In spite of this,” the Council report stated, “certain hospitals have in-
augurated as a matter of policy limitation of their staff appointments to physicians certified
by specialty boards or holding membership in certain special medical societies. Such a
policy is contrary to the principles of the Council and seems unsound. In publications which
have dealt with hospital standards, the Council has expressed repeatedly the need for a hos-
pital staff of high quality; it has never mentioned certification by a specialty board or mem-
bership in a special medical society as an important credential.”
The report called attention to a resolution which was adopted by the House of Delegates
at the San Francisco meeting in 1946 and which in part read as follows :
“Whereas, Many hospitals have not established general practice sections in their visiting
active staffs and their governing heads are doubtful whether such action has the approval
of the bodies which set up the rules and regulations for the approval of their hospitals for
interns and residents ; therefore be it
“Resolved, That hospitals should be encouraged to establish general practitioner services.
Appointments to a general practice section shall be made by the hospital authorities on the
merits and training of the physician. . . . The criterion of whether a physician may be a
member of a hospital staff should not be dependent on certification by the various specialty
boards or membership in special societies.”
The report stated further that the Council had published a statement in the Journal of the
American Medical Association of May 3, 1947, which read in part as follows: “It was never
intended that staff appointments in hospitals generally, or even in hospitals approved for
residencies, should be limited to board-certified physicians, as is now the policy in some
hospitals. . . . Hospital staff appointments should depend on the qualifications of physicians
to render proper care to hospitalized patients as judged by the professional staff of the
hospital and not on certification or special society memberships.
“In this opinion,” the report continues, “the Council has the full concurrence of the Ad-
visory Board for Medical Specialties.”
Also, “The American Board of Surgery is not concerned with measures that might gain
special privileges or recognition for its certificants in the practice of surgery. It is neither
the intent nor has it been the purpose of the Board of Surgery to define requirements for
membership on the staffs of hospitals.”
The concluding note in the supplementary report was to the effect that the Section on the
General Practice of Medicine is considering the establishment of an American Board of
General Practice. The Council expressed the opinion that the wisdom of such a move at
this time is debatable. Possibly a greater usage of the skill of the general practitioner in
hospital practice may make superfluous the need for a specialty board.
President, Minnesota State Medical Association
August, 1947
877
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
IF YOU WERE TOLD—
That President Truman in a message sent to
Congress, November 19, 1945, urged the enact-
ment of a national health program typified by the
Wagner-Murray-Dingell Bill which had been
submitted to Congress ;
That Thomas Parran, Surgeon General of the
U. S. Public Health Service, on December 10,
1945, sent a letter to all his field men and opera-
tives throughout the country telling them that the
executive agencies of the Government had been
instructed by the President to assist in carrying
out this proposed national health program ;
That pursuant to this policy, the U. S. Public
Health Service launched a series of so-called
“health workshops” throughout the country which
were meetings held in order to develop pressure
groups favoring the Wagner-Murray-Dingell
Bill;
That the “health workshops” were planned,
conducted and largely financed with Federal
funds by a key group on the Government payroll,
who used the workshop method of discussion
subtly to generate public sentiment in favor of
socalized medicine ;
That the Government paid the expense of at-
tendance at these “health workshops” of Federal
employes in the USPHS, the Children’s Bureau,
the Office of Education, the U. S. Employment
Service, the Department of Agriculture, and the
Bureau of Research and Statistics, Social Secur-
ity Board ;
That Federal employes arranged these “health
workshop” meetings, invited delegates, trained
delegates, presided at meetings, and framed reso-
lutions ;
That the Bureau of Research Statistics in the
Social Security Board prepared pamphlets and
propaganda literature for the CIO, AFofL and
Physicians’ Forum (a propaganda agency for the
Wagner-Murray-Dingell Bill) biased in favor of
socialized medicine;
That $75,000,000 were spent in 1946 in the ex-
ecutive branch of the Federal Government for
publicity and propaganda purposes and that dur-
ing that year 45,000 Federal employes were en-
gaged full or part time in such activities ;
That Mr. Isadore Falk, Director of the Bureau
of Research and Statistics, urged that one Jacob
Fisher, a member of his staff and an avowed
communist, be sent to New Zealand at Govern-
ment expense to study compulsory health insur-
ance there —
Would you believe it?
Yet this information* and more, too, was un-
earthed by a subcommittee of the Committee on
Expenditures of the Executive Department of
the House of Representatives, was transmitted to
the Speaker of the House, and was brought to
the attention of the U. S. Department of Justice
with the request that the Attorney General at once
initiate proceedings to stop this illegal expendi-
ture of public money.
While it is quite proper for the President of
the United States to transmit his views on legis-
lation to Congress, it is absolutely contrary to law
to use Federal funds for the purpose of influenc-
ing legislation pending before Congress.
We taxpayers are apparently employing indivi-
duals in the executive division of our Federal
Government who at our expense are trying to in-
fluence the public to enact the Wagner-Murray-
Dingell Bill, which will add thousands of em-
ployes and strength to bureaucratic Washington
and will lead to deterioration of medical care in
our country.
ASSOCIATED MEDICAL CARE PLANS
T T was not until the December, 1945, meeting of
the American Medical Association House of
Delegates that our national organization gave its
approval of voluntary nonprofit prepayment
plans for medical care. The organized profession
was slow to give its official approval to the Blue
investigation of the Participation of Federal Officials in the
Formation and Operation of Health Workshops. House Report
No. 786, 80th Congress.
878
Minnesota Medicine
EDITORIAL
Cross, although many physicians felt that hospital
expense was an insurable expense. The Blue
Cross eventually proved its practicability and ob-
tained the wholehearted support of the profession.
By December, 1945, some nine organizations
had established nonprofit prepayment plans for
medical care, the oldest statewide plan being the
California Physicians’ Service established in 1939.
These organizations had formed an informal
Council on Medical Care Plans, representatives of
which met with the AMA Council of Medical
Service in February, 1946, and formed Associated
Medical Care Plans, an independent corporation.
A few years ago there had been some talk of
forming a prepayment medical organization on a
national scale, but the idea was wisely abandoned.
The AMCP is governed by a commission of
thirteen members, ten of whom are selected from
persons directly associated with member Plans
and three of whom are nominated by the AMA
Council of Medical Service. Thus, while con-
trolled by component members of the organization,
AMCP is closely associated with the AMA.
On May 1, 1947, AMCP claimed thirty-nine
members, and many additional units in the proc-
ess of organization will doubtless be added in the
near future, Minnesota Medical Service being one.
The AMCP has several important functions.
It will assemble actuarial data which are essential
for any insurance undertaking. This will be made
available to the component units and to new or-
ganizations. Reciprocal arrangements will be
made for exchange of membership privileges with
a minimum of red tape. A mechanism is provided
for selling the idea of this type of insurance to
the medical profession, as well as to the public,
on a national basis. Insurance, no matter how
meritorious it may be, does not sell itself.
There is every reason to believe that medical in-
surance not only for the low-income group, for
whom the organizations sponsored by the profes-
sion provides complete coverage, but also for
those in the higher income brackets will grow by
leaps and bounds, just as hospital insurance has.
Members of the medical profession sold on the
idea can act as publicity agents by urging their
patients to buy medical insurance.
COMMUNITY CHEST
T7ACH year the 1,000 Community Chests
throughout this country and Canada put on
campaigns for raising funds for the 12,000 serv-
August, 1947
ices they support. These campaigns take place
each fall in the larger cities in Minnesota.
The idea of grouping the local services, which
depend on the generosity of citizens, began sixty
years ago in Denver, Colorado. This grouping
of local activities affects an economy in the rais-
ing of funds, enables the contributor to give one
sum yearly to a group of worthy activities in-
stead of giving to them separately and does away
with his not knowing how many he will be asked
to contribute to nor how much he should give
to each. He is also saved numerous calls from
solicitors. Another advantage of the Community
Chest idea is the apportioning of contributions by
the Chest Budgeting Committee so that certain
units do not suffer from lack of funds and others
are not surfeited.
During the war, foreign relief organizations
were combined with Community Chests thus
providing the same advantages and economies.
These affiliations were terminated last year.
The American Red Cross has never joined the
Community Chest and, we think, quite wisely.
The Red Cross has a special appeal, and its budget
varies from year to year being enormously in-
creased in war years and when other catastrophies
strike. The organization’s new undertaking of
establishing blood banks on a nationwide and
permanent basis is sure to prove a valuable but
expensive undertaking.
The Community Chest idea is what we like to
think of as a typical American institution. The
majority of citizens dig into their pockets to sup-
port activities for the benefit of the communities.
It is said that four out of ten individuals benefit
directly from chest-supported activities. The other
six undoubtedly benefit indirectly. The agencies
which provide activities for children and the
youth of the community and for the betterment
of family life constitute a large part of Chest
membership. With juvenile delinquency on the in-
crease, nothing is needed more. Last year in our
country 108,787 persons under twenty-one were
arrested. Though this represents only 16.9 per
cent of the total number arrested, it is a reflection
on present-day trends.
Community Chest units are not all dispensers
of charity. Many provide activities not charitable
in nature. Community Chests deserve whole-
hearted support, because they make life better
wherever they operate.
879
EDITORIAL
REPORT OF MINNESOTA AMA DELEGATES
This year, 1947, marked the 100th year of the or-
ganization of the American Medical Association at At-
lantic City. The occasion was made especially notable
by the visitation of noted medical representatives from
practically every country on the globe, who brought to
the convention offerings for the AMA, either from
their national medical societies or their respective gov-
ernments.
The meetings of the House of Delegates this year
were somewhat more arduous than usual, and Mr.
Delegate could find only two half days to visit the
scientific session and none for the commercial ex-
hibits.
There are several topics we would like to report on.
First, the day of the general practitioner is here, and
receiving more attention than usual. Last year a sec-
tion was created for the general practice of medicine;
suggestions were made that hospitals establish a division
of service for the general practitioner. This emphasis
was made necessary by the fact that many hospital
staffs are dictated to by the numerous specialty boards.
Second, the mid-year session of the House of Delegates
will hereafter be held in various sections of the United
States, two days being set aside, preceding the meet-
ing of the delegates, for scientific sessions devoted to
the general practice of medicine.
The nursing problem was another highlight, arousing
much discussion, and the questions of practical nursing
education and the shortening of nurses’ training periods
were brought up. It is apparent that too much stress
has been put on technical and scientific preparation for
the prospective student nurse rather than on her sympa-
thetic understanding of problems in patient handling.
We will hope for an attempt to bring about a solution
by a joint committee of members appointed by the
AMA, the American Board of Nursing, and the
American Hospital Association.
A new section on chest disease was created, which, it
is felt, will stimulate more knowledge on many ob-
scure problems of the chest.
Problems of the Army and Navy regarding medical
care in possible future wars resulted in the formation
of a National Emergency Medical Service, which will
undoubtedly not only change many medical problems re-
sulting from World War II, but plans of civilian medical
men. The next war, if and when there is one, will be an
atomic war, and non-combat areas must be protected
as well, if not better, than combat areas.
As a result of surveys made in 1946 by the AMA,
it is generally agreed that affairs at the Home Office
are gradually crystalizing into a far more efficient man-
agement. Dr. George Lull, general secretary and man-
ager, is rounding out a very capable group of executives
for the various divisions. The National Physicians Com-
mittee was again endorsed. During the past year they
did a most excellent piece of work in Hawaii, when a
bill to establish a socialized type of medical practice in
the Hawaiian Islands was defeated.
The inability to secure paper, in addition to the in-
ability to secure medical publications from abroad — a
result of the war — is about licked, and you soon will
see the Index Medicus on your shelves again. Also,
the Directory of the AMA will soon be published.
These are two very important publications.
The election of Dr. R. L. Sensenich of South Bend,
Indiana, as President-Elect, was unanimous. Dr. Sen-
senich, an able executive, excellent speaker and a good
internist with a keen grasp of AMA affairs, has the
highest respect of the medical profession.
Frank Savage, M.D.
E. W. Hansen, M.D.
A. W. Adson, M.D.
W. A. Coventry, M.D.
WATER-BORNE TULAREMIA
(Continued from Page 850)
3. Bow, Malcolm, R., and Brown, John H.: Water borne tula-
remia in Western Canada. Canada M.A. J., 50:14, 1944.
4. Burroughs, A. L., Holdenried, R., Longanecker, D. S., and
Meyer, K. F. : A field study of latent tularemia in rodents
with a list of all known naturally infected vertebrates. J.
Infect. Dis., 76:115, 1945.
5. Crawford, M.: Tularemia from ingestion of insufficiently
cooked rabbit. J.A.M.A., 99:1497, 1932.
6. Francis, E. : Sources of infection and seasonal incidence of
tularemia in man. Public Health Reports, 52:103, 1937.
7. Hunt, John S. : Pleuropulmonary tularemia. Ann. Int. Med.,
26:263, 1947.
8. Jellison, W. L., Kohls, G. M., Butler, W. J., and Weaver,
J. A. : Epizootic tularemia in the beaver, castor canadensis,
and the contamination of stream water with P. tularensis.
Am. J. Hygiene, 36:(2)168, 1942.
9. Karpoff, S. P., and Antonoff, M. I.: Spread of tularemia
through water, as new factor in its epidemiology. J. Bact.,
32:243, 1936.
10. Keefer, C. S.: Streptomycin in infections. J.A.M.A., 132:70,
1946.
11. Miller, D. H.: Transmission of tularemia by the fin prick
of a catfish. Mil. Surgeon, 84:23, 1939.
12. Parker, R. R., Jellison, W. L. Kohls, G. M., and Davis, G.
E. : Tularemia infection found in streams. Public Health
Reports, 55:(6)227, 1940.
13. Pearse, R. A.: Insect bites. Northwest Med., 3:81, 1911.
14. Stuart, B. M., and Pullen, R. L. : Tularemic pneumonia. Am.
J. M. Sc., 210:223, 1945.
TUBERCULOSIS AMONG RESIDENTS OF
OLMSTED COUNTY OVER THE
AGE OF SIXTY-FIVE
(Continued from Page 859)
tircularly since there was a definite overemphasis
on persons receiving old-age assistance, but the
finding of 8.6 per cent of this group with reinfec-
tion-tvpe tuberculosis is certainly of immediate
importance. In no other group of our population
can we find such a high percentage of significant
lesions.
References
1. Laird, A. L. : Tuberculosis in elderly people. Journal-Lancet,
64:208-211, (June) 1944.
2. Russek, H. I.; Rath, M. M.; Zohman, B. L., and Miller, I.:
The influence of age on blood pressure. Am. Heart J., 32:469,
(Oct.) 1946.
880
Minnesota Medicine
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D.. Chairman
DELEGATES DISCUSS HEALTH
QUESTIONS AT DULUTH MEET
Use of an anti-tuberculosis vaccine, a plan for
co-ordinating local health services, a program for
stimulating public interest in heart disease and a
cash sickness benefit system for railroad employes
were among the several important matters to come
up for discussion at the House of Delegates at its
annual session in Duluth last month.
Physicians were urged to “proceed with cau-
tion” as regards inoculating patients with the
widely popularized anti-tuberculosis vaccine,
BCG. The House of Delegates passed a resolution
opposing the indiscriminate use of this drug.
The new agent, whose full name is Bacillus-
Calmette-Guerin, is prepared by suspending vir-
ulent tubercle bacilli in an innocuous liquid. The
bacilli used for BCG are not as strong as some but
are strong enough to produce tuberculosis.
Not Sufficiently Studied
No organized, thorough studies have been made
to determine BCG’s actual value in treatment or
prevention of tuberculosis, the resolution pointed
out. It further said that inoculation with BCG
renders body tissues particularly sensitive to
tuberculin and thus nullifies the value of the
tuberculin test which has been used so effectively.
Further study of special groups under carefully
controlled conditions with sufficient time to make
the experiment worth while before its use is
publicly advocated was deemed necessary by the
delegates. The resolution deplored the widespread
publicity given to the use of BCG for tuberculosis
control work, which is leading to a feeling of
security among our citizens. In Minnesota highly
satisfactory results are being obtained by proved
methods, as shown by marked reduction in mor-
tality, morbidity and infection attack rates, and
therefore every effort should be exerted to protect
these results.
Health Council Plan Approved
A plan for the co-ordination of all health serv-
ices and the bringing together for greater mutual
understanding of all of the members of medical
and allied health professions who provide health
care and the citizens who receive the services was
approved by the House of Delegates, as outlined
in the report of the recently organized committee
on Rural Medical Service.
As its answer to the various problems with re-
gard to the distribution of medical and nursing
services, hospital facilities, school health and
health education programs and conflicting health
campaigns, which can beset an individual com-
munity, the Committee proposed that a health
council be organized at the local level to provide
a chance for interchange of ideas and opinions
leading to better understanding among those
groups involved.
The health council idea is not a new one. Other
states, notably Michigan, have formed them and
have found them to be a sound, practical answer
to much of the overlapping of services which can
occur. These councils are formed first at the local
level, in areas where they are deemed most ad-
visable. Later a council can be formed at the state
level, and eventually at the national level.
AMA Advocates Health Council Plan
Our State Committee on Rural Medical Service,
which with the approval of the House of Dele-
gates now has for its official project the formation
of local health councils, was created by action
of the Council of the Minnesota State Medical
Association following a request of the American
Medical Association. On January 4, 1947, the
present Committee, with one representative from
each of the nine Councilor Districts, was appoint-
ed by the Council ; and Dr. Paul C. Leek of Aus-
tin was named Chairman.
The activities of the present Committee are
co-ordinated closely with those of the parent com-
August, 1947
881
MEDICAL ECONOMICS
mittee of the AMA. At the two national con-
ferences on Rural Health, sponsored by the AMA
committee, there has been developed rather uni-
form agreement that health councils should be
organized to enable professional and lay groups
interested in health problems to> meet together.
The AMA Committee on Rural Medical Service
recommends that these health councils be organ-
ized on a local, county or trade-area basis before
state and national councils are developed. The
national committee further urges that the medical
profession show active leadership in organization
of these health councils as a part of a program
for extension of medical service.
Three Groups Represented
According to the proposals made at the National
Rural Health Conference, health councils should
be organized so as to represent three major
groups concerned. First of all, there should be
members of those allied and auxiliary professional
groups who render health service ; second, there
should be representatives of the public-at-large
who receive health service ; and, third, persons
representing governmental agencies manifesting a
continuing interest in health and medical care
should be admitted to membership in the health
council.
Health professions to be represented would, of
course, include doctors, dentists, nurses, pharma-
cists, and hospital administrators. The spokesmen
for the public-at-large could be chosen from
among the farm, labor, veterans’, women’s civic
and professional organizations, parent-teacher as-
sociations and members of the clergy and church
boards. Governmental agencies concerned would
include the county welfare board, the county
health unit, the city health unit, the city or
village council and the sanatorium commission.
Voluntary organizations, such bodies as the Tu-
berculosis association, the Infantile Paralysis
Foundation, the Cancer Society, the Crippled
Children’s association and the Red Cross, should
send their delegates.
Promote Discussion and Sound Planning
There are two major objectives of a health
council : ( 1 ) to bring together the interested
groups for the purpose of promoting discussion,
debate and interchange of opinions and the sound
planning of health and medical care programs
and (2) to encourage, stimulate, foster and sup-
882
port the establishment of health and medical care
councils in areas as deemed advisable within each
state.
To obtain these ends, the councils could survey
the medical and health needs, determining the
existing and needed facilities and personnel for
meeting the findings of such a survey ; recom-
mend ways and means of providing adequate
facilities and personnel to meet the constantly
changing needs ; disseminate as widely as possible
information pertaining to health and medical
care problems and programs ; and conduct or pro-
mote such meetings as may be helpful in effectuat-
ing the program.
Echoing the AMA’s original appeal for the co-
operation of the medical profession in the estab-
lishment of these health councils, which is so vital
to their success, the Committee urged in its report
to the House of Delegates that the local medical
societies lend their support to the project by ap-
pointing committees on rural health in each so-
ciety, to work with the State Committee.
The report pointed out that the very live in-
terest in the rural health problem on the part
of the public indicates the need for active leader-
ship by the medical profession. It further warned
that lay groups are prepared to proceed with their
own plans if the active interest of the profession
is not soon forthcoming.
Delegates Approve Heart Program
Recognizing the fact that a program to control
a disease which is responsible currently for one-
third of all deaths in the nation should not lack
public and professional support, the House of
Delegates approved a report submitted by the
Heart Committee, which outlined plans for the
establishment of a Minnesota branch of the Amer-
ican Heart Association.
The Heart Committee, of which Dr. Frank J.
Hirschboeck of Duluth is chairman, reported
that it had been planning during the year to 'ex-
pand its efforts toward activating public interest
in heart disease. At the request of the American
Heart Association, the Committee has held several
meetings to consider plans for the formation of a
Minnesota Heart Association. Dr. Hirschboeck
appeared before the Council of the Minnesota
State Medical Association and requested its ap-
proval for the Heart Committee to petition the
American Heart Association for a charter for the
Minnesota branch. This approval was granted
Minnesota Medicine
MEDICAL ECONOMICS
and the Committee has since been considering the
question of membership.
Present plans are based on a recent change
in policy of the American Heart Association, the
delegates were told. At first the AHA was in-
terested only in scientific matters, research and
education of physicians. Under the new policy,
the AHA plans to broaden its scope of activities,
to concentrate more on public health education.
And in order to foster this program for the
spread of information and the development of
public interest, it is proposed by the AHA to
have sectional or state Heart associations formed.
Members Include Physicians and Laymen
It is planned to extend membership not only
to physicians but to members of other professional
groups and to laymen, lay membership to be
limited to less than fifty per cent of the total.
The Committee noted in its report that Minne-
sota supplies a very satisfactory field for the for-
mation of a Heart association chapter, since in
this state the interest evidenced in heart disease
has been as intensive as in any other community
in the United States, if not more so. The interest
of various organizations, such as the Minnesota
Public Health Association, the American Legion,
the Variety Club, the Alpha Phi sorority, and
several others, has long been known. All have in-
dicated their interest and willingness to do their
share in advancing a definite research and educa-
tion program. The Minnesota Heart Association
will seek to co-ordinate and encourage the activi-
ties of all of these organizations.
An early meeting with representatives of the
medical profession, interested allied professional
groups and laymen is planned, at which time defi-
nite action for the formation of the Heart
Association will be discussed.
Hear Railroaders' Benefit Plan
A cash sickness benefit system for railroad
employes which became operative July 1, and
which will require the close co-operation of phy-
sicians, was explained to the House of Delegates
by representatives of the Railroad Retirement
Board. Benefits, the delegates learned, are pay-
able under the Railroad Unemployment Insurance
Act to qualified railroad employes when they are
unable to work because of sickness or injury.
Physicians are concerned in the program since in
order to receive benefits an employe must sub-
mit a statement of sickness signed by his physi-
cian.
Only doctors of medicine are authorized to
sign statements of sickness except when informa-
tion furnished on the form is derived from cur-
rent records of hospitals or institutions, in which
case the hospital superintendent or institutional
head may sign the statement.
Need Complete. Accurate Information
The need for complete and accurate informa-
tion as called for by each item of the form was
stressed in the report to the delegates. It is also
expected that the doctor will enter an estimate of
the date on which he believes the employe will
have recovered sufficiently to resume work in his
last occupation.
All disabilities which prevent railroad employes
from working, regardless of how or where they
occur, are covered under the program. It is
estimated that the program will require about
650, 000 medical examinations a year. Employes
are free to choose their own doctors ; and, since
the Retirement Board is not liable for any charge
in connection with completing the statement of
sickness, the relationship between the doctor and
the patient is not affected by this program.
There are two forms on which doctors are to
provide medical information. The first, which is
intended primarily for information at the be-
ginning of an illness or disability, is the “State-
ment of Sickness.” The second, intended to
provide additional information when it is needed
later on in connection with the same illness, is the
“Supplemental Doctor’s Statement.”
Prompt Mailing Required
The form to be filled in by the employe in
applying for sickness benefits and that to be filled
in by the physician are combined on the applica-
tion form, but if the physician considers the in-
formation he is entering to be confidential, that
part of the form can be detached and mailed by
him direct to the Board’s Regional Office. Prompt
mailing of the employe’s form and the doctor’s
statement is very important. If mailing is delayed,
the employe may lose benefits to which he is
otherwise entitled.
Any employe who earned $150 or more in rail-
road employment during a calendar year is
eligible to receive benefits if he applies for them
(Continued on Page 902)
August, 1947
883
Minnesota Academy of Medicine
Meeting of March 12, 1947
The regular monthly meeting of the Minnesota
Academy of Medicine was held at the Town and Country
Club on Wednesday evening, March 12, 1947. Dinner
was served at 7 o’clock and the meeting was called to
order by the president, Dr. E. M. Hammes, at 8 p.m.
There were forty-one members present.
Minutes of the February meeting were read and ap-
proved.
The secretary read a letter from Dr. H. Z. Giffin
presenting his resignation from the, Academy. However,
upon motion, it was voted unanimously to place Dr.
Giffin’s name on the Honorary List of the Academy, and
the secretary was instructed to notify Dr. Giffin of this
action.
The scientific program followed. Dr. Harvey O. Beek,
Saint Paul, and Dr. Vernon L. Hart, Minneapolis, each
read an Inaugural Thesis.
EDUCATIONAL MANAGEMENT IN PSYCHO-
SOMATIC MEDICINE, WITH SPECIAL REF-
ERENCE TO THE GASTROINTESTINAL
TRACT
HARVEY O. BEEK, M.D.
Saint Paul, Minnesota
The purpose of this paper is threefold: (1) to call
attention to the psychosomatic problem, especially in its
relation to certain diseases of and symptoms of the
gastrointestinal tract ; (2) to advocate and define the
concept of educational management in the treatment of
these cases; (3) to present cases illustrative of this com-
mon problem and their management.
Psychosomatic medicine changes the traditional con-
cept that disease is a fixed pathologic state. The tradi-
tional view, based on the precise pathologic studies of
Virchow, explained the symptoms of disease as being
a result of pathologic tissue changes which could be
traced back to certain mechanical, chemical, or infectious
factors, or to the natural process of aging. Psychoso-
matic medicine recognizes that certain symptoms and
pathologic anatomical changes are the consequences of
disturbed organ function which is associated with
chronic emotional conflicts.
According to Fultons’ belief, visceral changes are
secondary to the mental state or neurosis, that positive
mental and emotional states, concomitant with activity
of the cerebral cortex, are accompanied by visceral
changes also arising from cortical excitation. Another
view supported by psychological data suggests that the
visceral activity indicates a concomitant psychological
vector, and that the neurosis is both mental and visceral
change, and that they are inseparable.
Inaugural thesis.
It has been noted for a long time that functional dis-
orders of long duration may gradually lead to serious
organic disorders based on anatomical change. Common
examples of this are the hyperactivity of the heart with
resultant hypertrophy of the heart muscle, or hysterical
paralysis of a limb which may lead, due to inactivity, to
certain degenerative changes in the muscle. With the
development of the psychogenic concept it has become
evident there can be no sharp dividing line between
functional and organic.
Alkan in 1930 was one of the early leaders to point
out that organic disease could properly be studied by
psychologic methods. According to his belief organic
changes may be the final result of emotional dis-
turbances within the field of the autonomic nervous
system. He postulated that intrapsychic conflicts may be
expressed by spasms of smooth muscle which secon-
darily lead to anemia of an organ, vascular stasis, dyskin-
esia, atrophy or infection. The result of this may be
organic changes in visceral tissue or somatic structures,
which of themselves, as terminal events, are irreversible
and constitute the so-called organic disease.
Alexander and his group, through their psychoanalytic
studies, have become convinced of the psychogenic origin
of gastrointestinal disorders. It is their belief that the
organic changes are the last link in a complicated func-
tional chain of events with psychologic conflicts as the
basic etiologic factor.
Intensive psychic and somatic studies of cases of peptic
ulcer have produced marked evidence for the assump-
tion that emotional conflicts of long duration may be the
first step to a stomach neurosis which may result in
an ulcer. Present electroencephalogram studies on ulcer
patients are adding to this evidence by correlating the
electroencephalogram findings with the personality study.
Claude Bernard indicated the importance of the main-
tenance of a stabilized internal milieu of an organism
for its normal existence. The autonomic nervous sys-
tem has the major role in the maintenance of this con-
dition. Forces pulling in the opposite direction are
equilibrated to give an appearance of the rest homeos-
tasis of Cannon. An automatic response involved in the
interest of homeostatic balance or as an expression of
emotional behavior may become excessive and give rise
to symptoms.
Emotional conflicts and abnormal tensions that cannot
be expressed outwardly through normal channels are
converted to symptoms and organic disease. These emo-
tions become the source of excessive energy which,
centered in the hypothalmic region, overflows on the
nuclei of the autonomic nervous system. The dienceph-
alon with its regulating influence upon both major
divisions of the vegetative nervous system apparently
serves as the distributor of the emotional components
of disease. The cerebral cortex appears to transmit, un-
der conflict and abnormal tension, stimuli to the area in
884
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
the diencephalon which sets up impulses responsible for
secondary changes in function and structural change.
Grinker and Ingram have reviewed the evidence that
there are controlling nuclei for the sympathetic and
parasympathetic nervous systems in the hypothalmus
and that these centers are not only under the controlling
influence of the hypothalmus, but also of the hypophysis
and cortex. Stimulation of the hypothalmic region will
cause various sympathetic or parasympathetic responses
which will disappear when the vagus or sympathetic
nerves are cut. It is postulated that the tonus of the
two nervous systems is regulated in the area, and it is
apparent that emotional tension can affect either one or
the other separately or both simultaneously.
The manifestations of disturbed autonomic nervous
system are numerous and this discussion will be limited
to the gastrointestinal tract.
It was the experience of the medical corps in the
recent war that gastrointestinal manifestation replaced
the “soldiers heart” of World War I. In my practice,
in a charity clinic, and in an educational therapy class,
it is by far the most common condition.
1. In my private practice 25 per cent of the patients
seen have complained of gastrointestinal symptoms
which have been diagnosed as functional.
2. In a charity clinic figures based on samplings showed
approximately 40 per cent with these complaints.
3. In an educational therapy class of 150 members, 36
per cent gave gastrointestinal complaints as their
main problem.
There is probably no other system which shows such
fine shadings between functional and organic changes as
the gastrointestinal tract. Long-standing emotional dis-
turbances result in tissue changes as seen in the stomach,
duodenal ulcers and the ulcerative lesions of the colon.
There are certain factors which contribute to making
this area a logical endpoint for emotional tension : ( 1 )
the sheer length of the tract; (2) the abundant afferent
and efferent nerve supply of the gastrointestinal tract;
(3) the association of relief from physical discomfort;
(4) the fact that it is subjected to a wide range of abuses
and insults; (5) the demands made upon it for adjust-
ment and accommodation ; (6) the association of the
tract — through the act of feeding — with the emotions.
Wolf and Wolff have shown in their monograph,
“Human Gastric Function,” that the gastrointestinal
tract is a battle ground for conflicts between the body
and the emotional state. They demonstrated that al-
terations in gastric function may occur in response to a
very large number of stimuli, and that even in the case
of drugs and other physical and chemical agents, the
usual effects may be profoundly modified or even
reversed by changes associated with the situation in
which the subject found himself and his reaction to
it. It was further shown that these functional altera-
tions in the stomach, when sustained, lead to the ap-
pearance of distressing symptoms and structural dam-
age.
In a group of 158 patients attending an educational
therapy class the most prominent emotions found to be
the apparent causative factors of the tension state were
first, fear and anxiety, and next, hostility and resent-
ment.
Wolf and Wolff’s subject again demonstrated well
the changes in the stomach in response to these emotions.
Fear, giving a picture of pallor of the face with
blanching of the mucous membrane of the stomach
accompanied by reduced acid secretion ; anxiety, show-
ing hyperemia, hypersecretion, and hypermotility, with
flushing of the face; hostility and resentment showing
turgidity, engorgement, hyperacidity, and violent con-
tractions. Sustained emotional tension revealed the
changes in the stomach mucous membrane and the pa-
tient complained of cramps and diarrhea. The sensitivity
of the stomach to pain from vigorous contractions in-
creased at the times of hyperemia and engorgement.
The cases to be presented and discussed are given be-
cause :
1. The emotional and life situation of the patients is a
dominating factor in their illness.
2. They are all cases with sustained emotional tension.
3. All cases showed more than one manifestation of
autonomic nervous system imbalance.
4. In each case the emotional component was easily
accessible.
5. All cases had failed to respond to accepted medical
management.
6. They did respond to either educational management
alone or the addition of educational management.
Case Reports
Ca\s:e 1. — (Ulcer-like Syndrome) J. W. T. aged fifty-
five, a married white man, was first seen in May, 1946,
complaining of gas, gnawing sensation in the epigastrium,
intolerance of many foods, weakness, and stating
definitely that he had an “ulcer.” He also complained
of spells of rapid heart, fatigue, sweating, and “collapse.”
His symptoms first appeared in mild form between 1932
and 1934, and since then have been the focus point of his
life. During this period he had seven gastrointestinal
x-rays series, and two gall-bladder x-rays. One x-ray
examination supposedly showed a small ulcer in the
duodenum. A retrocecal appendix was removed in 1942.
He failed to respond to the large number of sedatives,
antispasmodics, diets, and interval feedings which his
physicians tried. An attempt was made by a surgical
consultant to explain his condition on a functional basis,
but this he absolutely refused to accept.
When seen in May, 1946, he was hospitalized and kept
on modified ulcer diet while an attempt was made to
start educational therapy. This failed and he was dis-
charged in five days. His symptoms continued and he
spent a great deal of the summer in bed. In September
he was again hospitalized, but again he refused to ac-
cept educational therapy and was discharged at the end
of seven days. On October 9, he had such a severe at-
tack of distress and tachycardia that he was returned to
the hospital, where x-ray studies failed to reveal an
ulcer. According to his statement he had reached such
a low ebb that he was willing to try anything. From
the moment that he was willing to admit his condition
was functional and was willing to accept educational
therapy, his progress was one of steady and rapid im-
provement. He was discharged from the hospital on
October 30, on a normal diet, no medication, no activity
restriction except the avoidance of excessive fatigue.
He has continued to the present, free from distress, and
has not missed a meal or work day in six months, a
August, 1947
885
MINNESOTA ACADEMY OF MEDICINE
record that had not been achieved in thirteen years. He
is able to eat any foods, and does not avoid moderate
amounts of alcohol. Under strain he does have mild
spells of tachycardia and some “tight sensation” in the
stomach, but he is able to break this immediately with
the relaxing exercises that he has been taught.
The history revealed that the symptoms began during
the depression years while the patient was guiding a
financially unsound business. He is of Irish decent, of
an explosive nature at times, and not given to con-
trolling his emotions.
This case history shows a patient who for a period
of fourteen years failed to respond to medical man-
agement for gastrointestinal complaints. With his im-
provement he realized that, after all, his condition was
functional and that the advocated educational therapy
did make sense. He also admitted that he had always
hoped for some definite organic finding and that he
had pounced on the one questionable x-ray with great
hopes, but that the failure of diet to cure him had been a
disappointment. This case well illustrates the change
from medical management to educational management.
Case 2. — (Gastritis) E. G., aged twenty-three, an un-
married Mexican woman, was first seen in January,
1946, complaining of nausea, burning in the epigastrium,
loss of weight, gas, distress after eating, and fatigue.
These symptoms had a duration of six years with vary-
ing degrees of intensity. She also complained of spells
of sweating, palpitation, and dizziness for three years.
During the period of six years she had been seen by
seven different private physicians and had failed to re-
spond to any of the types of therapy given.
The only significant findings on examination were
spasm of the gastrointestinal tract and moderate ten-
derness in the ileocecal region. The x-ray examination
showed a rather large stomach containing an excess of
secretion and slight changes suggestive of gastritis.
She was treated intentionally as an out-patient on
medical management until May, 1946, and continued to
have the same complaints with no signs of improvement.
In May, 1946, she was hospitalized for one month for
strict medical management. There was no change in her
symptoms or x-ray findings after this period. No at-
tempt was made to get a history of her emotional situa-
tion.
In August, 1946, a detailed life and emotional history
revealed that her father had become a drunkard and when
she was nine, a brother took to drinking with re-
sultant family drunken brawls. She had noted the ap-
pearance of a tight feeling in her stomach as the house-
hold tension developed, which was accentuated by each
violent episode. Her brother was convicted of “white
slavery” and at this time her symptoms increased and
became permanent. She refused to marry a boy whom
she was really fond of shortly before he went overseas.
He was soon killed, and her symptoms became more
marked. She had been unable to work for two years
because of her distress.
She was of average intelligence and desired to raise
herself above the level of her family.
After educational management was started in August,
she responded slowly but well, and in two months was
able to eat nearly all foods without distress, gained 5
pounds and obtained a position.
She gained sufficient understanding so that she volun-
teered that she could correlate her mother’s asthmatic
attacks with the home situations, and that she felt this
asthma was of the same functional nature.
In this case it is seen that the patient failed to respond
to treatment over a six-year period with seven different
physicians. It is to be noted that no adequate history was
taken during this time. This patient failed to respond to
medical management as an in- and out-patient over an
eight-month period, but did respond when educational
therapy was started and the emotional aspect of her
condition explained. This patient is still being followed.
886
Case 3. — (Duodenal Ulcer) E. M., aged fifteen, an un-
married negro girl (illegitimate), was first seen in
September, 1946, complaining of gnawing pain in the
epigastrium, nausea, vomiting, sweating, and weakness.
These symptoms had been persistent for two years.
The patient was said to have had stomach distress
ever since she was an infant. At the age of nine, her
condition became more marked and she was taken to
various clinics where the diagnosis of nervous stomach,
gastroenteritis, and food intolerance were made. In
September, 1945, because of a severe attack she was
given a gastrointestinal x-ray at a city hospital, and a
shallow ulcer crater about inch in diameter was
found on the posterior wall of the middle third of the
cap of the duodenum. She was placed on diet and
Sippy powders with only moderate relief. In September
at another clinic she had an x-ray study and the findings
were reported as showing an active ulcer with associated
gastritis. She was continued on the same diet and also
started on educational therapy. One month later she
showed decrease in the size of the ulcer crater, and her
improvement has continued. X-rays taken February 15,
1947, showed no signs of an ulcer crater.
In obtaining the history of her family and emotional
life it was found that this had not been done before.
The important points in the history revealed that she
believed her father had died shortly after her birth.
She lived with her mother, grandmother and aunt. There
was constant friction in the home, which the patient
realized caused her stomach to be upset. When she was
nine her mother married a man whom she feared, and
who refused to support and rejected the patient. At
this time she had a severe attack of stomach pain and
vomiting. She lived with her aunt. With the birth of
each of two half-sisters she developed severe attacks
and had to be taken to clinics. When she was fourteen
she had her severest attack. This followed an attempt
by the Welfare Board to urge her to return to her
mother and stepfather and she lived for a period in fear
that this might be brought about. It was at that time
the ulcer was found.
This case reveals a fifteen-year-old Negro girl in whom
a definite ulcer had been recognized for one year. It
had not responded to medical management, in the year,
but did respond when educational therapy was added to
this regime. The periods of exacerbation of her symp-
toms are easily correlated with the increase in the emo-
tions of fear, anxiety, and resentment.
Case 4. — (Duodenal Ulcer) R.R., aged sixty-two, a
married white woman, was first seen in November, 1946,
complaining of typical ulcer symptoms, insomnia, and
restlessness. She stated that she had been on ulcer re-
gime of restricted diet and medication for twenty
years, and that she had not been free of chronic dis-
tress during the last fourteen years.
X-Ray studies on November 4, 1946, showed an active
duodenal ulcer with marked deformity.
She was continued on medical regime and educational
management started. She soon experienced relief and on
November 18, 1946, the x-rays showed marked improve-
ment with no evidence of the previously demonstrated
ulcer crater.
The history revealed this person to be a chronic wor-
rier, with marked periods of anxiety.
This patient has not been followed very long, but she
is enjoying more comfort than in the past fourteen years
and has recently gone through a period of distress
caused by a tragic family death, which she states should
have made her stomach symptoms almost unbearable.
As in the other cases the only change in treatment was
the addition of educational management.
Case 5. — (Ulcerative Colitis) G. L. D., aged forty-five,
a married Jewish woman, was first seen in August, 1945,
complaining of bloody diarrhea, tenesmus, abdominal
cramps, weakness, loss of weight, insomnia, fatigue, and
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
dizziness, and sweating. Her first symptoms appeared as
mild cramps and diarrhea in 1934 and increased in
severity until 1941 when her physician made the diagno-
sis of ulcerative colitis. She was placed on various
medical regimes until August, 1945, when she was re-
ferred to a surgeon.
Proctoscopic and x-ray examinations confirmed the
diagnoses. Examination showed marked abdominal ten-
derness and moderate rigidity.
Emotional history revealed financial insecurity, nu-
merous family conflicts, anxiety over her husband and
children, one of whom was a marked behavior problem.
She was hospitalized from August 28 to December 16,
1945, on medical management and educational therapy.
She made slow and steady improvement. After her
discharge she continued educational management until
April, 1946, when she returned to her home in Detroit
to face unchanged conditions. She was able to do this
and handle difficult situations without an exacerbation,
and recent letters state that she is doing well at the
end of one year.
This case is of importance because it shows a typical
case of ulcerative colitis which was referred to a sur-
geon for operation. The surgeon recognizing the emo-
tional component placed the patient on educational man-
agement, instead of surgery.
Case 6.— (Diarrhea) G. M., aged forty-two, a married
white woman, was first seen in October, 1945, com-
plaining of occasional diarrhea, abdominal cramps, tachy-
cardia, and dizziness. Her symptoms had been present
three years.
Examination was negative except for marked spasm
and tenderness of the lower gastrointestinal tract.
History showed she had married a man twenty years
older than herself. When she discovered that he drank,
her symptoms appeared. She found that the sight of a
drunken man or the act of merely walking by a parlor
seeing people drink would bring on a violent attack of
diarrhea. She had failed to respond to diet and seda-
tion but did respond to educational management and is
free from diarrhea.
This case furnishes a good example of the reflex
action established by emotion, the strong feeling regard-
ing drink. It appears as a potential case of ulcerative
colitis without educational management.
Comment
It is interesting to note that, in a number of ulcer pa-
tients from the same group now being studied, the figures
show that patients on continued educational management
after cessation of the ulcer regime are less likely to
have recurrence of symptoms, than those in whom this
therapy is not used, the medical management in these
cases being modified ulcer diets and antiacids, or pro-
tein hydrolosate.
In none of these cases reported was a glucose tolerance
study made, but in some of the group this is being done,
and a low curve with a two-hour drop to 55-60 mg. is
being found, the degree depending on the severity of the
emotional problem. This is consistent with the studies
made on psychoneurotic soldiers.
Accepting one of the theories advanced for the role
which the autonomic nervous system plays in the pro-
duction of these conditions, it is easy to understand why
the usual medical management of these patients fails.
Once the emotional state has caused the regulating
mechanism to respond in this altered manner, and
established an emotional reflex, the condition cannot be
changed until the emotional component has been cor-
rected. The re-establishment of the emotional-autonomic
nervous system relationship is the purpose of educational
management.
Recognizing this conflict or tension pattern, the intern-
ist has been criticized for not more frequently seeking
psychiatric consultation in the handling of these cases.
It is felt that this consultation is impossible because of
the terrific case load, and that in the majority of cases
it is not necessary but might be unwise treatment.
Educational management as advocated is a means
for handling these functional problems which is within
the reach of any physician or surgeon who is willing
to take the time with his patient, and who is willing
to devote himself to understanding the emotional state
and response of his patients.
These patients are suffering from a condition which
is due to their own emotional response to situations and
their condition is usually accompanied by a general state
of tension. A study of a group of patients in an edu-
cational management class showed that nearly all of
them had more than one manifestation of autonomic
imbalance such as sweating, tachycardia, dilated pupils.
They must be made to understand their problem, the
importance of the emotional involvement, and the as-
sociation of relaxation.
Patients before being elegible for this form of therapy
must be thoroughly studied and all complaints inves-
tigated. There must be no doubt in the mind of the
examiner as to what the patient’s condition is. Any
doubt about the mental status of the patient has to be
evaluated by a psychiatrist. It has been pointed out that
the problems of these patients must be simple and on the
surface.
Educational management is exactly what its name im-
plies education in understanding oneself and one’s prob-
lems, and that most important tool, relaxation. The
program must be carried out by developing the two
phases at the same time.
The patient should be presented with the results and
facts of the examination in a manner any intelligent per-
son is entitled to. Any doubts about his condition or
questions pertaining to it must be satisfied. A patient
whose attitude is “Yes, Doctor, but” will not respond
as long as he maintains that' attitude. The best results
are obtained in group management, although a modified
program can be carried out individually. In attending
a group the individual gets things that he cannot when
handled alone. He quickly grasps certain very obvious
facts. The presence of many others assures him that,
contrary to his belief, he is not the only person in the
world with a functional problem. The most important
step is in making the patient realize that his ailment
is just as real as a definite organic disease, in making
him see that there is no more shame, stigma, or disgrace
in admitting he has a functional condition, than there
would be in admitting he had a broken leg or diseased
heart. In the group he learns that functional conditions
are not respectors of persons, that they may plague the
rich as well as the poor ; those of higher intelligence
levels and those of lower ; the laborer and the man be-
hind the desk. In the group he has the opportunity to
watch the progress of other individuals in the conquer-
August, 1947
887
MINNESOTA ACADEMY OF MEDICINE
ing of their problems ; he has the opportunity of talking
with them and learning at first hand of their progress
and does not have to rely on the statement of the physi-
cian. This is one of the extremely valuable facts in
developing his confidence. He learns that the physician
and the group furnish him tools, but that he alone can
get himself out of his difficulty. It is made clear to him
that his group attendance is not compulsory, that he must
want this type of therapy, that the results depend on his
desire to get well.
In the group his educational process consists of show-
ing him, by means of discussion in simple language,
something of the physiology and anatomy of the body.
He has to learn that emotions can, through a chain of
events, be converted into changes in function that may
even result in a structural change which produces his
symptoms.
As important as understanding the effects of emotions
is understanding the art of relaxation. This is taught
at the same time by having the group follow the physi-
cian through a simple series of exercises. The principle
of these is the simple contrast between tensed and
relaxed muscle groups, and a simple form of mental
relaxation.
The patient is encouraged to discuss openly in the
group his problem and his progress in handling it.
These patients are taught not to believe that all con-
ditions are functional, that organic and functional can
coexist, that while they may have a functional condition
they may acquire some other, and that new symptoms
must be explained by their physician.
A question has been raised as to whether or not this
form of therapy is not an encroachment on the field
of psychiatry. It is felt that it is not. There is no at-
tempt made to interpret dreams, to use uncovering tech-
nique, psychoanalysis or any other procedure which
rightfully belongs to the trained psychiatrist.
The statement has been made that because of its
simplicity this type of therapy could be abused. That is
correct. It could be degraded into a series of pep
talks and a modified form of “laying on hands.” If
abused, it could be very dangerous. Intelligently used,
it appears the ideal solution for handling a great many
functional cases.
The cases cited are from an educational management
group in Saint Paul, and opinions expressed about this
therapy were formed in the management of this group.
In summary it is felt that educational management is
a definite form of therapy in the field of psychosomatic
medicine, and that the problem of handling these pa-
tients resolves itself into that of handling the whole
man rather than his ulcer, gastritis, or colitis.
A British doctor, Crookshank, stated, “It always seems
to me odd in the extreme that doctors, who, when stu-
dents, suffered with frequency of micturition before an
oral examination, or who when in France had actual ex-
periences of the bowel looseness that occurred before ac-
tion, should persistently refuse to seek a psychological
correlative — not to say an etiological — factor when con-
fronted with a case of functional enuresis or mucous
colitis. I often wonder that some hard-boiled and or-
thodox clinician does not describe emotional weeping as
a ‘New Disease,’ calling it paroxysmal lacrymation, and
suggesting treatment by belladonna, astringent, local ap-
plications, avoidance of sexual excess, tea, tobacco, fluid
intake; proceeding, in the event of failure, to early re-
moval of the tear glands. Of course, this sounds ludi-
crous. But a good deal of contemporary medicine and
surgery seems to me to be on much the same level.”
Discussion
Dr. Moses Barron, Minneapolis : Dr. Beek’s paper
was a very instructive one. He touched upon a field in
medicine that is not sufficiently emphasized in our medi-
cal schools. I have always felt that it is very important
to obtain a careful history from the patients so as to
get a proper background in devising treatment. I my-
self have used a similar method in the care of my
gastrointestinal patients to which I do not give any
name such as education. I simply consider it as a
method of getting the co-operation of the patient in car-
rying out the treatment. I have tried to emphasize this
approach to the students and have insisted on careful
histories of the patients. In the treatment of ulcers, for
example, I carefully go over the entire field of manage-
ment with the patient, pointing out the importance of
regulating the diet, the reason for certain foods being
used, the reason for the various medicines used, and
just what we try to obtain by the management.
The importance of the psychic factors is always em-
phasized, the importance of eliminating tension and
excitement. I have found the procedure a very satis-
factory one. We realize that about 40 to 50 per cent
of our patients have complaints with no organic basis
that can be demonstrated. As Dr. Beek has well said,
the complaints and symptoms, whether organic or func-
tional, affect the patients just the same. They suffer
just as much and often more from functional ailments
than they do from definitely organic lesions. A care-
ful discussion with the patient will help toward an
understanding of just what is involved and will bring
about better results in treatment.
Dr. C. N. Hensel, Saint Paul : I am very glad to rise
to my feet and give commendation to Dr. Beek for
bringing this topic before the Academy.
I have been a member of this organization for some
thirteen years, and this is the first time I can recall
such a topic being presented here.
In view of so much stress being presently given to
psychosomatic problems, I think it is a very timely sub-
ject and very well presented. In my training as a
medical student I was indoctrinated by the force of the
pathological thinking of that time, namely, that unless
you could find a lesion in an organ during life or at
the autopsy table after death, no disease existed. There-
fore, after graduation and in my early years of
practice, I sought for the pathological lesion, applied the
proper treatment and expected the patient to get well.
When patients did not improve or get well, I was dis-
appointed and I then began to investigate further and
inquire what was wrong. Often I would discover that,
in addition to their complaints of sick organs, these
patients were carrying a flock of bothers and troubles,
that they had not mentioned when I first obtained their
history ; and so, without any training in psychoanalytical
technique, I attempted in a practical common-sense
way to resolve some of these bothers. If I was suc-
cessful in so doing, then these patients seemed to im-
888
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MINNESOTA ACADEMY OF MEDICINE
prove, and so I became interested in the relationship
of emotions and feelings to disease.
Thereafter when a medical problem would not be
resolved by medical management, I would inquire fur-
ther and sometimes I obtained a frank discussion by the
patient ; more often, I would be met by evasion or
denial that there was anything wrong emotionally in' the
patient’s life.
After repeated conferences, I might uncover factors
that were denied at the first visit. Personal pride and an
instinctive sense of protecting one’s weaknesses or in-
adequacies, seemed to be the greatest hindrance in pre-
venting such patients from freely discussing their basic
problems with the physician. And so, in order to relax
that pride, I would assume that certain problems (which
I had already come to suspect) existed in that pa-
tient’s life and proceed to discuss them as though they
were facts. With this lead, uncommunicative patients
might begin to talk about their problems and thus find
relief from inner tensions. I am convinced that it is ei-
ther pain or fear which most often drives patients to their
doctor. The pain motive is definite and tangible, usually
localized and inevitably leads the doctor to the proper
diagnosis and treatment. The fear motive is usually
hidden and the patient is unable to express it ; often such
patients come with some unrelated complaint, hoping,
perhaps, that in the course of the examination the doc-
tor will discover whether there is a cancer of the uterus
or the stomach or whether the palpitation of the heart
is serious.
Many patients who consult a doctor are inadequate
to their life’s situation, are unable to cope with their
problems, and they become dissatisfied with what they
are doing and unconsciously resort to perpetual com-
plaining as sort of an excuse for their inadequacy. To
such people the doctor must be not only their physician
but their guide and leader who helps them with their
problems. You cannot obtain an informative history
from such patients in ten or fifteen minutes ; you must
let these people talk and tell their story in their own way.
Confessions are made slowly and painfully and take time
if you are to obtain the crux of what is bothering the
patient. If you choke them off as too time-consuming
or discursive, you drive back deep within them the
trouble which is seeking an outlet. Such patients need
understanding* and a kindly guiding hand to help them
with the revelation of their problem which oftentimes
they are aware of themselves, but too shy or too
ashamed to reveal to others.
Dr. Beek has chosen the educational class method be-
cause it saves time and he can deal with a larger num-
ber of people with the same expenditure of effort. For
myself, I have liked the person-to-person relationship
and felt I could secure better results in this way.
Whichever method you have used and found best, you
yourself can use best. I can recall an oration by Dr.
Cannon, of Boston, at a meeting of the American Col-
lege of Physicians in 1938 on “The Role of the Emo-
tions on Bodily Functions and Disease,” in which he
deplored the fact that medical teachers were still bound
by Virchow’s ideas on cellular pathology and Freud’s
ideas of the unconscious. He felt that medical schools
should put more stress on emotional factors in the study
of disease.
Dr. Beek (in closing) : I want to comment on one of
the things which Dr. Hensel mentioned ; and that is I
do not wish to create the impression that the individual
is forgotten. We must have some personal contact
with them and that is done at other times than in the
class. We must maintain personal contact with our
patients.
August, 1947
CONGENITAL DISLOCATION AND CONGEN-
ITAL SUBLUXATION OF THE HIP
Etiology and Roentgenographic Features
VERNON L. HART, M.D.
Minneapolis, Minnesota
Congenital dislocation and congenital subluxation of
the hip joint are two separate and distinct clinical en-
tities and each may be the cause of serious disability.
The two conditions should be considered together be-
cause they have the same etiology.
Classical congenital dislocation of the hip is secondary
to a primary genetic dysplasia of the hip, or flat acetabu-
lum, and develops during intra-uterine life, or in the
course of the first or second year of postnatal life. Dis-
location is a consequence of the primary dysplasia or
“flat socket” ; it is a secondary and incidental phenome-
non. “Dysplastic acetabulum” is a term now generally
accepted, and means a congenital and genetic anomaly
of the acetabulum, with hip-joint instability and incon-
gruity. The primary anomaly is not limited to the ace-
tabulum, but involves all mesodermal structures of the
hip joint. Aplasia or hypoplasia of the roof or buttress
of the rim of the acetabulum causes a flat socket which
is the important expression of the dysplasia of the pel-
vis and hip joint. Dislocation of the femoral head
may result because the hypoplastic and insufficient roof
of the acetabulum lies in the axis of transference of
forces of body weight and muscle contraction. Ac-
clivity of the roof of the socket is the principal anatom-
ical feature and a constant defect in congenital disloca-
tion of the hip (Fig. 1).
Actual dislocation can, but need not necessarily, oc-
cur. Primary dysplasia of the hip without dislocation,
but with varying degrees of subluxation, is a distinct
clinical entity. The two entities, with and without dis-
location, are identical in their etiology but are different
in their clinical, radiological and pathological manifesta-
tions. Either entity may exist as a unilateral or bilat-
eral lesion of the hip joint; frequently the two entities are
present in a single patient with bilateral hip-joint dyspla-
sia (Fig. 2).
Hip dysplasia with potential dislocation in a child
one or several months of age may, if not properly treat-
ed, become a complete dislocation before or soon after
the child starts to walk. Dysplasia of the hip with
dislocation was at some previous period a potential
dislocation ; but hip dysplasia without dislocation does
not necessarily progress to a complete or classical
dislocation. Whether or not a gradual transition occurs
from potential to complete dislocation depends on the
degree of hypoplasia of the acetabular rim, the sex, the
position in ntero, and the forces of muscle contraction
and weight-bearing. It is now an established fact that
dysplasia of the hip with subluxation, which was thought
to be only a precursor of the classical dislocation, may
remain as a permament deformity with characteristic
clinical symptoms and roentgenographic findings.
Inaugural thesis.
889
MINNESOTA ACADEMY OF MEDICINE
In the textbooks, the chapter on congenital dislocation
of the hip is incomplete, since only the entity “disloca-
tion” is considered. The entity “subluxation,” which is
more common, and frequently more disabling than the
Fig. 1. Roentgenogram of patient twenty years after manip-
ulative reduction of congenital dislocation of the left hip. Note
that the principal anatomical feature and constant defect in con-
genital hip is acclivity of the roof of the acetabulum. The
patient is now twenty-five years old. There is no evidence of
traumatic arthritis which is inevitable at a later age. Secondary
roentgenographic features of maldevelopment of the femoral
head and neck are apparent ; also the adaptive physiological
sclerosis of the roof of the inadequate acetabulum.
classical dislocation, should be included. The terms
“dysplastic acetabulum” or “hip dysplasia without dis-
location,” “preluxation,” “potential dislocation,” “inade-
quate acetabulum,” “incompetent acetabulum,” “flat
socket,” and “subluxation” are synonymous, since they
are expressions for a single entity.
Heredity Conditions
Many authors have reported genetic occurrence in
families in about 20 per cent of all cases of congenital
hip dislocation. A notable and fundamental contribution
to our knowledge of congenital dislocation of the hip was
reported by Faber in 1937. Previous to Faber’s work,
all genetic investigations were based on the concept of
a “dislocation gene” or diseased chromosome. The only
“patients” in the genealogical studies were those with
classical dislocation. Faber’s research was based on
the concept that the heredity, upon which dislocation of
the hip depends, is not itself the hip dislocation, but,
instead, is a primarily existent defect or acetabular
anomaly which is in general designated as a flat socket.
Because of a flat socket, an actual dislocation of the
joint can, but need not necessarily, occur. There is no
“dislocation-gene-conditioned chromosome,” but there is
a “hip-dysplasia gene.” The hereditary factor is not
the dislocation, but is a primary hip and acetabular
dysplasia. Congenital hip dysplasia with dislocation and
with subluxation are clinical expressions of the same
gene-conditioned chromosome. They have the same
heredity.
Roentgenographic consanguinity investigations were
made by Faber on all living members of the families
of ten children with congenital dislocation of the hip
(Fig. 3). The ten children were considered ostensibly
sound in their heredity by those who accepted the con-
cept of a “dislocation gene.” From these studies, Faber
Fig. 2. Patient has always been disabled with a unilateral hip
dislocation. She is now forty-six years old, and has experienced
pain and stiffness during the past year in the opposite “normal”
hip. Note the characteristic signs of primary hip dysplasia of
the "normal” hip with .early traumatic osteoarthritis. Careful
study of dysplastic acetabiila shows that bilateral cases outweigh
the unilateral, which is the opposite of statements made by earlier
authors.
demonstrated that dysplasia of the hip joint without
dislocation was three times as frequent as was classical
hip dislocation. In a total of ninety-eight cases of pri-
mary hip dysplasia, twenty-five were with dislocation
and seventy-three without dislocation. The occurence of
primary acetabular dysplasia is, therefore, four times as
frequent as had been supposed up to the present time,
from the sole consideration of hip dislocation. In some
of the families, only a few individuals manifested classi-
cal dislocation, while many showed hip dysplasia with
subluxation. In one family, no dislocation was observed
although many flat sockets were demonstrated. Not all
apparently normal individuals were genetically sound.
Some patients with hip dislocation had parents who were
normal in (phenotype) appearance, but roentgenographic
studies showed one of the parents to have a flat socket.
The affected parent, although clinically normal, was a
latent carrier of the gene.
Variations in the manifestation or expressivity of the
gene indicate that other conditions are active in determin-
ing the penetrance of the gene, and thus the expression
of the character. Under the influence of function, a
growing child with hip dysplasia without dislocation
may in adolescent or adult life present a spontaneously
healed or normal hip joint; the apparently normal in-
dividual would be genetically abnormal and a conductor
or latent carrier of the “hip-dysplasia” gene. In many
instances, it is not possible to measure the exact environ-
mental condition which can affect the gene action.
Genes primarily active in the development of a trait may
act differently under various genotypes (genic milieu).
A trait develops as the result of the interaction of
890
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MINNESOTA ACADEMY OF MEDICINE
several gene pairs ; and, if one of these pairs is different,
the primary gene may not be able to produce a trait as
completely or as incompletely as it could under the
other genic complex. Some genes are secondary in their
Sex linkage in the hereditary pattern does not exist,
because the genealogical trees show transmission of the
genetic character of hip dysplasia from father to son.
The dysplasia gene is transmitted usually only from one
9 °t9
of*
o 9r
5
o
I 9
O Normal
® Dysplasia with dislocation
® Dysplasia without dislocation
Fig. 3. One of Faber’s roentgenographic consanguinity studies
shows that in the family of the mother of the patient no car-
riers were found, while in the family of the father four car-
riers of the primary hip dysplasia without dislocation were found.
(Reproduced from Stammtafel 8. Zeitschrift fur Orthopadie,
66:160, 1937.3)
nature of action, in that they modify the action of
the gene pair primarily associated with the trait. A
true genetic history cannot be gained from a study
limited to classical dislocation, since this expression of
the gene occurs only if the environment, genic and
otherwise, is proper for that complete expression. Only
by roentgenographic consanguinity studies can a true
genetic picture with all the variations of the penetrance
and expressivity of the gene-conditioned chromosome be
gained.
The sex ratio of the total number of dysplasias ap-
proached the universal average, showing that there is,
after all, not such a very great difference in the dyspla-
sias of the hip joint between the sexes. The sex ratio of
the total number of dysplasias with dislocation, however,
revealed a preponderance of dislocations among the fe-
male sex. The ratio between the sexes did not vary from
previously reported investigations on great numbers of
cases, which revealed a ratio of female to male, of
six to one. In the female, the dysplastic hip can lead
much more easily to complete dislocation than in the
male. This constant sex distribution is understood if
it is true that a sex-conditioned structure of the pelvis
exists — the female having a more perpendicular innom-
inate bone and a shallower acetabulum. The phenome-
non of female-sex predominance with actual dislocation
requires further investigation.
Fig. 4. Roentgenographic study of a normal hip (aged two
years). A horizontal line is drawn on the roentgenogram
through the clear areas in the depths of the acetabula, which
represent the triradiate or Y cartilages. This line is called the
Y line. A second vertical line is drawn through the lateral
border of the acetabulum and the Y line. Normally the capital
epiphysis lies below the horizontal line and within the lower
medial quadrant formed by the Y and vertical lines. The angle
of incidence of the roof of a normal acetabulum is about 20
degrees. This angle is formed by the junction of the Y line
with a line passing from the depth of the socket at the Y line
through the lateral border of the acetabular roof.
In case of unilateral hip-joint dysplasia, the vertical line is
drawn on the normal side; and on the opposite side a parallel
line is drawn at an equal distance from the mid-line.
In hip dysplasia without dislocation, but with varying degrees
of subluxation, the capital epiphysis lies below or partially above
the horizontal or Y line, but lateral to the vertical line. In hip
dysplasia with actual dislocation, it lies above the Y line and
lateral to the vertical line.
Note Shenton’s line and the tear-drop. Also note the line which
measures the distance from the most proximal shadow of the
diaphysis to the Y line.
of the parents, and a recessivity of the genes predispos-
ing to primary dysplasia of the hip is not probable. Hip
dysplasia is due to a dominant gene.
Mendelian ratios cannot be predicted in human fami-
lies because the genotypes are not known at the time of
mating, and the offspring do not occur in numbers great
enough to fulfill the mathematical expectancy.
Roentgenographic Features of the
Normal Hip
There is no one particular rotentgenographic form of
hip joint to be exclusively designated as the normal.
There is a range of normals, since there are numerous
variations which certainly do not fall outside the classifi-
cation of the normal. A range of normalcy so generous
and wide will be recognized in order to eliminate error
which would necessarily result from a narrow and
rigid definition of the normal.
The following description of the anatomical and
roentgenographic appearance of the normal hip is
quoted from Wiberg :
August, 1947
891
MINNESOTA ACADEMY OF MEDICINE
“The acetabulum of the hip joint is a hollow which
embraces 170 to 175 degrees of a sphere, and whose
opening looks forwards, outwards and downwards.
Lining the circumference of the hollow and enclosing
the acetabular fossa is the lunate surface, a horseshoe-
Fig. 5. Roentgenogram of a normal newborn (aged one day).
Note the acetabular index.
shaped surface with an anterior and posterior horn
which articulates with the head of the femur. Articular
cartilage is only found on the lunate surface. The ace-
tabular fossa is filled by the ligamentum teres and fat
tissue, and continues in front and below into the ob-
turator foramen by means of the acetabular notch (in-
cisura acetabuli). Attached to the bony margin of
the acetabulum and increasing the depth of its cavity
is the cotyloid ligament, otherwise known as the labrum
glenoidale or limbus of the hip joint. Its inner surface,
which is concave, constitutes a direct continuation of
the articular cartilage in the acetabulum ; its outer sur-
face is convex. The capsule is attached superiorly to
the bony margin of the acetabulum outside the attach-
ment of the cotyloid ligament, and consequently there is
a space between the two. At the acetabular notch, the
cotyloid ligament continues into the transverse ligament.
“The femoral head forms about two-thirds of a sphere
and is practically spherical in shape. Two-thirds to
three-quarters of the head are received into the acetabu-
lum and cotyloid ligament.
“The roentgen picture of an adult hip has a number
of characteristic features (Fig. 6). As a rule, the
acetabulum appears as a practically circular segment.
The upper part, the roof, runs practically horizontally,
with the vertex of the concavity lying almost directly
above the center of the head. The inferior part of the
acetabulum, the floor, lies practically vertically, and cor-
responds anatomically with the acetabular fossa. The
transition between these two parts of the joint cavity is
marked by a step. At the same time the bottom of
the acetabular fossa, the acetabular floor, gives rise to
the outer side of the formation which is called the
U figure, or the tear figure, whose inner side is formed
892
by the bony border of the small pelvis. That this is the
way the U figure is formed has been proved by Wern-
dorff, who made it disappear in the roentgen picture by
sawing out the bottom plate of the acetabular floor.
“The bone in the acetabular roof nearest the articular
Fig. 6. Note the characteristic features of primary dysplastic
acetabulum (Calot’s half-citron socket). There is physiological
adaptive sclerosis of the acetabular roof. The patient’s com-
plaints were hip fatigue and a mild limp when tired. Symptoms
were completely relieved by rest and change of occupation. The
opposite hip is normal. The patient is a female in the period of
early adult life. Her sister is disabled with a classical hip dis-
location.
cartilage is comprised of a thin layer of cortex which
appears as a dense zone in the roentgen picture . . .
(Fig. 6).
“If the line of the inner curve of the neck is extended,
it will continue along the upper border of the obtura-
tor foramen — Shenton’s line (Fig. 4).
“Children show a number of characteristic details in
the roentgen picture, due to the incomplete ossification
of their joints (Fig. 4). The cartilage connecting the
three pelvic bones in the acetabulum appears as a gap,
and because this cartilage has the shape of a Y ana-
tomically, it is called the Y (or triradiate) cartilage . . .
therefore . . . the line which is drawn through both
the gaps (is known as) the Y line. If the cartilaginous
area is broad, it may be difficult to know where to
draw the Y line. . . . The bony part belonging to the
ischium (is selected) as a definite point, and the line
(is drawn) so that it touches it. As long as the epiphys-
eal nucleus is still separated from the rest of the neck
by an epiphyseal line, the most medial part of the di-
aphysis of the neck looks like a spine, and is called the
spine of the neck.”
Proper roentgenographic technique is essential to
prevent distorted views and erroneous measurements.
The patient must be relaxed and placed flat on his or
her back. The lower extremities should be in contact,
the hips extended, and the patellae facing directly
forward. The roentgen tube must be centered in the
mid-line of the body and directly over the superior
border of the symphysis pubis.
Primary Roentgenographic Features of
the Dysplastic Hip
Radiographic diagnosis of hip dysplasia without dis-
location is very difficult during the first months of life,
and the condition is rarely recognized except where the
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MINNESOTA ACADEMY OF MEDICINE
routine examinations of the newborn are made. Most
often it is dislocation of the opposite hip which leads
to its discovery. Putti recognized and treated by his
abduction method a dysplastic hip without dislocation
Fig. 7. Hilgenreiner’s measurement. Note the Y line, acetab-
ular index (a), high position of the diaphysis as measured fr°m
the most proximal shadow of the diaphysis to the Y or triradiate
line (h), increased distance from the most proximal shadow of the
diaphysis to the acetabular floor (d). (Reproduced with slight
changes from Abbildung 1. Zeitschrift fur Orthopadie, 66:
151, 1937. 3)
in a child only thirty-four days old. Unless dislocation
is present on the opposite side, it is advisable to wait
until the third or fourth month before reaching a
definite conclusion; then the ossification center of the
femoral head is visible in the roentgenogram and the
possibility of error is reduced.
Hip dysplasia or “flat socket” refers not only to the
steep acetabulum, but also to all joint-forming parts of
the hip joint. However, the primary anatomical and
roentgenographic feature of hip dysplasia is the abnormal
acclivity of the roof of the acetabulum, which in-
creases the angle of incidence of the roof of the socket.
The acetabular index is the angle formed between the
roof or iliac portion of the acetabulum and a horizontal
line passing through the Y or triradiate cartilages (Fig.
4). Normally the acetabular index in a child is about
20 degrees. The angle is increased to 30 or more de-
grees in dysplasias (Fig. 7). Kleinberg and Lieberman
studied the angle of incidence of the roof of the ace-
tabulum and found the average angle of incidence in
the normal newborn to be 27.5 degrees (Fig. 5), and at
two years of age 20 degrees (Fig. 4). The angle was
37.5 degrees at the age of two years when the hip
presented dysplasia with dislocation. The authors stated
that if the angle of incidence is above 30 degrees in an
infant, a dislocation probably will develop (Fig. 5). The
flatness of the inadequate and incompetent acetabulum
can further be proved through the increase in the ra-
dius of curvature where the centrum of the sector,
which the acetabulum presents on the roentgenogram,
goes off laterally, instead of, as in the normal, lying
somewhere in the middle of the head of the femur
(Calot’s half-citron shape) (Fig. 6).
Besides all degrees of subluxation of the femoral
head, from the imperceptible to the extreme or poten-
tial dislocation, the following features, which are an
integral part of the primary dysplasia, should be noted :
1. Hypoplasia of the pelvis.
2. Hypoplasia of the head and central diaphyseal end
of the femur (observed before puberty).
3. Delayed appearance and hypoplasia of the epiphys-
eal ossification center of the head of the femur.
4. Disturbance of Shenton’s (obturator-coxofemoral)
line.
5. Delayed bony bridging of the ischiopubic synchon-
drosis.
6. Increased distance of the most superior shadow of
the metaphysis or neck of the femur from the acetabu-
lar floor or tear-drop shadow (if it is present).
7. High position of the diaphysis as measured from the
most proximal shadow of the diaphysis to the Y or tri-
radiate line.
8. The increase in the distance from the shadow of
the most medial part of the metaphysis of the neck,
which looks like a spine and is called the spine of the
neck, to the acetabular floor, or tear-drop, and the de-
crease in the distance to the Y line.
9. Frequently a classical dislocation of the opposite
hip.
10. The position of the limbus cartilage and the rela-
tion of the cartilaginous acetabulum and capsule to the
femoral head as shown by arthrography.
Putti, one of the greatest authorities on hip dysplasia
without dislocation, or preluxation as he called it, de-
pended on the following triad for diagnosis (Fig. 7) :
1. An increased distance between the upper femoral
diaphysis and the acetabular floor.
2. Hypoplasia or delayed development of the epiphyseal
nucleus of the femoral head.
3. An abnormally steep or short acetabular roof.
Secondary Roentgenographic Features
of the Dysplastic Hip
Because of the repeated trauma resulting from ab-
normal sheering forces, mechanical instability, and in-
congruity of the dysplastic hip, secondary changes are
added to the primary anatomical and roentgenographic
features. Abnormal development of bone and soft tis-
sues, vascular changes and arthritic sequelae are the
result. These changes may be listed as follows :
1. Increased subluxation when compared with previous
studies.
2. Delayed development of the epiphyses.
3. Delayed fusion of the epiphyses.
4. Maldevelopment of the femoral head and torsion
or anteversion of the femoral neck (Wolff’s law).
5. Increased sclerosis of the acetabular roof. The
degree of sclerosis is in direct proportion to the degree
of maldevelopment of the acetabular roof — physiological
adaptive sclerosis (Fig. 6).
6. Coxa valga luxans (Klapp).
August, 1947
893
MINNESOTA ACADEMY OF MEDICINE
Fig. 8. Note the characteristic features of hip dysplasia with
added secondary changes of traumatic arthritis, manifested by loss
of joint space, sclerosis, cystic areas of rarefaction, double acetab-
ular floor, osteophytic deposits, and capital drop. The patient is
now sixty years of age and walks with the aid of a crutch. Her
mother was disabled with classical hip dislocation.
7. Osteochondrosis, coxa plana, Legg-Perthes disease,
or osteochondritis deformans coxae juvenilis.
8. Traumatic hypertrophic arthritis of the hip joint
or malum coxae senilis with: (a) narrowing of the
joint space; (b) osteophytic deposits, capital drop, and
double acetabular floor; (c) sclerosis of bone and
areas of cystic rarefaction involving the weight-bearing
areas of the acetabulum and femoral head (Figs. 8-11).
9. Capsular adhesions, constriction and hypertrophy.
The author is aware of the fact that coxa plana or
Legg-Perthes disease does not necessarily have a dys-
plastic acetabular background. He has observed several
cases of coxa plana develop in clinically and roentgeno-
graphically normal hips. The acetabular changes were
adaptive and developed secondarily to the deformed
head. However, the author believes that primary
dysplasia of the acetabulum may be the precursor of a
group of cases with clinical findings and roentgeno-
graphic features that are indistinguishable from cases
of coxa plana of unknown etiology. This problem
should stimulate investigation.
Preiser in 1907 presented his theory that development
of osteoarthritis in the hip was due to poor adaptation
between the head and the joint cavity. Wiberg in
1939 conclusively demonstrated the correctness of Prei-
ser’s theory. He presented roentgenographic studies of
nineteen cases with primary hip dysplasia before and
after the development of secondary changes of osteo-
arthritis.
The author believes that osteoarthritis of the hip, or
malum coxae senilis, is frequently traumatic arthritis
and develops because of anatomical incongruity and in-
stability of a primary dysplastic acetabulum (Figs. 8-11).
He has studied twenty patients who had disability from
dysplastic acetabula. Each patient had one member
of the family disabled with classical congenital disloca-
tion of the hip. The author’s first case (Fig. 9) was
Fig. 9. Note the characteristic features of primary hip dys-
plasia with acclivity of the acetabular roof and subluxation. Sec-
ondary changes of traumatic arthrities with loss of joint space,
sclerosis, cystic rarefaction, and double acetabular floor have been
added to the primary features. The patient’s onset of symptoms
had occurred six years previously, with hip fatigue and limp.
One year previously severe pain, loss of motion, and deformity
developed. She was totally disabled for work, and was not
relieved by conservative measures. The opposite hip presents
a very mild expression of dysplastic acetabulum. She has a
sister disabled with bilateral hip dysplasia, with dislocations re-
duced in 1903 by Dr. Adolf Lorenz (Fig. 10). Arthrodesis of
the hip was advised and performed.
recognized in 1935. The patient’s sister had congenital
dislocation of both hips (Fig. 10), which were reduced
by Dr. Adolf Lorenz in Chicago in 1903. This patient
with hip dysplasia without dislocation, but with second-
ary traumatic arthritis, was being treated for tuberculosis
of the affected hip.
Roentgenographic Differential Diagnosis
The following list of hip-joint lesions may at times
require careful study for differentiation from primary hip
dysplasias :
1. Coxa plana or Legg-Perthes disease,
2. Epiphyseal separation,
3. Tuberculosis,
4. Infectious arthritis,
5. Hypertrophic arthritis,
6. Aseptic necrosis,
7. Late septic hip,
8. Neoplasm,
9. Neurotrophic lesions,
10. Old fracture-dislocations,
11. Endocrine dysfunction.
Summary
1. One human trait which has been difficult to ex-
plain genetically is congenital dislocation of the hip.
2. An individual does not inherit congenital disloca-
tion of the hip, but does inherit a primary defect, or hip
dysplasia, which produces anatomical and physiological
alterations of the joint called “flat socket.” Only
secondarily does actual dislocation occur, and dislocation
need not necessarily occur.
894
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
Fig. 10. The patient had bilateral hip dysplasia with dislo-
cations which were reduced by Dr. Adolf Lorenz in 1903 when the
patient was three years of age. Note the signs of bilateral hip
dysplasia with added changes of traumatic arthritis. The patient
is now seriously disabled at the age of forty-two years. Her
sister has hip dysplasia without dislocation, but with secondary
changes of traumatic arthritis (Fig. 9).
3. Primary hip dysplasia is due to a genetic back-
ground.
4. Roentgenographic consanguinity studies are essential
for a true genetic investigation of hip dislocation.
5. Dysplasia of the hip without dislocation but with
varying degrees of subluxation is a distinct clinical and
roentgenographic entity, and should be included in
textbooks in the chapter on classical dislocation, be-
cause the two entities have the same genetic etiology.
6. Dysplasia of the hip with subluxation occurs more
frequently and may be more disabling than classical
dislocation.
7. Acclivity of the roof of the acetabulum is the
primary anatomical feature of a dysplastic acetabulum
or flat socket.
8. Hip dysplasia refers not only to the acetablum, but
also to all joint-forming parts of the hip joint.
9. Primary hip dysplasia with dislocation on one side
is frequently associated with dysplasia with subluxation
on the opposite side.
10. Hip-joint instability and incongruity between the
head and socket are the physiological and anatomical
expressions of hip dysplasia.
11. Primary hip dysplasia with subluxation may re-
main asymptomatic for many years ; in some individuals
it may never be expressed clinically.
12. The extreme disability observed in some in-
dividuals is caused by traumatic arthritis of the hip
joint resulting from mechanical factors of instability
and incongruity.
13. The patient may gain relief of pain and disability
by conservative treatment and surgical measures.
14. The geneticist and the surgeon have a tremendous
opportunity for co-operative investigation.
15. Earlier recognition and earlier treatment of the
dysplastic hip is our only hope for reducing the dis-
ability of this large group of patients.
August, 1947
Fig. 11. Roentgenogram of patient thirty-five years old. Note
the primary and secondary roentgenographic features of bilateral
hip-joint dysplasia without dislocation. The patient’s brother has
classical dislocation of both hips.
References
1. Calot, F. : Les recentes acquisitions sur la luxation con-
genitale de la hanche. Presse Med., 28:666, 1920.
2. Calot, F. : L’Orthopedie indispensable aux Praticiens. Ed.
9. Paris: N. Maloine, Editeur, 1926.
3. Faber, Alexander: Erbbiologische Untersuchungen fiber die
Anlage zur “angeborenen” Hiiftverrenkung. Ztschr. f. Or-
thop., 66:140, 1937.
4. Hilgenreiner, H.: Zur Friihdiagnose und Friihbehandlung der
angeborenen Huftgelenkverrenkung.. Med. Klin., 21:1385-
1425, 1925.
5. Klapp : Coxa valga und Luxatio coxae. Deutsche med.
Wchnschr., 32:1884, 1906.
6. Kleinberg, Samuel, and Lieberman, H. S.: The acetabular
index in infants in relation to congenital dislocation of the
hip. Arch. Surg., 32:1049, 1936.
7. McMurray, T. P. : A Practice of Orthopaedic Surgery.
Baltimore: William Wood & Co., 1937.
8. Mercer, Walter: Orthopaedic Surgery. Ed. 2. Baltimore:
William Wood & Co., 1936.
9. Pare: Quoted by Alexander Faber.3
10. Preiser, Georg: Die Coxa valga congenita — die Vorstufe
der kongenitalen Hiiftverrenkung. Ztschr. f. Orthop. Chir.,
21:177, 1908.
11. Preiser, Georg: Die Arthritis deformans coxae und die
Variationen der Hiiftpfannenstellung. Leipzig: F. C. W.
Vogel, 1907.
12. Putti, Vittorio: Early treatment of congenital dislocation of
the hip. J. Bone & Joint Surg., 11:798 (Oct.), 1929.
13. Wiberg, Gunnar: Studies on dysplastic acetabula and con-
genital subluxation of the hip joint. With special reference
to the complication of osteo-arthritis. Acta Chir. Scandinav.
83: (Supplementum 58), 19.39.
Discussion
Dr. Leo G. Rigler, University of Minnesota : I was
glad to hear Dr. Hart say that the diagnosis of con-
genital dislocations could be made before the evidence
of development of the epiphysis. It is unfortunate that
these cases are missed. In my experience, the grand-
mother sometimes knows more than the doctor about con-
genital dislocations of the hip. A while ago a doctor
called me and told me that the grandmother of a little
patient he was treating was making a lot of trouble for
him ; the grandmother insisted that the child had dislo-
cation. He sent the child in for x-ray examination
and I had the unhappy task of admitting to them that
the grandmother was right and the doctor was wrong.
This was bilateral. Some years ago Dr. Hart brought to
our attention this matter of dysplasia of the acetabulum.
There are one or two things that always intrigue me
about that. If the flat acetabulum is the major factor
in congenital dislocations, why don’t we meet more dis-
locations in older children? The other thing that is
of interest was the beautiful development of the socket
when the dislocation is well reduced in early infancy.
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MINNESOTA ACADEMY OF MEDICINE
The pressure of any object against bone will tend to
produce a socket for it to fit into. The absence of
the pressure of the head of the femur may well be a
factor in the flatness of the acetabulum. On the whole,
however, the evidence favors the theory that Dr. Hart
advances.
Dr. Logan Leven, Saint Paul : I wish to ask Dr.
Hart one question. He mentioned that dysplasia of the
acetabulum was the primary factor in congenital dislo-
cation of the hip and that the deformity of the head
and neck of the femur resulted according to Wolff’s
law. In one case that he showed, there was some
dysplasia of the head and neck of the femur at age
three months. Since this would be before weight bear-
ing, I do not think that Wolff’s law would be a sig-
nificant factor. Does not the dysplasia affect the head
of the femur as well as the acetabulum?
Dr. Hart (in closing) : The flat socket which I de-
fined is referred to as a dysplastic hip — a term generally
used today. The dysplasia is not limited to the socket
but also involves all mesodermal tissues entering into
the formation of the hip joint. Bilateral involvement is
common. For many years we have focused our atten-
tion on the dislocated side and failed to recognize dys-
plasia of the opposite “healthy” hip. If we study both
hips we will find some degree of dysplasia on both sides
in the majority of patients. We are continuing to study
this problem clinically and radiologically but it is very
difficult to approach it genetically. It is practically im-
possible to obtain roentgenograms of an entire family
tree. One must have roentgenological consanguinity
studies for a thorough genetic study. If we could study
the entire family tree roentgenologically, I am sure that
we could repeat the evidence which Dr. Alexander Faber
reported in 1935. The bane growth changes of the
epiphysis are both primary and secondary, the primary
cause being genetic and the secondary cause the result
of Wolff’s law.
Dr. Rigler: Many have flat acetabuli but do not
have dislocations.
Dr. Hart: It is true that the subluxated hip never
dislocates. I believe that it is the degree of dysplasia
of the capsule as well as the degree of dysplasia of the
socket which determines dislocation or subluxation.
The meeting adjourned.
A. E. Cardle, M.D., Secretary.
INFECTION OF THE NECK
AFTER TONSILLECTOMY
(Continued from Page 853)
for signs and symptoms of the onset of infection
in the neck. Should such infection occur, prompt
and rational treatment should be instituted. Two
cases in which infection in the neck occurred after
tonsillectomy are reported.
References
1. Mosher, H. P. : The submaxillary fossa approach to deep
pus in the neck. Tr. Am. Acad. Ophth., pp. 19-36, 1929.
2. New, G. B., and Erich, J. B.: Deep infections of the neck;
collective review. Internat. Abstr. Surg., 68:555-567, (June)
19391
DOCTOR OF WHAT?
The J.A.M.A.1, in discussing editorially the term
“doctor” in America, says :
Dr. Edward M. Repp, of Philadelphia, has a question
for the medical Emily Post. His daily work requires
occasional conferences with his druggist and also with
the head of a laboratory who examines specimens.
Should he address these associates as doctor or mister?
In the neighborhood where he resides are also an oste-
opath, a chiropactor, and a chiropodist. These, too, he
meets occasionally while en route on his medical tasks;
he never knows whether to say “doctor” or something
different. A similar question disturbed Hugh J. Mc-
Donald,2 who discussed the subject not long ago in the
Journal of Higher Education. A survey of the graduate
degrees awarded by the colleges and schools of New
York State during 1937 reveals thirteen types of doc-
tors’ degrees awarded during the year. . . .
The degree of doctor is now conferred in so many
areas of learning that the result is confusion. McDonald
feels that the conferring of the doctoral degree is in
need of a thorough house cleaning.
The degree of doctor of philosophy (Ph.D.) is grant-
ed for three years of full-time study and examination
and the preparation of a thesis following the bachelor’s
degree. The degree of doctor of science (D.Sc.) is
granted for an identical program when the major part
of the work is in science.
Many times in education, history, literature, eco-
nomics, sociology, and natural sciences the Ph.D. seems
to be granted for meeting a standard of mediocrity. . . .
As McDonald points out, in the field of ill health
the assortment of doctorates now includes the degree
of naprapathy, which can be had in ninety days without
any entrance requirements ; doctor of chiropractic in
from one to four years depending on the school, with
the minimum entrance requirement usually just an ele-
mentary school education; doctor of surgical chiropody
in from eighteen months to three years, with an en-
trance requirement like that of chiropractic; doctor of
optometry three to four years after high-school gradu-
ation ; doctor of osteopathy a minimum of four years,
with one year of college work as prerequisite; doctor
of public health, with as yet little standardization and,
incidentally, available to graduates in bacteriology or
related fields after three years’ study. McDonald be-
lieves that some of these people have about as much
legitimate claim to a doctor’s degree as would a hotel
dishwasher to a D.D.W. Then there are also. doctors
of medicine, doctors of dental medicine, doctors of vet-
erinary medicine, and doctors of dental surgery with
better standardized requirements.
Educational authorities might well consider the de-
sirability of some standardization in this area so that
the degree of doctor, regardless of the field of learning
in which it is applied, will have real significance.
Furthermore, the public should be able to determine
from a title the actual qualifications of the man who
adorns himself with it. Finally, the economists who de-
vote themselves to propaganda for revolutionizing
medical care persistently trade on their doctor of phi-
losophy degrees and thus perpetrate a fraud on the pub-
lic, who take it for granted that these “doctors” are
physicians. — Editorial, Nciv York State Journal of Med-
icine, Dec. 15, 1946.
1. J.A.M.A., 129:1168, (Dec. 22), 1945.
2. McDonald, Hugh J. : J. Higher Education, 14:189 (April)
1943.
896
Minnesota Medicine
METAMUCIL
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The "smoothage” principle — the
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encourages normal
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Metamucil is the registered trademark of
G. D. Searle & Co., Chicago 80, Illinois.
RESEARCH IN THE SERVICE OF MEDICINE
August, 1947
897
Reports and Announcements
♦
MEDICAL BROADCAST FOR AUGUST
The following radio schedule of talks on medical
and dental subjects by William O’Brien, M.D., Di-
rector of Postgraduate Medical Education, University
of Minnesota, is sponsored by the Minnesota State
Medical Association, the Minnesota State Dental Asso-
ciation, the Minnesota Hospital Service Association in
co-operation with the Minnesota Hospital Association
and the Minnesota Nurses Association, and the Uni-
versity of Minnesota School of the Air.
Aug. 5 9:00 A.M. WCCO
Aug. 7 9:00 A.M. WCCO
Aug. 12 9:00 A.M. WCCO
Aug. 14 9:00 A.M. WCCO
Aug. 19 9:00 A.M. WCCO
Aug. 21 9:00 A.M. WCCO
Aug. 26 9:00 A.M. WCCO
Aug. 28 9:00 A.M. WCCO
Orthopedic Nursing
Coronary Heart Disease
Hospital Annual Report
What is High Blood Pressure
Cost of Chronic Patient Care
Diseases of Allergy
Personality of an Ideal Nurse
Oral Disease
AMERICAN ASSOCIATION FOR
THE STUDY OF GOITER
The annual meeting of The American Association for
the Study of Goiter will be held in the King Edward
Hotel, Toronto, Canada, May 6, 7, and 8, 1948.
The program for the three-day meeting will consist
of papers dealing with goiter and other diseases of
the thyroid gland, dry clinics and demonstrations.
Communications regarding the program may be ad-
dressed to the Corresponding Secretary, T. C. Davi-
son, M.D., Atlanta, Georgia.
AMERICAN COLLEGE OF ALLERGISTS—
INSTRUCTIONAL COURSE
The American College of Allergists has announced
that its annual Fall Graduate Instructional Course in
Allergy will be given in Cincinnati, Ohio, November 3-8,
inclusive, under the auspices of the Medical College of
the University of Cincinnati.
The program this year is the best ever offered by
the College. Forty-six formal lectures are listed and
also a special allergy clinic of case presentations. An
added feature this year will be three informal discus-
sion groups led by various members of the faculty.
The faculty is composed of more than forty outstand-
ing physicians and scientists from prominent medical
centers and colleges in the United States and Canada. The
Course presents a comprehensive study of the entire field
of allergy — covering the fundamentals, special allergies,
specific diseases, and all modern methods of treatment.
Symposiums on dermatologic and pediatric allergy are
also included, as well as a survey of the laboratory
approach to the subject including preparation and stand-
ardization of extracts and skin testing.
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Duluth • Eau Claire • Huron • La Crosse .Miles City
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Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY —Two-week Intensive Course in Surgical
Technique, starting September 22, October 30, No-
vember 17.
Four-week Course in General Surgery, starting Sep-
tember 8, October 6, November 3.
Two-week Course in Surgical Anatomy and Clinical
Surgery, starting September 22, October 20, Novem-
ber 17.
One-week Course in Surgery of Colon and Rectum,
starting September 15 and November 3.
Two-week Course in Surgical Pathology, every two
weeks.
FRACTURES AND TRAUMATIC SURGERY— Two-
week Intensive Course, starting October 6.
GYNECOLOGY — Two-week Intensive Course, starting
September 22, October 20.
One-week Course in Vaginal Approach to Pelvic Surg-
ery, starting September 15 and October 13.
OBSTETRICS — Two-week Intensive Course, starting
September 8, October 6.
MEDICINE — Two-week Intensive Course, starting Oc-
tober 6.
Two-week Course in Gastro-enterology, starting Oc-
tober 20.
Two-week Course in Hematology, starting September
29.
One-month Course in Electrocardiography and Heart
Disease, starting September 15.
DERMATOLOGY and SYPHILOLOGY — Two-week
Course, starting October 20.
General, Intensive and Special Courses in all Branches
of Medicine, Surgery and the Specialties
TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar, 427 S. Honore St., Chicago 12, III.
898
Minnesota Medicine
REPORTS AND ANNOUNCEMENTS
The course is recommended to all those especially in-
terested in allergy, and to the general practitioner and
specialist who anticipates treating his own allergic pa-
tients. It is designed to provide a more comprehensive
understanding of the many manifestations of allergy so
commonly encountered by the doctor, and to empha-
size methods of diagnosis and treatment so that the
physician is prepared to offer the greatest aid to his
patient.
Programs and complete information can be obtained
by writing to the College Secretary, Dr. Fred W. Wit-
tich, 423 La Salle Medical Building, Minneapolis 2,
Minnesota.
AMERICAN COLLEGE OF CHEST
PHYSICIANS— POSTGRADUATE COURSE
The American College of Chest Physicians is spon-
soring a second annual postgraduate course in diseases
of the chest to be held during the week of September
15-20, 1947, at the Municipal Tuberculosis Sanitarium,
Chicago, Illinois.
The emphasis in this course will be placed on the
newer developments in all aspects of diagnosis and treat-
ment of diseases of the chest.
The course will be limited to 30 physicians. Tuition
fee is $50.00.
Further information may be secured at the office of
the American College of Chest Physicians, 500 North
Dearborn Street, Chicago 10, Illinois.
AMERICAN COLLEGE OF PHYSICIANS—
RESEARCH FELLOWSHIPS
The American College of Physicians announces that
a limited number of Fellowships in Medicine will be
available from July 1, 1948-June 30, 1949. These Fellow-
ships are designed to provide an opportunity for research
training either in the basic medical sciences or in the
application of these sciences to clinical investigation.
They are for the benefit of physicians who are in the
early stages of their preparation for a teaching and in-
vestigative career in Internal Medicine. Assurance must
be provided that the applicant will be acceptable in
the laboratory or clinic of his choice and that he will
be provided with the facilities necessary for the proper
pursuit of his work. The stipend will be from $2,200
to $3,000.
Application forms will be supplied on request to
The American College of Physicians, 4200 Pine Street,
Philadelphia 4, Pa., and must be submitted in duplicate
not later than November 1, 1947. Announcement of the
awards will be made as promptly as is possible.
The next annual session of the American College of
Physicians will be held in San Francisco, April 19-23,
1948.
"EUREKA! I THINK
THIS IS IT!”
Said A Doctor When Shown
The Spencer Breast Support
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Improve circulation and tone, rendering
breasts less likely to inflammation or dis-
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breathing. Release strain on muscles and
ligaments of chest, neck, shoulders and
back.
Aid antepartum-postpartum patients by
protecting inner tissues, helping prevent
outer skin from breaking; guard against
caking and abscessing during postpartum.
Individually designed for each patient.
For a dealer in Spencer Supports, look in
telephone book for “Spencer corsetiere” or
“Spencer Support Shop,” or write direct
to us.
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AMERICAN COLLEGE OF SURGEONS—
CLINICAL CONGRESS
The thirty-third annual Clinical Congress of the
American College of Surgeons, including the twenty-
sixth annual Hospital Standardization Conference, will be
August, 1947
Name M.D.
Street
City & State 0-8-47
SPEN C E R ^DES/GNEl^ SUPPORTS
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REPORTS AND ANNOUNCEMENTS
Human Convalescent Serums
are available for prevention or treatment
HYPER-IMMUNE PERTUSSIS
MUMPS SCARLET FEVER
POLIOMYELITIS MEASLES
POOLED NORMAL SERUM
Address or telegraph communications or
requests to
Human Serum Laburatury
West-108, University Hospital
Minneapolis 14, Minn.
Main 8551, Ext. 276 24-hour Service
ACCIDENT • HOSPITAL • SICKNESS
INSURANCE
FOR PHYSICIANS, SURGEONS, DENTISTS EXCLUSIVELY
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$5,000.00 accidental death $8.00
$25.00 weekly indemnity, accident Quarterly
and sickness
$10,000.00 accidental death $16.00
$50.00 weekly indemnity, accident Quarterly
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$15,000.00 accidental death $24.00
$75.00 weekly indemnity, accident Quarterly
and sickness
$20,000.00 accidental death $32.00
$100.00 weekly indemnityt accident Quarterly
and sickness
ALSO HOSPITAL EXPENSE FOR MEMBERS
WIVES AND CHILDREN
86c out of each $1.00 gross income used for
members’ benefits
$3,000,000.00 $14,000,000.00
INVESTED ASSETS PAID FOR CLAIMS
$200,000.00 deposited with SUL ef NtbritU tor pfoUctlon of our rnomhon.
Disability need not be incurred In line of duty — benefits from
the beginning day of disability
PHYSICIANS CASUALTY ASSOCIATION
PHYSICIANS HEALTH ASSOCIATION
45 year* under the the une menaiement
400 fIRST NATIONAL BANK BUILDING • OMAHA 2, NE8RASKA
900
held at The Waldorf-Astoria, New York, from Septem-
ber 8 to 12.
The five-day program will feature operative and non-
operative clinics in thirty-eight hospitals in New York
and Brooklyn, and scientific sessions in general surgery
and the surgical specialties, official meetings, hospital con-
ferences, medical motion pictures, and educational and
technical exhibits, at the headquarters hotel. Dr. How-
ward A. Patterson of New York is Chairman of the
Committee on Arrangements ; Dr. Frank Glenn is Sec-
retary. Dr. Malcolm T. MacEachern and Dr. Bowman
C. Crowell, Chicago, the Associate Directors, are in gen-
eral charge.
For particulars address L. G. Jackson, American
College of Surgeons, 40 E. Erie Street, Chicago 11, Illi-
nois.
CHICAGO OPHTHALMOLOGICAL SOCIETY-
REFRESHER COURSE
The Chicago Ophthalmological Society will give a
40-hour refresher course December 8 to 13, inclusive.
The faculty will include members of the Eye Department
of The University of Chicago, The University of Il-
linois, Loyola University, Northwestern University and
staff members of all of the principal hospitals of
Chicago. Instruction will consist of didactic and prac-
tical course, emphasis being placed on the practical
courses given to small groups.
Physicians practicing ophthalmology and eye, ear, nose
and throat are eligible for the course. The fee will
be $100.00. For details write to the registrar, Miss
Maude Fairbairn, 8 West Oak Street, Chicago, 111.
MEDICO-LEGAL CONFERENCE AND SEMINAR
A medico-legal conference and seminar for pathol-
ogists, medical examiners and coroners will be held Oc-
tober 13-18, 1947, at Harvard Medical School, Boston.
The Department of Legal Medicine of the medical
schools of Harvard, Tufts, and Boston University in
association with the Massachusetts Medico-Legal So-
ciety will present a six-day program of lectures, con-
ferences, and demonstrations having to do with the in
vestigation of deaths in the interests of public safety.
Attendance will be limited to twenty-five persons who
have registered in advance.
Further information may be obtained from the De-
partment of Legal Medicine, 25 Shattuck Street, Bos-
ton, Massachusetts.
FIFTIETH ANNIVERSARY CELEBRATION
The September meeting of the Ramsey County Medical
Society will be held at 8 P.M. September 23 in the
society auditorium, and will be devoted to a celebration
of the Fiftieth Anniversary of the founding of the li-
brary. Dr. John F. Fulton, Sterling Professor of Physi-
ology at Yale University, will be the speaker of the
evening. His being a former St. Paulite, well-known
author and authority on medical libraries, makes his
choice a particularly happy one. All physicians are
cordially invited to attend this meeting.
In 1895, a loan medical library for mutual better-
Minnesota Medicine
REPORTS AND ANNOUNCEMENTS
ment was established by Dr. J. L. Rothrock, Dr. Arthur
Dunning and Dr. Edward Boeckman with headquarters
in a room in the old Lowry Arcade in St. Paul. Medical
books and journals were contributed and collected by
enthusiasts, among whom were Dr. Boeckman and Dr.
H. L Taylor. In the fall of 1897, the Ramsey County
Medical Society took over the activities of the Library
Association, and a library committee consisting of Drs.
J. L. Rothrock, W. B. Morley, and H. L. Taylor was
appointed. In 1898, this committee endorsed the publica-
tion of a medical journal to provide funds and ex-
changes for the support of the library. The St. Paul
Medical Journal began publication in 1899 with Dr.
Burnside Foster as editor. From such a modest beginning
the Ramsey County Medical Society Library has become
one of the largest and best in the state.
MISSISSIPPI VALLEY MEDICAL SOCIETY
The twelfth annual meeting of the Mississippi Val-
ley Medical Society at Burlington, Iowa, October 1-2-3,
1947, will have over thirty clinician-teacher speakers.
October 1 will feature an all-St. Louis program con-
ducted by clinical teachers from St. Louis and Wash-
ington Universities. On October 2 there will be speak-
ers from various medical centers including Dr. E. L.
Bortz, President, American Medical Association, Dr. I.
H. Neece, President, Illinois State Medical Society, Dr.
M. B. Simpson, President, Missouri State Medical Asso-
ciation, and Dr. H. A. Spilman, President, Iowa State
Medical Society. There will be a social hour and ban-
quet on this date. The afternoon program will be de-
voted to presentations by a group from the University
of Iowa. October 3 will feature an all-Chicago pro-
gram with a number of well-known clinical teachers
from Chicago medical schools. A Clinico-Pathologic
Conference and a Round Table luncheon will be fea-
tured on this date.
The fourth annual meeting of the Mississippi Valley
Medical Editors’ Association will be held during the
annual convention of the Mississippi Valley Medical
Society on October 1.
A complete, detailed program will be available Sep-
tember 20 and may be obtained from Dr. Harold
Swanberg, Secretary, W.C.U. Building, Quincy, Illi-
nois.
CIVIL SERVICE EXAMINATIONS
FOR PHYSICIANS
The State Civil Service Department is announcing un-
assembled examinations for physicians for appointment
in state hospitals and institutions in general medicine as
well as in such specialties as psychiatry and tuberculosis.
Salary levels are as follows:
Physician I $270-$320 in five $10 steps
Physician II $397-$457 in five $12 steps
Physician III $474-$544 in five $14 steps
Announcements and application blanks may be ob-
tained by writing the State Department of Civil Service,
122 State Office Building, St. Paul. Applications will be
received until further notice, but for inclusion on the
first list should be submitted by September 22, 1947.
August, 1947
1909 1947
RHEUMATISM
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ST. PAUL MINNEAPOLIS
901
REPORTS AND ANNOUNCEMENTS
SOUTHERN MINNESOTA MEDICAL ASSOCIATION
The annual meeting of the Southern Minnesota Medi-
cal Association will he held in Turner Hall, New Ulm,
Minnesota, Monday, September 8, 1947.
The morning session will include the following papers,
ending with a Clinical Pathological Conference :
Management of Minimal Pulmonary Tuberculosis
— David T. Carr, M.D., Rochester
Management of Bronchial Asthma in Childhood — George
B. Logan, M.D., Rochester
Experiences with Urethane in the Treatment of Myel-
ogenous Leukemia — Charles H. Watkins, M.D., Roches-
ter
Results of Treatment of Subacute Bacterial Endocarditis
— Charles H. Scheifley, M.D., Rochester
Diverticulitis — W. G. Sauer, M.D., Rochester
A complimentary luncheon and the annual business
meeting will occupy the noon hour.
The afternoon session, beginning at two o’clock, will
include a number of case reports and the following
papers :
Proctology and the General Practitioner — W. C. Bern-
stein, M.D., Saint Paul
New Proctologic Dressings — James K. Anderson, M.D.,
Minneapolis
Complications Following Hip Fractures — Forrest L.
Flashman, M.D., and R. K. Ghormley, M.D., Rochester
Incidence of Pulmonary Embolism in Venous Sclerosing
Therapy — M. A. Johnson, M.D., and F. L. Smith,
M.D., Rochester
Physical Rehabilitation of the Paraplegic: Treatment of
Spastics (Movie) — Earl Elkins, M.D., Rochester
The banquet will be in Turner Hall at 6 :30 o'clock,
following which L. A. Buie, M.D., Rochester, President,
State Medical Association, will speak. The Presidential
Address will be delivered by C. M. Robilliard, M.D.,
Faribault.
TAILORS TO MEN
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the hand tailoring we al-
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J. T. SCHUSLER co.
379 Robert St. St. Paul
DELEGATES DISCUSS HEALTH
QUESTIONS
(Continued from Page 883)
and claims them, provided he is not receiving pay
for time lost, or other remuneration (this does not
include payments made by private insurance com-
panies), if the Railroad Retirement Board finds
the employe is not able to work because of sick-
ness or injury and if he meets the other legal
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Minnesota doctors can obtain application forms
or other information relative to this program
by writing to the Minneapolis Regional Office of
the Railroad Retirement Board.
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Minnesota Medicine
In Memoriam
JOSEPH H. ABRAMOVICH
Dr. Joseph H. Abramovich of Saint Paul died June
12, 1947, at the age of sixty-eight.
Born in Russia in 1878, Dr. Abramovich came to
America as a boy. He graduated from Hamline Med-
ical School in 1905 and took postgraduate study in
Vienna. He had practiced most of the past forty years
in Saint Paul and recently was a medical consultant
for the Veterans Administration in Minneapolis. He
was a member of the Ramsey County Medical Society,
the Minnesota State and American Medical Associations.
He is survived by his wife, two brothers, and three
sisters.
WILLIAM DAVIS
Dr. William Davis, for fifty-six years a general prac-
titioner in St. Paul before his retirement on April 30.
1939, passed away on May 9, 1947, at the age of ninety-
three.
Dr. Davis was born in Plymouth, Massachusetts, Sep-
tember 28, 1853, the ninth lineal descendant of his Pil-
grim ancestors to be born in that historic New England
town. Following his graduation from Phillips Exeter
Academy in 1871, on the advice of his physician as a
cure for astigmatism, he went as passenger on a sailing
vessel carrying a cargo of ice from Boston to India.
On the return trip he read all the books of Virgil during
his spare hours.
After graduating from Harvard College in 1876 he
attended Harvard Medical School receiving his M.D.
in 1879 and served a three months’ internship at the
McLean Lying-In Hospital in Boston. One June 26,
1878, he married Sally White Holyoke and in 1880
spent a year in Vienna where his second child was born.
After practicing in Syracuse, New York, for three
years, Dr. Davis moved to Saint Paul in 1883, the same
year joining the Ramsey County Medical Society. On
the occasion of the Diamond Jubilee dinner celebration
of the Society in 1935 he told of the early days ; how
in 1885 many doctors had no telephone but used those
in the nearby drug stores, the public being allowed to
use the phones located in the fire department barns for
calling a physician. The attendance at the County Medi-
cal Society meeting was poor until dinner meetings Were
instituted in 1890. “Das Essen ; das ist die Hauptsache”
as he was wont to quote from his Vienna days, proved
true of medical meetings in the early days as well as
the present.
Dr. Davis was president of the Ramsey County Medi-
cal Society in 1892, president of the Minnesota State
Medical Association in 1901, a charter member of Minne-
sota Academy of Medicine which was founded October
12, 1887, and its president in 1903, and a member of the
Minnesota State Board of Medical Examiners from
1900 until 1906.
Dr. Davis contributed much to early medical publica-
tions having been Associate Editor of the N orthwestern
Lancet from October, 1886, until December, 1899, and on
the Editing and Publishing Committee of the Saint Paul
Medical Journal from 1901 until 1912.
Beginning in 1905, Dr. Davis spent his summers at
South Orleans, Massachusetts, building a summer home
there in 1907. This practice he continued until 1942
when gasoline rationing interfered with motoring East,
which he so much enjoyed.
Dr. and Mrs. Davis celebrated their golden wedding
in 1928. They were blessed with four children, fourteen
grandchildren and twenty-three great grandchildren.
Their summers were spent surrounded by members of
their large family and friends. Mrs. Davis died in 1929.
Dr. Davis was a member of Unity Church, Saint Paul,
and for many years belonged to the Informal Club. He
had little use for clubs in general. Fond of bridge, he
played a keen game until he was invalided as a result
of a fractured hip in November, 1945.
Dr. Davis was held in high esteem by the profession
and his many patients, for his medical sagacity and his
lovable personal qualities. His was a richer and longer
life than most of us can expect to attain.
George E. Senkler
Carl B. Drake
CHARLES MILTON KISTLER
Dr. Charles Milton Kistler was born August 12, 1869,
at Pleasant Corner, Carbon County, Pennsylvania. He
was descended from Peter Kistler, President of the
Republic of Berne, Switzerland. His parents were David
and Mary Kistler.
Dr. Charles Kistler came to Minneapolis in 1887,
where he studied pharmacy. After three years, however,
he entered the Medical Department of the University of
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903
IN MEMORIAM
Minnesota, where he graduated in 1893. He then took a
course at the New York Polyclinic Institute.
His early hospital practice was at the St. Barnabas
and Asbury Hospitals. At the beginning of the century,
when the New Swedish Hospital was opened, he joined
the surgical staff.
On March 29, 1900, he married Grace T. Braem of
Alma, Wisconsin.
He went abroad for special work in surgery several
times — in 1900, in 1905 and in 1934.
Dr. Kistler practiced in Minneapolis for fifty years,
restricting his work to surgery. When he became ill
four years ago, he retired and spent much time in travel.
During the past year, however, he was confined to his
home, where he died on July 8, 1947.
Dr. Kistler was a member of the Hennepin County
Medical Society, the Minnesota State Medical Associa-
tion and the American Medical Association.
He is survived by his wife, Grace, his son, Stuart, a
sister, Mrs. Arthur Kistler of Saint Paul and several
nieces and nephews, among whom is Dr. Alvin Kistler
of Minneapolis.
CHARLES WESLEY MORE
Dr. Charles Wesley More of Eveleth, prominent in
medical circles in northern Minnesota for many years
before his retirement several years ago, died June 1,
1947, at the age of eighty-six.
Dr. More was born in Elkader, Iowa, January 6, 1861.
He graduated from Northwestern Medical School in
1888 and took postgraduate work at the Polyclinic in
New York.
He began practice at Two Harbors in 1888 and in
1889 moved to Ely. For the next four years he prac-
ticed at Ely and from 1891 to 1893 served as a member
of the first Board of Health of that city.
He came to Eveleth in 1893 at the time iron mining
on the range was just beginning to be developed. He
began practice and established a hospital in a one-story
building before the town of Eveleth was platted. In
1900 he built the present hospital which bears his name.
Dr. More was a member and past chairman of the
Public Library Board of Eveleth, a member and past
chairman of the Eveleth Board of Education, one of
the first directors of the Miners National Bank of
Eveleth, a director of the First National Bank since
1921. During the first World War he was active in
the Liberty Loan and American Red Cross drives.
Dr. More was a member of the St. Louis County
Medical Society, the Minnesota State and American
Medical Associations, a founder and third Master of
the Eveleth Masonic lodge, a member of the Scottish
Rite and Aad Temple, Ancient and Arabic Order of
the Mystic Shrine in Duluth. He was also an active
member of the First Methodist Church.
On October 26, 1892, Dr. More married Blanche E.
Streiter and they celebrated their Golden Wedding An-
niversary in 1942. Mrs. More passed away in 1944, and
for several years Dr. More resided with his daughter,
Margaret.
The following editorial which appeared in the Eveleth
Neuis-Clarion well expresses the esteem in which Dr.
More was held in his community.
He Surely Left His Mark
All Eveleth bowed in silent respect and deep sadness
when it learned last Sunday morning that the soul of
Dr. Charles W. More had departed this earth for its
place in Heaven.
So much of the history of this community from its
very infancy was wrapped up in this lovable character,
that every home was sorely affected.
He was one of the remaining stalwarts who had seen
the town outgrow its muddy streets, mining shacks and
frontier handicaps to a clean, modern and progressive
city.
He was one whose profession was a religion, who
brought many a present-day citizen into this world, who
took a personal interest in his patients, no matter what
the risk or difficulty to reach them and who maintained
the pace until his reserve strength was all but exhausted.
Few people will ever know all that he did for the
community and for the cause of suffering humanity.
Never once did public confidence and respect ever flag
in Dr. More’s ability and honesty. He was Eveleth’s
No. 1 gentleman.
Keenly interested in seeing that youngsters of this
community secured the best in education, Dr. More
served many years on the library and school boards
and our entire school system is a memorial to his efforts
—for he was one of its foremost champions.
When his name became connected with a local business
institution, it immediately carried public confidence.
His own hospital, about the earliest and most recog-
nized on the Mesaba Range, stood for the best in medical
and surgical attention. It is significant that this man
passed to his eternal reward in the institution that he
founded.
To this great example of manhood, the editor pays his
humble tribute.
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MAIN 2494
904
Minnesota Medicine
IN MEMORIAM
ROBERT HUGH MONAHAN
Dr. Robert H. Monahan of International Falls, for-
merly an orthopedist in Minneapolis, died June 3, 1947,
at the age of seventy-six, while en route to his former
home in New Brunswick, Canada.
Dr. Monahan obtained his medical degree from the
University of Minnesota in 1906 and practiced at In-
ternational Falls and at Blackduck. He held the rank
of Captain in the British Army Medical Corps during
World War I, and located in Minneapolis in 1920. In
1935 he returned to International Falls. While in Min-
neapolis he was a member of the Hennepin County Med-
ical Society and transferred to the Upper Mississippi
Medical Society on moving to International Falls.
Dr. Monahan is survived by his wife, Dr. Elizabeth
Monahan of Minneapolis, a son Robert, Jr., a daughter,
Mary, and five grandchildren.
LLEWELLINGTON D. PECK
Dr. L. D. Peck, prominent physician of Hastings for
the past forty-five years, died July 4, 1947 at St. Mary’s
Hospital, Rochester, from cerebral thrombosis. He had
been seriously ill for six weeks and was sixty-nine years
old at the time of his death.
Born in Rochester, Minnesota, August 22, 1877, Dr.
Peck received his early schooling there, graduating from
the Rochester High School. He received his medical de-
gree from Hamline Medical School in 1902. The same
year he began practice in Hastings and for the entire
period of his practice there served as physician for the
river division of the Milwaukee railroad. About fifteen
years ago he established St. Francis Hospital. For a
number of years he served as alderman and twice was
elected mayor. He was also an active and influential
member of the Hastings school board.
Dr. Peck was a member of the Dakota County Medi-
cal Society, of which he was secretary at the time of
his death, the Minnesota State and American Medical
Associations. He was a member of the Guardian Angels
church and the Knights of Columbus.
During World War I, Dr. Peck was chosen as medical
examiner for Dakota County.
In 1904 Dr. Peck married Katherine Fasbender of
Hastings. He is survived by his wife and two children,
Dr. Llewellyn R. Peck, who was a partner with his
father, and a daughter, Mrs. Cyrus C. Erickson of
Durham, North Carolina.
For these many years active in the civic life of Hast-
ings, Dr. Peck will be greatly missed by his many
patients and friends.
EMIL C. ROBITSHEK
Dr. Emil C. Robitshek, a prominent surgeon of Man-
kato and Clinical Assistant Professor of Surgery at the
University of Minnesota, died June 23, 1947. He was
sixty-six years of age, having been born in Bohemia,
August 18, 1880. As an infant he came to America and
became a naturalized citizen in 1903.
A graduate of South High School, Mankato, Dr.
Robitshek obtained his medical degree from the Uni-
versity of Minnesota in 1903, and interned at the Min-
neapolis General Hospital. He took postgraduate work
in Vienna, Berlin, and Prague before beginning practice
in Minneapolis.
Dr. Robitshek was a Fellow of the American College
of Surgeons, a diplomate of the American Board of
Surgery, and a past president of the Minneapolis Sur-
gical Society. He was also a member of the Minne-
sota Academy of Medicine and a staff member of Eitel
and Abbott Hospitals. He was a member of the Hen-
nepin County Medical Society, the Minnesota State and
American Medical Associations. He also belonged to
Phi Delta Epsilon medical fraternity, Acacia Lodge
and Zuhrah Shrine Temple.
Dr. Robitshek is surved by his wife, a son, H. J
Robitshek of Green Bay, Wisconsin, and a daughter.
Mrs. Lewis K. Wayne of Minneapolis.
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905
Of General Interest
Dr. J. W. Hawkinson, Luverne, in July moved from
his old office to new quarters in the recently constructed
Fitzer Building in Luverne.
* * *
Dr. O. M. Rotnem, formerly of Minneapolis, has
moved to. Spring Grove and formed a partnership
medical practice with Dr. L. A. Knutson of that city.
* * *
Dr. W. J. Bushard, Minneapolis, has moved his of-
fices to 704 Physicians and Surgeons Building. His prac-
tice is limited to ophthalmology and ophthalmic surgery.
* * *
Dr. Herman F. Hilleboe has resigned as Assistant
Surgeon General of the U. S. Public Health Service and
has been appointed State Commissioner of Health of
New York.
Announcement has been made that Dr. Karl W.
Pleissner, Minneapolis, has opened an office in Loretto
and is conducting a practice there every Wednesday,
day and evening.
* * *
Dr. Paul F. Dawn, Minneapolis, has been elected
president of the Minnesota Heart Association, a project
initiated by the Heart Committee of the Minnesota State
Medical Association.
'(• 'I* f
Eighty-five years old, Dr. E. E. Shrader, Winsted’s
only physician, is still maintaining an active medical
practice. He celebrated his eighty-fifth birthday on June
30.
* * *
Dr. N. J. Kulzer, Hastings, was elected department
surgeon of the Veterans of Foreign Wars at the annual
state VFW convention in Duluth during the last week of
June.
* * *
Dr. William H. Hollingshead has become associated
with Dr. Harvey O. Beek in the practice of internal
medicine, with offices at 1352 Lowry Medical Arts
Building, Saint Paul.
* * *
Reappointed to the State Board of Medical Examin-
ers, Dr. Albert Fritsche, New Ulm, will serve on the
board for a term ending May 1, 1954. Dr. Fritsche has
been a member of the board since 1933.
* * *
Major Charles W. Fogarty, a former member of the
Alayo Clinic staff, has been separated from the army
and plans to enter private practice in Saint Paul, it
was announced July 2.
* * *
Eighty-two pediatricians from thirty different countries
visited the Lffiiversity of Minnesota Hospitals on July 26
as part of a tour of pediatric centers throughout the na-
tion. The tour followed the Fifth International Congress
of Pediatrics, held in New York City during July.
* * %
Dr. Albert G. Schulze, Saint Paul, has resigned from
the Ramsey County Welfare Board, it was announced
July 2. Dr. Schulze had been a member of the board
since May 18, 1942.
* * *
Dr. B. R. Kirklin, Rochester, will direct a series of
special courses for more than 1,000 radiologists at the
forty-eighth annual meeting of the American Roentgen
Ray Society in Atlantic City, September 16 to 19.
* * *
The appointment of Dr. H. R. Tregilgas, South Saint
Paul, to the State Board of Examiners in Basic Science
was announced on June 19. Dr. Tregilgas, whose term
extends to April 1, 1953, succeeds Dr. Charles Bolsta,
Ortonville.
* * *
Dr. Arnold E. Naegeli has completed a year of post-
graduate study at the University of Alinnesota, follow-
ing his discharge from military service and has re-
sumed the practice of surgery at 1154 Medical Arts
Building, Saint Paul.
* * *
At the recent annual meeting of the American Medical
Association in Atlantic City, Dr. Cecil J. Watson, head
of the Department of Medicine in the University of Min-
nesota Medical School, was elected chairman of the asso-
ciation’s Section on Internal Medicine.
s|c :jc jJ<
Announcement has been made that Dr. S. E. Friefeld,
Wadena, has passed the examination of the American
College of Radiology and become a diplomate of the
American Board of Radiology. Dr. Friefeld is a staff
member of W esley Hospital in Wadena.
$ ;*c
The Associated Alumni of the Llniversity of Colorado
has awarded the Norlin Aledal for distinguished achieve-
ment to Dr. O. T. Clagett, Mayo Clinic surgeon, it was
recently announced. Dr. Clagett graduated from the Uni-
versity of Colorado School of Aledicine in 1933.
sjc :Jc
Dr. Theodore Armstrong, formerly of Northfield, who
has been on the staff of Alinneapolis Veterans Hospital
since his return from military service, has moved to
Seattle, Washington, where he has accepted a two-year
residency in surgery in the Virginia Mason Hospital.
* * *
A resident physician at the University of Minnesota
Hospital, Dr. Robert H. Conley, formerly of Watertown,
South Dakota, will be married on September 6 to Miss
Harriette Alarie Hathaway of Alankato. A graduate
of the University of Minnesota Medical School, Dr.
Conley is specializing in internal medicine.
906
AIinnesota Medicine
OF GENERAL INTEREST
Dr. C. A. Aldrich and Dr. T. J. Dry, Rochester, at-
tended a meeting of the International Congress of Pe-
diatrics, held in New York City in July. While there, Dr.
Aldrich attended a meeting of the Committee on Ma-
ternal and Child Feeding of the National Research Coun-
cil.
* * *
Formerly of Wheaton, Dr. George W. Bagby has op-
ened an office for the practice of medicine in Cannon
Falls. Dr. Bagby, who recently completed his internship
at Ancker Hospital in Saint Paul, is a graduate of the
medical school of Temple University in Philadelphia.
* * *
Announcement has been made that Dr. P. S. Hench,
Rochester, has been elected chairman of the American
committee of the Ligne International Contre le Rheuma-
tism, and will be in charge of arrangements for the In-
ternational Congress on Rheumatic Diseases to be held
in the United States in 1949.
sf: ^ sf:
As guest speaker at the sanatorium commission meet-
ing in Crookston on July 9, Dr. Gilbert Mark of the State
Board of Health discussed a proposed x-ray survey to be
conducted, using mobile x-ray units, in parts of P'olk
County for a six- week period in November and De-
cember.
* * *
President-elect of the American Orthopaedic Associa-
tion is Dr. Ralph K. Ghormley, Rochester, who was chos-
en for the office at the association meeting in Hot
Springs, Virginia, on June 30. Dr. Ghormley, head of
the Orthopedic Section of the Mayo Clinic, will assume
the presidency in June, 1948. He has been a member of
the association for twenty years.
afc 5*S 3fc
Dr. E. G. Hubin, formerly of Swanville, opened his
medical practice in Sandstone on June 30, replacing Dr.
Manuel Brownstone wdio has moved to Clear Lake, Iowa,
to start a new practice.
Dr. Hubin, a graduate of the University of Minnesota
Medical School in 1929, was affiliated with a Deerwood
sanatorium before moving to Swanville to conduct a
general practice.
* ❖ *
On June 15 Dr. and Mrs. J. H. Dudley, of Windom,
celebrated their golden wedding anniversary. Married
in Albert Lea fifty years ago, they have lived in Win-
dom since 1906.
Dr. Dudley, after graduating from Rush Medical Col-
lege in 1896, practiced medicine in Heron Lake before
moving to Windom to carry on his medical practice from
1906 to 1940. In that year he gave up his medical career
to become probate judge.
* * *
On July 4 Dr. William O. Finkelnburg, Saint Paid,
formerly of Winona, was married to Miss Mary Evelyn
Mitchell of Belle Fourche, South Dakota. The cere-
mony was performed at the home of friends in Saint
Paul.
Dr. Finkelnburg, a graduate of the University of Min-
nesota Medical School, interned at Ancker Hospital in
Saint Paul and is now taking postgraduate work in surg-
ery in Saint Paul.
* * *
Plans are being made to conduct a series of rural
health clinics in Goodhue County during September and
October. Through the clinics every member of rural
families will have the opportunity to be Mantoux-tested
for tuberculosis, vaccinated for smallpox and immun-
ized against diphtheria.
Among those co-operating in the rural clinic program
will be Dr. Karl Pfuetze, superintendent of the Mineral
Springs Sanatorium.
* * *
The resignation of Dr. M. W. Smith, Red Wing, from
the Mineral Springs Sanatorium commission was an-
nounced on July 15. Dr. Smith was first appointed to the
commission when the sanatorium was built in 1913, and
he served on it until he entered service in 1918. He was
reappointed to the position in 1929 and served continuous-
ly until his resignation in July.
Appointed to succeed Dr. Smith as a Goodhue County
representative on the commission was Dr. Royal V. Sher-
man of Red Wing.
* * *
Dr. R. G. Bickford, a Mayo Clinic research associate
in biophysics, flew to London on July 12 to appear on
the program of the International Electroencephalography
Congress meeting, held in London on July 14 to 24.
Dr. Bickford presented a paper written in collabora-
907
August, 1947
OF GENERAL INTEREST
tion with Dr. E. J. Baldes, Rochester, entitled “The
Electroencephalogram in Posterior Fossa Tumors,” and
another paper, written with Dr. M. E. Griffin, Rochester,
on “Diagnostic and Theoretical Significance of the In-
ter-Ear Electroencephalogram.”
* * *
A homecoming celebration was held on July 13 in
honor of Dr. M. L. Ransom, Hancock, who has practiced
medicine in that city for forty-four years. Highlight of
the celebration was a parade comprised entirely of per-
sons whose births Dr. Ransom attended. The procession
was divided into five divisions, according to the birth
years of the participants, with the first section consisting
of persons brought into the world by Dr. Ransom from
1903 to 1910. Succeeding divisions were for the years
1911 to 1920, 1921 to 1930, 1931 to 1940 and 1941 to 1947.
* * *
Fifty years in the practice of medicine were celebrated
by Dr. K. E. Berquist, Battle Lake, on June 10.
A graduate of Hamline University in 1899, Dr. Ber-
quist served his internship at Bethesda Hospital in Saint
Paul. He then practiced in several cities in Minnesota
before moving to Chicago to specialize in eye, ear, nose
and throat diseases. From 1914 to 1935 he carried on
his medical practice in Duluth and then joined his son-
in-law, Dr. C. A. Boline, in Battle Lake. Since 1943 he
has been affiliated with the Otter Tail County Sanato-
rium.
* * *
Robert G. Rossing, son of Rev. T. H. Rossing of
Sacred Heart, Minnesota, a member of the graduating
BROWN &l DAY. INC
St. Paul 1. Minnesota
class of the University of Minnesota medical school this
year, was presented on July 24 by Dean Diehl with an
award consisting of a silver medallion and a check for
$100.00, the prize offered by the Southern Minnesota
Medical Association to the member of the Senior Class
who has shown the greatest proficiency in the clinical
fields of medicine and surgery during his Junior and
Senior years. Rossing is twenty-two years of age, mar-
ried, and plans to become a medical missionary to China
after completing his internship.
* * *
Knighthood was recently conferred upon a former
fellow of the Mayo Foundation, Dr. A. H. Mclndoe,
London, for conspicuous services to the state.
Coming from New Zealand, Dr. Mclndoe became a
fellow in surgery in the Mayo Foundation in January,
1925, and in 1930 he received an M.S. degree from the
University of Minnesota. He then went to England and
entered private practice. Specializing in plastic surgery,
he won high recognition for his contributions both before
and during the war. In 1936 he delivered a Mayo
Foundation lecture in Rochester on the subject of plastic
surgery as practiced in England.
* * *
Dr. Herbert A. Hartfiel, formerly of New York City,
has announced the opening of his office for the practice
of medicine and surgery in Montevideo.
A pre-medical student at the University of Minnesota,
Dr. Hartfiel took his medical training at the University
of Kentucky in Louisville. Following internship in Nor-
ton Memorial Infirmary and St. Joseph’s Hospital in
Louisville, he engaged in general practice in Northwood,
Iowa, for several years. He then went to Europe and
studied surgery for two years in Berlin and Vienna. Up-
on his return he practiced for ten years in New York
City before coming back to Minnesota.
* * *
July 27 was “Dr. Higgs Day” in Park Rapids when
residents of that city and surrounding communities
gathered to celebrate the thirty-fifth anniversary of the
arrival of Dr. Walter Higgs in Park Rapids as a prac- I
ticing physician.
The celebration began with a parade, which had as a
principal feature a large group of the persons brought
into the world by Dr. Higgs in the past thirty-five years,
many of whom were accompanied by their own children.
At a program in the school park following the parade,
tribute was paid to Dr. Higgs by the principal speaker,
Dr. Charles H. Pierce of Wadena. After the program
a community picnic was staged in the park.
* * *
Formerly of Duluth, Dr. W. O. McLane has joined
the Wadena Clinic, taking over the Eye, Ear, Nose and
Throat Department, left vacant last fall by the death of
Dr. Harry T. Frost. In his new practice Dr. McLane
is associated with Dr. C. H. Pierce and Dr. J. S. Gro-
gan of the Wadena Clinic.
Dr. McLane was graduated from Rush Medical Col-
lege, Chicago, in 1928. He then practiced in several
Minnesota cities until 1942. From 1943 to 1946 he took
postgraduate work in eye, ear, nose and throat diseases
908
Minnesota Medicine
OF GENERAL INTEREST
at the University of Illinois, after which he became as-
sociated with Dr. F. N. Knapp and Dr. A. 0. Olson in
Duluth. He moved to Wadena on July 15.
* * *
Liberation of the University of Minnesota's non-
resident admission policy as it pertains to the school of
nursing now permits consideration of the admission ap-
plications of young women high school graduates from
outside the state who desire to study nursing.
Students admitted under this new liberalized policy
must meet the required admission qualifications. They
must also remain in the nursing program to be permitted
to remain in the University.
The University of Minnesota nursing program in-
cludes basic professional training in nursing leading to
the bachelor of science degree, advanced professional
training for professional nurses, a certificate course in
clinical nursing for professional nurses and a certificate
course in practical nursing.
* * *
Surgical research at the University of Minnesota will
be greatly benefited when the proposed Mayo Memorial
building is completed, Dr. Owen H. Wangensteen, head
of the Department of Surgery at the University, has an-
nounced.
“Construction of the building also will augment our
opportunity to bring the work of our experimental surg-
ical laboratory into closer liaison with the work being
done in the University Hospitals,” he stated.
At present the eight operating rooms of the University
Hospitals are divided into three suites in three different
sections of the hospitals, while the surgical laboratory is
located in Millard Hall, a block away from the hospitals.
The nineteen-story Mayo Memorial, on which construc-
tion is expected to start next spring, will provide the
Department of Surgery with a compact unit on one floor,
including sixteen operating rooms, surg cal laboratories,
offices and consulting rooms.
i}c :jc
A father and five sons practicing together in a group
is unique and worth recognition. Dr. William F. C.
Heise of Winona, head of the Heise Clinic of that city,
has four sons, Herbert, William, Carl, and Paul already
associated with him, and his fifth son, Phillip, will join
the group November 1. Dr. William F. C. Heise has
been practicing in Winona since 1898, having graduated
from Rush Medical College in 1896. Dr. Herbert
graduated from Jefferson Medical College and has
specialized in surgery; Dr. William graduated from
Northwestern and is a pediatrician ; Dr. Phillip, now a
resident at St. Barnabas Hospital in Minneapolis, has
specialized in obstetrics and gynecology ; Dr. Paul, a
graduate of Marquette University, has specialized in
surgery and pathology, and Dr. Carl, a graduate of Jef-
ferson Medical College has chosen eye, ear, nose and
throat for his specialty. The new clinic building which
is completely equipped for the best in medical service,
was officially opened July 7, 1947.
August, 1947
DR. MELLBY HONORED
In recognition of forty years of service to the com-
munity of Thief River Falls, the citizens of that city
celebrated Doctor Mellby Day on Tune 30, 1947. The
celebration consisted of a banquet at the Trinity Lutheran
Church followed by a community program at the Lincoln
Hight School Auditorium, which was concluded by an
address by President James L. Morrell of the University
of Minnesota.
Dr. O. F. Mellby came to Thief River Falls in 1907
when the estimated population of the town was about
5,000. The son of the Reverend Ole Andreas Mellby of
Norway who came to Le Sueur in 1872, Dr. Mellby at-
tended St. Olaf Academy in Northfield, St. Olaf Col-
lege, and the Minneapolis College of Physicians and Sur-
geons. After a year’s internship at Ancker Hospital and
five years of practice at Willmar and Warren, Minne-
sota, he began practice at his present location in August,
1907. Those were the days of long trips by horse and
buggy, and Dr. Mellby had his share of that strenuous
life.
Dr. Mellby has been active in civic, social and reli-
gious affairs, having served on the local school and
park boards. For nine years he served on the Minne-
sota State Board of Health. He was a trustee of the
Trinity Lutheran Church a number of years.
To those who know Dr. Mellby, this recognition of
forty years of service is justly deserved.
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Nine months' course open to high school
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education.
For further information
write
Mrs. Lydia Zielke, Supt. of Nurses
FRANKLIN HOSPITAL
501 Franklin Avenue Minneapolis 5, Minnesota
909
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
RH: ITS RELATION TO CONGENITAL HEMO-
LYTIC DISEASE AND TO INTRAGROUP
TRANSFUSION REACTIONS. Edith L. Potter,
M.D., Ph.D., Assistant Professor of Pathology. Dept,
of Obstetrics and Gynecology, The University of Chi-
cago and the Chicago Lying-in Hospital. 344 pages.
Prices $5.50. Chicago: Year Book Publishers, 1947.
Since the discovery of the Rh factor in 1941, the
literature, both lay and scientific, has been flooded — at
times to surfeit — with articles concerning it. Unfortu-
nate it is, that a development of such importance should
have appeared during the war years in which the activ-
ities of physicians left little time for comprehensive
study of the many new developments in medicine. W hile
at the same time the lay press, in attempts to dramatize
the new techniques of medicine has, at least in the in-
stance of the Rh factor, created considerable concern
among the laity.
Dr. Potter’s book, therefore, appears at an oppor-
tune moment. The author is admirably qualified to pre-
sent an authoritative summary of the subject. She is
a pathologist in the field of obstetrics and of diseases
of the fetus and newborn infant and has had wide ex- i
perience with infants who suffer from erythroblastosis j
or anemia of the newborn.
The book is unusually easy to read for a treatise — the
logical flow of ideas, the carefully arranged plates and
tables, the excellent topography and pleasing format,
all contributing. The author is especially to be com-
mended for her clear presentation of a subject with such
a complex, contradictory, and labile terminology.
In contrast to usual procedures, the author has pre-
sented in the first twenty pages of the book a general
summary of the entire subject. This, in itself, is a
tremendous aid to the hurried practitioner. Succeeding
chapters give a comprehensive study of the literature
leading to the discovery of the Rh factor in 1941 and
concerning subsequent studies. The history, theoretical
background, genetic theories of the Rh factor as well
as the theory, pathology clinical diagonsis, course, dif-
ferential diagnosis, prevention, and treatment of hemo-
lytic disease of the newborn are discussed. The author
includes a chapter on techniques of determination of
Rh status and of antibody determination.
The volume is highly recommended, both as an in-
troduction to the subject and as a constant reference for
all practitioners who will find in it the basis for valid
judgments, preventative care, and therapy in practice.
John G. Mayne, M.D.
Classified Advertising
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WANTED— Physician as an assistant in excellent gen-
eral practice, with object of buying practice. Address
E-25, care Minnesota Medicine.
FOR SALE — Deceased general practitioner’s office equip-
ment, including diathermy electric stethoscope, micro-
scope, many other items. Will sell items separately.
Address E-26, care Minnesota Medicine.
PHYSICIAN WANTED— Large North Dakota
farming community. No physician within 30-mile ra-
dius. Two-room office, heat and light, free for one
year. Good schools. Residence available immediately.
Write Peter Heth, Chairman, Tuttle, North Dakota.
WANTED — Medical secretary in busy office. Good sal-
ary. Write Dr. Otto J. Seifert, New Ulm, Minnesota.
ASSISTANT WANTED — By busy general practitioner
in county seat town of 2,800 population. Good living
quarters and a liberal salary. Excellent hospital facili-
ties. Address E-28, care Minnesota Medicine.
FOR SALE — Unopposed southern Minnesota practice
for price of equipment. Population 1,000. Exception-
ally active practice. Immediate possession. If desired,
will remain three months to help establish. Address
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WANTED — Young physician to take over general prac-
tice during September. Board, room, car furnished.
$400.00 a month. Write Dr. N. T. Norris, Caledonia,
Minnesota.
PHYSICIAN WANTED — To join group in northern
Minnesota. Good salary or percentage, if desired. Ad-
dress E-27, care Minnesota Medicine.
FOR SALE — Complete office equipment for general
practitioner at ridiculously low price. Excellent con-
dition. Address Howard A. Shaw, M.D., 3347 Emer-
son Avenue South, Minneapolis 8, Minnesota. Tele-
phone PLeasant 7113.
WANTED — Assistant for General Practice in southern
Minnesota with view to permanent association with
another doctor. Very active general practice with
some major surgery. Nothing to sell — just too much
work. If interested, write, giving full particulars about
yourself. Address E-30, care Minnesota Medicine.
FOR SALE — General medical practice in resort town
20 miles from Twin Cities. Execellent opening for
young man. Local and city hospitals available. Will
introduce. Address E-32, care Minnesota Medicine.
SHORT WAVE DIATHERMY
New parallel tuned unit. Uses cable electrodes,
pad electrodes, and has surgery circuit. Equipped
with two pad electrodes, cuff electrode and cable
electrodes. Has never been used — must sacrifice.
Manufacturer’s guarantee. Write E-31, care
Minnesota Medicine.
910
Minnesota Medicine
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August, 1947
911
1000 cc. flasks
500 cc. flasks
125 cc. flasks
for hospitals.
Ullll
to
I
pRoi°^^9
,0, o-'
Like Amigen, Protolysate is an enzymic
digest of casein and consists of amino
acids and polypeptides. Like Amigen,
Protolysate supplies the nitrogen es-
sential for maintenance, repair and
growth.
Unlike Amigen, which may be em-
ployed both orally and parenterally,
Protolysate is designed only for oral
use.
The function of Amigen and Protolysate
is to supply the amino acids essential
for nutrition. Both can be given in place
of proteinwhen protein cannot be eaten
or digested, or in addition to protein
when the protein intake is insufficient.
Administered in adequate amounts,
they prevent wastage of protein, restore
previous losses, or build up new body
protein.
PROTOLYSATE
For Oral Administration
^ dry enzymic digest of casein containing sm
ac*ds and polypeptides, useful as a source of rea
absorbed food nitrogen when given orally
tu^e- Protolysate is designed for adminis'
l0n in cases requiring predigested protein-
mi,de of administration and the amount to
^lvvn should be prescribed by the physic*
: :
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1 lb. cans at drug stores
MEAD JOHNSON & CO., EVANSVILLE 21, INDIANA
[There is no shortage now of AMIGEN for parenteral use. There is no shortage now of PROTOLYSATE for oral use.
912
Minnesota Medicine
• The myth of laudable pus has long been shattered. As science advances,
suppuration and the underlying pyogenic infection, exposed as major impediments
to wound healing, become more amenable to control.
Now that TYROTHRICIN is available, wound contamination with gram-positive
pathogens is still less likely to preclude early tissue repair. Streptococci,
staphylococci, pneumococci and other gram-positive bacteria are inhibited by this
highly potent, topical bactericide. TYROTHRICIN by irrigation, instillation and
wet packs affords better antibiotic therapy to topical and accessible
infection— in contaminated wounds, various types of ulcers, abscesses,
osteomyelitis, and certain infections of eye, nasal sinus and pleural cavity.
TYROTHRICIN, Parke, Davis & Company, is one of a long line of Parke-Davis
preparations whose service to the profession created a dependable symbol
of significance in medical therapeutics — medicamenta vera.
TYROTHRICIN is available in 10 cc. and 50 cc.
vials, as a 2 per cent solution ( 20 mg. per cc. )
to be diluted with sterile distilled water before use.
PARKE, DAVIS & COMPANY • DETROIT 32, MICHIGAN
Your Ability to Earn
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PROTECT YOUR EARNING CAPACITY WITH LONG
TERM NON-CANCELLABLE DISABILITY INSURANCE
The policy provides the following features: v
NON-CANCELLABLE. Guaranteed re-
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INCONTESTABLE. Incontestable after
2 years, similar to your life insurance
policies.
WAIVER OF PREMIUM. After 90 days
of total disability, premium payments
are waived until such disability termi-
nates.
NO HOUSE CONFINEMENT. It is
never necessary to be confined within
the house to receive the indemnities
provided.
BODILY INJURY. Indemnity is paid on
the basis of the result of the injury, not
the manner in which it occurred.
NON-AGGREGATE. The full policy
limits payable for each new disability.
TOTAL DISABILITY. Covers inability
to engage in the insured’s regular oc-
cupation for 4% years and thereafter
any gainful occupation up to 8*/j years.
In case of disability by accident, cov-
erage is for life.
GRACE PERIOD. In the payment of
premiums, you are permitted a grace
period of 31 days.
FULL MEDICAL EXAMINATION—
required.
MASSACHUSETTS INDEMNITY INSURANCE COMPANY
Ralph H. Brastad, Agency Manager
1400 RAND TOWER GENEVA 8319
MINNEAPOLIS 2, MINNESOTA
914
Minnesota Medicine
QHmnes&k QUeMcine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 September, 1947 g
Contents
Prolonged Labor, with Special Reference to
Postpartum Hemorrhage.
Alexander M. Watson , M.D., Royalton, Minnesota. 945
The Management of Obstetric Emergencies.
F. L. Schade, M.D., Worthington, Minnesota 949
The General Problem of Anesthesia in Obstetrics.
Edward B. Tnohy, M.D., Rochester, Minnesota. . . 953
Medical Therapy in Ulcerative Colitis.
P. G. Boman, M.D., Duluth, Minnesota 956
Medical Treatment of Peptic Ulcer.
J . Allen Wilson, M.D., Ph.D., Saint Paul,
Minnesota 960
Vagotomy in Peptic Ulcer.
Waltmam Walters, M.D., Harold A. Neibling,
M.D., William F. Bradley, M.D., John T. Small,
M.D., and James W. Wilson, M.D., Rochester,
Minnesota 965
Lumbar Retroperitoneal Ganglioneuroma.
Lawrence M. Larson, M.D., Ph.D. (Surg.), Min-
neapolis, Minnesota 969
Minnesota Serological Evaluation Study.
H. E. Michelson, M.D., Minneapolis, Minnesota.. . 972
Roentgen Therapy of Bronchiogenic Carcinoma.
Eugene T. Leddy, M.D., Rochester, Minnesota. ... 975
Clinical-Pathological Conference :
Diagnostic Case Study.
Bernard J. Terrell, M.D., Arthur H. Wells,
M.D., and Harold, H. Joffe, M.D., Duluth
Minnesota 978
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. (Continued from August
issue).
NoraH. Guthrey, Rochester, Minnesota 982
President’s Page 988
Editorial :
Pertussis Immunity and Mixed Antigens 990
Cancer 990
Life Insurance for State Association Members 991
Medical Economics :
Prepaid Medical and Surgical Care for Minnesota
People 992
Emergency Maternal and Infant Care Program
to End Gradually 993
Federal Funds Used to Promote Compulsory
Health Insurance 994
University Receives Grant for Mental Health
Studies 995
Minnesota State Board of Medical Examiners 996
Reports and Announcements 998
In Memoriam iQOO
Of General Interest 1004
Communication iqh
Book Reviews
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage prorided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918.
September, 1947
915
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
G. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — $3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions — $3.50.
The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
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ST. CROIXD ALE ON LAKE ST. CROIX
PRESCOTT. WISCONSIN
MAIN BUILDING— ONE OF THE 8 UNITS in “COTTAGE PLAN”
A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous and Mental Disorders
Located on beautiful Lake St. Croix, eighteen miles from the Twin Cities, it has the advantages of both
City and Country. Every facility for treatment provided, including recreational activities and occupational
therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
NEUROPSYCHIATRISTS
PRESCOTT OFFICE
Prescott, Wis.
Howard J. Laney, M.D.
Tel. 39 and Res. 76
Hewitt B. Hannah, M.D.
Joel C. Hultkrans, M.D.
Howard J. Laney, M.D.
511 Medical Arts Building
Minneapolis. Minnesota
Tel. MAin 1357
SUPERINTENDENT
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Prescott, Wisconsin
Tel. 69
916
Minnesota Medicine
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Investigated and Recommended by:
Minneapolis District Dental Society
.Hennepin County Medical Society
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Minnesota State Dental Society
Minnesota State Pharmaceutical
Minnesota State Bar Association
Hennepin County Bar Association
Ramsey County Bar Association
West Central District Dental Society
September, 1947
917
cUe*ari*
eminent et
dub!
At meal time his renowned judgment deserts him.
Eating only the food he likes, a choice of notably
limited range, he thrice daily produces a burlesque
on proper nutrition. Inevitably, this perennial first-
nighter makes his entrance into some physician’s recep-
tion room — the victim of a self-made, borderline vita-
min deficiency. In the same cast, you will find other
familiar types. Included in it are the ignorant and in-
different, people "too busy” to eat properly, those on
self-imposed and badly balanced reducing diets, exces-
sive smokers, food faddists and alcoholics, to name a
few. First thought in such cases is dietary reform, of
course. Along with that, a dependable vitamin supple-
ment may well be in order. When you prescribe an
Abbott vitamin product, you are assured that the
patient will receive the full vitamin potencies intended.
Your pharmacy carries a complete line of Abbott vita-
min products in a variety of dosage forms and pack-
age sizes, and will be pleased to fill your prescriptions.
Abbott Laboratories, North Chicago, Illinois.
SPECIFY
Abbott Vitamin Products
918
Minnesota Medicine
New plastic cartridge
300,000 units in 1 cc. dou-
ble-cell plastic cartridges
for B-D* Disposable
Syringes or in B-D° per-
manent syringes.
*T. M. Reg. Becton, Dickinson & Co.
CRYSTALLINE PENICILLIN
G SODIUM SQUIBB
in Oil and Wax
You get these advantages with Squibb’s New Double-Cell
Plastic Cartridges for B-D* disposable or permanent syringes:
• New Plastic Cartridges minimize breakage hazards
• Sterile Aspirating Test Solution guards against acciden-
tal intravenous injection
• Crystalline Penicillin G Sodium Squibb in Oil and Wax
at room temperature requires no heating
• Improved lubrication of stoppers further decreases break-
age-speeds injections
CRYSTALLINE PENICILLIN G SODIUM
Squibb in oil and wax
NOW comes in the new plastic double-cell cartridge which
minimizes breakage hazards.
One cell of the double-cell cartridge contains 300,000 units
of crystalline penicillin G sodium in refined peanut oil and
4.8% bleached beeswax (Romansky formula). The other cell
contains Sterile Aspirating Test Solution. Therapeutic serum
concentration levels are maintained for 24 hours with a single
injection. In overwhelming infections, the dose may be doubled
but the frequency need not be. Ambulatory treatment is prac-
tical for many diseases formerly requiring hospitalization.
For real convenience in administering penicillin in the home,
office or emergencies try Crystalline Penicillin G Sodium Squibb
in Oil and Wax in the new plastic double-cell cartridge.
September, 1947
919
Regi
Blood Sugar Level
Formation of
Fibrinogen and Other
Plasma Proteins
Desaturation of
Fatty Acids
Formation of
Plasma Phospholipids
Destruction of
Excess Estrogens
Detoxifying Action
Secretion of Bile
Deamination of Storing the
Amino Acids Hematmic Principle
Hemoglobin
Synthesis
Destruction of
Erythrocytes
The complex nature of the manifold functions of the liver is reflected
in the diagram shown above. To maintain its functions in an efficient
manner, the liver must be adequately protected against toxic in-
fluences. Parenchymatous damage with ensuing decreased functional
capacity can lead to severe metabolic derangements.
Protein deficiency is an important factor in precipitating im-
paired liver function. Hence an adequate intake of biologically
complete protein, ordinarily in the form of protein foods, is indis-
pensable as a safeguard of liver competency.
Among man’s protein foods, meat ranks high not only because
of its generous content of protein, but also because its protein is
complete, capable of satisfying all protein requirements. Further-
more, all meat is 96 to 98 per cent digestible.
The Seal of Acceptance denotes that the nutri-
tional statements made in this advertisement
are acceptable to the Council on Foods and
Nutrition of the American Medical Association.
AMERICAN MEAT INSTITUTE
MAIN OFFICE, CHICAGO . . . MEMBERS THROUGHOUT THE UNITED STATES
920
Minnesota Medicine
odor — Judge
Philip Morris suggests you judge . . . from
the evidence of your own personal obser-
vations . . . the value of Philip Morris Ciga-
rettes to your patients with sensitive throats.
PUBLISHED STUDIES* SHOWED WHEN SMOKERS
CHANGED TO PHILIP MORRIS SUBSTANTIALLY EVERY
CASE OF THROAT IRRITATION DUE TO SMOKING
CLEARED COMPLETELY, OR DEFINITELY IMPROVED.
But naturally, no published tests, no matter
how authoritative, can be as completely con-
vincing as results you will observe for yourself.
Philip Morris
PHILIP MORRIS & CO., LTD., INC.
119 FIFTH AVENUE, NEW YORK, N. Y.
*Laryngoscope, Feb. 1935, Vol. XLV, No. 2, 149-1 54-
Laryngoscope, Jan. 1937, Vol. XLVI1, No. 1, 58-60.
TO THE DOCTOR WHO SMOKES A PIPE: We suggest an unusually fine new blend —
Country Doctor Pipe Mixture. Made by the same process as used in the manufacture of
Philip Morris Cigarettes.
September, 1947
921
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922
Minnesota Medicine
High-concentration Elixir Pyribenzamine hydrochloride now
provides a second administration form of this proved antihistaminic.
Containing 20 mg. of Pyribenzamine hydrochloride per 4 cc. (teaspoonful),
the Elixir has obvious advantages in special cases, notably in infants
and children, and in adults who prefer liquid medication.
Scored tablets of Pyribenzamine also facilitate small dosage when
indicated— the 50 mg. tablets are easily broken to provide 25 mg. doses.
Council Accepted. PYRIBENZAMINE hydrochloride (§) (brand of tripelennamine hydrochloride)
PHARMACEUTICAL PRODUCTS, INC., SUMMIT, N. J.
September, 1947
923
wnfriMj growmy infant,
miccJt ad one t^UrcC of iAe yroiein^of die
may 6e retamecC for &iufcCay new
• Nutritional authorities warn that "the possibility of
protein deficiency in the diets of children has received some,
but insufficient, attention” . . . and that children "with
normal values are the exception rather than the rule.”*’
• Many progressive pediatricians, in prescribing formulas,
standardize on the high-protein infant food, Dryco —
since it represents such a rich source of all the essential
amino acids. Dryco is also characterized by a high-mineral,
low-fat and intermediate carbohydrate content — with
more than adequate vitamins A, Bi, B.' and D.
It is quickly soluble in cold or warm water,
and may be used with or without added carbohydrates.
Special processing facilitates digestion by
assuring soft curd formation in the stomach.
♦BOGERT, L. Nutrition and Physical Fitness, 4th edition, 1943,
Chapter IX, p. 22.
Handbook of Nutrition, 1943, p. 360.
BORDEN’S PRESCRIPTION PRODUCTS DIVISION
350 MADISON AVENUE, NEW YORK 17, N. Y.
DRYCO is made from spray-dried, pasteurized, superior quality whole milk
and skim milk. Provides 2500 U.S.P. units Vitamin A and 400 U.S. P.
units Vitamin D per reconstituted quart. Supplies 31*/2 calories
per tablespoon. Available at all drug stores in 1 and 2/z lb. cans.
924
Minnesota Medicine
G-E X-RAY PROUDLY ANNOUNCES
THE NEWEST ADDITION TO THE FAMILY
The G-E Prescription Model Ultraviolet Lamp offering you all the famous
G-E X-Ray quality and service in a new low cost ultraviolet lamp.
Please send me detailed information on your new
Prescription Ultraviolet Lamp.
Name-
Address.
State or Province-
2667
This new, economically priced lamp features
the famous G-E Uviarc high pressure mercury
quartz burner — economical to operate and with
emission characteristics covering the full range
of therapeutic ultraviolet. Long familiar to users
G-E professional type lamps, the Uviarc
burner emits intense, uniform radiation through-
out the spectral bands of proven clinical value.
The compact, sturdily constructed burner
housing is mounted on the Dazor Floating Arm. Fabulously flexible
and almost human, this remarkable arm with its fingertip control makes
the positioning of the lamp amazingly swift and simple. Raise, lower,
swing the burner housing through an arc; it freezes in position wher-
ever you stop it— and it stays there too until you move it again. Nothing
to tighten, no time consuming adjustments. This revolutionary feature
facilitates rapid positioning of the lamp and offers a wide selection of
treatment distances.
flan now to offer your patients the benefits of ultraviolet the year-
round, with the G-E Prescription Model Ultraviolet Lamp. Clip and
mail the convenient coupon today to: Dept. 2667, General Electric
X-Ray Corporation, 175 West Jackson Boulevard, Chicago 4, Illinois.
GENERAL (g) ELECTRIC
X-RAY CORPORATION
September, 1947
925
"SIMPLICITY
WITH
ACCURACY"
IS ASSURED
WITH
Immediate Delivery!
JONES WATERLESS MOTOR BASAL METABOLAR
ONLY JONES
HAS THESE
EXCLUSIVE
FEATURES:
\\\\\ v
"/// r
\\\\\ V
///// r
\\\\\ v
77777 r
Vy\\\ \
77777 r
\\\\\ V
77777 r
\\\\\ v
7/7/7 r
# Operative simplicity, accuracy checked
by protractor
# Alcohol checked to 99% accuracy
# Motor blower for easy breathing
# Economical — 7 cents per test
# Automatic slide rule calculator, no com-
putation or mathematical errors
# Protractor eliminates technical errors
Write for free descriptive booklet
C. F. ANDERSON CO., Inc.
Surgical and Hospital Equipment
901 MARQUETTE AVENUE MINNEAPOLIS 2. MINN.
926
Minnesota Medicine
You Prescribe
We Provide . . .
Dorseij
DEPENDABLE PHARMACEUTICALS
Like a gem, every case in your daily practice presents
many facets besides the strictly medical ones — constitution,
temperament, environment, AND the reliability of the medica-
tion you prescribe.
Most of these contributing factors are outside your control.
Certainly, in these busy days, you cannot take time to trace
the manufacturing history of every drug you use.
What you can do is to prescribe pharmaceuticals of un-
questioned reliability — drugs you can depend upon.
You can depend upon Dorsey products for unvarying pur-
ity and potency, for they are made under rigidly standard-
ized conditions. Laboratory and manufacturing equipment, per-
sonnel and procedure are constantly protecting your treat-
ment with Dorsey drugs.
THE SMITH-DORSEY COMPANY
LINCOLN, NEBRASKA
Branches at Dallas and Los Angeles
4 4
wla
MANUFACTURERS OF
PURIFIED SOLUTION OF LIVER-DORSEY
SOLUTION OF ESTROGENIC SUBSTANCES-DORSEY
September, 1947
927
^iroTcirT^
for use in control of overweight—
Benzedrine Sulfate has been accepted
by the Council on Pharmacy and Chemistry
of the American Medical Association
According to Freed (J. A. M. A., Feb. 8, 1947),
ffBenzedrine Sulfate ... is of inestimable value
in controlling the desire for food
and in reducing the level of satiability
to a more normal one. This drug is commonly
administered in dosages of 5 mg. three times
a day, thirty to sixty minutes before each meal.
Occasionally patients will require 10 mg.
at one or more times during the day, depending
on their response to the drug.”
The use of Benzedrine Sulfate alone ordinarily
should achieve the desired appetite reduction.
Combinations of amphetamine and thyroid serve
no useful purpose and may even be dangerous.
In this connection, a recent report of the Council
(Drugs for Obesity , J. A. M. A., June 7, 1947)
says: "The fallacy and dangers of
overstimulating the body with thyroid and of
using laxatives to aid in reduction are
well known to the medical profession.”
benzedrine
sulfate
Smith, Kline & French Laboratories, Philadelphia
(racemic amphetamine sulfate, S.K.F .)
One of the fundamental drugs in medicine
928
Minnesota Medicine
Compare the compact, easy-to-operate efficiency of this Ritter ENT Unit
with ordinary equipment. Every tool for your examination and treatment is
ready within arm's reach on the Ritter Unit. Controls of air pressure, vacuum
suction and voltage are centralized at your fingertips. The cautery handle,
two low-voltage instrument holders and the Ritter air cut-off are mounted in
an angled position for quick selection. As you pick up your tongue depressor,
it lights. As you release it and return it to the holder, the current automatically
shuts off. These are a few examples of the many exclusive features of this
handsome, modern Unit.
Write for further information
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
MINNEAPOLIS MINNESOTA
September, 1947
929
crisis
The first 30 days of life might be called a truly critical period
since the greatest number of infant deaths— 62.1%— occur during
this time. The proportion of infants who die within the first month
has, in fact, increased nearly 10% in the past 20 years, while in-
fant mortality on the whole was substantially reduced.*
So much the greater, then, is the importance of providing the most
favorable conditions for maximum health during this fatal first
month. Considering the role nutrition plays in infant health, a
good start on the right feeding warrants special attention.
'Dexin' has proved an excellent "first carbohydrate" because of its
high dextrin content. It (1) resists fermentation by the usual in-
testinal organisms; (2) tends to hold gas formation, distention
and diarrhea to a minimum, and (3) promotes the formation of soft,
flocculent, easily digested curds. 'Dexin' does make a difference.
* Vital Statistics — Special Reports: Vol. 25, No. 12, National Office of Vital Statistics,
Washington, D. C. (Oct. 15) 1946, p. 206. 'Dexin' Reg. Trademark
I
HIGH DEXTRIN CARBOHYDRATE
Composition — Dextrins 75% • Maltose 24% • Mineral Ash 0.25% • Moisture
0.75% • Available Carbohydrate 99% • 115 calories per ounce • 6 level packed
tablespoonfuls equal 1 ounce • Containers of twelve ounces and three pounds •
Accepted by the Council on Foods and Nutrition. American Medical Association.
BRAND
Literature on request
BURROUGHS WELLCOME & CO. (U.S.A.) INC., 9 & 11 East 41st St., New York 17, N. Y.
930
Minnesota Medicine
im m.
Music provides a retreat
from the anxieties and cares of
the moment, where, in imagina-
tion, you live in a world care-
free and gay.
The superb new Capehart
offers you preferred passage
to this wonderland of music.
This magnificent instrument re-
creates the living presence of
the artists and instruments
themselves as it flawlessly re-
produces the recorded music
of your choice.
Model illustrated is the
Capehart Georgian
McGowans
23 W. SIXTH ST.
ST. PAUL 2. MINN
September, 1947
931
For better skin care
Even the mildest soaps contain fatty acids and
alkali which, on continued use, may be
come a source of irritation that produces
or aggravates eczematous lesions,
'"limiMM the modern
soapless detergent, has the
same pH as the normal skin
and is hypoallergenic, con-
taining no fatty acids,
alkali, color or perfume.
pHisoderm effectively
cleans without irritation.
It makes an abundant
lather in hard and cold
water, and is approxi-
mately 40 per cent more
surface active than soap.
Write for detailed
literature and samples.
\u//
WINTHROP
sudsing detergent cream
Regular, Oily and Dry Types in bottles
of 2 oz., 7 oz., 12 oz. and 1 gallon.
Also in 3 oz. refillable hand dispensers.
OMPANY, INC.
New York 13, N. Y. • Windsor, Ont.
932
Minnesota Medicine
Rudolf Virchow
(1821-1902)
proved it in pathology
Virchow’s research on leucocytosis, leontiasis ossea, and
other pathological conditions added much to medical
knowledge. Although the idea was not original with him,
Virchow’s experiences with many pathological specimens
led to his conception of the cell as the center of pathologi-
cal change. He believed that every morbid structure con-
sisted of cells derived from pre-existing
cells — a great advance in pathology.
EXPERIENCE during the wartime
shortage taught smokers the dif-
ferences in cigarette quality. Millions
of people smoked more different brands
then than they would normally have
tried in years. More smokers came to
prefer Camels as a result of that ex-
Yes, and experience is the best teacher in smoking too!
perience, so that today more people
are smoking Camels than ever before.
But, no matter how great the de-
mand, we don’t tamper with Camel
quality. Only choice tobaccos, prop-
erly aged, and blended in the time-
honored Camel way, are used in Camels.
fig!
R. J. Reynolds Tobacco Co.
Winston-Salem, N. C.
According to a recent Nationwide survey-
More Doctors
smoke Camels
t/ian any ot/ier cigarette
September, 1947
933
ANGINA PECTORIS
and other
Manifestations of
CORONARY
INSUFFICIENCY
The following episodes may be prevented
by appropriately regulated administra-
tion of a vasodilator having a sustained
effect:
FOR THE PERSON
• who is compelled to stop and rest
when climbing a flight of stairs.
A who suffers “indigestion” and
“gas” on exertion, or after a heavy
meal.
\
• who is stricken with precordial
pain on unusual exertion or emo-
tion, or when exposed to cold.
The vasodilatation produced by Ery-
throl Tetranitrate Merck begins 15 to
20 minutes after administration, and
lasts from 3 to 4 hours.
It is generally agreed that the acute attack of anginal pain is most readily relieved by the prompt removal
of the provocative factor, and by the use of nitrites. For prophylactic purposes — to control anticipated
paroxysms — the delayed but prolonged aclion of erythrol tetranitrate is effective. Erythrol tetranitrate,
because of its slower and more prolonged action, is also considered preferable for the purpose of preventing
nocturnal attacks.
ERYTHROL TETRANITRATE
MERCK
(ERYTH RITYL TETRANITRATE)
'is’oimce/ ^4cce/ifet£
MERCK & CO., Inc. RAHWAY, NEW JERSEY
934
Minnesota Medicine
FOR AN ACTIVE MIDDLE AGE
A “PLUS”
The "plus" is the gratifying "sense of well-being" so many menopausal patients
experience following “Premarin" therapy. It is the intangible factor which,
added to relief of distressing symptoms, enables the middle-aged woman to
resume her normal routine of useful and enjoyable activities.
"Premarin" provides naturally occurring, conjugated estrogens for effective ther-
apy by the oral route. Untoward side effects are rarely noted with “Premarin."
"Premarin" is now available as follows:
Tablets of 2.5 mg in bottles of 20 and 100
Tablets of 1.25 mg in bottles of 20, 100 and 1000
Tablets of 0.625 mg in bottles of 100 and 1000
Liquid containing 0.625 mg. per 4 cc. (one teaspoonful) ... in bottles of 120 cc.
While sodium estrone sulfate is the principal estrogen in "Premarin,” other
equine estrogens . . . estradiol, equilin, equilenin, hippulin are also present
as water-soluble sulfates. The water solubility of conjugated estrogens
(equine) permits rapid absorption from the gastrointestinal tract.
CONJUGATED ESTROGENS
(equine)
AYER ST, McKENNA & HARRISON Limited
22 EAST 40th STREET, NEW YORK 16, N.Y.
“Premurin?
September, 1947
935
Convenience is achieved and time saved through the use of
National’s “D-T-P” (Diphtheria-Tetanus-Pertussis Combined).
These combined antigens are prepared from carefully
standardized toxoids and bacterial vaccines which provide a
maximum of activity in a minimum-dose volume. Alum
precipitation, used in all combinations, produces more
effective action in stimulating immunity response.
Diphtheria-Tetanus-Pertussis Combined is recommended
for infants and pre-school children. Treatment
consists of three subcutaneous injections at intervals
of from three to four weeks.
iphtheria
etanus
ertussis combined
ALUM PRECIPITATED
Diphtheria-Tetanus-Pertussis Combined is available in multiple-dose vials.
936
THE NATIONAL DRUG CO. • Philadelphia 44, Pa.
PHARMACEUTICALS, BIOLOGICALS, BIOCHEMICALS FOR THE MEDICAL PROFESSION
Minnesota Medicine
is a proud profession
. . . and rightfully so. For next to the doctor in service rendered stands
the present-day nurse. Into her hands is entrusted the care of the sick,
and often the success of the doctor’s work depends directly upon her skill.
NURSING
“Hospital administrators and doctors throughout the
country are seriously concerned over the dangerously inadequate
nursing care available. Results of a recent survey indicate that 55
to 60 per cent of the required amount is obtainable . . .
“ . . approved hospitals should provide training for
such vocational nurses by means of short courses.’
“The doctor is responsible for the care of the patient.
In order to meet this obligation, the medical staff together with the
hospital and nursing administrators, are urged to undertake the de-
velopment and execution of this program.”1
“It is time that some of the present-day advantages
of a nursing career be made known to young women.”2
GlenMood Hills Hospital — through its school of nursing — is
anxious to cooperate with you in your effort to increase the
number of nurses in your community. A student from your
locality will result in increased nursing assistance to you in the
near future. Tour help is greatly needed in recruiting candi-
dates for this profession. A one-year course in psychiatric
nursing is currently being offered to eligible applicants. Tui-
tion is free. Regular classes begin in January, June and Sep-
tember. For full information write Miss Margaret Chase,
R.N., B.S., Director, School of Nursing.
TEACHING STAFF
Margaret Chase, R.N., B.S Director
Mrs. Virginia Bowers, R.N., B.S Assistant Director
Julius Johnson, M.D Case Study
Robert Meller, M.D Psychiatry
C. O. Erickson, M.D Psychiatry
Donald Reader, M.D Neurology
N. J. Berkwitz, M.D Psychiatry , Neurology
Grace Johnson. O.T.R Occupational & Recreational Therapy
June McChora, B.A Dietetics
Marian Tucker, B.S.M.T. (ASCP) Bacteriology
Mrs. Mabel Pelletier Vocal Music
SCHOOL OF PSYCHIATRIC NURSING
Candidates for the January class should make reservations at once.
School and health records must be reviewed prior to acceptance.
1 Irvin, Abell, M.D., Chairman, Bd. of
Regents, Am. Col. of Surgeons; Am.
Jl. of Nursing, March, 1947.
2 A. E. Hedback, M.D., Editor, Modern
Medicine; Jl. -Lancet, April, 1947.
enuuood
1 s OS
]i a s
3501 Golden Valley Road
Route Seven Minneapolis, Minn.
September, 1947
937
DO
YOU
KNOW
WHAT
THESE
SYMBOLS
STAND
FOR?
DRUGS
REXALL FOR RELIABILITY
For centuries the owl has symbolized great
knowledge and superior wisdom. "Wise as an
owl" was a quip of Caesar's time. The canny
bird was sacred to Minerva, Roman goddess of
learning and of science. The natural assumption
was that the owl acquired wisdom from his
patroness.
For many years, the familiar Rexall symbol
has denoted excellent standards of pharma-
ceutical science. From coast to coast more than
10,000 selected, independent pharmacies dis-
play this sign. It assures you that fine,
laboratory-tested Rexall drug products and
skilled pharmacists are at your service.
REXALL DRUG COMPANY
LOS ANGELES, CALIFORNIA
PHARMACEUTICAL CHEMISTS FOR MORE THAN 44 YEARS
938
Minnesota Medicine
there’s an
economical
alternative
BENADRYL may frequently afford an
economical alternative to long journeys
to expensive resorts in "pollen-free”
It is now established that the symptoms
of anaphylaxis are usually the result
of an excessive amount of histamine
in the tissues. By antagonizing this
substance, BENADRYL frequently
renders the patient free of the symp-
toms of allergy. From 25 to 50 mg.
are usually sufficient to produce relief.
BENADRYL (diphenhydramine hydro-
chloride) is available in Kapseals® of
50 mg. each, in capsules of 25 mg.
each, and as a palatable elixir con-
taining 10 mg. in each teaspoonful.
f Benadryl
hydroch
hydrochloride «
■y C A V
PARKE. DAVIS & COMPANY, DETROIT 32, MICHIGAN'-
Hb
September, 1947
939
PYOKTANIN SURGICAL GUT
Plain and Jemalijed
Manufactured Since 1099 by
The Laboratory of the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia.
i
• • •
Price iUt
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE G NONBOILABLE
Sizes 000 — 00 — 0—1 — 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
• • I
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FDR SALE BY SURGICAL DEALERS AND DRUGGISTS
940
Minnesota Medicine
.During the most productive years of his life,
Charles Darwin was a victim of peptic ulcer.1
His might be called the average case of peptic
ulcer. Had modern medical understanding of
ulcer treatment been available to him, his
life could have been far more comfortable —
and even more productive!
Proper use of an alumina gel antacid and
an occasional sedative would doubtless
have carried him through his most active
years without suffering.
IRehfuss, M. E„ The Ulcer Life, Clinics 3:480-493 (Oct.) 1944
WYETH INCORPORATED
PHOSPHALJEL, Aluminum Phosphate Gel,
, Wyeth, is unexcelled in the treatment of
"average” ulcer cases as well as in stubborn
or complicated ones. It provides quick relief
from pain . . . lays a protective coating over
the inflamed mucosa . . . safely buffers gas-
tric acidity with no danger of alkalosis or
"acid rebound.” Phosphaljel permits a lib-
eral bland diet — patients are more contented
during treatment, gain strength and weight
more quickly.
«
PHOSPHALJEL®
PHILADELPHIA a, PA.
September, 1947
941
VTA 1 Beginning placement of diaphi
llV, i on introducer.
m
xM
ragm
m
NO.
insertion t A
ning
diaphragm.
JJQ 2 Diaphragm placed on introducer.
NO 3 *PPlication ol )0% to diaphragm. JJQ g Placement of diaphragm.
m
m
mm
&
The insertion and correct placement of the RAMSES Flexible
Cushioned Diaphragm are simplified by the use of the "RAMSES"
Diaphragm Introducer as illustrated.
Our booklet "Instructions For Patients will be found helpful in
guiding patients in the proper use of the "diaphragm-jelly technique".
A supply will be sent to physicians on request.
JULIOS SCHMID, INC. 423 WEST 55th ST.. NEW YORK 19. N. Y.
•The word "RAMSES’’ is a registered trademark of Julius Schmid, Inc.
__ hi warn mm mm
942
Minnesota Medicine
All nutritional statements made in this
advertisement are accepted by the Council
on ! Foods and Nutrition of the American
Medical Association.
specially prepared -offer an appetizing,
natural source of complete, high-quality proteins
Many doctors now recommend
Swift’s Strained Meats for patients
on soft, smooth diets where a
high-protein intake is required.
These specially prepared meats
provide a highly palatable source
of biologically complete proteins,
B vitamins and minerals in a form
desirable for a soft oral diet. Swift’s
Strained Meats may easily be used
in tube-feeding, too — the minute
particles of meat are so fine.
Tempting variety
of 6 different kinds
The wholesome meat flavors in
Swift’s Strained Meats are readily
accepted by most patients — even
when appetite is impaired. The
variety includes: beef, lamb, pork,
veal, liver and heart. Prepared with
expert care from selected, lean U. S.
Government Inspected Meats,
Swift’s Strained Meats are carefully
trimmed to reduce fat content to
a minimum. Each tin of Swift’s
Strained Meats contains three and
one-half ounces.
Also . . .
Swift’s Diced Meats
Those tender cubes of juicy,
lean meat are highly desirable
for patients who can eat meat
in a form more nearly like that
of ordinarily prepared meats.
Swift’s Diced Meats are soft
and may easily be mashed to
the desired consistency. Six
kinds: beef, lamb, pork, veal,
liver and heart. Five ounces
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We will be happy to send you complete information and compli-
mentary samples of Swift’s Strained and Swift’s Diced Meats.
Please write Swift & Company, Dept. B. F., Chicago 9, Illinois.
SWIFT &
September, 1947
COMPANY
CHICAGO
9 , ILLINOIS
943
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Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 September, 1947 No. 9
PROLONGED LABOR, WITH SPECIAL REFERENCE TO POSTPARTUM
HEMORRHAGE
ALEXANDER M. WATSON, M.D.
Royalton, Minnesota
"PROLONGED labor is always a cause for anx-
iety on the part of the obstetrician and as
time passes without the completion of delivery,
he may be apprehensive of serious complications.
Labor that extends beyond thirty hours in a pri-
mipara or twenty hours in a multipara suggests
the presence of complications.
The causes of prolonged labor can be divided
into two main classes.
1. In the first class are those variations in the
shape and size of the pelvis that obstruct the
passage of the fetus and anomalies of the fetus
itself, such as hydrocephalus, monstrosities, et
cetera.
In this class can be placed also those cases of
faulty presentations, such as brow and face, im-
pacted occipitoposterior and transverse positions.
There are still other conditions in this class that
can prolong labor, such as fibromata of the uterus,
other tumors or cysts in the pelvis, bicornate
uterus and a long rigid cervix.
This first group of conditions that tend to
prolong labor will not be considered in detail in
this paper. If careful and repeated prenatal care
is carried out, it will be possible to detect the
majority of these causes of prolonged labor before
labor starts, and the obstetrician can then be pre-
pared to carry out the proper treatment. This
should include x-ray examination to determine
the pelvic measurements and the shape and size
of the fetal parts. It has been said that early
exposure of a three-month fetus to x-ray may
Read in a symposium on Obstetrics in General Practice at the
annual meeting of the Minnesota State Medical Association,
Duluth, Minnesota, July 1, 1947.
Sf.ptfmber, 1947
cause damage. I have not seen any such dam-
age myself ; however, I think that the x-ray of
the maternal pelvis and the fetus should be carried
out in the last month of pregnancy, as one can
then get a better idea of the relative size of the
fetal head and the mother’s pelvis.
I want especially to emphasize the great import-
ance of a complete and careful prenatal examina-
tion. There is no one thing the physician can do
for the expectant mother that will be of more
value to her than complete and careful prenatal
examinations during her pregnancy.
2. The second cause of prolonged labor is the
condition of inertia uteri. In inertia uteri there
is a failure of the uterus to contract frequently
enough or forcibly enough to carry on the labor.
This condition I shall discuss in some detail, as
it is a common cause of postpartum hemorrhage.
Inertia of the uterus may develop during labor
and continue into the postpartum period. It may
appear without warning, and in the postpartum
period it may be the cause of hemorrhage.
Inertia uteri has been divided into secondary
and primary inertia.
Adam G. Sheddon, in the Medical Journal of
Australia, says : “Secondary inertia is a condition
of temporary uterine exhaustion usually appearing
in the second stage of labor and resulting from
an obstruction, which however is not insuperable.”
This, he says, is really a protective mechanism.
He defines primary inertia as a complication of
labor characterized by uterine contractions, which
from their onset are sluggish, infrequent and
inco-ordinate. This classification seems to define
945
PROLONGED LABOR— WATSON
the condition clearly. He notes that this condition
is prone to develop in the older primipara with a
rigid os.
John W. Harris, in the American Journal of
Surgery for February, 1937, says that primary
inertia of the uterus is a common type of dystocia
and is next in frequency to the dystocia from
contracted pelvis. The pains are severe enough
to make the patient very uncomfortable, and the
physician is often forced by the patient and rela-
tives to hasten or interrupt the labor. Thus, many
cases are mismanaged.
Many medical men have observed that primary
inertia only becomes evident during labor and
that a means of detecting the probability of pri-
mary inertia during the last month of pregnancy
would be of great value.
In many cases of primary inertia, a diagnosis
is made of rigid cervix that cannot dilate, whereas
the reason for dystocia is not the cervix but
rather the inadequate contraction of the uterus.
This false conception of the condition frequently
results in mismanagement. A careful examination
during the pains which are often apparently se-
vere, will show that the fetal head does not
engage or push down during the pain. Instead
of attempts at forcing delivery, the patient should
be given several hours of complete rest and ade-
quate nourishment ; then labor may be resumed.
The cause of primary inertia has not been estab-
lished.
There are many theories as to the cause of nor-
mal labor, among which are the following: (1)
increased venosity of placental blood; (2) me-
chanical distention of the uterus; (3) senility of
the placenta; (4) maturity of the fetus; (5) the
influence of hormones.
It has been suggested that a disturbance or non-
functioning of one or more of these may be the
cause of inertia. However, we do know that this
occurs more frequently in elderly primipara and
in multigravida who are emotionally unstable and
apprehensive, so every effort should be made to
gain the patient’s confidence and reassure her.
In connection with a method or means of fore-
telling the possible development of primary inertia,
some interesting work has been done with the
tocograph. The tocograph is an instrument for
measuring uterine motility. Many methods have
been tried to measure the power of uterine con-
tractions, mostly by some sort of bag inserted
946
in the uterus, vagina or rectum, and attached to
a recording device. Obviously, this is not a prac-
tical method and exposes the patient to many
hazards.
Sandor Larand in 1936 published a description
of the second model of his tocograph. The in-
strument consists of a series of levers actuated
by a rod that projects about 5 mm. from the
bottom of the box in which the apparatus is
contained. The graph strip revolves on a drum,
and the writing lever inscribes the graph on the
paper. The whole thing is a little larger than a
deck of cards. It is placed on the abdomen at
the most prominent area and held in place by
an elastic belt.
Dr. Douglas P. Murphy, working in hospitals
in Philadelphia and in the University of Pennsyl-
vania, has carried out a series of 3,154 tocograph
readings in 1,153 individuals. Of the 3,154 read-
ings 1,936 were made before the onset of labor.
This year he published a book on this subject,
and he says that he undertook this work because
one of the chief problems of the obstetrician is
created by inadequate uterine pains, which pro-
long labor and jeopardize the life of the mother
and child. As a result of his tocograph readings,
he has made certain observations :
1. He has established a normal graph, both
prenatal and during labor.
2. He has established a graph of the normal
uterine tension during labor and between pains.
3. He has been able to detect inadequate and
irregular contractions in prenatal readings that
during labor developed into inertia of the uterus.
He has come to several other interesting con-
clusions, but as this paper is not a review of the
book, I can only say that the book is of great
interest and will well repay the reader.
I can remember the time when we had no blood
pressure instrument, when there was no electro-
cardiograph, when there was no basal metabolism
machine, when a roentgenogram was a curiosity,
obtained only from a static machine or Vulcan
coil. So I consider it possible that the tocograph
for measuring uterine motility may become a use-
ful and valuable instrument to the obstetrician.
1 he diagnosis of primary inertia is not difficult
when it is established. The pains are irregular,
cause a great deal of discomfort, and no progress
is made. I he fetal parts do not engage and the
Minnesota Medicine
PROLONGED LABOR— WATSON
os does not dilate ; all this, notwithstanding the
fact that previous prenatal examinations have
shown that there are no abnormalities of posi-
tion, pelvis or fetus that would obstruct labor. We
can sometimes anticipate the condition in an
elderly primipara or a multipara who has had
many children close together. One thing which
all patients with inertia uteri have in common
is a nervous condition of apprehension and a feel-
ing that it is impossible for them to deliver
their babies.
These patients can usually be detected during
the earlier prenatal calls, and it is then that the
physician should do everything to gain their con-
fidence and build up their morale. This is of
vast importance.
The treatment during the progress of labor
consists in trying to establish normal labor, and
this can often be done. First, the patient should
have long rest periods of several hours with the
use of sedatives. My favorite is demerol, 100 mg.
with 1/100 grain of hyoscin hydrobromide gr.
1/100 and I repeat it if needed in an hour or two.
In many cases, following the sedative, labor be-
comes normal and progresses to a favorable termi-
nation. I prefer demerol to the barbiturates.
Brodie C. Nalle, in Southern > Medicine and
Surgery in 1941, discussing the subject of pro-
longed labor, states that the cause of inertia of
the uterus may be due to : ( 1 ) a disturbed auto-
nomic system; (2) calcium deficiency; (3) a com-
bination of the two.
The autonomic nervous system, consisting of
the sympathetic and parasympathetic nerves is an
involuntary system and innervates the uterus.
This nervous system is susceptible to emotions of
anger, fear, anxiety and suppressed emotions.
Thus the emotional instability of the patient will
affect the work of the uterus.
He was impressed by the fact that the demand
for calcium during the last ten weeks of pregnancy
was very great and that the patients often ex-
hibited clinical evidence of calcium deficiency
such as cramps in the calves of the legs, frequent
periods of false pains, and paresthesias. The
estimation of diffusible blood calcium is difficult,
but the clinical evidence is reliable. Normal blood
calcium which is available for use has a sedative
effect on the sympathetic system, and if adequate,
the uterus contracts in a normal manner. On this
basis, he gives the patient calcium gluconate with
September, 1947
vitamin D from the third month on. It has been
my practice for several years to give calcium
gluconate grs. 30 daily for the last trimester, with
vitamin D. In the majority of cases, I am satis-
fied that this is of great benefit and the incidence
of nervous, apprehensive patients, with inertia
uteri is not so great as formerly.
The use of oxytocic drugs in prolonged labor,
due to primary inertia, deserves mention. These
drugs are potentially very dangerous to both moth-
er and child and therefore should not be used
unless the cervix is fully dilated and it is cer-
tain that there is no mechanical obstruction to
the delivery of the child. This should be the rule
in the use of these potent medicines. The oldest
of the oxytocics is ergot. It was first described
one hundred years ago by Prescott. The alkaloid
ergonovine or ergotrate is the preparation used.
It is used almost entirely postpartum. In England
and Europe this alkaloid is called ergometrine.
In 1906 Dale discovered that the extract of the
posterior pituitary gland had a remarkable action
as an oxytocic. Since then it has become uni-
versally used. Given by intramuscular or intra-
venous injection, it produces strong and regular
uterine contractions. The following rules, how-
ever, must be followed or the uterus may rupture :
1. Pituitary extract should not be used if the
intrauterine tension is high or if the uterus is in
a state of tetanic contraction.
2. It should not be used if the os is not fully
dilated, or easily dilatable.
3. It should not be used if there is any ob-
struction to labor such as a deformed pelvis, or
anomaly of, or excessive- size of, the fetus.
4. The dose should be small (about 2 minims)
of obstetrical pituitrin.
With these precautions, pituitary extract is a
very useful drug and will often cause normal
strong contractions that will terminate the labor,
in the presence of primary inertia.
There are other oxytocic drugs, such as estro-
gens and quinine but ergot and pituitary extracts
are the most commonly used.
In many cases of primary inertia, due to the
condition of the mother or fetus, it may be in-
advisable to use oxytocics, so some form of
obstetrical operation may be needed. Forceps in
the midpelvis or at the outlet are familiar to all
of us and are generally successful. Using high
947
PROLONGED LABOR— WATSON
forceps is an operation that is dangerous to mother
and child and in my opinion a podalic version is
preferable. This has its dangers but if done care-
fully is preferable to high forceps. In these cases,
due to the long labor and probable examinations
and loss of the liquor amnii, I would consider
cesarian section contraindicated as the danger
of sepsis is great and peritonitis is very likely
to occur.
The most serious complication that occurs as
a result of prolonged labor from primary inertia,
is postpartum hemorrhage. This is the direct result
of weak and ineffectual contractions of the uterus,
extending into the postpartum period. Post-
partum hemorrhage is second only to sepsis as
a cause of maternal mortality. This may result in
a great loss of blood in a short time or a steady
trickle that may not be alarming, but may even-
tually result in death, if not checked.
Odell, Randall and Scott, in an article published
in the Journal of the AM A of March 15, 1947,
on this subject, state that when the total loss of
blood (measured and estimated) exceeds 600 c.c.
or more, postpartum hemorrhage is diagnosed.
In a long series of cases they found the majority
of those listed as prolonged labor were in the
inertia group. They further stated that the in-
cidence of postpartum hemorrhage was higher in
the mothers who had operative interference of
any sort to conclude the labor, than in those who
delivered spontaneously. In such instances they
give early a 5 minim dose of pituitary extract
followed by ergotrate. If this is not successful,
they advocate douching the uterus with cold
sterile water and tamponade. In the treatment
of postpartum hemorrhage it is well to review the
proper procedure notwithstanding the fact that
it is a familiar subject.
If hemorrhage develops after the delivery of
the placenta, the uterus should be grasped firmly
and massaged to induce contractions. Often one
can feel the uterus relax and become soft, when
the contraction fails. The nurse is instructed
to give pituitary extract 5 minims intramuscularly,
followed by ergotrate 1/320, by the same method.
If the bleeding continues, the birth canal is ex-
plored for lacerations of the vagina and cervix.
If found, they should be sutured, which will
control the bleeding. If, however, the bleeding is
from the uterus, the hand should be inserted into
the uterus and any secundi that are present should
94S
be removed. I found a placenta succenturia in one
instance. In case the patient is still bleeding, it
will be necessary to pack the uterus. In our de-
livery room we have, at all times, a sterile pack
seven yards long and three inches wide con-
sisting of several thickness of gauze. This is
enough to pack the uterus tight as well as the
vagina. If the mother has reached this stage of
bleeding, she is in more or less shock from loss
of blood, so plasma is given and arrangements are
made for blood transfusion. The patient’s blood
should be typed and the Rh factor ascertained so
that suitable blood can be used. Some writers have
stated that packing of the uterus is an outmoded
procedure, but I think that it is often a life-saving
treatment and is the only method for controlling
some cases of hemorrhage. It has been said that
it is very liable to cause infection. This is not so
likely to occur if conducted in a modern hospital.
Also the infection can usually he controlled by
the use of penicillin, sulfonamides, and blood
transfusions. I therefore continue to pack the
uterus if the need arises.
Postpartum hemorrhage occurring before the
delivery of the placenta is equally formidable. The
first thing to do is to deliver the placenta. The
Crede method of expulsion should be tried but
as this often fails, it becomes necessary to do a
manual separation. John P>. Pastore, in an article
on postpartum hemorrhage in the American Jour-
nal of Surgery, states that the placenta should be
separated by the ulnar side of the hand, starting
at the top of the fundus and separating from
above downward. In this wav, the uterus con-
tracts on the retreating hand and placenta and
avoids the bleeding that occurs in the reverse
procedure. He says, further, that if in case of
inertia, the placenta has separated but is not ex-
pressed, clots accumulate and blood loss is great.
He states that many cases are mismanaged at this
stage. First, it is not recognized that the placenta
has separated while a perineal repair is being
carried out. Second, efforts are made to express
the placenta by pressing the uterus down into the
pelvis and causing pressure on the uterine veins,
thus increasing the bleeding. He says no repairs
should be attempted till the placenta is ex-
pressed, and he condemns the practice of using
the uterus as a piston to express the placenta.
When the uterus changes from a discoid shape to
(Continued on Page 996)
Minnesota Medicine
THE MANAGEMENT OF OBSTETRIC EMERGENCIES
F. L. SCHADE, M.D.
Worthington, Minnesota
NOWHERE in the entire field of medicine
can dire emergencies develop as suddenly
and acutely as in obstetrics. Twenty-five years
ago there were few specialists in this field. Most
women were delivered by the family doctor or
kindly neighbor women. Today, a growing num-
ber of women in the United States recognize the
better care provided by physicians especially
trained in obstetrics, and the demand for mater-
nity care by specialists is increasing. However,
the general practitioner today is conducting and,
I think, always will conduct the vast majority of
childbirths in the United States. Therefore, the
management of obstetric emergencies lies in our
hands as well as in the hands of specialists.
When we, as practicing physicians, accept the
responsibility of taking care of a woman through
her prenatal care and labor, it behooves us to be
adequately prepared for any emergency that may
arise. The phrase, “Too little and too late,” ap-
plies all too often to tragedies occurring in the
delivery room.
As many obstetric emergencies involve hemor-
hage and/or shock and transfusion; and as time
is such an important factor in these conditions,
the Rh status of every pregnant woman should
be determined during the early part of her preg-
nancy. The pregnant woman’s blood should be
tested for hemoglobin content, Rh factor, and
Wassermann reaction, the first time she presents
herself for prenatal care. If the patient is Rh
negative, an Rh negative donor in the proper
group must be found and the name of the donor
put on her record. Some centers go so far as
to determine the blood group of each pregnant
woman. When a woman goes into labor, plasma
should be on hand to combat shock and hemor-
rhage while blood is being obtained for transfu-
sion.
Let us quickly review the emergencies which
well may arise !
Placenta Previa
This condition occurs in at least one of 300
obstetric patients. When the placenta is im-
Read in the symposium on Obstetrics in General Practice* at
the annual meeting of the Minnesota State Medical Associa-
tion, Duluth, Minn, July 1, 1947.
September, 1947
planted in the region of the internal os, partial
detachment with hemorrhage results from the
tissue realignment incident to formation of the
lower uterine segment. The initial hemorrhage
appears at or before the onset of labor, and every
patient with placenta previa must be considered
as a candidate for fatal hemorrhage ; thus —
1. A patient with suspected placenta previa
should be immediately hospitalized.
2. Her blood should be typed and cross
matched.
3. A donor should be selected and ready for
immediate blood transfusion.
Cystography in the diagnosis of placenta previa
was introduced in 1934 by Ude, Weum, and
Urner, who outlined the soft tissue space between
fetal presenting part and bladder by filling the
latter with an opaque medium. The technique
used is as follows :
1. Empty bladder with a catheter.
2. Introduce 40 c.c. of sodium iodide solution
into bladder, clamp catheter.
3. Anteroposterior film with tube centered on
bladder and table tilted, feet down ten degrees
from horizontal.
4. Unclamp catheter, allow bladder to drain.
Remove catheter.
The interpretation of the roentgenogram in
vertex presentation may be difficult, and in breech
and transverse presentations it is virtually im-
possible.
Dipple and Brown, in 1940, were able to vis-
ualize the placenta with a single roentgenogram
in about 90 per cent of 200 pregnant women by
using a soft tissue technique. Interpretation and
x-ray technique requires experience for accuracy.
The x-ray method represents a distinct advance in
diagnosis but for accuracy cannot displace sterile
vaginal examinations. There is only one absolute
diagnosis of placenta previa — namely, digital pal-
pation of the placenta through the cervical os.
When the gloved finger introduced through the
os cannot feel placenta, the patient does not have
placenta previa.
A note of warning ! Digital examination must
949
OBSTETRIC EMERGENCIES— SCHADE
never be performed until the delivery room is
completely set up for emergency delivery, since
palpation of the placenta occasionally produces
more bleeding.
Delivery is mandatory after repeated bleeding.
The method of delivery may be vaginal or abdom-
inal and the choice of procedure depends largely
upon the probability of fetal salvage.
If the fetus is viable, a cesarean section should
be performed on all cases of complete placenta
previa. If the placenta previa is marginal or in-
complete or if the fetus' is not viable, one may
resort to vaginal delivery. Acceptable vaginal
methods include :
1. Spontaneous labor with or without rupture
of membranes. Spontaneous labor may be brought
about by medical means and artificial rupture of
membranes.
2. Scalp traction. Personally I have never re-
sorted to this means of delivery.
3. Insertion of a hydrostatic bag.
4. Braxton-Hicks version. This, of course,
should never be attempted before full dilation
of the cervix.
Except for the spontaneous labor with or with-
out antecedent rupture of membranes, all these
methods increase- the fetal hazard.
Premature Separation of the Normally
Implanted Placenta
(Ablatio or abruptio placenta)
These terms are reserved for the separation of
all or part of the normally implanted placenta oc-
curring after the twenty-eighth week of gestation
and prior to the onset of the third stage of labor.
The incidence of premature separation is vari-
ously reported between 1 TOO and 1 :500.
Symptoms. — A moderate amount of vaginal
bleeding usually associated with pain indicates
partial placental separation. If the placenta is im-
planted on the anterior wall of the uterus, there
is frequently a circumscribed area of uterine
tenderness.
Vaginal examination, again under sterile pre-
cautions, revealing no evidence of placenta previa,
confirms the diagnosis by exclusion.
Treatment. — As with placenta previa, the value
of blood transfusion cannot be overemphasized.
Even with mild vaginal bleeding, the physician
must make preparation even though subsequent
events render transfusion unnecessary. In every
case, management depends upon the rate of bleed-
ing and the condition of the cervix. Minimal
bleeding requires little or no treatment. When
bleeding is at a rate demanding delivery for hemo-
stasis, whether we use the abdominal or vaginal
route depends upon the condition of the cervix.
With an uneffaced, firm and tightly closed cervix,
cesarean section is mandatory.
Cervical effacement and partial dilation gen-
erally motivate vaginal delivery. Artificial rupture
of the membranes institutes labor and the bleed-
ing is controlled by the contracting uterus. If
necessary, small doses of pitocin may be admin-
istered with relative safety. Never give more than
one minim of pitocin for the initial dose! If these
measures do not control the bleeding, insertion
of a Voorhees bag to produce compression on
a possible low-lying placenta, and the occasional
employment of an abdominal binder, to raise
intrauterine pressure to parity with the blood
pressure, may be beneficial.
Uteroplacental Apoplexy or the Courvelaire
Uterus
This rare accident is too dramatic to omit, al-
though the average practitioner will probably
never encounter it. Retroplacental hemorrhage is
sudden, extensive and forceful, and produces
acute symptoms of profound shock and board-
like uterus. The typical boardlike uterus is not
simulated by any other condition. Immediate ces-
arean section is the treatment of choice ; despite
known presence of a dead baby. Why cesarean
without fetal salvage? In this condition blood
infiltrates directly into the uterine muscle, dis-
sociates the muscle fibers and inhibits uterine con-
tractility. If the uterus will not respond to oxy-
tocic drugs, a hysterectomy must be done.
Postpartum Hemorrhage
One just cannot discuss obstetric emergencies
and omit postpartum hemorrhage. As we are
bringing the toxemias of pregnancy and the
puerperal infections under control, hemorrhage
is assuming a relatively more important role in
maternal mortality.
Tt is unfortunate that accumulated experience
is not as impressive as personal experience and
that some women must die to make some of us
“hemorrhage conscious.”
950
Minnesota Medicine
OBSTETRIC EMERGENCIES— SCHADE
The emergency tends to appear at a time the
attendants are relaxing. The baby is born, the
labor is all but concluded, when suddenly a des-
perate fight to save the patient’s life ensues.
Preparedness and the prompt institution of
treatment can all but eliminate one of the most
frequent causes of maternal mortality. Deaths
from hemorrhage are largely preventable.
As a prophylactic measure, especially in hos-
pitals without blood banks, the routine practice
of typing all obstetric patients prenatally is recom-
mended. Also, the Rh status of each obstetrical
patient should be established and special precau-
tions taken should the patient be Rh negative.
Prolapsed Cord
Prolapse of the cord in vertex presentation is
usually an indication for immediate delivery, pro-
vided the child is alive and the cervix is dilated
enough. This implies six to seven centimeters
dilation in multigravid and eight to nine in primi-
gravid women. With dilations less than these,
hasty extraction of the child usually leads to
severe cervical lacerations and seldom results in
a living child. Delivery by forceps is justifiable
only if the head lies at mid-plane or below. With
higher stations, the procedure of choice may be
podalic version and extraction.
If the cord has prolapsed and the proper dila-
tion has not been obtained, the patient should be
placed in a deep Trendelenburg’s position and
closely watched until the cervix is dilated suffi-
ciently to permit the necessary maneuvers. Re-
placement of the cord- through a partially dilated
cervix is almost universally unsuccessful and I
believe should not even be attempted. Prophylactic
doses of penicillin or one of the sulfa drugs
should be given to each patient with cord prolapse
to prevent ascending infection.
Prolapse of the cord occurs once in approxi-
mately 150 deliveries and its occurrence depends
upon three factors : the presence of an excessively
long cord ; inadequate filling of the pelvic basin
by the presenting part ; and ruptured amniotic sac.
Tetanic Contraction of the Uterus
Tetanic contraction of the uterus is a possible
sequel to administration of pituitary extract. Doses
as small as one minim may produce tetanic con-
tractions enduring as long as five minutes. Other
factors, including long or obstructed labors, are
September, 1947
operative in causing this condition unless the
uterus can be relaxed. Two dangers become im-
minent, rupture of the uterus and asphyxia of the
child. The time-honored remedy is ether anes-
thesia. Magnesium ions have a relaxing effect
and the intramuscular administration of 2 c.c. of
a 50 per cent aqueous solution of magnesium
sulfate may be of benefit.
Bandl's Ring or Contraction Ring
The upper active contractile segment of the
uterus and the lower passive segment are sep-
parated by a physiologic ring of muscle which
normally is of little significance. In mechanically
obstructed labors, the upper segment progressively
becomes thicker and the lower thinner. This pro-
duces a gradual elevation of the physiologic ring
above the symphysis.
In rare instances pathologic constriction of this
physiologic ring about the child occurs. In these
cases a spastic stricture of uterine muscle is pro-
duced. Diagnosis is made by internal palpation. The
ring will probably not disappear but may be suf-
ficiently relaxed to permit delivery following the
intravenous injection of five minims of 1 :1000
epinephrine solution. Deep ether anesthesia also
lias a relaxing effect.
Uterine Rupture
Rupture of the uterus occurs once in 2000 to
3000 cases and may be incomplete or complete.
Despite its infrequency, discussion of the acci-
dent is included because of its dramatic nature
and potential dangers.
The fetal mortality approaches 100 per cent
and the maternal risk is considerable.
The principal etiologic factors include : pre-
vious cesarean section ; previous cervical operation
or repair ; obstructed labor with overdistended
uterine segment and operative procedures, espe-
cially internal version.
The diagnosis of uterine rupture is based upon
sudden, acute and lancinating pain, with abrupt
cessation of uterine pain and cessation of labor,
and the rapid development of hemorrhage and
profound shock.
The rupture of a previously intact uterus may
cause a dire obstetric emergency from shock and
hemorrhage, and death within the hour unless
heroic measures are applied.
Two methods of treatment are current : con-
servative and radical. Conservative treatment
951
OBSTETRIC EMERGENCIES— SCHADE
consists of either uterine and vaginal tamponade,
or laparotomy with suture of the rent. Hysterec-
tomy represents the radical method of treatment.
The latter is much preferred and is the generally
accepted treatment. Its advantages are numerous
and offers the best chance of recovery for the
mother. Nowhere in the entire field of medicine is
there such vital need for rapid mobilization of
facilities and early administration of plasma and
blood as in the emergency of acute uterine rupture
with severe hemorrhage. Sometimes rapid hyster-
ectomy is demanded despite falling blood pressure.
Plasma and blood must be given while the opera-
tion is being performed.
Inversion of the Uterus
Inversion of the uterus is a rare obstetric com-
plication but mention is made here because it
appears with sufficient frequency to make it nec-
essary for anyone doing obstetric practice to
familiarize himself with therapeutic procedures
for this condition. Reported incidence in various
parts of this country has ranged between 1 :740
to 1 : 16,000 deliveries.
Attempts to expel the placenta before its separa-
tion either bv pushing from above or by pulling on
the cord may be a predisposing cause although
the fundamental etiologic factor is unknown.
The symptoms are shock and hemorrhage asso-
ciated with absence of the uterine body from the
abdominal cavity and its presence in the vagina
as a rounded tumor, a mass whose upper end is
constricted by the encircling cervix.
Active and long-continued shock therapy is all-
important ! The immediate replacement of the in-
verted uterus under deep anesthesia has given the
unfavorable mortality rate of 10 to 43 per cent.
A few writers have pointed out that this is a
dangerous and unnecessary procedure.
Recent treatment has been to deal with the
inversion per se at any suitable time after the
patient is restored to normal health, preferably
four to twelve weeks following the acute episode.
The inverted uterus may be left entirely alone
unless the extent of the bleeding from it is such
as to require the application of a tight vaginal
pack. Treatment of the shock is the all-important
thing. If it is not present, it should be anticipated.
Multiple blood transfusions may be required not
only to combat the shock but also to hasten the
restoration of normal hemoglobin levels. Systemic
chemotherapy should be instituted at once as a
prophylactic agent. Local infection should be
further combated with daily application of local
antiseptic vaginal packing. After four to six
weeks in the hospital, the well-involuted uterus
may then be restored surgically to its normal
position or removed.
In conclusion, I wish to place emphasis on being
prepared for the emergencies that may be expected
in an obstetrical practice. We, as general prac-
titioners, conduct the vast majority of childbirths.
Emergency is a sudden condition — calling for im-
mediate action, and time is an all-important factor.
By its very nature, we cannot place the care of
emergencies in the laps of specialists.
DOES IT PAY TO WORK HARDER?
Does it pay to ivork harder? For the man who earns
$4,000 above his exemption, it manifestly pays to work
harder and earn $2,000 more, for Uncle Sam lets him
keep three dollars out of every additional four that he
gains by his hustling. The man making $8,000 above
iris exemption will probably feel it worth while to add
$2,000 to his income, for he is still privileged to keep
two out of every three added dollars. However, for
the man having an income of $15,000 above his exemp-
tions, the worthwhileness of striving to take in another
$5,000 raises serious questions in his mind, for, in his
case, the Federal Government takes more than half of
the added gains. One can hardly expect the man receiv-
ing $100,000 to he much interested in doubling his in-
come, for, if he does, he can only keep for his own
use one dollar out of every additional seven.
Obviously, the present income tax law constitutes an
effective device for preventing the most efficient business
and professional men from fully utilizing their talents.
The law acts, therefore, as a damper on production,
and hence lowers the income of the average citizen.
In addition, it prevents him from accumulating capital,
and thus hampers not only his progress, but that of
the nation as a whole. These are the results which
advocates of progressive taxation persistently refuse to
consider. There are none so blind as those who will
not see !
Willford I. King, author of “Wealth and Income of the
People of the U. S.” and Professor Emeritus of Economics
at New York University.
From Insurance Economics Survey, August, 1947.
952
Minnesota Medicine
THE GENERAL PROBLEM OF ANESTHESIA IN OBSTETRICS
EDWARD B. TUOHY, M.D.
Rochester, Minnesota
rPHE problem of providing anesthesia to women
in childbirth and of performing the safe de-
livery of newborn infants is a major responsi-
bility, especially for the general practitioner. In
hospitals where obstetric facilities are readily
available the teamwork between the anesthesiol-
ogist and the obstetrician simplifies somewhat the
general problem of handling the parturient mother.
There are certain factors which should be con-
sidered in the choice of any general or local
anesthetic, analgesic or amnesic agent. They are
as follows :
1. What is the physiopharmacologic action of
the agent on both maternal and fetal structures?
2. What fetal or maternal diseases or abnor-
malities exist which may alter the selection of
certain agents?
3. What agent or agents and method are best
suited to the emotional and physical status of the
mother ?
4. Is the method used one which will afford the
greatest safety to the mother and the infant?
Certain criteria should be present in the choice
of any agent or method. These agents should
possess adequate properties to obtund the pains
of labor without any untoward systemic reac-
tion. Secondly, the agent should be reasonably
prompt in its action and should not possess cumu-
lative effects. Thirdly, effective means of counter-
acting an overdose or idiosyncrasy to the agent
should be available.
It might be pointed out at this time that the
wisdom or advisability of the attempts to relieve
the pains of labor totally have been seriously
questioned by some authorities on this subject.
De Lee and Greenhill have emphasized repeatedly
the price that is paid to make childbirth painless.
Heaton in writing on obstetric anesthesia and
analgesia commented: “Perhaps, as the psychia-
trists have suggested the inordinate demand for
painless childbirth is symptomatic of the anxiety
and insecurity existing among certain groups in
our culture today. It is questionable from a psy-
From the Section on Anesthesiology, Mayo Clinic, Rochester,
Minnesota.
Read in the symposium on Obstetrics in General Practice
at the annual meeting of the Minnesota State Medical Asso-
ciation, Duluth, Minnesota, July 1, 1947.
September, 1947
chologic standpoint whether the passive role as-
signed to women in painless childbirth is a de-
sirable one.”
Opinions of various investigators with respect
to the effects of certain agents are occasionally
controversial, so that the comments made here
are a composite opinion and not one individual’s
conviction.
Many methods of analgesia and anesthesia have
been proposed but some of these are limited in
their practical application because they are too
technical and complex. Continuous caudal anes-
thesia might be mentioned as an example of a
highly technical procedure which is very valuable
but has limited application. In the conduct of
the average uncomplicated labor and delivery the
obstetrician and the anesthesiologist, singly or to-
gether, focus their attention on amnesic, analgesic
and anesthetic agents which will obtund pain and
produce at least relative amnesia. In the first
stage of labor analgesic and amnesic agents are
usually sufficient. In the second and third stages
of labor anesthetic agents are required, as a rule.
First Stage of Labor — Amnesic and
Analgesic Agents
At present, scopolamine in conjunction with a
barbiturate such as pentobarbital sodium is one of
the most effective combinations. The dose of
scopolamine is 1/150 or 1/100 grain (0.00043 or
0.0006S gm.) hypodermically administered when
labor pains are well established and regular and
there is effacement and beginning dilatation of
the cervix. Simultaneously 1/ to 3 grains (0.1
to 0.2 gm.) of pentobarbital sodium are given
orally. The administration of scopolamine is re-
peated about one hour after the initial injection.
Some authorities recommend three doses of 1/100
grain (0.00065 gm.) of scopolamine alone sub-
cutaneously administered at intervals of half an
hour when labor is established. The duration of
action of scopolamine is about two hours in the
dose mentioned. In prolonged labor additional
amounts of scopolamine may be required at inter-
vals of two hours. At least one drawback to this
method is the occasional occurrence of extreme
excitability and stimulation of the patient, neces-
sitating constant nursing attention.
953
ANESTHESIA IN OBSTETRICS— TUOHY
Another combination of agents which has more
analgesic effect as well as amnesic action is the
use of scopolamine, barbiturates and demerol.
The experience of several investigators has shown
that the combination of demerol and scopolamine
causes less fetal respiratory depression than sco-
polamine and demerol plus a barbiturate. A sug-
gested regimen with these agents is the hypo-
dermic injection of 100 mg. of demerol along
with 1/150 grain (0.00043 gm.) of scopolamine
when the labor pains are strong and regular. If
these two agents are not quite sufficient a barbitur-
ate can be given orally or rectally as a supplement.
The administration of demerol and scopolamine
may be repeated at intervals of three to four hours.
At this point a word should be said about mor-
phine and pantopon. In general, these opiates
should not be used within less than two hours
from the time of delivery, since they cause fetal
respiratory depression, and when a general an-
esthetic agent follows in sequence the incidence
of asphyxia neonatorum is definitely increased.
This is particularly true when one is dealing with
premature infants.
Rectal analgesia should be mentioned because
it is liked by many obstetricians and is a well-
accepted method of producing analgesia in labor.
Ether in oil (65 per cent ether — 35 per cent oil),
the original Gwathmey technique, has been modi-
fied to include paraldehyde, avertin, chloral hy-
drate and pentothal sodium as rectal analgesics.
The use of intravenous anesthesia is not recom-
mended, as a rule, in labor because of the rapid
and concentrated action of the agent on both
fetal and maternal respiration.
Of the inhalation anesthetic agents for obstetric
analgesia both the volatile agents, such as ether,
chloroform and divinyl ether, and gases, such as
nitrous oxide, ethylene and cyclopropane, are em-
ployed. Whereas various techniques of adminis-
tration of these agents have been described, in-
cluding self-administration, they are usually ad-
ministered during the second stage of labor when
anesthesia rather than analgesia is required.
Analgesia and Anesthesia in the Second
and Third Stages of Labor
Multiparous women give birth frequently spon-
taneously without the addition of any agent other
than the basal analgesia supplied. In most cases,
however, some form of general anesthesia or re-
gional anesthesia is required. Time-honored drop
ether and chloroform are used extensively, par
ticularly in deliveries at home. In hospitals where
the assistance of an anesthesiologist is available
many combinations of agents may be used. Dur-
ing delivery when the presenting part distends the
perineum the depth of general anesthesia should
be carried to plane 1 or 2 of the third or surgical
stage of anesthesia. Uterine contractions are not
abolished at this level of anesthesia but such pro-
cedures as episiotomy and application of forceps
can be done without pain to the patient. Nitrous
oxide will usually require the addition of ether
vapor to provide safe anesthesia in the second and
third stages of labor. One should avoid using any
concentrations of nitrous oxide greater than 80
per cent along with 20 per cent oxygen. Cyclo-
propane and ethylene are best suited for the ter-
minal stages of labor and should be administered
carefully by the closed technique.
Regional Anesthesia
Many procedures have been and are being
used, including pudendal block, transsacral block,
paravertebral block, caudal block, local infiltra-
tion and low spinal anesthesia. Certain techniques
require specific training, skill and experience; oth-
ers, such as local infiltration and pudendal nerve
block require minimal specialized technique. Tuck-
er and Benaron, Cleland, Lull and Hingson,
Lundy and Tovell and others have described their
techniques, and the merits of these techniques are
well established. Lor example, pudendal nerve
block is a successful type of block anesthesia for
many obstetric operations, including spontaneous
delivery, low forceps application, episiotomy and
perineorrhaphy. The contribution of Hingson and
his associates has shown that the continuous cau-
dal method has a definite place in obstetric an-
esthesia. It should be performed only by those
persons familiar and sufficiently trained in re-
gional anesthesia to know the indications and con-
traindications to this method. Caudal anesthesia
is applicable chiefly to hospitalized patients. Low
spinal or saddle anesthesia with hyperbaric solu-
tions is becoming more and more widely used.
Any one of several local anesthestic agents may
be used ; for example, procaine hydrochloride or
pontocaine hydrochloride. If procaine hydro-
chloride is used 50 to 75 mg. are dissolved in
2 c.c. of 10 per cent solution of dextrose. After
a lumbar puncture at the level of the third and
fourth lumbar interspace, this mixture is diluted
954
Minnesota Medicine
ANESTHESIA IN OBSTETRICS— TUOHY
with an equal volume of spinal fluid and injected
slowly. The injection is made with the patient
in the sitting position. Anesthesia is established
quickly and lasts for one to one and a half hours.
Postpartum bleeding is diminished and the babies
have little, if any, respiratory or circulatory de-
pression.
Cesarean Section
Cesarean section presents a difficult problem
as far as the choice of anesthesia is concerned.
What may be best for the mother may not be
best for the fetus. Prolonged general anesthesia
leads to marked fetal respiratory depression and
often to death of the fetus. Improperly controlled
spinal anesthesia has led to disastrous results.
Local infiltration or block anesthesia of the lower
abdominal wall in combination with inhalation
anesthesia or intravenous anesthesia at the time
the uterus is opened has been advocated by many
authors. If the timing of the general anesthetic
agent is correct, little, if any, depression of the
unborn child occurs. The objection to this proce-
dure by the mother is the main obstacle.
Hingson has advocated continuous caudal an-
esthesia utilizing posture to advance the anes-
thesia high enough to permit incision of the ab-
dominal wall above the umbilicus. The continuous
spinal technique has offered another method of
anesthesia which, if performed carefully, will
permit safe and satisfactory results for the mother
and child. There is usually less loss of blood in
cesarean section with local, caudal or continuous
spinal anesthesia than with inhalation anesthesia.
Of the inhalation anesthetics, if they alone are
used, cyclopropane is best as far as the baby is
concerned but resuscitation procedures are much
more common in these cases than with regional
methods or combinations of regional and general
methods.
Anesthesia in Complications of Pregnancy
Several outstanding complications are note-
worthy; namely, (1) hypertensive cardiac disease,
(2) nephritis, (3) pre-eclampsia and eclampsia,
(4) pernicious anemia, (5) leukemia, and (6)
other blood dyscrasias, including hemorrhagic
diathesis. In the presence of these complications
local or regional anesthesia is to be preferred to
general anesthesia, particularly with ether, chloro-
form or avertin.
Conclusions
If I may quote from an anonymous editorial:3
“The obtundation of pain and discomfort inci-
dental to parturition must necessarily occupy a
secondary role in most obstetricial deliveries. It
does not follow, however, that the pains during
labor and delivery usually do not belong in the
same category as pain associated with disease or
that caused by surgical operation. Labor is not a
disease, and expulsion of the fetus is not always
a surgical operation. They usually constitute a
physiologic process.
“The medical profession and its scientific allies
have not ignored the pangs of the parturient. In
fact efforts have been so generous at times that
pain relief seems to be exalted from its secondary
role in obstetrics to a place equalling the more
essential functions of the accouchement.
“During all the anesthesia years every new
drug or method introduced to facilitate surgery or
allay pain has found its way into obstetric prac-
tice. The use of ether and chloroform during
childbirth had a formidable place in early con-
troversies surrounding the acceptance of anes-
thesia but the drugs have played an important role
in obstetrics since. The lay press and non-medical
benefactors formulated and expressed opinions on
the merits of the early pain-relieving procedures.
They have followed through with similar jour-
nalistic efforts with the advent of every new de-
parture. Not infrequently obstetricians have re-
sented the publicity and particularly the inac-
curacies published for public edification. Their
remonstrances have led the modern accredited
press to more conducive reporting based upon
statements that may claim authority. However,
enthusiasm may often obscure the acumen of the
physician as well as the journalist.”
It should be our aim to make pain of the par-
turient as easy as possible, constantly keeping in
mind the safety of the newborn and the mother.
References
1. Cleland, J. G. P. : Paravertebral anesthesia in obstetrics;
experimental and clinical basis. Surg., Gynec. & Obst., 57 :
51-62, (July) 1933.
2. De Lee, J. B., and Greenhill, J. P. : The principles and
practice of obstetrics. Ed. 8. Philadelphia : W. B. Saunders
Company, 1943.
3. Editorial: Anesthesia for the pain of uncomplicated child-
birth. Anesthesiology, 6:410-413, (July) 1945.
4. Heaton, C. E. : The history of anesthesia and analgesia in
obstetrics. Hist. Med. & Allied Sc., 1 :567-572, (Oct.) 1946.
5. Lull, C. B., and Hingson, R. A. : Control of pain in child-
birth: anesthesia, analgesia, amnesia. Philadelphia: J. B.
Lippincott Company, 1944.
6. Lundy, J. S., and. Tovell, R. M. : Anesthesia for childbirth.
Northwest Med., 34:346-350, (Sept.) 1935.
7. Tucker, Beatrice E., and BenarOn. H. B. W. : The man-
agement of some obstetrical complications in the home.
M. Clin. North America, 22:197-21-2, (Jan.) 1938.
September, 1947
955
MEDICAL THERAPY IN ULCERATIVE COLITIS
P. G. BOMAN. M.D.
Duluth, Minnesota
'TT'HE term ulcerative colitis has been used in
connection with a variety of lesions of the
colon characterized by inflammation and ulcera-
tion. Many writers7’9’10’13 do not attempt to clas-
sify or to differentiate these conditions except
along general lines, but Bargen and associates1’2’3
have long contended that only by classifying them
according to etiology can we properly understand
and treat these situations. It is obvious that an
etiological basis can be found and demonstrated
in many cases of ulcerative colitis, i.e., those due
to tuberculous, amebic, bacillary and venereal
lymphogranulomatous infections.
There is considerable uncertainty about the
largest group which Bargen has classified under
the term, “streptococcic ulcerative colitis” and
which he differentiates from the regional colitis
and the colitis of unknown origin. Others classify
these conditions under one heading, contending
that they are different manifestations of the same
disease. Kiefer and Jordan10 have defined this
type as “a chronic disease of unknown etiology
in which there is a diffuse inflammatory reaction
involving all coats of the colon and rectum, either
as a whole or as a part — subject to unexplainable
remissions and exacerbations — and complicated by
varying degrees of sepsis, ulcerations and necrosis
of the mucosa which often results in extensive
fibrosis of the intestinal wall.” Bockus9 defines it
as “a clinical syndrome ushered in with a suppura-
tive, ulcerative inflammation of the colonic mucosa
with or without a recognizable initial specific
bowel infection, but associated with a bacterial or
toxic invasion of the bowel wall, conditioned by
varying immunologic, allergic, nutritional and
nervous phenomena.” It seems obvious that no
single etiologic agent obtains and that various
factors enter in. Influence of nutritional and emo-
tional states4’6 and allergic manifestations14 must
be given consideration along with infectious and
toxic factors. The one consistent and constant fact
about this type is that the reaction in the wall of
the bowel, viewed through the proctosigmoido-
From the Department of Internal Medicine, the Duluth Clinic,
Duluth, Minnesota.
Read in Symposium on Gastrointestinal Ulcerative Diseases at
the annual meeting of the Minnesota State Medical Association,
Duluth, Minnesota, June 30^ 1^47.
scope or demonstrated by the roentgenogram, is
characteristically diagnostic and not usually con-
fused with other clinical conditions. The lesions
begin in the most distal portion of the rectum and
progress upward. Whether a small part of the
colon or the entire colon is involved, the lesions
are continuous, uninterrupted and affect the entire
wall of the bowel. In the early stages the mucosa
presents a diffuse congestion and edema with tiny
submucosal hemorrhages. In the chronic stages
the mucosa has a dull red appearance with a rough
granular surface which bleeds with the slightest
trauma. Necrosis, ulceration and sloughing of the
mucosa are only seen in the most severe forms.
Anal and peri-anal lesions are common complica-
tions and polypoid changes in the mucosa are late
sequelae. Malignant changes undoubtedly take
place in some of these. Adenocarcinoma of the
bowel has been reported by Kiefer and Jordan10
in 7 per cent of chronic cases of ulcerative colitis.
Polypoid changes probably different from the
usual colonic polyps had developed in these cases.
The relationship of real polyps to carcinoma is
well known.
Because of the extensive involvement of the
wall of the bowel, the roentgen picture is charac-
teristic, especially in the chronic form. There is
a narrowing of the lumen, loss of haustral mark-
ings and a shortening of the colon, giving it in
the later stages the appearance of a smooth tube.
In the early and mild cases where the disease is
limited to the rectum, the roentgen findings may be
normal.
The clinical manifestations are extremely vari-
able, depending upon the stage of the disease and
the extent of the involvement of the colon. In the
mild cases with involvement of the rectum or
rectosigmoid, general systemic symptoms may be
mild or absent. There may be normal bowel
movements with additional purulent bloody dis-
charges occurring two to three times a day. As
the disease progresses, the rectal discharges in-
crease until diarrhea results and, correspondingly,
general systemic effects become apparent. In the
severe fulminating form the disease progresses
rapidly, with severe local and systemic effects.
956
Minnesota Medicine
ULCERATIVE COLITIS— BOMAN
There may be high fever, frequent bloody dis-
charges from the rectum, great prostration and
rapid decline. The disease may progress slowly
or remain latent for long periods, only to be-
come active again. Often the insidious form
may become fulminating following some inter-
current infection or emotional disturbance.
Regional ulcerative colitis and ulcerative colitis
of unknown origin are considered by Bargen2 as
being separate and distinct from the streptococcic
variety. Others5 feel that they are atypical mani-
festations of the same disease. In the regional type
any part of the colon may be involved, ranging
from 6 to 12 inches in length and with normal
adjacent bowel. The disease may be acute or
chronic, occasionally fulminating in character.
The symptoms will vary according to the severity
and chronicity of the disease. There is usually
diarrhea which may be mild or moderately severe
and is often preceded by abdominal cramps or pain
localized in the lower abdomen, more often in
the lower right quadrant of the abdomen. The
cramps and pain are usually relieved by evacua-
tion of the bowel. The stools are as a rule mushy,
liquid or mucoid in character and may or may
not contain blood. Gross hemorrhage, while rare,
may occur. General manifestations are generally
apparent and at times are more severe than those
seen in the average diffuse type. In the more
severe cases they are characterized by fever, weight
loss, anemia and occasionally by ocular, joint and
cardiac complications. The etiology is obscure and
may well be similar to that of the generalized
form of chronic ulcerative colitis. The diagnosis
depends on the clinical picture, characteristic
roentgen findings, and the absence of a specific
etiological factor.
Amebic ulcerative colitis caused by the Enda-
moeba histolytica involves primarily the cecum
and the flexures of the colon although the entire
bowel may be involved, in which case the lesions
are visible through the proctoscope. They present
a characteristic picture of punched-out areas with
raised margins surrounded by a hyperemia and
covered by mucus. Between the ulcers the mucosa
appears normal. The involvement is mainly in
the mucosa and not in the wall of the bowel. While
the symptoms as a rule are mild and general sys-
temic effects are not noted, severe manifestations
may be observed. Bleeding occurs relatively late
in the disease instead of being present as one of
the early symptoms. The roentgen findings are
usually characteristic and a great help in the
diagnosis. Early in the disease there may be some
narrowing and irritability of the cecum and as-
cending colon. Later the cecum becomes coned
or narrowed and irregular narrowing may be
noted in the entire ascending colon, differing from
the smooth diffuse narrowing encountered in the
streptococcic type. The demonstration of the En-
damoeba histolytica in motile or cyst form will
confirm the diagnosis.
Ulcerative colitis due to the virus of venereal
lymphogranuloma involves the distal portion of
the colon and the rectum. The disease attacks the
entire wall as well as the mucosa and the lymphatics
around the bowel, producing a rather stiff, thick-
ened tube. Multiple small sinuses from the mucosa
to the deeper structures may result. Symptoms are
minimal and complaints concern mainly, rectal dis-
comfort. The diagnosis is made from the procto-
scopic appearance, the history of previous venereal
infection and the positive Frei test.
Chronic bacillary infection of the intestinal
tract may produce ulcerative lesions. The lesions
are regular as to size and shape and are dis-
seminated. While the roentgen findings may be
characteristic, the diagnosis depends on positive
stool cultures or positive agglutination tests. Spe-
cialized technique employed by experienced labo-
ratory personnel is essential in making these stool
cultures if reliable results are to be obtained. The
agglutination tests may be unreliable because of
antigenic variants.
Tuberculous ulcerative colitis, while usually as-
sociated with tuberculous disease in the small
bowel, may occur as a primary entity. It is us-
ually secondary to tuberculosis of the lungs or
tuberculosis in some other part of the body. The
ulcers are distributed irregularly and are asso-
ciated with lesions visible on the serous surfaces
of the bowel and with miliary tubercles. The
disease progresses from the ileum downward and
involves most frequently the proximal portion of
the colon. Seldom are the lesions visible through
the proctoscope, and one must rely on the roentgen
evidence to make the diagnosis.
While it is not generally accepted that intes-
tinal allergy is a primary factor in the develop-
ment of true ulcerative colitis, Rowe14 believes
that chronic ulcerative colitis may be caused by
severe allergic reactivity in the colonic mucosa
September, 1947
957
ULCERATIVE COLITIS— BOMAN
similar to that responsible for atopic dermatitis.
Ulceration, fibrosis, scar tissue formation and
bowel perforation may arise from superimposed
secondary infections from various bowel bacteria.
iBargen is of the opinion that intestinal allergy
should be considered as a condition quite apart
from ulcerative colitis. He states that it may
play a part in many ulcerative intestinal inflam-
mations, but that it is not necessarily causative
in any of them.
The proper medical management depends on
classifying the various types of ulcerative colitis
from the standpoint of etiology and on a careful
differential diagnosis. While it is doubtful that
any medical regime can bring about a permanent
cure of this disease, much can be done to pro-
mote a remission or an arrest of the active dis-
ease. If organic changes, such as fibrosis and
scarring, have occurred, these are as a rule per-
manent and irreversible, and surgical treatment
may be indicated. However, under these condi-
tions, medical management may produce improve-
ment in bowel function and in the general health
of the patient as the active phase of the disease
is arrested.
Medical management might well be divided into
( 1 ) general supportive measures and symptomatic
relief, and (2) the use of specific measures best
suited to the individual case. In the idiopathic
or streptococcic type of ulcerative colitis, rest plays
an important part. In mild cases rest in bed may
not be necessary. However, in the more severe
cases total body rest is indicated. Increasing
recognition of the role played by mental and' emo-
tional stress as the precipitating or aggravating
factor merits our attention.6’7’® Due consideration
should be given to this factor and attempts should
be made to eliminate it as far as possible. Often-
times psychiatric approach and treatment may be
necessary. In many instances, assurance and the
use of simple sedation will be sufficient.
Likewise, rest for the colon in the form of re-
lieving intestinal peristalsis should be secured ;
this can best be obtained by the selection of a
proper low-residue diet, the use of adsorptive
powders, such as bismuth and kaolin, the use of
antispasmodics and, at times, opium and its deriva-
tives.
Dietary considerations are important both from
the standpoint of preventing irritation in the lower
bowel as well as that of correcting malnutrition.
The diet should be high in calories, proteins and
vitamins and lowr in residue. The amount and type
of food will depend upon the patient’s ability
to tolerate it. It may be necessary to begin with
small feedings, increasing the food intake cau-
tiously until an optimum amount can be taken.
Supplemental vitamin administration is indicated
in nearly all cases. In the more severe and ful-
minating cases, if malnutrition and hypoprotein-
emia are present, whole blood, plasma and intra-
venous amino acids are indicated. When allergic
manifestations or deficiency states are present,
special consideration must be given to these fac-
tors.
As anemia is almost invariably present and in
many instances may be severe, this must receive
careful attention. The more severe anemias must
be treated by blood transfusions, using a series of
small transfusions rather than a few of larger
amounts. Iron should be given in minimal amounts
and administered with caution because of the ir-
ritating effect often produced on the intestines.
Chemotherapy in ulcerative colitis has shown
varying results. Many optimistic reports on its
use have been noted, especially in the acute and
septic phases, but often it has proven of little or
no demonstrable value. While there does not ap-
pear to be any specific effect upon the primary
cause of the disease, there is undoubtedly consider-
able value in the control and prevention of sec-
ondary bacterial invasion. Various drugs of the
sulfonamide series, such as azosulfamide (neo-
prontosil), succinlysulfathiazole (sulfasuxidine),
sulfaguanidine, sulfathaladine, nisulfadine and ni-
sulfazole have been used with varying success.
Azosulfamide and succinlysulfathiazole have re-
ceived the most favorable mention.2 In the acute
septic cases a more absorbable form, such as sulfa-
diazine, may be indicated. Average amounts may
range from 50 to 100 grains daily, given in divided
doses. Careful consideration must be given to the
reaction of the individual patient and the admin-
istration governed accordingly.
Penicillin and streptomycin have shown promise
in certain cases, especially when used in the acute
cases.11’12’15 However, they have not been given
adequate trial to fully evaluate them. It seems
probable that their effect will be similar to that
of the sulfonamides. Bargen has long been an ad-
vocate of the use of antistreptococcus vaccine and
feels that it is of distinct value in prolonging re-
958
Minnesota Medicine
ULCERATIVE COLITIS— BOMAN
missions and in preventing recurrences. Fever
therapy produced by the intravenous administra-
tion of typhoid vaccine has been used in the
chronic form with results comparable to those
obtained with other forms of medical therapy.10
Recently A. Morton Gill8 of London has re-
ported on the use of a preparation extracted from
the mucosa of the small intestines of pigs. While
the results were encouraging, further study is
necessary to evaluate this form of therapy.
There has been considerable difference of opin-
ion as to the use of surgical measures in non-
specific or streptococcic ulcerative colitis. Bargen
believes that this form of therapy should be re-
served for complications and for use in certain
patients who do not react favorably to a careful
medical regime. In his experience the mortality,
especially in the acute severe cases, has been lower
under medical management than where surgery
has been employed. Kiefer and Jordan and asso-
ciates believe that well directed and aggressive
surgical measures will save many lives, especially
in the acute septic cases, and that it will also
rehabilitate chronic colitis invalids. They state
that total colectomy can be called the only actual
cure of ulcerative colitis now available.
Ileostomy, which is employed to place the colon
at rest, seems indicated in acute febrile cases as
an emergency measure where medical management
has failed, in impending perforation and in in-
stances of gross hemorrhage. The mortality in
these cases will be high, especially if it is done as
a last resort. If the procedure is carried out early
before the patient’s resistance has become too
low, the mortality is reduced.10 In the chronic
cases where recurrences are frequent and severe
and where complications are developing, ileostomy
should be considered. It is seldom that an ileos-
tomy is of a temporary nature and must be con-
sidered as a permanent measure or as preliminary
to complete colectomy. Partial or complete colec-
tomy will in certain instances restore chronic
invalids to a useful existence. Considered judg-
ment and surgical skill are necessary to obtain a
low mortality.
In regional ulcerative colitis, medical manage-
ment of the type described above may bring about
remissions and apparent cure. However, it is
largely confined to the problem of rehabilitation
for future surgical treatment. Because of the
high incidence of recurrence and the unpredictable
manner in which this disease behaves, radical sur-
September, 1947
gical excision is the treatment of choice. This
should only be carried out after a careful and
proper rehabilitation of the patient and the reduc-
tion of infection to a minimum.
In amebic ulcerative colitis, a combination of
general supportive measures and the administra-
tion of suitable preparation of ipecac, arsenic and
iodine will usually control or cure the disease.
Continued observation of the patient with exami-
nation of the stools is necessary in order to ascer-
tain whether the treatment has been effective. The
drugs usually used are emetine hydrochloride, car-
barsone, diodoquin and chiniofon.
In the chronic bacillary type of colitis, the sul-
fonamide preparations, particularly sulfadiazine,
succinylsulfathiazole and sulfaguanidine, have
given very satisfactory results. In the acute stages
sulfadiazine'alone or in conjunction with succinyl-
sulfathiazole or sulfaguanidine should be used. In
the more severe chronic cases sulfaguanidine given
in large doses has been most effective.
In ulcerative colitis due to the virus of venereal
lymphogranuloma, chemotherapy, especially the
sulfonamide compounds, has proven of the great-
est value. Here again succinylsulfathiazole and
sulfaguanidine appear to be the most useful be-
cause of their lack of toxicity and because of
the minimal systemic absorption.
In tuberculous ulcerative colitis, the newer
forms of chemotherapy, especially streptomycin
and some of the newer sulfonamide compounds,
undoubtedly will prove of great value in the man-
agement of this disease. This must be supple-
mented with adequate care in a sanatorium with
all of the known therapeutic measures usually
used in the treatment of tuberculosis.
Summary
1. Ulcerative colitis is a disease of known and
unknown etiologies characterized by specific
changes in the colon and influenced by various
infectious, toxic, allergic, nutritional and neuro-
genic factors.
2. Classification according to etiology is neces-
sary to properly understand and treat this disease.
3. Medical management is dependent on a
careful differential diagnosis and the proper ap-
plication of known effective theraputic measures.
4. Surgical measures complementing medical
management are indicated in severe, intractable
cases and in the presence of complications.
(Continued on Page 964)
959
MEDICAL TREATMENT OF PEPTIC ULCER
J. ALLEN WILSON, M.D., Ph.D.
Saint Paul, Minnesota
TN considering the medical treatment of peptic
ulcer, the treatment of the patient and his
problems, conflicts and habits is fully as impor-
tant as the treatment directed at the ulcer. Bock-
us1 has emphasized that the mental conflicts and
anxieties common to all of us contribute to the
development, chronicity, and recurrences of pep-
tic ulcer. Business or financial worries, marital
incompatibility and domestic unhappiness are
common factors.
We all know how the stresses of this last war
caused a tremendous increase in the incidence of
ulcer. One authentic striking example occurred
in the crew of an American submarine which was
submerged and under heavy depth charging by a
Japanese destroyer squadron for forty-eight
hours. When that submarine finally limped into
port, 40 per cent of the crew had developed severe
gastrointestinal syndromes and 14 per cent of the
crew were found to have definite peptic ulcers.
Many a patient first notices ulcer symptoms
after vainly trying to perform the duties of a job
for which he is not suited or qualified. The treat-
ment of those patients includes an effort by the
physician or psychiatrist to help remove the nerv-
ous tension or conflict. Where domestic unhap-
piness exists, the patient should be removed from
that environment to a hospital for the first part of
his treatment. A talk with the patient’s employer
may straighten out the worry about his job. Get-
ting the patient to take a much needed vacation or
to go off on fishing or hunting trips or to develop
a hobby are all means of helping the nervous
background for ulcer. Encouraging the patient to
develop regular hours of eating and sleeping and
to eat slowly are all important parts of treatment.
Excessive use of alcohol and tobacco must be
stopped, and there is no doubt that complete absti-
nence from both agents is essential in the ma-
jority of patients. In this country we rarely see
deficiencies of diet or of vitamins playing a role in
ulcer development or recurrence.
In treatment directed toward the peptic ulcer
itself, what are some of the factors required to
produce healing?
Read in Symposium on Gastrointestinal Ulcerative Diseases at
the annual meeting of the Minnesota State Medical Association,
Duluth, Minnesota, June 30, 1947. f
1 . The motor and secretory activity or work
of the stomach must be reduced. Physical inac-
tivity of the patient reduces his appetite and sub-
sequent hunger contractions. A bland diet with-
out stimulating meats or irritating foods reduces
the chemical and hormonal phase of gastric se-
cretion. Vagus depressants and central nervous
system sedatives help also to modify motor and
secretory activity.
2. Bed rest, preferably in a hospital, for the
first three weeks of an ulcer management un-
doubtedly helps all ulcer patients to make a good
start on healing the ulcer and in educating them
to their medical regime. Hospitalization is abso-
lutely essential in patients with intractable pain,
or with bleeding, obstruction or symptoms sug-
gesting early penetration or possible perforation
of the ulcer. Actually, however, I find that in
office practice, especially now when hospital beds
are extremely difficult to obtain without a consid-
erable delay, that probably not more than 10 to
15 per cent of ulcer patients urgently need to be
hospitalized. A satisfactory ambulatory medical
regime can be very effective in the majority of
uncomplicated duodenal ulcers or small gastric
ulcers of the lesser curvature.
3. Diet is of great importance in the healing of
an ulcer. It should consist of frequent small feed-
ings of milk and cream, or other bland feedings,
avoiding regular sized meals at first in order to
avoid gastric distention with its increased secre-
tion of acid gastric juice. The addition of cream
to the milk adds calories and inhibits the secretion
of acid, as well as tending to hold the mixture in
the stomach long enough to allow neutralization
to take place. I usually have the patient take 3
ounces of two-thirds milk and one-third cream
each hour between meals, carrying a thermos bot-
tle to work with him if he is on an ambulatory
regime. No milk or food is to be used after 7 :00
p.M. in order to cut down the continued secretion
of acid gastric juice after bedtime. In an uncom-
plicated ulcer, on an ambulatory schedule, I allow
three bland meals, in addition to milk and cream,
insisting that the evening meal be the smallest of
the three in volume, again in an effort to reduce
continued secretion through the night, and thus to
960
Minnesota Mehicine
PEPTIC ULCER— WILSON
reduce night pain. I believe it is bad practice to
allow milk at bedtime. Chicken, fish or tender
lamb or beef may be allowed at the noon meal,
but not in the evening. In hospitalized patients,
where there is a suspicion or definite evidence of
obstruction, one must, of course, be much slower
to add regular meals or to increase the bulk of
food intake until obstruction due to spasm and
edema has been relieved or until it has been estab-
lished that there is an organic obstruction. In
rare instances, where an ulcer patient is allergic
to milk, one can often use evaporated milk, jun-
ket, milk with lime water added, powdered skim
milk, or protein hydrolysates. Goats’ milk or soy
bean milk at times can be helpful. If none of
these are helpful, one must then depend on a
two-hourly schedule of feedings with cooked ce-
real, egg, gelatin, soups with flour thickening, et
cetera.
4. There is much divergence of opinion as to
the need for antacids in the management of the
uncomplicated ulcer, yet almost all recognized au-
thorities use some form of antacid in ulcers com-
plicated by severe pain, obstruction or hemor-
rhage. Many writers feel that hourly feedings of
milk without antacids are as effective in produc-
ing symptomatic relief and ulcer healing as the
Sippy method of complete neutralization. Hollan-
der6 found that peptic activity ceases at a pH of
4.5 to 5 ; yet complete neutralization requires an
elevation of pH to 7. He felt that the acid-peptic
factor is the important one in ulcer genesis and
healing — not just free acid alone. However, it is
this speaker’s experience that pain, especially
night pain, will disappear sooner, and healing will
begin more rapidly, and that bleeding will stop
more promptly, if an antacid is used on an hourly
schedule throughout the day (halfway between
milk feedings) and at half-hourly intervals after
7:00 p.m. (when all milk is stopped) until bed-
time. In hospitalized patients, if night pain is
persistent, the stomach is emptied at 9:30 p.m.
and antacid is given at hourly intervals until mid-
night and at two-hour intervals throughout the
night for the first few nights until the pain dis-
appears. The antacid used has been a colloidal
suspension of aluminum hydroxide alone or with
magnesium trisilicate added. Tests of patient’s
gastric contents at various times of the day have
shown that free acid is very low or absent when
3 ounces of milk and cream are used on the hour
and 2 teaspoonfuls of colloidal aluminum hydrox-
September, 1947
ide are taken on the half hour. On an ambulatory
regime I allow patients to use tablets of aluminum
hydroxide, which can be easily taken at work.
Milk of magnesia may be required once or twice
daily to prevent constipation. Soluble alkalies are
now rarely justified because of the danger of al-
kalosis, which is not found with aluminum hy-
droxide or aluminum phosphate. Occasionally
aluminum hydroxide has been found to combine
with a large mass of blood clots to cause bowel
obstruction during a hemorrhage, though this is,
fortunately, very rare. I have never observed
such a complication.
5. Tincture of belladonna or atropine given at
four- to six-hour intervals will be of considerable
help in relieving intractable pain and reducing
spastic obstruction to emptying of the stomach.
In the latter cases, atropine should be given by
hypodermic. In ambulatory patients, tincture of
belladonna, with sodium bromide or phenobar-
bital or pavatrine tablets containing phenobarbital
are very helpful in the ulcer management. At-
ropine, belladonna and pavatrine, whereas not as
effective as vagus resection, at least do put a
strong brake on vagus action. The bromide or
phenobarbital helps to slow down and relax the
tense, driving individual with whom we usually
have to deal. In the early stages of an ulcer diet,
especially when milk and cream alone may be
used, vitamins B and C are advisable. Ferrous
sulphate should be added if the hemoglobin is
low, for an ulcer diet is poor in iron.
There are various procedures which may be of
considerable aid in the medical treatment of pep-
tic ulcer. Gastric aspirations at bedtime, probably
by means of an Ewald tube, are of great help in
determining the presence of clinical gastric reten-
tion. If such evening aspirations done at 9:30
p.m. with no milk or water intake after 7 :00 p.m.
yield much more than 200 c.c. of gastric contents
night after night for two weeks, with no gradual
decrease in the amount aspirated, one may be
quite sure he is dealing with organic pyloric ob-
struction and the patient should be referred for
operation. However, if the evening aspirated gas-
tric contents increase gradually under treatment
from 800 to 1,000 c.c. down to less than 200 c.c.,
one may be sure the retention has been due to
spasm and edema at or near the pylorus. Contin-
uous aspiration of the night secretion of the stom-
ach through a nasal tube may be helpful in ques-
tionable cases. Sandweiss et al10 have shown that
961
PEPTIC ULCER— WILSON
after a well-balanced meal, taken at 6:00 p.m., an
average amount of 446 c.c. of gastric juice was
obtained on continuous suction from 12 :00 mid-
night to 7 :00 a.m. in normal persons and in un-
complicated duodenal ulcer cases. In ulcers, ac-
companied by pyloric obstruction, the amount is
much greater. Jejunal feedings, by means of a
nasal tube which has been passed through the py-
lorus into the small bowel, may rarely be needed
to reduce pyloroduodenal motility in cases of in-
tractable pain. The gastric acidity can be con-
trolled by continuous suction through another
tube introduced into the stomach, or by using
small hourly oral doses of aluminum hydroxide.
Continuous nasal drip of alkalinized milk or of
aluminum hydroxide has been recommended espe-
cially for bleeding ulcers. This has the advantage
of continuous protection of the ulcer from acid
but is irritating to the patient and thus may
cause more harm than good, as a result of vagus
effects on the stomach.
In the past twenty years innumerable other
agents and regimes have been suggested and tried
and usually found ineffective or inferior to the
acid neutralization method. Gastric mucin was
discarded because it had little neutralizing power
for acid and was difficult to administer. Innu-
merable substances for parenteral injection have
been introduced including aolan B. prodigiosus,
lipoproteins with emetine, and many vaccines. It
has been shown that almost any form of protein
shock may ameliorate the symptoms of ulcer but
have no effect on the healing of the ulcer. Histi-
dine injections have had wide usage and popular-
ity in many quarters. The writer, in 1938-39,
studied a series of eighteen duodenal and gastric
ulcer patients who were given full courses of in-
jections of histidine (Larostidin). Many of the
patients reported considerable relief of pain but
in nbt one patient were the x-ray findings of an
active ulcer (with crater) improved at the end of
the course of treatment. Bockus1 states : “I know
of no scientific basis for the use of histidine par-
enterally in ulcer therapy.” He also found no
clinical justification for its use in these cases.
Deep x-ray has also been used in ulcer therapy
but has dangerous side effects and its only value
would seem to be in intractable duodenal ulcer
and some cases of jejunal ulcer, where the tem-
porary achlorhydria has been helpful.
Two other newer adjuncts in the treatment of
peptic ulcer may be briefly described. Greengard,
Atkinson, Grossman and Ivy4 have reported that
parenterally administered enterogastrone, a highly
purified mucosal extract of the first few feet of
the small bowel of the hog, has an inhibitory effect
on gastric secretion. It has protected Mann-Wil-
liamson dogs from death or ulcer recurrence,
often for one to five years after cessation of ulcer
management and the authors have now confirmed
the beneficial effect on fifty-eight human ulcer pa-
tients. The material is effective only on parenter-
al injection and was administered three to six
times weekly for a year. This method as yet is
still in the experimental phase, and it is unlikely
that enterogastrone will ever become a widely
used adjunct in the ^treatment of peptic ulcer,
though it may find limited use.
The second newer adjunct in ulcer treatment is
the use of protein hydrolysates. Reports by Co
Tui et al2 in 1945, and by Kimble7 and Hodges5
in 1947 have pointed out the value of protein
hydrolysates obtained from milk or beef in sup-
plying a concentrated easily assimilable food for
frequent-feeding schedules which correct the pro-
tein deficiency which has been found to exist in
the blood of many ulcer patients. Solutions of
these protolysates can be given intravenously, by
continuous intragastric drip, or by hourly or two-
hourly feedings (alone or alternating with a
standard milk-cream feeding. The use of amino
acids in the treatment of ulcers was first sug-
gested by Levy and Siler.8 Co Tui found ulcer
craters disappeared (by x-ray) in from ten to
thirty days. Recurrences of the ulcer promptly
occurred if no further dietary regime was fol-
lowed. Kimble found the average serum proteins
before nine days of treatment was 5.3 gms. per
cent and increased after treatment to 6.2 grams
per cent. In nine of fifteen cases, x-ray evidence
of ulcer disappeared after an average of nine
days of treatment. These patients were then
placed on a partial ambulatory ulcer regime at the
end of this protolysate treatment. Hodges, in a
series of twenty-six patients, selected largely pa-
tients who had had no benefit from, or had had a
recurrence of ulcer symptoms while on "ade-
quate” conventional dietary therapy. The average
patient received 285 gms. of protein and 2,900
calories daily. This regime proved more effective
in producing ulcer remissions than was convention-
al treatment but the frequency of relapses after
treatment (two to three weeks) was not decreased.
The present writer has had experience with this
962
Minnesota Medicine
PEPTIC ULCER— WILSON
method, using Parenamine and glucose intraven-
ously without oral feedings or using a mixture of
Essenamine (a protolysate), glucose, sodium
chloride and water in hourly oral feedings. Both
methods have the same advantages over conven-
tional ulcer treatment but are much more expen-
sive to the patient and necessitate careful observa-
tion in a hospital. As Hodges reports, protein hy-
drolysates may be a useful adjunct in the medical
treatment of peptic ulcer, but as now used are no
panacea.
How long is it necessary to continue a medical
regime for peptic ulcqr in order to insure healing
of the ulcer? The criteria usually used for heal-
ing of an ulcer are disappearance of the duodenal
or gastric ulcer crater and loss of irritability or
spasm of the duodenal cap. Using these criteria
Cummins, Grossman and Ivy3 found the average
“healing time” in sixty-three duodenal ulcers to
be thirty-seven days (range thirteen to sixty-eight
days) and in six gastric ulcers to be forty -two
days (range eighteen to sixty-eight days). Sev-
eral gastroscopic studies have shown gastric ulcer
to heal in three to six weeks in some cases and in
over twelve weeks in others. Gastroscopic check
on x-ray studies has often found re-epithelization
soon after disappearance of the niche. In other
cases, a shallow crater still remained after the
niche had disappeared. Recently, Pollard, Bach-
rach and Block9 have reported on the rate of
healing of a series of 100 gastric ulcers (judged
by disappearance of the crater on x-ray) . Thirty-
eight benign gastric lesions failed to heal under
hospital treatment in an average stay of twenty-
three days ; thirty-three patients were left in the
hospital until a negative x-ray was obtained. This
required an average of twenty-five days’ (range
of ten to fifty days). The authors found that, in
general, the ulcers which did not heal had a high-
er acidity than had the “healed” group. I am
strongly of the opinion that x-ray evidence of
healing of an ulcer, especially a duodenal ulcer, is
not adequate evidence of clinical healing, and my
ulcer patients are advised to follow a full ambu-
latory management for a minimum of four to
six months, depending on the location of the ulcer
and its chronicity. Partial neutralization is car-
ried out for several months more. Surveys made
in the past of several thousand ulcer patients
treated by the Sippy method have revealed that
the highest percentage of ulcer recurrences fol-
lowed cessation of a strict medical regime in one
September, 1947
or two months, and those who remained on it for
six months up to a year had a very low percent-
age of ulcer recurrences. The factors which are
most prone to produce an ulcer recurrence are too
early discarding of the careful medical ulcer re-
gime ; periods of anxiety, mental conflict or nerv-
ous tension ; heavy smoking ; and more than oc-
casional use of alcohol.
The space allotted for this paper will not allow
more than bare mention of the medical treatment
of the complications of peptic ulcer. Perforation
and its sequellae, penetration, organic pyloric ob-
struction, all require surgical treatment. The
medical treatment of obstruction preliminary to
surgical procedures includes correction of the de-
hydration, hypochloremia, alkalosis and hyperazo-
temia, as well as building up the blood proteins
by intravenous amino-acid or protolysate admin-
istration. Keeping the stomach empty or from
overdistention, by means of morning and evening
aspirations or at times by constant nasal suction,
is very important. The presence of or recent his-
tory of hematemesis or melena is not an indica-
tion for operation unless bleeding cannot be
checked by a. medical regime. Usually a second
episode of bleeding, while under medical manage-
ment, is an indication for prompt surgical treat-
ment if the patient is in the arteriosclerotic age
group. In younger patients a medical regime,
particularly complete acid neutralization day and
night by means of aluminum hydroxide (in addi-
tion to protolysate or merely milk and cream feed-
ings hourly throughout the day) has promptly
stopped the hemorrhage and yielded stools free
of occult blood within seven to ten days. Liver
function tests should be done if hepatic cirrhosis
is suspected of being the cause of the bleeding
when a patient is first seen. Carcinoma is respon-
sible for not over 5 per cent of all massive gastric
hemorrhages. Bnckus1 states that a patient with
upper gastrointestinal hemorrhage who is not in
shock should not be treated for shock and that
unnecessary blood transfusions may be disastrous.
This is very true but such patients can go into
shock quickly at times so they must be very care-
fully watched by very frequent pulse and blood
pressure readings. Hypodermoclysis or a slow
intravenous drip of glucose in saline or of pro-
tolysate may be all that is needed to restore the
blood volume gradually. Massive hemorrhage, of
course, requires blood plasma or repeated blood
transfusions. The mortality in massive hemor-
963
PEPTIC ULCER— WILSON
rhage has been given as not over 10 per cent —
probably no greater than the average operative
mortality when surgical intervention is attempted
in the case of hemorrhage.
The medical management in these cases should
include careful neutralization of acid through the
night hours — otherwise it differs little from that
of nonbleeding ulcers. The Meulengracht diet has
never seemed rational to this speaker since it use
defeats the entire principle of acid neutralization
and motor rest for the stomach.
Carcinomatous ulcer of the stomach becomes at
once a surgical problem. It has been my practice
to treat medically any gastric ulcer of the upper
two-thirds of the lesser curvature which on x-ray
and gastroscopy appears probably benign and
where free acid is present in the gastric contents.
The ulcer is observed by both methods at two-
week intervals until the lesion has completly dis-
appeared. Stools are watched for occult blood.
If the progress of healing ceases at any time, sur-
gical consultation is requested. It is felt that the
number of carcinomas whose prompt diagnosis is
delayed by this method is no greater than the
number of surgical fatalities among benign le-
sions unnecessarily operated upon.
In conclusion it is emphasized that the medical
treatment of peptic ulcer must primarily treat the
patients, his habits, and the factors in his nervous
make-up and in his domestic and economic envi-
ronment which have contributed to development
of his ulcer. In treatment directed at the ulcer
itself, the motor and secretory work of the stom-
ach must be reduced and the gastric acidity must
be largely, if not completely, neutralized by hour-
ly feedings and non-absorbable antacids. The im-
portance of controlling the night secretions of
acid is stressed, especially in bleeding ulcer cases.
Protein hydrolysates have been briefly discussed
and are found valuable especially in ulcers com-
plicated by non-organic obstruction or by hemor-
rhage.
References
1. Bockus, H. L. : Gastroenterology. Vol. 1. Philadelphia:
W. B. Saunders Company, 1946.
2. Co Tui, F. ; Wright, A. M. : Mulholland, J. H. ; Galvin, T. ;
Burcham, I., and Gerat, G. R.: The hyperalimentation treat-
ment of peptic ulcer with amino acids (protein hydrolysate)
and dextrimaltose. Gastroenterology, 5:5, 1945.
3. Cummins, G. M. ; Grossman, M. I., and Ivy, A. C. : A study
of the time of “healing” of peptic ulcer in a series of sixty
nine cases of duodenal and gastric craters. Gastronenterol-
ogy, 7:20, 1946.
4. Greengard, H.: Atkinson, A. J. ; Grossman, M. I., and Tvy,
A. C. : The effectiveness of parenterally administered “en-
terogastrone” in the prophylaxis of recurrences of experi-
mental and clinical peptic ulcer. Gastroenterology, 7:625, 1946
5. Hodges, H. H.: Protein hydrolysate therapy for peptic ulcer;
report on twenty-six cases. Gastroenterology, 8:476, 1947.
6. Hollander, F. : What constitutes effective neutralization of
gastric contents? Am. J. Digest. Dis., 6:127, 1939.
7. Kimble, S. T. : A preliminary report on protein hydrolysate
therapy for peptic ulcer. Gastroenterology, 8:467, 1947.
8. Levy, J. S., and Siler, K. A.: Clinical studies of amino
acids. I. The effect of oral administration of a solution of
an amino acid mixture on gastric acidity. Am. J. Digest.
Dis., 9:354, 1942.
9. Pollard, H. M.; Bachrach, W. H., and Block, M.: The rate
of healing of gastric ulcers. Gastroenterology, 8:435, 1947.
10. Sandweiss, D. J.; Friedman, M. H. F. ; Sugarman, M. H.,
and Podolsky, II. M. : Nocturnal gastric secretion. II. Studies
on normal subjects and patients with duodenal ulcer. Gas-
troenterology, 7:38, 1946.
MEDICAL THERAPY IN ULCERATIVE COLITIS
(Continued from Page 959)
References
1. Barbosa, J. C.; Bargen, J. Arnold, and Dixon, Claude F. :
Regional segmental colitis. S. Clin. North America, p. 939-
968, (Aug.) 1945.
2. Bargen, J. Arnold: The Modern Management of Colitis.
Springfield, Illinois: Chas. C. Thomas, 1943.
3. Bargen, J. Arnold: The medical management of ulcerative
colitis. J.A.M.A., 126:1009-1013, (Dec. 16) 1944.
4. Bercovitz, Z., and Page, Robert C. : Metabolic and vitamin
studies in chronic ulcerative colitis. Ann. Int. Med., 20:
239-254, (Feb.) 1944.
5. Crohn, Burrill B.; Garlock, John H., and Yarnis. Harry:
Right-sided regional colitis. J.A.M.A., 134:334-338, (May
24) 1947.
6. Daniels, George E.: Nonspecific ulcerative colitis as a psy-
chosomatic disease. M. Clin. North America, p. 593-602,
(May) 1944.
7. Drueck, Charles J. : Treatment of chronic ulcerative colitis.
Am. J. Digest. Dis., 11:10-13, (Jan.) 1944.
8. Editorial: Organotherapy in ulcerative colitis: a new and
interesting therapy. Am. J. Digest. Dis., 14:77-78, (Feb.)
1947.
9. Johnson, Major Thomas A.: Diagnosis and management of
ulcerative colitis. M. Clinics North America, p. 329-335,
(March) 1946.
10. Kiefer, Everett D., and Jordan, Sarah M.: A review of the
problem of chronic ulcerative colitis. Tr. Am. Proct. Soc.,
p. 487-506, 1946.
11. Kirschner, Benjamin: Acute fulminating ulcerative colitis.
New York State J. Med., 46:525-526, (March 1) 1946.
12. Korostoff, Capt. Bernard B., and King, Capt. Harry E.:
Penicillin therapy in ulcerative colitis. Am. J. M. Sc., 211:
293-298, (March) 1946.
13. Major, Ralph H.: Treatment of ulcerative colitis with
nisulfadine and nisulfazole. J. Lab. & Clin. Med., 31:219-
226, (Feb.) 1946.
14. Rowe, Albert H.: Chronic ulcerative colitis: allergy in its
etiology. Ann. Int. Med., 17:83-100, (July) 1942.
15. Streicher, Michael H.: Oral administration of penicillin in
chronic ulcerative colitis. J.A.M.A., 134:339-341, (May 24)
1947.
16. Wilkinson, S. Allen, and Smith, Francis H.: Intravenous
typhoid vaccine therapy in the management of ulcerative
colitis. Gastroenterology, 6:171-175, (March) 1946.
964
Minnesota Medicine
VAGOTOMY IN PEPTIC ULCER
WALTMAN WALTERS. M.D., HAROLD A. NEIBLING, M.D., WILLIAM F. BRADLEY. M.D.,
JOHN T. SMALL, M.D., and JAMES W. WILSON, M.D.
Rochester, Minnesota
TDECAUSE of space and time limitations, we
shall be able to present only an outline of the
results of our studies on vagus nerve resection
for duodenal, gastric and gastrojejunal ulcer.
Recently4 we presented our studies of the ana-
tomic variations in the vagus nerves of human
beings from a point well above the diaphragm
to the stomach. It suffices to say that in 92 per
cent of cases, the nerves, in the vicinity of the
diaphragm, consisted of two main trunks which
could be isolated and resected as well below as
above the diaphragm. In 8 per cent of cases the
nerves were multiple and variable in their posi-
tions so that it probably would have been difficult
to dissect all the branches regardless of the sur-
gical approach made to them. On previous oc-
casions we also reported in detail the early results
of vagus nerve resection for gastroduodenal and
jejunal ulceration, first in a group of sixty-six
cases5 and later in a group of eighty-three cases3
which included the original sixty-six cases.
It is interesting to note in our cases, as well as
in those reported by Dragstedt, that in at least
8 per cent of cases, results of the insulin test made
subsequent to the operation indicated that all the
branches had not been divided.
Emphasis hardly needs be placed on the fact
that if one is to evaluate scientifically the results
of vagus nerve resection, it is necessary to present
proof, other than that obtained by visual inspec-
tion or palpation of the esophagus, that all the
nerves have been resected. It would seem that
the Hollander insulin test, the mode of action of
which has been previously reported elsewhere,2
is an essential part of the study of the patients if
one is to be sure that a complete surgical proce-
dure has been carried out, and the tissue removed
must be examined microscopically to determine
whether it is nervous tissue. It is likewise very
important that one ascertain by inspection, palpa-
tion and, if advisable, by biopsy that a peptic ulcer
Dr. Walters is with the Division of Surgery, Mayo Clinic,
Rochester, Minnesota; Drs. Neibling, Small and Wilson are
Fellows in Surgery, and Dr. Bradley is a Fellow in Medicine,
Mayo Foundation, Rochester, Minnesota.
Read in Symposium on Gastrointestinal Ulcerative Diseases at
the annual meeting of the Minnesota State Medical Association,
Duluth, Minnesota, June 30, 1947.
September, 1947
exists, that it is not malignant and that there are
or are not other associated intra-adbominal lesions.
One of our patients who gave a good history
for ulcer and positive roentgenologic evidence of
duodenal ulcer presented no evidence of ulcer
when the duodenum and the lower part of the
stomach were opened. He obtained complete relief
of symptoms after pyloroplasty. Another patient
had an associated Meckel’s diverticulum and a dis-
eased appendix. In the fifty cases in which the
senior author performed vagus nerve resections,
it was thought necessary and advisable to do
additional intra-abdominal operations, other than
on the stomach, simultaneously in seven cases.*
Moreover, it is necessary, in studying the re-
sults of vagus nerve resections done by various
surgeons, to be sure to determine what percentage
of the total number of patients with proved duo-
denal ulcer underwent the operation. In the series
of 170 cases in which Dragstedt performed the
operation, 86 per cent were done on patients with
duodenal ulcer, 9 per cent on patients with gastro-
jejunal ulcer and 5 per cent on patients with gas-
tric ulcer. In the Mayo Clinic series in which
the operation was performed, 65 per cent of the
patients had duodenal ulcer, 29 per cent had gas-
trojejunal ulcer and 6 per cent had gastric ulcer.
The results reported by Grimson, Moore and
Colp closely parallel those which we have re-
ported from the clinic.
In 1928 approximately 40 per cent of the pa-
tients with duodenal ulcer who came to the Mayo
Clinic were operated on. Many of these patients
had a small duodenal ulcer for which the opera-
tion of pyloroplasty or gastroduodenostomy gave
satisfactory results. In 1946, 13.7 per cent of the
patients with duodenal ulcer were operated on.
Most of these patients had a large, chronic, per-
forating or obstructing duodenal ulcer ; they were
the types of patients on whom both medical men
and surgeons were convinced that surgical proce-
dures, probably partial gastrectomy, were indi-
*Of the seven patients two had associated cholecystectomy and
four had_ associated appendectomy. One additional patient had a
mesenteric mass removed which microscopically proved to he fat
necrosis.
965
VAGOTOMY IN PEPTIC ULCER— WALTERS ET AL
cated. It is because of the large size of these
ulcers and the danger of occurrence of serious
gastric retention as a result of the gastric atony
that follows this operation that vagus nerve re-
section alone without other operations on the
stomach was performed in but seventeen of the
fifty cases in the senior author’s cases (Series 1).
In Series 2 (patients operated on by our col-
leagues) vagotomy was performed but thirty-one
times without other gastric operations in their
sixty-eight cases.
If vagotomy is combined with a drainage opera-
tion on the stomach, whether gastroenterostomy
or partial gastrectomy, it is quite apparent that it
is difficult to determine just how much of the re-
sult obtained is attributable to vagotomy, gastro-
enterostomy or partial gastrectomy. It will require
the passage of time to determine whether patients
who have had vagotomy and gastroenterostomy
will have anastomotic ulcers. Although it has been
stated that complete division of the vagus nerves
causes an immediate cessation of the pain of ulcer,
three of our patients who gave negative reactions
to the insulin test which indicated complete vagus
nerve resection, either had continuation or re-
currence of distress from ulcer. The presence of
a recurring ulcer was demonstrated roentgeno-
graphically in two of these cases and pathologically
in the third case when partial gastrectomy was
performed for a large recurring, perforating gas-
tric ulcer.
The most troublesome sequelae of the opera-
tion have been disturbances in gastrointestinal
motility. These occurred in the immediate post-
operative period in 40 per cent of our cases ; in
follow-up studies they were found to be present
in 12 per cent of the cases nine months after oper-
ation. These symptoms consist of a distressing
feeling of fullness, nausea, belching of foul-smell-
ing gas, and abdominal distention. Some patients
had vomiting and diarrhea. The use of urethane
of /?-methylcholine chloride (urecholine) in the
treatment of these disturbances of motility has
been too recent to permit formation of a definite
opinion as to the value of this drug. That it does
promote gastric peristalsis can be demonstrated in
some cases by roentgenologic examination. Two
recent patients, however, obtained no clinical
benefit from administration of the drug, and gas-
tric retention remained unchanged. Both of the
patients had considerable retention for approxi-
mately two and a half weeks after removal, four
and a half days postoperatively, of the indwelling
tube in the stomach.
The atony of the stomach which results from
complete vagus nerve resection and which is re-
sponsible for retention of food and gastric secre-
tion within the stomach is, we believe, the main
reason for the relief of pain from ulcer which
these patients experience. In several such cases
roentgenologic examination before the patient’s
departure from the clinic revealed the ulcer still
to be active. Necropsy carried out in one of our
colleagues’ cases, in which death occurred on the
fourteenth day after vagotomy and gastroenter-
ostomy, revealed an unsuspected perforated duo-
denal ulcer with a subdiaphragmatic abscess.
Weeks has reported a similar unsuspected perfor-
ation of duodenal ulcer following vagotomy.
The favorable results of the operation seem to
be in the cases of recurring ulceration after par-
tial gastrectomy and in cases of gastrojejunal
ulcer. The senior author has performed the opera-
tion in a group of seven patients who had such
recurring ulcers. In one of these it was thought
advisable to do a resection of the stomach in addi-
tion to vagotomy because the large jejunal ulcer
had its base on the transverse colon and there
was impending perforation into the latter. Rather
than take a chance that the vagotomy might be in-
complete or that the ulcer might not heal, it was
thought advisable to remove the ulcer and an ad-
ditional amount of the stomach. Tn four cases of
gastrojejunal ulcer, the gastroenteric stoma was
removed and the gastrojejunal ulcer excised be-
cause of the fear that with healing of the ulcer,
if healing did occur, the gastroenteric stoma would
be occluded, as did occur in one of Dragstedt’s
cases in which Cole performed partial gastrectomy
to relieve the obstruction. Two additional cases
included one gastroduodenal ulcer and one gastro-
jejunal ulcer, each of which followed a Finsterer
type of gastric resection (allowing the pylorus to
remain). In these two cases only vagotomy was
done. With the procedures which have been out-
lined the immediate results of the operation have
been very satisfactory.*
In our Series 1, insulin tests were made in thir-
ty-nine of fifty cases. Failure to carry out the
tests in the other eleven cases occurred for the
most part during the months of May, June and
•Since this paper was presented, one of the patients has re-
turned because of weight loss and loss of appetite. He has no
pain but a roentgenogram of his stomach ten months after op-
eration shows a recurring duodenal ulcer with a crater.
966
Minnesota Medicine
VAGOTOMY IN PEPTIC ULCER— WALTERS ET AL
July, 1946, when we were feeling our way along
in the performance of the procedure and in a
study of the results, for there is some risk in a
test which requires that the blood sugar be low-
ered to a value below 40 mg. per 100 c.c., pref-
erably to 30 mg. per 100 c.c. In the past nine
months insulin tests have been carried out in
thirty-six of thirty-eight cases. A positive reac-
tion to the insulin test occurred in thirteen, or 33
per cent, of the thirty-nine cases, indicating that
all the branches of the vagus nerves had not been
divided. Interestingly enough, however, all of
these patients were relieved of distress from ulcer
after operation, and the incidence of achlorhydria
and disturbances of motility practically paralleled
that observed in the group in which the insulin
test gave negative results, indicating that all vagus
fibers had been cut. Roentgenologic examinations
of the stomach showed atonicity in seven patients,
in five of whom clinical evidence of disturbances
of motility developed. Gastric acidity was re-
duced to an achlorhydric level in six of the thir-
teen patients who gave positive reactions to the
insulin test and three additional patients had
significant reductions of gastric acidity.
In the fifteen patients who gave definitely nega-
tive reactions to the insulin test after the blood
sugar was reduced to a level below 40 mg. per
100 c.c., three patients had distress from ulcer
postoperatively, two of whom had definite ulcera-
tion on roentgenographic examination two and a
half months and six months respectively after
operation. Likewise approximately a half, or
seven of the fifteen patients, gave evidence of
achlorhydria. The other five patients had a re-
duction of gastric acidity.
There is a third group of eleven additional
patients who gave a negative reaction to the in-
sulin test and whose blood sugar level did not
go below 40 mg. per 100 c.c. during the insulin
test; in seven of these, however, the value for
blood sugar went well below 50 mg. per 100 c.c.
None of this group of eleven patients had post-
operative distress from ulcer although four com-
plained of disturbances of motility. Ten patients
in this group had postoperative roentgenograms,
four of which showed an atonic stomach and one
showed a gastric ulcer still present one month
postoperatively. Eight of the eleven patients ob-
tained an achlorhydria and another had a reduc-
tion of gastric acidity. Still another patient in
September, 1947
this group, when studied four months after opera-
tion, although free of symptoms of ulcer, had full-
ness and belching of foul-smelling gas. The roent-
genogram showed dilatation of the stomach with
a small recurrent gastric ulcer.
The following deductions are evident: (1) Re-
lief of the symptoms of ulcer has not been depend-
ent on the completeness of the division of the
vagus nerves, if the Hollander insulin test can
be assumed to be an accurate method to determine
the completeness of the dissection. (2) Disturb-
ances of motility have occurred almost as fre-
quently in the group of patients who gave a posi-
tive reaction to the insulin test as in the group in
which a negative reaction to the insulin test was
obtained. (3) Reduction of acidity occurred in
approximately 69 per cent of the cases in which
a negative reaction to the insulin test was obtained
and in 93 per cent of the cases in which a posi-
tive reaction was obtained ; the reduction reached
an achlorhydric level in 46 per cent of the cases
in the former and in 60 per cent of the cases in
the latter.
Space does not permit discussion of the cases
in Series 2 (sixty-eight cases) in which vagotomy
with and without other operative procedures was
carried out by other surgeons at the Mayo Clinic.
References have been made to this series in pre-
vious papers presented by us and the cases will
be reported in detail later by the surgeons them-
selves. \
Summary and Conclusions
On previous occasions we have reported in
detail our studies on the variations in the anatomy
of the vagus nerves and the early results which
have followed the performance of vagus nerve
resection for gastroduodenal and jejunal ulcera-
tion, first in a group of sixty-six cases and later
in a group of eighty-three cases which included
the original sixty-six cases.
The results of vagus nerve resection in human
beings in the treatment for peptic ulcer are in-
constant, variable and, in most cases, unpredictable
as regards disturbances of motility. Three of our
fifty patients have had distress from ulcer post-
operatively ; two of these gave evidence of ulcera-
tion on roentgenologic examination two and a half
months and six months, respectively, after opera-
tion. Gastric resection for a large gastric ulcer
was later performed on one of these patients. A
fourth patient was thought to have an ulcer four
967
VAGOTOMY IN PEPTIC ULCER— WALTERS ET AL
months postoperatively although dilatation of the
stomach, food remnants and retention of secre-
tion made the examination not entirely satisfac-
tory. In addition, the roentgenogram of a fifth
patient made one month after operation showed
evidence of a considerable amount of jejunitis.
In all these cases all the vagus nerve fibers had
been resected, as indicated by the fact that the re-
action to the insulin test was negative.
Of patients who gave negative reactions to the
insulin tests in Series 2, one who had undergone
vagotomy elsewhere several months previously,
showed roentgenologic evidence of jejunitis. This
patient was found at operation at the clinic to
have a large gastrojejunal ulcer that had not
healed subsequent to the previous vagotomy. Re-
moval of the gastroenteric stoma, excision of the
ulcer-bearing area and resection of the stomach
were performed.
In evaluation of the results of the operation of
vagus nerve resection, it must be proved that an
ulcer was present at operation and that the vagus
nerves were completely sectioned. It is our opin-
ion that the best approach in most cases in which
vagotomy is contemplated is by means of an ab-
dominal incision, for such an approach allows both
examination of the ulcer and exploration of the
intra-abdominal structures, especially the gastro-
intestinal and biliary tracts, and the performance
of such procedures as might seem necessary to
supplement the vagotomy.
The greatest field of usefulness for vagotomy
seems to be in the treatment of recurring ulcers
after partial gastrectomy and gastroenterostomy
and in certain patients with non-obstructive duo-
denal ulcers in which the cephalic phase of gastric
secretion is marked and pain is intractable. If the
operation is used in the treatment of gastrojejunal
ulceration which follows gastroenterostomy, the
possibility of obstruction at the stoma and at the
site of the healed or reactivated duodenal ulcer
must be considered. It has no place in the treat-
ment of chronic gastric ulceration for which the
results of partial gastrectomy are excellent unless
the ulcer cannot be removed with safety, in which
event the edges of the ulcer should be excised and
the tissue examined for evidence of malignancy.
When vagotomy is performed simultaneously with
other gastric operations, the relative value of each
procedure may be difficult of interpretation unless
several years elapse without recurrent ulceration.
In view of the inherent ability of the gastro-
intestinal tract of human beings, like that of the
gastrointestinal tract of animals in the experi-
mental laboratory, to regain through autonomic
and compensatory mechanisms its function after
operative procedures which disturb neuromuscu-
lar continuity, and since restoration of gastric
acidity and gastric motility has occurred within
a two-year period in dogs in which vagotomy has
been performed, the possibility of such a return
in human beings must be kept in mind con-
stantly.
The operation of vagus nerve resection con-
tinues to be in the investigative stage and the
effects of the operation should be carefully studied
and should be further evaluated by all those in-
terested in the progress and advancement of sur-
gery.
References
1. Dragstedt, L. R. : Unpublished data.
2. Walters, Waltman: Developments in surgery of the upper
abdomen. Postgrad. Med., 1 :360-367, (May) 1947.
3. Walters, Waltman; Neibling, H. A.; Bradley, W. F. ; Small,
J. T., and Wilson, J. W. ; A study of the results, both
favorable and unfavorable, of section of the vagi nerves
in the treatment of peptic ulcer. Unpublished data.
4. Walters, Waltman; Neibling, H. A.; Bradley, W. F. ; Small,
J. T., and Wilson, J. W. : Favorable and unfavorable results
of vagus nerve resections in the treatment of peptic ulcer:
an anatomic, physiologic and clinical study. Unpublished data.
5. Walters, Waltman; Neibling, H. A.; Bradley, W. F. ; Small,
J. T., and Wilson, J. W.: Gastric neurectomy for gastric
and duodenal ulceration ; an anatomic and clinical study.
Ann. Surg., 126:1-18, (July) 1947.
6. Weeks, Carnes; Ryan, B. J., and Van Hoy, J. M.: Two
deaths associated with supradiaphragmatic vagotomy. J.A.-
M.A., 132:988-990, (Dec. 21) 1946.
TUBERCULOSIS AND THE GENERAL HOSPITAL
Whenever a considerable number of tuberculosis deaths
occur in the homes of the community, a serious source
of tuberculosis infection exists and undermines other
control measures.
The general hospital has an important role in reducing
this hazard. By expanding facilities for care of tuber-
culous patients, particularly for patients during the pre-
968
sanatorium period, the latter institution will be able to
utilize its facilities for all patients needing long term
care, or palliative treatment. The general hospital can
provide the diagnostic service and short term care
required by the large number of persons in whom case-
finding programs discover minimal tuberculosis. — Jacob
Yerushalmy, M.D., Hospitals, August, 1946.
Minnesota Medicine
LUMBAR RETROPERITONEAL GANGLIONEUROMA
Review of Literature and Report of Case
LAWRENCE M. LARSON, M.D., Ph.D. (Surg.)
Minneapolis, Minnesota
ANGLIONEUROMATA, whatever their lo-
cation, are rare tumors, but they seem to
occur especially infrequently in the abdominal
retroperitoneal area. These tumors have been re-
ported in the central nervous system, cranial
nerves, nerve roots, ganglions, neck, thorax, me-
sentery, appendix, pelvis, suprarenal glands, in-
testine, cervix, ovary, uterus and knee. They no
doubt occur with much greater frequency than
reported cases would indicate, the reason being
that they usually do not produce symptoms until
a vital structure is encroached upon. They rarely
become malignant, they practically never metas-
tasize, and consequently many are not noted until
found at autopsy.
The first description of a ganglioneuroma was
given by Loretz in 1870, but the first one noted
in the lumbosacral retroperitoneal area was de-
scribed by Chiari in 1898 and a year later a
similar case was reported by Cripps and William-
son. Up to 1931 when McFarland reviewed the
literature only thirteen such cases had been re-
ported, and in a similar review through 1943
Clayton found only seventeen cases. However,
practically all of these were presacral or precoc-
cygeal in origin and only about eight cases of
those actually in the lumbar area could be found
in the literature. Because of the war it has been
impossible to obtain copies of isolated case reports
in many foreign languages, such as Russian,
Japanese, Czechoslovakian and so forth, so it is
not known just how many such cases are in the
literature. As a matter of fact, Reynolds and
Cantor stated there were probably fewer than
fifty up to November, 1946. Perusal of the files
of the Pathology Department, University of Min-
nesota, both those from operative and autopsy
records, fails to reveal a single case of a retro-
peritoneal ganglioneuroma. Also, in a review
which the author made with Dr. Judd in 1934
of all retroperitoneal tumors at the Mayo Clinic,
of which there were forty-six, not a single case
of this type was found. There was one ganglio-
^ Presented before the Minneapolis Surgical Society, Marcji 6,
September, 1947
neuroma, but its origin was the suprarenal gland
and not the lumbar sympathetics.
These tumors occur more frequently in the
thorax where they have been found in the pos-
terior mediastinum and chest wall. Several de-
scriptions of these have emphasized the fact that
they may be of the “dumb-bell” or “collar but-
ton” type, in which extension of the tumor
through the intervertebral spaces to the other side
occurs. In this type, complete removal is dif-
ficult or impossible, and recurrence of the tumor
may be expected.
Symptomatically, these tumors all behave more
or less similarly. They occur usually in young
adults, and due to their slow growth and the fact
that they rarely encroach on vital structures, they
usually go unnoticed for a long period of time.
They seem to occur more frequently in females,
although this may be relative more than actual,
since pelvic examinations are more frequent in
women. Pain and the presence of a mass seems
to be the main complaint, although other symp-
toms occur depending upon structures encroached
upon, such as the bowel, kidney, ureter, bladder,
and so forth.
The physical signs are mainly those of a mode-
rately soft or firm mass, fixed posteriorly, usually
smooth, and located on one side or other of the
vertebral column. They are usually painless and
have been present for many years without symp-
toms. They are practically always single, although
two case reports of multiple ganglioneuromas
have been noted. In their surgical removal most
authors comment on the dense adhesions sur-
rounding the tumor ; in fact, in several cases the
ureter or large arteries and veins, such as the
iliac, have been torn, and operative death has
ensued.
Differential diagnosis from sarcoma, lipoma,
fibroma and so forth, at the time of operation is
usually impossible, and only microscopic section
will reveal the true nature of the tumor.
Pathologically these tumors usually are more
or less encapsulated, they are firm and somewhat
elastic, and vary in size up to 12 inches in diam-
969
LUMBAR RETROPERITONEAL GANGLIONEUROMA— LARSON
eter. On section, the capsule retracts and the
incised edges become everted, while the appear-
ance of the interior is usually pale yellowish or
pink, with many connective tissue septa dividing
the substance into lobules.
Microscopically there are nerve and connec-
tive tissue elements. Bundles of nerve fibers in
longitudinal and transverse sections are surround-
ed by a connective tissue stroma. Mature ganglion
cells are present singly or in groups, and extend-
ing from the cell body, one or more nerve proces-
ses may be seen. Their cytoplasm is granular
and the nucleus may be single or multiple, and
occasionally vacuolar degeneration is present. The
stroma may be dense or fine and usually consists
of many neurofibrils, along with areas of degene-
ration.
It is obvious that these tumors are derived from
specific nerve tissue, being the result of hyperpla-
sia of ganglia, and consisting of medullary and
non-medullary nerve fibers and of ganglion cells.
Reynolds and Cantor have described the method
of development of this tumor. Their description
indicates the fact that in the migration of the
ganglionic crests during embryonic life, certain
cells become displaced or miscarried. The sym-
pathetic ganglionic organization, as is well known,
is the result of migration of individual cells from
the neural crest substance down to the dorsal
nerve roots and peripheral trunks to form paired
ganglionic clusters. These migrating cells may
never reach the ganglionic mass, and no doubt
most frequently never give rise to any difficulty.
However, they may begin to proliferate at any
time along the line, and the type of tumor that
is formed by these cells depends on the level of
differentiation that has been attained. The gang-
lioneuroma represents the tumor formation from
the mature cells, or from the neurocyte that has
reached the end stage of its development. They
therefore are undoubtedly congenital in origin.
With complete removal of these tumors, often
difficult, the prognosis is usually good, although
recurrences have been noted. Evans and Francona
have recorded rare instances of metastases, but
these must be exceedingly uncommon. Roentgen
therapy, as one would expect from the nature
of this tumor, is of no value.
Case Report
The patient is a white woman, twenty-eight years of
age. Her past history is essentially irrelevant except
for that recorded. Whether many of the details per-
tain to this case is problematical, but due to the bizarre
nature of many of the symptoms, it was considered best
to record them as they occurred in the progress of the
case.
The patient started early in childhood with an in-
definite pain in her right lower abdomen and lower back,
severe enough that she avoided stepping on her right
foot. In fact, her mother was constantly scolding her
because she continually wore out her left shoe long
before the right. These pains at first were intermittent
but soon became so frequent as to keep her in bed for
several days at a time. In 1933, at the age of eighteen,
she was examined completely at a large clinic because
of these pains, and an orthopedic consultant advised
that her symptoms were due to a mild scoliosis which
she had had for many years. Other causes of this pain
were excluded, especially appendicitis or pelvic dis-
orders. Treatment of the scoliosis by exercises resulted
in considerable improvement in her symptoms, but she
still was confined occasionally to bed because of the
pain. She found that when she was the most active,
such as when she was playing baseball, swimming or
dancing, she felt better. Periods of inactivity always
made the pain more severe. She stated that the better
condition in which she kept her muscles through
athletics, the more infrequent and the less severe her
symptoms were.
She was married in 1938 and in 1940 the left tube
was removed for ectopic pregnancy. At this time ap-
pendectomy wras also done. Convalescence was normal
but no change in her backache resulted, and she con-
tinued to have the same right-sided pain. This was un-
influenced through four normal pregnancies.
The pains continued to recur in this same fashion
until August, 1946, when she for the first time developed
severe constant pain in the left lower abdomen. This
was most pronounced in changing from a standing to a
sitting position. It radiated through to the lower left
lumbar area of the back but was not associated with
genito-urinary symptoms and there was no nausea or
vomiting. As long as she lay quiet, the pain was present
but not severe.
Physical Examination. — Her appearance was not that
of an acutely ill individual. Her temperature was
98.6° F., pulse rate 74 per minute, blood pressure 100
systolic and 64 diastolic in millimeters of mercury.
The head, neck and chest were normal. The abdomen
was normal except for the following : There was a low
midline scar, solidly healed. The patient located the
pain in an area to the left of the midline and just be-
low the umbilicus, and on palpation of this area a
firm fixed smooth mass could be made out measuring
about 6 cm. wide and 12 cm. in length. It lay along-
side the vertebral column at the level of the third
and fourth lumbar vertebrae and on pressure, pain was
produced locally radiating through to the back. Move-
ments of the spine in this area also produced similar
distress. Vaginal examination gave essentially negative
results and the tumor could not be reached through the
pelvis. The reflexes, both superficial and deep, were all
970
Minnesota Medicine
LUMBAR RETROPERITONEAL GANGLIONEUROMA— LARSON
Fig. 1. (above) Low power view of section of tumor. The
left half shows mainly connective tissue stroma while that on
right presents many ganglion cells and nerve processes.
Fig. 2. ( center ) High power view of connective tissue and
nerve process elements.
Fig. 3. (below) High power view of ganglion cells with nerve
processes.
normal and equal. The remainder of the examination
was essentially negative.
Laboratory Data. — The value for hemoglobin was
15.2 grams per 100 c.c. ; white cells 4,600 per cubic mil-
limeter, with 51 per cent neutrophiles, 38 per cent lym-
phocytes, 5 per cent monocytes and 6 per cent eosino-
philes. Urinalysis gave negative results. The blood
Wassermann reaction was negative. Roentgenographic
examination of the dorsal, lumbar and sacral spine gave
negative results. The outline of the kidneys was nor-
September, 1947
mal, and apparently there was no connection between
them and the mass.
A diagnosis of a tumor of uncertain nature and most
likely retroperitoneal in origin was made, and ex-
ploration was done on August 6, 1946. At this time
the tumor was found to lie alongside the left vertebral
margin, measuring about 12 by 6 cm., being smooth
and oval in shape, and firmly attached posteriorly to
the vertebrae. The overlying peritoneum was incised
and reflected medially and the tumor removed in one
mass. Considerable difficulty was encountered in its re-
moval due to its vascularity and its firm and dense
adherence to the surrounding structures, especially pos-
teriorly to the vertebral column. The ureter was iso-
lated and retracted so that no damage could be done to
it. The tumor was completely removed, a Penrose
drain was inserted in the cavity and peritoneolization
was completed. Her immediate postoperative condition
was good and her convalescence was normal except for
the condition to be described.
Pathological Data, — The tumor removed measured 10
by 4 cm. It was fairly well encapsulated, rounded,
smooth and of pale grayish color, firm in consistency and
with a nerve structure apparently passing through its
substance. On microscopic section the picture was that
of a fibromatous mass with many scattered sympathetic
ganglion cells. The portion of tumor resembling a nerve
was a sympathetic ganglion structure (Figs. 1, 2, and 3).
Immediately postoperatively, as soon as the patient be-
came conscious, she complained of abnormal warmth of
the left leg as compared to the right, and on examina-
tion this was found to be the case. The temperature
of the left leg from then on, and to the present, has
been constantly one or two degrees above that of the
right. After further discussion of this symptom with
the patient, she stated that she had always had abnor-
mally cold feet, and she noticed that for the first time
the left one was of normal temperature.
Up to the present, ten months postoperatively, she
has had no recurrence of the pain of which she has
complained for many years. Whether this tumor was the
cause of her right-sided pain is a matter of conjec-
ture. At any rate, she has remained completely free of
this distress, so that one must feel that the ganglioneu-
roma must have had some bearing on this symptom.
The left leg has continued to remain warmer, by one
or two degrees, than the right leg in spite of changes
in the environment. It is obvious that with the removal
of this tumor the sympathetic chain has been partially
removed on this side, and the equivalent of sympathec-
tomy has been done, such as that done for the relief
of high blood pressure. No changes in her blood
pressure have occurred, probably because it was not
elevated preoperatively and also because only one ex-
tremity was involved.
Summary
A case of retroperitoneal ganglioneuroma of
the left lumbar sympathetic system is reported in
(Continued on Page 977)
971
MINNESOTA SEROLOGICAL EVALUATION STUDY
H. E. MICHELSON. M.D.
Chairman of the State Serologic Committee
Minneapolis. Minnesota
A REPORT of the first evaluation study of
serological tests for syphilis as performed in
Minnesota was made in 1941. 2 A brief review
of the national evaluation studies since 1934, as
well as the organization of the Minnesota study,
was included. A second report, covering the
evaluations as conducted in 1941 and 1942, was
made in 1943. 1 The plan and arrangements for
conducting the evaluation studies in the state since
that time, i.e., 1943 to 1946, inclusive, have been
changed somewhat, but retain the original pur-
pose, namely, to supply specimens and compile
the findings, so that the methods of performing
serological tests in the state may be evaluated.
As can be seen from Table I, the number of
laboratories participating increased considerably
during the first three years. The number remained
almost constant from 1943 to 1946 in spite of the
huge problems of equipment and personnel en-
countered during that time. There was also an
increase in the number of laboratories that use
three or four procedures per specimen. These
laboratories generally are in larger institutions and
reflect the trend of using multiple tests, including
a complement-fixation test, in solving the diagnos-
tic problems of patients with doubtful or slightly
positive serological reactions but no historical or
clinical findings to explain those reactions.
The number of serological techniques used by
the participating laboratories in the state has de-
creased from twelve in 1941 to nine in 1946,
while at the same time there was an increase in the
number of laboratories using the tests recommend-
ed by the United States Public Health Service on
the basis of author-evaluation studies.3 Table II
gives the number of participating laboratories
using the various techniques.
The State Department of Health laboratories
have participated in the national evaluation of
serological tests for syphilis since 1936. In these
evaluation, 125 to 160 specimens from non-
Original members of the State Serologic Committee were: N.
H. Lufkin, M.D., Francis W. Lynch, M.D., Paul A. O’Leary,
M.D., Arthur H. Sanford, M.D., Lucy Heathman, Ph.D., M.D.,
(ex officio), R. R. Sullivan, M.D., (ex officio).
Margaret W. Higgenbotham, D.Sc., Anne Kimball, Ph.D., and
Henry Bauer, M.S., Minnesota Department of Health, Division
of Preventable Diseases, assisted in these studies.
TABLE I. NUMBER OF TECHNIQUES USED BY
PARTICIPATING LABORATORIES
1941
1942
1943
1944
1945
1946
One
17
27
28
29
27
27
Two
11
14
12
10
9
9
Three
2
1
3
3
4
5
Four
1
2
1
. 1
3
2
Total No. of labs
31
44
44
43
43
43
TABLE II. TECHNIQUES IN USE AND NUMBER
OF LABORATORIES USING EACH
1941
1942
1943
1944
1945
1946
Kline-diagnostic f*
18
29
27
26
30
32
Standard Kahnf*
9
14
13
13
14
12
Rvtz
5
3
3
5
6
4
Kline-exclusionf*
2
3
5
6
5
6
Kolmer-Wassermannf*
3
3
4
3
5
5
Hintonf*
2
3
3
2
2
2
Laughlin
2
3
3
2
0
0
Other complement
fixation tests
4
3
2
2
1
1
Mazzini*
0
2
2
2
3
5
Eaglet*
1
1
2
1
1
1
Leiboff
1
2
1
0
0
0
Ide
1
0
0
0
0
0
Meinicke
1
0
0
0
0
0
Total No. of techniques
12
11
11
10
9
9
fTechniques used by Minnesota Department of Health; Eagle
discontinued in 1946.
*Techniques recommended by U. S. Public Health Service.
syphilitic persons and 190 to 235 specimens from
syphilitic patients are tested. The results are
evaluated on the basis of percentage sensitivity
and percentage specificity. The formula for cal-
culating sensitivity is :
Positive results Tl4 doubtful results = percentage
Syphilitic specimens sensitivity
The formula for calculating specificity is :
Negative results T Vi doubtful results — percentage
Nonsyphilitic specimens specificity
Criteria of satisfactory performance are that
participating laboratories must have a sensitivity
rating of not more than 10 per cent below the
author serologist, and a specificity of not less than
99 per cent.
Table III shows the sensitivity and specificity
ratings of the Minnesota Department of Health
laboratories in the national evaluations. The
specificity of the Kline exclusion, used as a screen
test only, is usually slightly below suggested
072
Minnesota Medicine
SEROLOGICAL EVALUATION STUDY— MICHELSON
TABLE III. PERFORMANCE OF MINNESOTA DEPARTMENT OF HEALTH AND AUTHOR-LABORATORIES
IN NATIONAL EVALUATION STUDIES
1941
1942
1943* *
1944
1945
1946
Test
MDH
Author
MDH
Author
MDH
Author
MDH
Author
MDH
Author
MDH
Author
Kline — ex elusion
Specificity
Sensitivity
98.8
86.9
100.0
86.0
97.6
91.9
100.0
88.5
97.8
88.9
100.0
84.4
97.2
87.6
97.8
88.4
99.7
84.5
100.0
82.5
97.8
90.1
100.0
87.3
Kline — diagnostic
Specificity
Sensitivity
99.2
78.0
100.0
76.0
100.0
86.0
100.0
83.1
100.0
75.3
100.0
65.6
100.0
79.3
100.0
82.2
100.0
76.2
100.0
76.5
99.3
82.7
100.0
81.8
Kolmer — W assermann
Specificity
Sensitivity
100.0
83.9
100.0
77.6
100.0
86.8
100.0
84.9
100.0
69.8
100.0
82.0
100.0
76.8
99.4
85.5
99.3
77.7
98.6
78.3
100.0
75.0
100.0
88.4
Standard Kahn
Specificity
Sensitivity
100.0
75.8
100.0
79.2
100.0
75.7
100.0
80.0
100.0
73.9
100.0
82.1
100.0
69.8
100.0
77.7
100.0
80.1
100.0
83.1
Hinton*
Specificity
Sensitivity
99.6
81.3
100.0
84.7
*Hinton tests substituted for Kahn in 1943. Samples are sufficient for only the fotir tests.
Bold figures indicate ratings below standard.
TABLE IV. TECHNIQUES PERFORMED BY MINNESOTA DEPARTMENT
OF HEALTH*
Classified as Satisfactory or Unsatisfactory as to Sensitivity and/or Specificity.
1941
At Btf
1942
A B
1943
A B
1944
A B
1945
A B
1946
A B
Sensitivity and specificity satisfactory
8
14
12
21
9
21
14
19
14
18
18
27
Specificity only satisfactory
5
5
4
5
0
1
4
5
6
7
4
5
Sensitivity only satisfactory
14
8
26
17
31
19
26
20
30
26
29
20
Unsatisfactory sensitivity and specificity
9
9
7
6
4
3
2
2
4
3
4
3
Too few specimens reported
0
0
4
4
10
10
5
5
3
3
2
2
Total No. of performances
36
53
54
51
57
57
*Kline (diagnostic and exclusion), Kahn, Kolmer-Wass. and Hinton, also Eagle except in 1946.
f A. Using 99 % or above for satisfactory specificity.
ffB. Using 97% or above for satisfactory specificity.
TABLE V. TECHNIQUES NOT PERFORMED BY M.D.H. *, ** CLASSIFIED AS
Satisfactory or Unsatisfactory as to Sensitivity and/or Specificity.
1941
At Bff
1942
A B
1943
A B
1944
A B
1945
A B
1946
A B
Sensitivity and specificity satisfactory
Specificity only satisfactory
Sensitivity only satisfactory
Unsatisfactory sensitivity and specificity
Too few specimens reported
1 4
2 2
7 4
2 2
1 1
4 6
1 1
5 3
0 0
3 3
2 2
1 3
2 2
4 2
2 2
2 4
2 2
4 2
2 2
1 1
1 3
1 3
5 3
3 1
0 0
2 3
1 1
2 2
2 1
4 4
Total No. of performances
13
13
11
11
10
11
fA. Using 99 % or above for satisfactory specificity.
ffB. Using 97 % or above for satisfactory specificity.
*See Table II.
**Complement fixation tests compared with M.D.H. Kolmer-Wassermann results; precipitation tests
compared with M.D.H. Kline-diagnostic results.
standards. The specificity of all the other tests
evaluated was well above the suggested minimum.
The sensitivity ratings of each technique have
been satisfactory every year except for the Kol-
mer-Wassermann in 1943 and 1946.
For comparative purposes, in the state evalua-
tion studies, the various procedures as carried out
by the Department of Health laboratories may be
September, 1947
considered control performances such as those of
the author-laboratories in the national evaluations.
Tables IV and V summarize the number of pro-
cedures showing satisfactory performance, ac-
cording to the suggested criteria, for the years
1941 to 1946, inclusive. Table IV shows com-
parisons for the techniques routinely in use at the
state laboratories, namely, Kline-exclusion-Kline-
973
SEROLOGICAL EVALUATION STUDY— MICHELSON
diagnostic, Standard Kahn, Kolmer-Wassermann,
Eagle, and Hinton. In Table V the performance
of other techniques, i.e., Mazzini, Rytz, et cetera,
are compared to the S.B.H. Kline-diagnostic.
Admittedly, this record does not give a true com-
of thirty-two meeting the satisfactory specificity
criterion of 99 per cent in 1946. As will be seen,
there has been some improvement in the specific-
ity performance of the Kline-diagnostic proce-
dures in the 1946 study.
TABLE VI. PERFORMANCE OF KLINE-DIAGNOSTIC TEST ONLY
1941
At Bff
1942
A B
1943
A B
1944
A B
1945
A B
1946
A B
Sensitivity and specificity satisfactory
1
4
5 11
4 10
4 9
4 6
7 12
Specificity only satisfactory
2
2
0 1
0 0
1 2
2 2
2 3
Sensitivity only satisfactory
9
6
16 10
18 12
17 12
21 19
20 15
Unsatisfactory sensitivity and specificity
6
6
6 5
3 3
3 2
2 2
3 2
Too few specimens reported
0
0
2 2
2 2
1 1
1 1
0 0
Total No. of labs
18
29
27
26
30
32
|A. Using 99% or above for satisfactory specificity.
tfB. Using 97 % or above for satisfactory specificity.
TABLE VII. PERFORMANCE OF STANDARD KAHN TEST
1941
AtBft
1942
A B
1943
A B
1944
A B
1945
A B
1946
A B
Sensitivity and specificity satisfactory
6
7
4
5
3
5
3
3
5
6
4
6
Specificity only satisfactory
1
1
4
4
0
1
3
3
2
2
1
1
Sensitivity only satisfactory
1
0
4
3
5
2
4
4
6
5
5
3
Unsatisfactory sensitivity and specificity
1
1
0
0
0
0
0
0
0
0
0
0
Too few specimens reported
0
0
2
2
5
5
3
3
1
1
2
2
Total No. of labs
9
14
13
13
14
12
fA. Using 99% or above for satisfactory specificity.
tfB. Using 97% or above for satisfactory specificity.
parison of performance, but for economic reasons,
it was impossible to conduct all techniques in
the state laboratories.
It is noted in Tables IV and V that the larger
number of techniques have satisfactory sensitivity
ratings only, and are low in specificity perfor-
mance. Because a relatively small number (100
or fewer) of nonsyphilitic sera were tested by
each technique, one false positive or two false
doubtful reactions would reduce the specificity
below the required 99 per cent. Therefore, in the
second column under each year in the tables, the
numbers of techniques showing satisfactory per-
formance under a slightly reduced specificity rat-
ing (97 per cent) are tabulated. It is readily seen
that the number of procedures meeting the amend-
ed criteria of satisfactory performance in sensi-
tivity and specificity is thus increased.
In Table VI are listed the performance ratings
of the Kline-diagnostic procedures as carried out
in the participating laboratories. This procedure
in general shows good sensitivity performance,
but seems to be poor in specificity, i.e., only nine
It is shown in Table VII that the Standard
Kahn procedures gave relatively good ratings in
the state evaluations, but that the percentage of
satisfactory performances in regard to specificity
as well as sensitivity has decreased somewhat in
1946.
In general, the performance of serological tests
for syphilis has shown improvement in the state
as reflected by the evaluation studies recorded, and
it is hoped that this improvement may be extended
and increased.
We wish to thank the pathologists and technicians of
the participating laboratories for their interest and co-
operation in these studies. The facilities of the Min-
nesota Department of Health are available to any
laboratory in the state wishing to use them. We also
wish to thank Miss Jennie Schey of the Department
of Dermatology, University of Minnesota Hospitals, for
assistance in arranging for the donors.
Bibliography
1. Michelson, H. E. : Minnesota evaluation serology study.
Minnesota Med., 26:1081-2, (Dec.) 1943.
2. Michelson, H. E. : Minnesota serological evaluation study.
Minnesota Med., 24:643-49, (Aug.) 1941.
3. Technics of the Eagle, Hinton, Kahn, Kline and Kolmer
tests for the Serodiagnosis of Syphilis. Venereal Disease
Information, Supp. 11.
974
Minnesota Medicine
ROENTGEN THERAPY OF BRONCHIOGENIC CARCINOMA
EUGENE T. LEDDY, M.D.
Rochester, Minnesota
TN the treatment of bronchiogenic carcinoma
the radiologist’s lot is not a happy one. His
patients are usually feeble men who are in or past
the sixth decade of life, and the malignant lesion
has progressed beyond the stage of operability,
either through their own fault in not seeking
medical attention earlier or because, for various
reasons, the diagnosis was not made in an early
stage of the disease.
For these patients, “cure” is out of the question.
Since the hopelessness of their situation might
have been prevented by diagnosis at a time when
pneumonectomy might have offered a good chance
of complete cure, it may be well to review some
of the warning signs of bronchiogenic carcinoma.
The data have been drawn mostly from a recent
paper by Moersch and Tinney.
Perhaps the reason why an early diagnosis of
bronchiogenic carcinoma is seldom made is be-
cause of the failure to think of carcinoma.
Cough, which is the most frequent symptom,
occurred in 81 per cent of the 448 cases reported
by Moersch and Tinney ; however, because many
patients who suffer from other diseases complain
of this symptom, its importance often is misinter-
preted. As the tumor increases in size, obstruc-
tion to drainage of the bronchus occurs, the re-
tained secretions become infected, and the cough
becomes more productive and purulent. Chills and
fever ensue, and such an episode is often mistaken
for pneumonia. In this regard, a carefully taken
antecedent history is very important in all cases
of pneumonia, lest the diagnosis of bronchiogenic
carcinoma be missed.
In about half of the 448 cases the patients had
expectorated blood. Because hemoptysis often
had been associated with cough and fever, an
erroneous diagnosis of tuberculosis had been made
in some of the cases. In this connection, it is only
fair to state that the differential diagnosis of
bronchiogenic carcinoma often is very difficult.
The degree of dyspnea may be out of propor-
tion to the size of the lesion and to the amount
of atelectasis which it produces. Usually, dyspnea
develops gradually, but occasionally it develops
From the Section on Therapeutic Radiology, Mayo Clinic,
Rochester, Minnesota.
Read at the meeting of the Buffalo Radiological Society, Buf-
falo, New York, February 4, 1946.
September, 1947
suddenly and, when it is associated with wheezing
respiration, it may be mistaken for asthma. Dysp-
nea may be due to pleural effusion, which results
from invasion of the pleura by carcinoma cells.
A pleural effusion was present in 15 per cent of
the 448 cases.
Pain occurs in about half the cases, and occa-
sionally is the first symptom. Pain indicates that
carcinoma has spread to the pleura, to the thoracic
cage, or to the mediastinum and neighboring
nerves. It usually indicates that the tumor has
reached an advanced stage. The intensity of the
pain may vary from a mild, easily tolerated dis-
comfort to a constant severe or agonizing pain
which requires morphine for relief.
Other symptoms, including hoarseness, loss of
weight and clubbing of the fingers, may be en-
countered. Their presence is not characteristic of
bronchiogenic carcinoma but they should arouse
suspicion of this lesion.
In the 448 cases reported by Moersch and Tin-
ney, the average duration of symptoms from their
onset until the diagnosis was made was eight and
a half months. For this delay in diagnosis thev
gave three important reasons : ( 1 ) the lack of
specificity of the symptoms; (2) failure to sus-
pect the presence of carcinoma of the bronchus,
and (3) difficulty in making a positive diagnosis
even when the presence of bronchiogenic car-
cinoma is suspected.
Although the roentgenologic and physical signs
of bronchiogenic carcinoma are very important,
they will not be considered in detail in this paper.
In 73 per cent of the cases reported by Moersch
and Tinney, the roentgenologic findings caused
the roentgenologist to suspect the presence of
bronchiogenic carcinoma.
The early diagnosis of bronchiogenic carcinoma
is most easily and most accurately made by
bronchoscopy. This procedure was used in 399
of the 448 cases reported by Moersch and Tinney,
and the results of biopsy were positive in 368
(92 per cent) of the cases. However, attention
should be called to the fact that when the results
of bronchoscopic examination are negative, or
when a pathologist reports that tissue removed is
not malignant, this does not eliminate the possi-
bility of bronchiogenic carcinoma.
975
BRONCHIOGENIC CARCINOMA— LEDDY
Another reason why the prognosis is bad in
cases of bronchiogenic carcinoma in which the pa-
tients are referred to the radiologist for treatment
is that about 80 per cent of the lesions are of the
highest grade of malignancy, and more than half
of them are squamous cell epitheliomas.
1 have omitted from this consideration both
the so-called Pancoast tumor and “adenoma” of
the bronchi, because both of these neoplasms us-
ually are considered to be special lesions which
are different from a bronchiogenic carcinoma.
In 1940, Moersch and I reported the results of
a review of 250 cases of bronchiogenic carcinoma.
Of the 125 patients who did not receive roentgen
therapy, none lived more than a year after the
diagnosis was made. Follow-up data were avail-
able in 315 (70 per cent) of the 448 cases reported
by Moersch and Tinney. In the 315 cases, the
average duration of life after the diagnosis was
made was six months. The authors did not state
the type of treatment that was employed in these
cases. They said that the prognosis in cases of
adenocarcinoma was the same as it was in cases
of squamous cell epithelioma, regardless of the
grade of malignancy.
It is very seldom that a young, vigorous patient
who has bronchiogenic carcinoma is referred to
the roentgenologist for treatment. When such a
patient is referred to the roentgenologist, he us-
ually has refused to undergo an operation. As
I have already said, most patients who have
bronchiogenic carcinoma are debilitated and dysp-
neic, have a chronic cough and often have fever;
their physical condition is so poor that only
mild, or palliative, roentgen therapy can be em-
ployed. Regardless of all other contraindications
to intensive treatment, a danger sign on which
I place particular emphasis is fever. I regard
fever as especially dangerous when it is accom-
panied by bleeding.
From what has been said about the physical
condition of the patients, it is self-evident that
large doses of roentgen rays rarely are admin-
istered, particularly by the administration of pro-
tracted fractional doses. Nevertheless, at the
Mayo Clinic, we have administered doses of 3,000
r or more per field in a carefully selected group
of cases in which the physical condition of the
patients was comparatively good. In these cases,
the roentgen rays were administered through four
thoracic fields. The beam of rays was directed so
as to cross-fire the lesion. The roentgen rays were
generated at 200 kilovolts and a filter equivalent
to 2 mm. of copper was used. A target skin dis-
tance of 50 cm. was used routinely.. The results
obtained by this technique have given little cause
for enthusiasm. Not only were the results no
better than those which we have obtained by the
method usually employed but the patients did
not tolerate this kind of treatment well. The pro-
tracted fractional method of treatment may not
have been suitable for the patients ; the technical
details of the method may have been faulty, or
we have been unduly impressed by the reactions
we have seen. Whatever the reason for the un-
satisfactory results, I have abandoned, for the
time being, all doses greater than 1,500 r per
field, and I now prefer other doses and tech-
niques which I think are safer.
I realize, of course, that the term “safe dose”
is inaccurate, ambiguous, indefinite and no more
capable of precise estimation than are the doses
of many medicaments in clinical use. It perhaps
is easier to state what the dose is not than to
state what it is. A safe dose of roentgen rays
may be regarded as one that will not produce a
permanent or a severe temporary reaction. The
time required for the course of roentgen therapy
should not be so long that it will prove a hard-
ship for the patient, and the cost of the treatment
should not be excessive.
In the cases of bronchiogenic carcinoma which
I have observed, I have found that it is safer to
employ two courses of relatively mild doses of
roentgen rays than it is to employ one course of
relatively strong doses. Jt seems very important to
distinguish roentgen therapy that is curative from
roentgen therapy that is at best palliative. The
dose of roentgen rays should depend on the age
of the patient, the physical condition of the pa-
tient and the stage of development of the malig-
nant lesion. At present, radiologists do not know
nearly as much about the radiosensitivity of ade-
nocarcinomas and squamous cell epitheliomas of
the bronchi as they do about the radiosensitivity
of similar tumors in other parts of the body. In
cases of bronchiogenic carcinoma, the role of the
tumor bed is, so far as I know, quite unknown.
In the cases of bronchiogenic carcinoma which
I have observed, any thought of cure is senseless.
The most that can be obtained is palliation of an
indefinite degree. In outlining the type of treat-
ment to be employed in such cases, the most im-
portant consideration is to determine the smallest
976
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BRONCHIOGENIC CARCINOMA— LEDDY
doses of roentgen rays that will be efficacious.
As a rule, provided there is no contraindica-
tion, most patients receive treatment through four
fields, which are laid out so that the beam will
cross-fire the bronchial lesion. Each field gen-
erally receives a dose of 500 r. The roentgen
rays are generated at 200 kilovolts and are filtered
through 0.75 mm. of copper. This treatment is
usually given in four days. When the patient is in
much better than average physical condition, the
total dose may be increased to 1,000 r for each
of the four fields, the treatment being protracted
for sixteen days. This technique, it should be
emphasized, is used in cases in which the physical
condition of the patients is exceptionally good.
In cases in which cachexia or fever is present,
less intensive treatment is employed. In such
cases, a dose of 250 to 500 r, depending on the
clinical findings in the individual case, may be
administered through an anterior and a posterior
field. If the physical condition of the patient is
very poor, or if there is any suspicion that the
lesion may be a lymphoblastoma instead of a
bronchiogenic carcinoma, the roentgen rays are
generated at 130 kilovolts.
Since palliative results are the best that can be
expected in most cases, the selection of the method
of treatment in a given case requires precise
clinical judgment. In the average case, it seems
more sensible to err on the side of undertreatment.
In this connection it has been my experience1
that the results obtained by simple cross-firing of
the bronchial lesion with moderate doses of roent-
gen rays have been as worth while as those ob-
tained by the more radical methods. My own
results have not been at all proportional to the
magnitude of the dose employed. Nevertheless,
roentgen therapy, if judiciously administered, is an
excellent method of palliation. I think that any
patient whose physical condition is not precarious
should receive at least one course of roentgen
therapy; otherwise, his life expectancy is at most
a year. After the completion of roentgen therapy
the radiologist sees an outstanding result just
often enough to rekindle the dying fire of en-
thusiasm. Possibly, the radiologist’s lot would be
a less unhappy one if he treated more favorable
lesions or if some refinement of treatment could
assure a happier outlook to the patient with
bronchiogenic carcinoma.
References
1. Leddy, E. T.: Roentgen therapy for bronchiogenic carcinoma.
Radiology, 41:249-255, (Sept.) 1943.
2. Leddy, E. T., and Moersch, H. J. : Roentgen therapy for
bronchiogenic carcinoma. T.A.M.A., 115:2239-2242, (Dec.
28) 1940.
3. Moersch, H. J., and Tinney, W. S. : Carcinoma of the lung.
Minnesota Med., 26:1046-1051, (Dec.) 1943.
LUMBAR RETROPERITONEAL GANGLIONEUROMA
(Continued from Page 971)
a twenty-eight -year-old white woman. This tumor
had produced definite severe pain locally on the
left side and possibly on the right side of the
abdomen and lower extremity. Complete relief of
these symptoms followed its surgical removal.
An interesting postoperative sequelae of perma-
nent increase in temperature of the lower extrem-
ity on the same side is noted, similar to that
occurring with sympathectomy for hypertention.
A review of the literature has been made, and
a description of the symptoms, findings and path-
ologic nature of this tumor are recorded.
Clinically and grossly these tumors are indis-
tinguishable from neuroma, fibroma, sarcoma and
so forth, and it is only by microscopic examina-
tion that the true nature of the tumor can be
made out. They are no doubt congenital in origin
and probably arise from cell nests displaced in
September, 1947
embryonic life. They rarely recur when com-
pletely removed and practically never metastasize.
The rarity of this lesion is indicated by the fact
that there are probably less than fifty similar cases
recorded in the literature and there are no sim-
ilar tumors recorded in the files of the Depart-
ment of Pathology, University of Minnesota.
Bibliography
1. Chiari, H.: Verhandl d. Deutsch path. Gesel., 1898.
2. Clayton, S. G. : A case of retroperitoneal ganglioneuroma.
J. Obst. & Gynaec. Brit. Emp., 51:44-48, (Feb.) 1944.
3. Cripps, H. and Williamson, H. : Brit. M. J., 2:10, 1899.
4. Evans, J. H., and Francon, N. T.: Surgical removal of
large retroperitoneal sacrolumbar ganglioneuroma. Am. J.
Surg., 48:675-680, (June) 1940.
5. Holubec, K. : Retroperitoneal ganglioneuroma of lumbar
sympathetics. Casop. lek cesk., 77:222-224, (Feb. 25) 1938.
6. Loretz, W. : Vireh. arch. f. Path. Anat., 40:435, 1870.
7. McFarland, J.: Ganglioneuroma of retroperitoneal origin.
Arch. Path., 11:118, 1931.
8. Reynold, R. P., and Cantor, M. O. : Surgical removal of
large retroperitoneal lumbar ganglioneuroma. Surgery, 20:
571-579, (Oct.) 1946.
9. Roncoroni and Cid: Lumbar sympathetic ganglioneuroma.
Bol. Soc de cer de Rosario, 11:329-336, (Oct.) 1944.
10. Yamada, C.: Retroperitoneal ganglioneuroma. Gann, 35:
148-151, (June) 1941.
977
CLINICAL-PATHOLOGICAL CONFERENCE
DIAGNOSTIC CASE STUDY
BERNARD I. TERRELL. M.D.. ARTHUR. H. WELLS, M.D., and HAROLD H. IOFFE, M.D.
Duluth, Minnesota
Dr. A. H. Wells : A good tough diagnostic problem base and crackling rales in the lower one third of both
always has its teaching points when the answers are lungs. Also, there was a grade II cyanosis. Chest
known. films revealed a diffuse disease process in both lungs
Fig. 1. Anterior-posterior roentgenogram
of thorax.
Dr. B. J. Terrell: A forty-year-old white miner and
lumberjack (Nopeming Sanatorium No. 20990) was
first admitted to the hospital on November 18, 1946,
complaining of a cough. Two months before admission
while working in a sawmill he caught a “cold.” At
this time he became somewhat short of breath and there-
after orthopneic. This condition did not appear to be
progressive, but it was continuous. The symptoms
were noticed mostly at night and there was a moderate
amount of frothy sputum and some pain in the left side
of the chest. There was also some wheezing, but no
night sweats, noticeable fever, ankle edema, weight loss
or abdominal pain. His appetite was fairly good and
his bowel movements were normal. One sister had
died of tuberculosis in 1914. The father died of a
stroke and the mother died from cancer of the stomach.
The patient’s induction radiograph at Fort Snelling re-
vealed “healed primary complex” in the right lung.
He had been an underground miner for eight years,
prior to 1931.
His physical examination revealed dullness in the left
From the Nopeming Sanatorium and Department of Pathology,
St. Luke’s Hospital, Duluth, Minnesota.
Fig. 2. Lateral roentgenogram of thorax.
(Figs. 1 and 2) and also some cardiac enlargement
and mild pleural effusion. His blood pressure was
134/94, temperature 99 degrees and pulse 75. Multiple
sputum examinations were negative for acid-fast bacilli.
The Wassermann test was negative. His hemoglobin
was 15 grams, red blood cell count 5,100,000 and white
blood cell count 9,900 with neutrophiles 72 per cent,
lymphocytes 22 per cent, monocytes 4 per cent, and
eosinophiles 2 per cent. The red blood cell sedimenta-
tion rate was 19.5 millimeters per hour (Cutler), and
the urinalysis was essentially normal.
He was obviously seriously ill and not a fit subject
for drastic diagnostic procedures. Based on the history
of familial tuberculosis, a positive Mantoux test, dif-
fuse pulmonary disease in the x-ray picture and a his-
tory of underground mining, our tentative diagnosis was
that of silicotuberculosis with pulmonary congestion
and questionable pleural effusion.
His underground mining experience proved to consist
of the repair and maintenance of electric motors and
had nothing to do with hard rock mining. This ex-
perience we did not feel was compatible with silicosis
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CLINICAL-PATHOLOGICAL CONFERENCE
and the x-ray picture was not typical of this disease.
Further delving into the patient's past history revealed
that he was a heavy drinker and that he had been
working in a lumber camp cutting “deadheads” that
had been removed from lake bottoms several months
Fig. 3. Photomicrograph of dense fibroblastic reaction about
small clumps of highly anaplastic epithelial cells frequently found
in lymphatics.
before. Some of this wood was still wet. His work
was close to the saw, and he was exposed to a spray
of material from the logs for one month preceding
the apparent onset of his illness. Rotten logs are a
quick prey to various fungi, and spores liberated while
working in this sort of material were long ago re-
ported as a cause of pneumonitis. Again flukes are
found in the snails in lakes hereabouts which would
lodge in deadheads, and should be kept in mind.
We felt that the outstanding diagnostic possibilities
included the following diseases : pulmonary congestion
on the basis of myocarditis, valvular disease or peri-
carditis, Ayerza’s disease, bronchopneumonia, metastatic
or local infiltrative neoplasms, miliary tuberculosis, rare
infiltrates due to yeasts, molds, actinomycosis, blas-
tomycosis, histoplasmosis, et cetera, and interstitial pneu-
monitis of rheumatic origin.
An extensive search was made for tubercle bacilli,
fungi, parasites, et cetera, in the sputum by inocula-
tion of appropriate culture media and an examination
of multiple smears with appropriate stains. Skin test
was negative for histoplasmosis. His pleural reaction
September, 1947
increased and, accordingly, we aspirated fluid from the
left thorax three times a week totaling up to 700 c.c.
at a sitting. The bloody exudate was examined for
neoplastic cells; cultures and smears were made for
organisms.
In the meantime, fluoroscopic examination revealed
very little cardiac motion and the blood pressure fell
from 134/94 to 100/80, leading us to suspect pericar-
dial effusion or adhesive pericarditis despite the lack of
dependent edema and the forceful cardiac sound. The
cardiac silhouettte was enlarged in all diameters. The
conus was not particularly prominent. Electrocardio-
grams were interpreted as indicating myocardial dis-
ease of undetermined type, and there was no evidence
of cor pulmonale. The patient’s temperature curve
revealed a few peaks of one degree above normal dur-
ing the first week, and from then on it remained nor-
mal. His pulse varied from 72 to 95, and the serial red
blood cell sedimentation rate read consecutively 16.5,
16.5, 12, 12, and 1.
We felt that his clinical course was pointing away
from an infectious process since all of the bacteriologi-
cal studies failed to reveal etiologic agents, and his tem-
perature and white blood cell count remained normal.
This left us with the most likely possibility of either a
constrictive pericarditis or neoplastic process. The pa-
tient’s prostate was normal, and his gastrointestinal
tract functioned quite well until five days before his
death, when he developed nausea and vomiting of co-
pious quantities of mucoid material which gradually
assumed a coffee ground character. There was no ob-
struction, however, as he continued to have normal ap-
pearing bowel movements. In addition, his chest pains
became more and more marked ; rather more than the
effusion would be likely to cause. His dyspnea increased
and he sat up all of the time, securing very little rest.
He expired on the night of February 8, 1947, almost
three months after admission to the sanatorium. Very
slight edema was noted on the lower extremities about
two days before his death.
Dr. A. H. Wells : The case is now open for diag-
nosis.
Physicians : Miliary tuberculosis, pulmonary my-
cosis, carcinomatosis of hidden origin, silicotuberculosis
with cor pulmonale and chronic congestive right heart
failure, carcinoma of the stomach with pulmonary
metastasis.
Autopsy Findings
Dr. A. H. Wells : The postmortem examination re-
vealed four outstanding disease processes or complica-
tions. There was a moderately severe diffuse (1) fi-
brous pancreatitis of long standing with (2) a small
(2 cm. in diameter) carcinoma in the slightly enlarged
head of the pancreas associated with metastatic carci-
noma to the adjacent retroperitoneal lymph nodes about
the head of the pancreas and to the lungs and adrenals,
(3) cor pulmonale with congestive right heart failure
and (4) acute gastric dilatation. The metastatic carci-
nomatous infiltration of the lungs was particularly inter-
979
CLINICAL-PATHOLOGICAL CONFERENCE
esting in that there was a dense network of fibrous
connective tissue throughout all parts of the lungs.
These coarse strands of scar tissue could be easily seen
on the cut surfaces and the lungs were firm, fibrous
and rubbery throughout. Microscopically (Fig. 3), the
fibrous trabeculae in the lungs revealed scattered clumps
of highly anaplastic gland forming epithelial cells simi-
lar to those in the pancreas, located primarily about the
margins of the broad areas of fibrous scarring and in
lymphatics. The prominent dense scarred areas were
obviously originally the site of carcinoma cells which
subsequently became atrophic or disappeared due to the
density of the connective tissue. These fibrous trabecu-
lae were located primarily along the blood vessels and
the disease process is obviously the cause of increased
pulmonary tension and resultant cor pulmonale with
some evidence of chronic congestive right heart failure
in the form of periphereal edema and chronic passive
congestion of the liver and spleen.
The huge stomach half filled the abdominal cavity.
It weighed 2450 grams and contained approximately
400 c.c. of gas beside the bile-stained mucous contain-
ing watery fluid. The walls were relatively thin and
there was no organic obstruction at the pyloric valve
and no significant dilatation of the duodenum or esopha-
gus.
Cor Pulmonale
For years the generally accepted definition of cor
pulmonale (pulmonary heart) has been right ventricular
strain due to pulmonary hypertension resulting from
pulmonary diseases with either or both clinical and an-
atomical evidences of this strain on the right heart.
More recently a new concept originated by Brill1 has
been widely accepted by cardiologists and internists.
4,6,i4,is,22 This new interpretation of the meaning of
cor pulmonale includes a host of diseases of the heart,
lungs, and great blood vessels causing right heart strain.
Theoretically, these lesions are all supposed to cause
hypertension in the pulmonary circulation. Therefore,
the logic of using the term cor pulmonale is to express
their effect on the right side of the heart. With this
interpretation, cor pulmonale becomes practically syn-
onymous with right heart strain or pulmonary hyper-
tension. Why not call right heart strain or pulmonary
hypertension just that and specify the cause when pos-
sible but not distort well-established medical nomen-
clature and the English language any more than it is.
Because of its widespread acceptance, I would like to
predict that this new concept of the term cor pulmonale
will be a constant handicap in medical intercourse for
decades to come.
I would like to call on Dr. J. P. Tetlie for a discus-
sion of cor pulmonale and later Dr. H. M. St. Cyr
might briefly summarize the subject of acute gastric
dilatation for us.
Dr. J. P. Tetlie: Cor pulmonale has been fairly
logically divided into the acute, subacute and chronic
types. The acute form16 is generally due to embolism
of the pulmonary arterial tree but may rarely result
from pulmonary thrombosis, rupture of an aortic aneu-
rysm into a pulmonary artery, spasm of arterioles due
to irritants and allergy, and possibly to a diaphragmatic
hernia suddenly compressing the lungs.15 Animal ex-
perimental methods9 have revealed a critical level of
acute obstruction of the pulmonary artery .circulation at
approximately 60 per cent of its volume flow. Beyond
this, serious right heart failure rapidly supervenes.
Subacute cor pulmonale5 has been considered due in
most instances to cancer metastasis to the lungs. This
carcinomatous invasion results in obstruction of pulmon-
ary blood flow by cicatricial constriction of small arter-
ies and arterioles because of a diffuse involvement of
the adjacent lymphatics (carcinomatous lymphangitis).
Carcinomatous endarteritis and numerous small carci-
nomatous emboli in the small pulmonary arteries14
may also seriously impede the circulation. The pri-
mary site of this cancer is most often in the stomach,
but may be in any of the visceral organs. The usual
duration of the clinical evidence of cor pulmonale due
to cancer is from two weeks to two months. Sickle
cell anemia with its vascular obstruction has been in-
cluded in the subacute group of pulmonary heart dis-
eases.
The chronic form of cor pulmonale is by far the
most common variety causing right heart strain. It
has been described as having resulted from various lung
conditions constricting the pulmonary circulation such
as the different causes of emphysema,21 fibrous scarring
and lung tissue destroying lesions as well as pulmonary
arteriolar sclerosis. A list of these pulmonary diseases
would include: Emphysema, chronic bronchitis, asthma,
pneumonectomy, reduction of thoracic volume due to de-
formities of the chest and spine, thoracoplasty, multiple
lung cysts, bronchiectasis, pneumoconiosis, tuberculosis,
unresolved bronchopneumonia, fungus and parasitic in-
vasion and Ayerza’s disease.
Among the sixty selected cases of cor pulmonale stud-
ied at autopsies by Spain and Handler20 the distribu-
tion was as follows : Emphysema — 40 ; bronchiectasis —
6 ; bronchial asthma — 6 ; silicotuberculosis — 3 ; pulmonary
tuberculosis — 2; kyphoscoliosis — 1; pulmonary arterio-
sclerosis— 1 ; and organized thrombi — 1.
Brill and those who agree with his “broader sense”
or “physiologic concept” of cor pulmonale would in-
clude practically all causes of right heart tension except
those diseases which affect the heart as a whole such
as beriberi, hyperthyroidism, acute myocarditis, myx-
edma, anemia and arrhythmias. For instance, his “pri-
mary cor pulmonale” includes interventricular or inter-
auricular septal defects and tricuspid, mitral or pul-
monary valve stenosis. In fact, any disturbance of the
circulation of blood from the vena cavae to the mitral
valve which causes any right heart strain regardless of
the site of the disease constitutes “primary cor pul-
monale.” His “secondary cor pulmonale” includes prac-
tically all diseases which first cause left heart failure in-
cluding hypertension, coronary disease, et cetera.
The clinical manifestations of chronic cor pulmonale
can be divided into two phases : that due to the pul-
monary disease, and that resulting from right heart
failure. The general symptoms of the pulmonary
phase include dyspnea, cough, hemoptysis, cyanosis,
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CLINICAL-PATHOLOGICAL CONFERENCE
polycytemia, and clubbing of the fingers. Right heart
failure is evidenced by engorgement of neck veins,
swelling and tenderness of the liver, ascites, peripheral
edema, orthopnea, et cetera. These are ominous signs
in cor pulmonale and generally appear only a few weeks
or months before exodus.
Accentuation of the pulmonic second sound due to a
more forceful closure of the leaflets is a most important
sign of increased pulmonary tension in adults. Incon-
stant findings include cyanosis, clubbing of fingers and
toes, and the various physical signs of chronic pulmo-
nary diseases usually complicated by cor pulmonale.
Roentgenoscopic and roentgenographic studies17 in all
positions frequently reveal characteristic enlargement
of the pulmonary artery and the right ventricle before
there is any other evidence of right heart strain. The
electrocardiogram generally reveals right axis devia-
tion19 due to hypertrophy of the right ventricular mus-
culature. It is hoped that the new catheterization tech-
nique of obtaining blood pressures in the right ventri-
cle might be of great aid in this diagnostic field.
Acute Gastric Dilatation
Dr. H. M. St. Cyr : Acute dilatation of the stomach
occurs most frequently following laparotomies and other
major surgical procedures or after any type of opera-
tion in which general anesthesia is used. It is also
found after blows to the abdomen and spine, and also
in patients confined to bed with severe wasting diseases
such as pulmonary tuberculosis, diabetes, cancer, and
chronic heart disease. The condition is frequent enough
so that its recognition and therapy must be constantly
kept in mind.
There appears to be a fairly general agreement that
an initial loss of gastric tonus is followed by an accu-
mulation of secretions and gas, resulting in ballooning
of the stomach. Why gastric motility is decreased may
not always be apparent. General and spinal anesthesia
can depress the stomach musculature.11 Reflex altera-
tion of the vagus and splanchnic innervation8-13 may
possibly be of fundamental importance. Individual pre-
disposition,11 aerophagia,7 duodenal constriction by the
superior mesenteric artery,2 morphine and atropine pre-
medication,11 debilitation and senility, severity of trau-
matic injury and the depth of anesthesia may all be
important factors in selected cases. Much argument fills
the literature concerning the etiology of acute gastric
dilatation and it may be some time before the various
factors can be properly evaluated as to their impor-
tance.
The symptoms are restlessness, epigastric discom-
fort and the signs of beginning shock. There is eructa-
tion and a regurgitation of large amounts of brownish-
black fluid. Examination of the abdomen reveals a
fullness in the hypochondrium with obliteration of the
normal concavity at the costal margin, and there is a
succusion splash. Shock and dehydration may be se-
vere. The high blood urea nitrogen, low chlorides and
high carbon dioxide combining power are characteristic.
Treatment is aimed at relieving the distention and
replacement of the lost fluids and electrolytes. De-
compression is best accomplished by a Wangensteen
September, 1947
type of nasal suction and frequent lavage of the stom-
ach. Replacement of the lost fluid by intravenous saline
and glucose solution is essential. A modified knee-chest
position should be encouraged to relieve the pressure of
the superior mesenteric artery on the duodenum. Jo-
seph12 feels that getting the patient to stand up or walk
is of great benefit.
At the autopsy, the stomach is found enormously dis-
tended with gas and 1500 to 4000 c.c. of fluid. There
may be no other pathological change found.
Summary
A difficult diagnostic case study of a forty-year-old
underground iron miner and lumberjack is presented.
He suffered from a continuous cough productive of
frothy sputum associated with dyspnea and orthopnea
for five months preceding death. In addition, there
was chest pain, pleural effusion, wheezing, familial
tuberculosis, positive Mantoux test, crackling rales in
the chest, cyanosis and a diffuse x-ray shadow through
the lungs. Cyanosis, orthopnea, and edema of the ex-
tremities were prominent late manifestations. During
the last five days, copious vomiting was severe.
The autopsy revealed a primary carcinoma of the
pancreas associated with severe metastatic carcinoma-
tous lymphangitis of the lungs resulting in cor pulmon-
ale with right heart failure. In addition, there was an
acute gastric dilatation.
There is a brief discussion of cor pulmonale and acute
gastric dilatation.
References
1. Ackerman, L. V., and Kasuga, K. : Chronic cor pulmonale.
Am. Rev. Tub., 43:11-30, (Jan.) 1941.
2. Beck, F. C. : Acute gastroduodenal obstruction. Arch.
Surg., 52:538, (May) 1946.
3. Brill, I. C. : Cor pulmonale. Modern Concepts Card.
Dis., 12:11, (Nov.) 1938.
4. Brill, I. C.: The clinical manifestations of the various
types of right-sided heart failure (cor pulmonale). Am.
Int. Med., 13:513-522, (Sept.) 1939.
5. Brill, I. C., and Robertson, T. D. : Subacute cor pulmonale.
Arch. Int. Med., 60:1043, 1937.
6. Bondurant, A. J. : Pulmonary conditions in relation to
disease of the heart. Med. Bull. Vet. Admin., 17:253-262,
(Jan.) 1941.
7. Doolin, W. : Acute dilatation of the stomach. Brit. J.
Surg., 6:125, 1919.
8. Dragstedt, L. R., Montgomery, M. L., Ellis, F. C., and
Matthews, W. B.: The pathogenesis of acute dilatation of
the stomach. Surg. Gynec. & Obst., 52:1075-1086, 1936.
9. Fineburg, M. H., and Wiggers, C. J. : Compensation and
failure of the right ventricle. Am. Heart J., 11:255, 1936.
10. Greenspan, E. B. : Carcinomatous endarteritis of the pul-
monary vessels resulting in failure of the right ventricle.
Arch. Int. Med., 54:625-644, 1934.
11. Johnson, C. R., and Mann, F. C. : Effect of anesthesia on
gastric tonus and motility. Surgery, 12:599 (Oct.) 1942.
12. Joseph, E. C. : New treatment for acute dilatation of
stomach. Am. J. Surg., 60:381 (June) 1943.
13. MacRae, R. D. : Acute dilatation of stomach. Brit. M. J.,
2:579 (Nov.) 1943.
14. Mason, D. G. : Subacute cor pulmonale. Arch. Int. Med.,
66:1221-1229, (Dec.) 1940.
15. McGinn, S., and Spear, L. M.: Diaphragmatic hernia pre-
senting the clinical picture of acute cor pulmonale. New
England J. Med., 224:1014-1018, (June) 1941.
16. McCinn, S., and White, P. D.: Acute cor pulmonale re-
sulting from pulmonary embolism. T.A.M.A., 104:1473-1480,
(Apr.) 1935.
17. Rigler, L. G., and Hallock, P. : Chronic cor pulmonale.
Am. J. Roentgenol., 50:453-460, (Oct.) 1943.
18. Robb, J. S., and Robb, R. C.: A survey of the problems
concerned in cor pulmonale. M. Woman’s J., 48:291-300,
(Oct.) 1941.
19. Simon, S. D.: Chronic pulmonary heart disease (cor pul-
monale). J. Med., 21:535-539, (Feb.) 1941.
20. Spain, D. M., and Handler. B. J.: Chronic cor pulmonale.
Arch. Int. Med., 77:32-65, (Jan.l 1946.
21. Wells, A. H., and Merriman, L. L.: Minn. Med., 29:438-
441. (Mav) 1946.
22. Willius, F. A.: Cor pulmonale. Canad. M.A.T., 54:42-46,
1946.
981
History of Medicine In Minnesota
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester, Minnesota
(Continued from August issue)
Lafayette Redmon, born in Ohio in 1833, a member of the regular school
of medicine and one of the earliest of pioneer physicians of Fillmore County,
for twenty-six years or more played a prominent part in the social, civic
and professional life of Fillmore County, chiefly in Preston Township, and the
contiguous communities and, for a time in the middle and late seventies, in
Lanesboro, Carrolton Township.
Dr. Redmon arrived in Preston in the fifties, from Indiana, it is believed,
and various subsequent references to him which were made editorially in
the local newspapers from time to time lead to the conclusion that he was
one who had come seeking the much-vaunted salubrious climate of Minne-
sota. The first appearance of his name observed was in the Chatfield Re-
publican of September 19, 1857, in which, as of August 8, Dr. Redmon pub-
lished a notice as administrator of an estate at Forestville, a village near
Preston. Often thereafter, especially in the Preston Republican, there were
items and notices that have served as an index to his activities. In 1861
it was stated : “We regret to learn that Dr. Redmon who, since his residence
here has done much to acquire the good will of the people, is now danger-
ously ill and we hope for the best, but have some fears. He has suffered
considerable hemorrhage of the lungs.” In the following summer, however,
when steps were being taken “toward celebrating in a manner creditable
to the village the coming anniversary of our national Independence,” Dr.
and Mrs. L. Redmon and Dr. and Mrs. J. W. Crees were in the forefront
of making arrangements, and on July 4 Dr. Redmon acted as officer of the day.
In that autumn he took over locally for Dr. Luke Miller, of Chatfield, who
was surgeon for the county, in the examination of applicants for exemption
from military duty. And on October 10, 1862, there appeared an item which,
in view of the participation of Mrs. L. Redmon only three months earlier
in the celebration of the Fourth of July, is arresting: “Dr. L. Redmon has
lately returned from Indiana. He was married in Noblesville in that state
to a fair lady and returned not alone. We welcome him back with his help
mate. Long life and much happiness to them both.” This congratulatory
statement was substantiated by a notice of the marriage, on Monday,
September 29, at the residence of the bride’s father, of Dr. La Fayette Redmon,
of Preston, Minnesota, to Miss Mary E. DeMoss, of Noblesville, Indiana.
Pioneer residents of Preston have recalled that Dr. Redmon had a daughter,
Callie.
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HISTORY OF MEDICINE IN MINNESOTA
On April 29, 1863, Dr. Redmon extended his associations in the com-
munity by joining the Masonic Blue Lodge of Preston. About a year later,
evidently having just returned after an absence, or an illness, he announced
to the citizens of Preston, again through the Republican, that he would con-
tinue to reside in the village, that he intended to make it his permanent resi-
dence, that he was grateful to the people of the village and vicinity and that
he trusted that he might be able to deserve a continuance of the same. And
this hope he attempted to make good by additional study, for in the spring
of 1865 he had returned from “having spent the winter east rehearsing at
the Medical Institution.” He was then in residence at the Stanwix Hotel
(which was established by an early and solid citizen, John Kaercher) and
was giving special attention to medicine and surgery.
It was in the period from 1855 to 1867 that promotion of the Southern
Minnesota Railroad was at its height and Dr. Redmon was actively participat-
ing in the program; in 1867 he was one of a committee of citizens of Preston
appointed to investigate the possibility of securing the right of way for the
road, which presumably would pass through Preston. The village was dis-
appointed, as were many other settlements; it was not until 1879, as has
been told, when Caledonia, Mississippi and Western was extended from Cale-
donia, that Preston had railway facilities.
That this physician had scientific imagination and forethought was evi-
denced by his initiative in helping to organize the Fillmore County Medical
Society; the organizational meeting was held in his office on October 17,
1866, and there were present besides himself, Drs. R. W. Twitchell and
A. H. Trow, of Chatfield ; H. Wilson and G. M. Willis, of Carimona ; and
T. E. Loop of Spring Valley. Other charter members were added soon
afterward.
In 1868 Dr. Redmon assumed an additional professional responsibility by
serving as Examining United States Pension Surgeon for Fillmore County
to succeed Dr. E. J. Kingsbury, of Spring Valley, who had resigned. And
in the autumn of 1869, perhaps in consideration of the attempt made that
year through the legislature to regulate medical practice in the state, he
again left Preston temporarily to take a course of postgraduate study, as
did Dr. O. A. Case also. It was because of the departure of these two prac-
titioners that Dr. John A. Ross, a young and well-trained Scotch physician,
newly out of Rush Medical College, came to Preston. In January, 1870, Dr.
Redmon returned and was re-established, finding his old home more attrac-
tive than ever.
It should be said here that early in 1869, at the first semi-annual meeting
of the recently reorganized Minnesota State Medical Society, Dr. Redmon
had been elected a member of the Board of Censors and he continued on the
board into 1870; in 1871 he was a member of the Committee on Obstetrics
and Gynecology ; he aided the Committee on Surgery, as one of the seven-
teen physicians in the state to send in reports of cases and statistics for the
year ending February, 1871 ; and in this year, again, in a report to the Com-
mittee on Surgery, he observed that goiter was “quite prevalent among Nor-
wegians,” of whom there were many in Fillmore County, and expressed the
belief that high altitudes were productive of the disease ; his treatment for
the disorder was giving soft water to drink and administering iodides inter-
nally and externally. It should be noted also that this pioneer physician
co-operated in due time with the State Board of Health, which was organized
September, 1947
983
HISTORY OF MEDICINE IN MINNESOTA
in 1872; in 1880 he was one of the eleven physicians, so aften mentioned
in this paper, of Fillmore County to respond to an inquiry from the board
as to the local incidence of diphtheria in the preceding years.
Apparently Dr. Redmon was one who recognized the value of sound medi-
cal publications in the advancement of scientific medicine, for in September,
1870, the Northzvestern Medical and Surgical Journal published a note of “sin-
cere thanks and gratitude,” to Dr. Franklin Staples, of Winona, and Dr. L.
Redmon, of Preston, “for having not only sent us many a cheering word, but
canvassing successfully in their neighborhoods, sending more than one sub-
scriber and the accompanying needful on which our journal lives.” And
still another manifestation of his constructive interest in his profession was
his encouragement, through preceptorship, of sound preparation for medical
practice. In 1869 and 1870 and perhaps into 1871 he took into his office as
a student Albert Wentworth Powers, of Fountain, who subsequently studied
at Rush Medical College, and it seems a fair assumption that other young
aspirants to medicine came under his influence.
Although he had returned to Preston in 1870, by October of 1871 Dr. Red-
mon was moving and was to be replaced by Dr. A. C. White, lately of Muske-
gon, Michigan, who had just arrived. Late in November, 1872, however, the
following note appeared in the Preston Republican:
RETURNED: After a few months residence in Cedar Rapids, Iowa, where he and his
family stood an immense amount of shaking up with fever and ague, Dr. L. Redmon lias
returned to Preston with his entire household, hoping to regain health and happiness. The
doctor says he has tried to find a better place to live in than Fillmore County and failed.
He thinks no man can afford to exchange a Minnesota home for one anywhere in any other
state in the Union. His old friends welcome him back most heartily.
This was followed early in January, 1873, by two statements: first, that
he and his family were improving; second, that he had sufficiently regained
his health to be able to enter upon the practice of medicine and surgery with
reasonable assurance of being able to attend to all cases promptly at all
times. The editor went on to say: “If he has a specialty, it is surgery, in
which we know he possesses superior skill. He is a close student and keeps
well posted in the science of medicine, an indispensable requisite to success
in the healing art. Plis old friends and patients are glad to welcome him
back to Preston.” Dr. Redmon then had his offices in the Carpenter Building
(still standing in 1944) south of the Court House.
Nevertheless, Dr. Redmon departed yet again, in the early spring of 1874,
and in April was building a fine new residence in Lanesboro where, it is
believed, he remained for some years. And yet again he returned to Preston.
In late December, 1881, he was announcing that he had supplied himself
with pure bovine vaccine for vaccinating all who desired permanent pro-
tection from smallpox.
His medical contemporaries in Preston were many. In addition to the
physicians already named, there were in the village at different periods dur-
ing Dr. Redmon’s long residence the following men, to mention only a few,
who are given in chronological order of their coming, from the early sixties
into the early eighties; at all times there were more than one physician in
the village: J. W. Eighmy, — — Huffman, Lyman Viall, S. Wallace, C. H.
Jacobson, Henry Jones and George A. Love.
In May, 1882, well liked though he was both personally and professionally
984
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HISTORY OF MEDICINE IN MINNESOTA
in Preston, Dr. Redmon made his final departure from the village and moved
to Winona, Winona County, attracted by the larger field. Regrettably, the
story of his later years has not been learned.
If emphasis, perhaps undue, has been placed in these paragraphs on Dr.
Redmon’s minor removes and changes of residence, it has been done with
reason. He was typical, it is believed, of a fairly large group of the earliest
physicians in Minnesota, Fillmore County and elsewhere, of better prepara-
tion and broader professional viewpoint than the average practitioner of the
day, who had come to the state for the benefit of their health in its superior
climate. It has been observed in reading of many physicians who were
obviously of this group that each of them strove to find the place that would
meet his threefold problem of maintaining his health, supporting his family
and advancing his profession.
Lewis Reynolds, one of the earliest physicians of Fillmore County, was
both practitioner and innkeeper in Granger, Bristol Township. . . In 1865
Dr. Lewis Reynolds built the State Line House. . . . Dr. Reynolds was the
first resident physician in Granger.” Other reference to this pioneer has
not been observed.
Hogan J. Ring, born Haaken J. Fjorkenstad and named for his paternal
grandfather, was born on February 17, 1851, at the farm home of his parents,
Jens Haagensen Fjorkenstad and Helene Fjorkenstad Fjorkenstad (daugh-
ter of Johannes Fjorkenstad; the two families were not related), near Lake
Mjosen on a large estate, Ringtogen. The boy was the fourth of ten children.
In 1863 Johannes, the eldest of the children, immigrated to the United
States and to Minnesota. In the new country he soon found that the family
name of Fjorkenstad was too hard for the Americans to pronounce and he
therefore cast about for a new surname; at first he tried Jensen, but because,
as he said, that name was on practically every corner in the community of
Preston, where he had settled, he shortened the name of his birthplace, Ring-
togen, and thereafter was known as Johannes (or John) Ring.
These two brothers, Johannes and Haaken, were musicians, playing violins
that their father had made and performing ably on other instruments also.
Hogan Ring could not remember, his children have quoted him, when he
first started to play the violin ; he took lessons from his brother until the pupil
was playing better than the teacher. In Norway the two boys played for
family and guests at home and for dances in their neighborhood. It happened
that after Johannes had left Norway, Haaken’s playing attracted the atten-
tion of Ole Bornemann Bull, the great Norwegian violinist, who would have
educated the boy at the University of Stockholm. The stories of American
wonders that came home from Johannes were more attractive, however, than
the prospect of a musical career under Bull’s sponsorship, and in 1865 Haaken,
aged fourteen, took passage on the sailing vessel, the Emerald, to Canada
and earned his way by playing his violin for dances on shipboard. Arrived
in Canada, he traveled by waterways the St. Lawrence River and the
Great Lakes, and overland, probably by railway from Chicago, to La Crosse,
Wisconsin, and thence to Preston, Fillmore County, Minnesota. Once more
the brothers made music together, and the younger by means of his violin
earned his way through school. It was in Preston, soon after his arrival, that
Haaken J. Fjorkenstad became Haaken J. Ring and later, when he became a
September, 1947
985
HISTORY OF MEDICINE IN MINNESOTA
citizen of the United States, that Haaken was changed to Hogan. Johannes,
never strong, lived only a few years after coming to America.
For several years Hogan Ring in the summer worked on farms near Pres-
ton and in the winter went to school in the village. After he had left school,
he worked four and a half years as apprentice and clerk in the drugstore of
Albert Weiser in Preston until, in 1872, he went into partnership with Mr.
Weiser in a new store in Whalan. At about this time a newspaper item, giv-
ing an account of the Whalan Cornet Band, stated that “H. J. Ring fingered
the 1st B flat.” In December, 1873, he was appointed postmaster in the village,
in place of G. G. Walker, resigned, and the Preston Republican commented,
“Hogan is a reliable young businessman and will no doubt make a good
postmaster.” The village of Whalan, on the Root River and the Southern
Minnesota Railroad, was named for John Whaalahan, an early settler; com-
mon usage reduced the number of letters in the name. In the days when
Hogan Ring first lived in Whalan, the settlement had 160 residents, “three
flour mills, telegraph and express,” various stores and the drug shop of
Weiser and Ring.
From boyhood Hogan Ring had dreamed of becoming a physician but
it was not until he had been several years in Whalan that he accumulated
sufficient money with which to realize his ambition. In the middle seventies
he enrolled at the Bennett College of Eclectic Medicine and Surgery in Chi-
cago and in 1877 he received his diploma. In the last year of his medical
course he was married, on August 15, 1875, to Ida Orcelia Lowe, daughter
of Mr. and Mrs. Garrison A. Lowe, of Belvedere, Illinois, and immediately
after his graduation he brought his wife to Whalan, where they lived for
about two years. In Whalan Dr. Ring practiced medicine and continued in
the drugstore, of which he became sole owner ; subsequently he sold it to
A. Backman. In Whalan, also, on December 21, 1877, was born Dr. and
Mrs. Ring’s first child, Johannes Glenellyn. When the baby was ten months
old, Hogan and Ida Ring started with him for Nebraska, traveling by horse
and buggy. In Grand Island, Hall County, Nebraska, they made their home
for nine years, and there became the parents of two daughters, Verna Helene,
born on September 13, 1882, and Mildred, on May 14, 1887. In Grand Island
Dr. Ring advanced his medical career and for two years served as county
coroner.
In the autumn of 1887 the Ring family left Nebraska for the Pacific Coast
and late in December arrived in Ferndale, Humboldt County, California,
where Dr. Ring at once began his forty-three years of service in the village
and community. In Ferndale two more sons were born to Dr. and Mrs.
Ring, Ronald Lowe, on January 31, 1894, and Arden Garrison, on October
31, 1899. Mrs. Ring died on June 7, 1901, from carcinoma of the breast.
Two years later Dr. Ring was married to Eleanor Black Andreasen, a widow,
of Ferndale; of the second marriage there were two children, Harlan J. and
Ingwald M. Ring.
Early in 1930 Dr. Ring, because of rapidly failing health, was taken to
San Francisco for temporary hospitalization and special medical care; he
died in that city from carcinoma of the rectum on April 26, at the home of
his stepson, Dr. Olaf Andreasen, survived by his wife, his children, two
stepchildren, one brother, Jacob H. Ring, and a sister, Mrs. Pauline Hel-
gestad, all of whom were in the West, and a sister, Mrs. Oliane Backman, of
986
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
Whalan, Minnesota. In 1943, of this group there were living the brother,
J. H. Ring, of Ferndale, and the seven children : J. Glen Ring, of Willits,
California; Verna (Mrs. Paul W. Hunter), of Fortuna, California; Mildred
Ring, of Covelo, California ; Ronald L. Ring, of Denton, Texas, colonel in
the United States Army; Arden G. Ring, of Seattle, Washington, lieutenant
(S. G.) in the United States Naval Reserve; and Harlan J. Ring and Ing-
wald M. Ring, of Berkeley.
Dr. Ring became a member of the Eclectic Medical Society of California
in 1888, and also was a member of the Masons, Odd Fellows, Knights of
Pythias, Woodmen of the World and other fraternal orders. He was a good
and useful citizen, a faithful and valued physician and a respected and loved
resident of his city, where his name is honored and where there are many
memories of his kindness and ability. He never failed a patient ; and although
he has been gone seventeen years, many of his techniques and prescriptions
are still in use. A scholarly man, Dr. Ring not only kept abreast of his own
profession but he also studied other sciences than medical and wrote of his
observations. Early in the century an article of his on astronomy was pub-
lished in one of the current scientific journals. In his later years he was
engrossed in a study of the effect of winds, air pockets and other aerial
phenomena on aviation.
Soon after his death the citizens of Ferndale erected a memorial to this
beloved physician, a flagstaff that stands on the lawn of the Carnegie Library.
Its inscription reads :
In Memory of
Hogan J. Ring, M.D.
in
Recognition of Forty-three Years
of Unselfish Service
to this Community
1851 1930
(To be continued in October issue.)
6
September, 1947
987
Pi esident s fettei
IN 1943 eight out of ten citizens of the United States claimed that their physicians had a
! personal interest in them and their welfare, and 74 per cent felt that there were suffi-
cient physicians, nurses and hospitals to meet all needs. In 1947, 79 per cent complain of
shortages of nurses, hospital facilities and physicians, and 47 per cent have found it difficult
to pay a doctor’s fee or a hospital bill. Seventy per cent believe that something might be
done to make it easier to meet such expense. In 1943 the term “socialized medicine” was
known to about four out of ten persons but in 1947 the percentage of these individuals has
increased to 55 per cent.
Nine out of ten physicians are familiar with the Wagner-Murray-Dingell National Health
Bill. Eleven per cent consider that the Wagner-Murray-Dingell Bill would be a good thing
from the standpoint of the general public. Nine per cent think it would be a good thing
from the standpoint of the physicians of the country.1
Many physicians believe that their worries concerning the threat of socialized medicine
came to an end when the composition of the Congress was altered in the last election. They
are familiar with the effort which has been made to pass legislation which might place
the Federal Government in control of the practice of medicine, but they feel that there is
no need, at this time, for concern about this vital matter. Possibly this is a normal reac-
tion. However, if physicians knew of all of the activities in which proponents of the
Wagner-Murray-Dingell Bill are engaged during this period of apparent inactivity, they
would realize that their sense of security is unjustified and that this is no time for lethargy.
Recently the Committee on Expenditures in the Executive Departments2 completed an
investigation through a subcommittee authorized to investigate publicity and propaganda
of Federal officials in the formation and operation of health workshops. In this report it
was stated that “on the basis of hearings held on May 28 and June 18, 1947, it (the Com-
mittee) finds that at least six agencies in the executive branch are using Government
funds in an improper manner for propaganda activities supporting compulsory national health
insurance, or what certain witnesses and authors of propaganda refer to as ‘socialized medi-
cine’ in the United States.” The statement goes on to say :
“The departments, bureaus and agencies now participating in this campaign are :
1. The United States Public Health Service
2. The Children’s Bureau
3. The Office of Education
4. The United States Employment Office
5. The Department of Agriculture; and
6. Bureau of Research and Statistics, Social Security Board.”
The Committee called attention to “the extraordinary executive pressure” exerted on the
staff of the United States Public Health Service to further the campaign for socializing
medicine by publishing a portion of a letter written under date of December 10, 1945, by
Thomas Parran, Surgeon General of the United States Public Health Service, to all field
men and staff operatives throughout the country. This letter referred to the message sent
to Congress on November 19, 1945, by President Truman, urging enactment of a national
health program. The quotation from Surgeon General Parran’s letter is as follows :
“The appropriate executive agencies of the Government have been specifi-
cally instructed by the President to assist in carrying out this legislative
program. . . . Every officer of the Public Health Service will wish to familiar-
ize himself with the President’s message and will be guided by its provisions
when making any public statement likely to be interpreted as representing the
official views of the Public Health Service.”
All of the evidence presented before this Committee indicated that “health workshops were
planned, conducted and largely financed with Federal funds by a key group on the Government
payroll who used the workshop method of discussion subtly to generate public sentiment
in behalf of . . . socialized medicine. It is evident from the record that most of the planning
was done by the Federal officials in Washington prior to each workshop conference.” These
conferences were organized “to agitate for compulsory health insurance, as then pending
in Congress.”
'Opinion Research Corporation’s official tabulation on surveys of opinions of the public on selected issues
and opinions of physicians on selected issues.
2Third Intermediate Report of the Committee on Expenditures in tile Executive Departments, House
Report 786 of the First Session, 80th Congress, submitted July 2, 1947, to the Committee of the Whole
House on the State of the Union.
988
Minnesota Medicine
It was found that the Bureau of Research Statistics of the Social Security Board pre-
pared pamphlets and propaganda literature for the C.I.O., the A.F. of L., and the Physicians’
Forum (the propaganda agency for the Wagner-Murray-Dingell Bill). This material, pre-
pared at Government expense, supported “socialized medicine in every approach and dis-
missed contemptuously all arguments controverting the fixed position of the Social Security
Board.”
Also, attention was called to the fact that the Chief of the Medical Economics Section
of the Division of Research Statistics of the Social Security Board had “charted, arranged
and conducted the Jamestown (N.D.) Health Workshop,” and that this Federal employe
had helped draft the Wagner-Murray-Dingell Bill.
The Committee showed that thirteen of these workshops had been planned and carried
out. Two of these meetings were held in Minneapolis, the first one on December 20, 1945,
and the second on January 9, 1946, and from February 6 to 10, 1946, one of the largest
workshops was held in Saint Paul. Qn that occasion, seven Federal agencies were repre-
sented by fifteen Federal employes.
The method used in the workshops is impressive. “A hand-picked group of leaders from
various local societies were brought in for the purpose of being trained in workshop proce-
dure. This training program was handled entirely by tbe employes of the Federal Govern-
ment. . . . The hand-picked group from the local societies were designated as delegates
and in training them they were seated around a conference table with the twenty-one con-
sultants (Federal representatives) lined up behind them.” It was urged that “letters be writ-
ten to senators and representatives advocating immediate action on the Wagner-Murray-
Dingell Bill. ... It was very interesting to note that when left to themselves the delegates
seemed unable to think of any particular health problems in the State.”
Among the topics listed in the procedures of these meetings are: (1) Technics for the
organization of citizen groups; (2) formation of pressure groups; and (3) methods of bring-
ing about group action.
Testimony demonstrating the efficacy of this indoctrination of delegates by the Federal
officials was found in the formal summary of the Jamestown Workshop, as presented by
the United States Public Health Service. One section urged that congressional candidates
and incumbents be polled by the Committee on their stand on the national health program
and that their opinions be sent to the State organizations for publication. It was shown
clearly that Federal employes arrange the meetings, invite the delegates, train the delegates,
preside at the meetings, and then frame the formal summary of resolutions and actions.
One portion of this report calls attention to the fact that it was the activities of the
Group Health Association of Washington, D. C., which led to the filing in 1937 of the
antitrust proceedings against the American Medical Association under the Sherman Anti-
trust Act. It is well known that this legal action by the Department of Justice was carried
to the Supreme Court of the United States on the basis of the original complaint and
accusation of the Group Health Association of Washington, D. C., serving effectively to
“intimidate and restrain the activities of the American Medical Association in resisting the
Federal propaganda.”
In the report it was stated that “for the fiscal year 1946 total expenditures in the execu-
tive branch for publicity and propaganda activities were 75 million dollars. During that
fiscal year 45,000 Federal employes were engaged, full or part time, in such activities.
. . . An increase of approximately 300 per cent in Federal expenditures for publicity and
propaganda in a period of five years is deemed by your Committee to be a proper subject
for inquiry by the Congress.” And the recommendation of the Committee was summed
up in these words : “We have, therefore, brought these matters to the attention of the
Department of Justice with the request that the Attorney General at once initiate proceed-
ings to stop this unauthorized and illegal expenditure of public moneys.”
These are not doubtful or hypothetical inferences. They are not matters of opinion which
may be disputed, but are stubborn certainties supported by irrefutable testimony. Having
seen these evils, the knowledge which we have obtained should create in us a determination
to provide a remedy. We cannot accomplish this by a continuance of complacency.
efyCitL A (Xj&Uju
President, Minnesota State Medical Association
September, 1947
989
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
PERTUSSIS IMMUNITY AND MIXED
ANTIGENS
N AN earnest effort to simplify immunization
procedures and minimize the number of
doses of antigens employed, biological manufac-
turers have recently fostered the preparation and
use of “triple” antigens (pertussis, diphtheria,
tetanus).
Ramon5 showed that the immune response to
a toxoid (in the form of antitoxin) was enhanced
by a mixture of toxoids. Bordet recommended
pertussis vaccine and diphtheria toxoid in combi-
nation. A number of reports on mixed immuni-
zation have since appeared.2’9 Bigler1 and others
now believe that the degree of immunity to per-
tussis, tetanus and diphtheria correlates best with
the total dosage of antigen used. Lapin3 has
shown that 80 billion Phase I pertussis organisms
modify active pertussis whereas 120 billion pre-
vents the disease in older infants. Since the re-
cent increase in pertussis, it has become apparent
that bacterial counts in previously used mild anti-
gens have been very inadequate. At Stanford
University Clinic, Miller4 reports the need of ad-
ditional pertussin antigen when triple “D-P-T”
vaccine is used in babies.
The problem before manufacturers is still that
of mixing enough pertussis antigen without pro-
ducing severe local and general reactions. More-
over, the “small volume” alum precipitated per-
tussis vaccine now available has been shown by
Sako6’7 to be capable of protecting babies as
young as two months of age with doses of only
1. Bigler, J. A., and Werner, M. : Active immunization against
tetanus and diphtheria in infants and children. T.A.M.A.,
116:2355, 1941.
2. Hamilton, P. M., and Knouf, E. G. : Combined immuniza-
tion against diphtheria, tetanus and pertussis. T. Fed., 25 :
236, 1944.
3. Lapin, J. H. Mixed immunization in infancy and childhood.
J. Ped., 22:439, 1943.
4. Miller, John J. : Immunization procedures in pediatrics.
T.A.M.A., 134:1064, (July 26) 1947.
5. Ramon, G. : Mixed vaccinations. Internat. Clin., 1:241,
1939.
6. Sako, W. : Studies on pertussis immunization. J. Ped.,
30:29, 1947.
7. Sako, W. : Treuting, W. L. ; Witt, D. B., and Nichamin,
S. J. : Earling immunization against pertussis with alum-
precipitated vaccine. J.A.M.A., 127 :379, 1945.
8. Sauer, L. W. : The age factor in whooping cough. Am. J.
Path., 15:719, 1941.
9. Simon, H., and Craster, C. V. : Simultaneous immunization
with combined diphtheria-whooping cough vaccine. J.M.
Soc. New Jersey, 38:461, 1941.
0.2 c.c., 0.3 c.c., and 0.5 c.c. (40 billion A-P).
This has stimulated trials at immunity to other
diseases at younger age levels and a number of
studies are now in progress in various parts of
the country. In young infants it begins to ap-
pear8 that alum-precipitated antigen is superior,
whereas in the older infant and child, plain vac-
cine is effective and more prompt in its recall of
“booster” role. Although mixed antigens may be
used for babies if extra doses of pertussis are
given, it would seem best in the light of present
knowledge to reserve the triple antigen for boost-
er purposes in the previously immunized child
starting kindergarten.
Until a more efficient and reaction-free mixed
antigen is available, it may be better to immunize
against pertussis alone at the third, fourth, or
fifth months, and diphtheria-tetanus at the sixth,
seventh, or eighth months with triple mixtures
reserved for use as reinforcing agents. As great-
er improvement occurs in the manufacture of
mixed antigens, it is hoped that an ideal prepa-
ration for small infants will evolve which will
adequately protect against all three diseases.
Erling S. Platou, M.D.
CANCER
'THE public has become cancer-minded as evi-
denced by the millions contributed to the
American Cancer Society and the additional mil-
lions appropriated out of taxes for cancer re-
search. While money is necessary for research,
it is not necessarily true that if enough millions
of dollars are available the cause of cancer will
be found and the cancer problem solved. Medi-
cal discoveries in the past have been the result of
the work of a few scientists who have not had
much financial backing but who have had that
rare type of mind which characterizes research
workers.
In facing the problem of cancer, not only is it
highly desirable to discover the cause of cancer,
but it is also very important to detect the pres-
ence of cancer in its early stages when it can be
990
Minnesota Medicine
EDITORIAL
more likely cured by our present methods of
treatment.
In attaining this later objective, we hear more
and more about the desirability of Cancer Detec-
tion Clinics composed of a group of specialists.
Wangensteen* in a recent article states, “There
is need for Cancer Detection Clinics set up at
strategic places with competent specialists in the
various branches of medicine and surgery. More-
over, there is need for the co-operation of all
men and women in attending such clinics, when
established, approximately three times a year.
If the support in funds and of the public in at-
tendance on such clinics is forthcoming, I believe
that it will represent the best use of the available
knowledge in dealing with the problem of can-
cer.”
The author is doubtless impressed with the
number of patients in whom cancer of the stom-
ach is diagnosed too late for operative cure. He
apparently believes that if everyone in the cancer
age were examined frequently by competent spe-
cialists, more cancer would be detected early
enough for cure. This is true. The same would
be true if everyone consulted his physician three
times a year. But is such a suggestion realistic?
Some 20 per cent of the 140 million people in
the country (28 million) are over fifty years of
age. At three examinations a year, that would
mean 84 million examinations a year — examina-
tions not for cancer of the stomach alone but for
cancer of all the organs.
With the chance of perhaps one in a thousand
of detecting cancer in this age group, would it
be reasonable to expect normal individuals to go
to the expense of such frequent examinations?
The number would be few. To operate to any
extent, such Cancer Detection Clinic would
have to be tax supported ; and who would advo-
cate loading the present burden of the taxpayers
with a possible 84 million examinations?
We do not wish to decry wholly the idea of
the Cancer Detection Clinic. It is quite likely
that physicians would welcome the establishment
of such clinics to which they could refer patients
in whom they suspected cancer. We are not
convinced, however, that periodic examination of
large numbers of normal individuals at Cancer
Detection Clinics would contribute valuable addi-
tional knowledge to what we now have as to
early symptoms.
‘Wangensteen, Owen H. : The problem of gastric cancer.
J.A.M.A., 134:1161, (Aug. 2) 1947.
September, 1947
The problem of cancer and its early detection
presents a distinct challenge to the profession
today, as it has in the past. Physicians should
always be cancer-minded. Every patient, and par-
ticularly those in the later age groups, should be
approached with the possibility of cancer as well
as tuberculosis, cardiac disease, diabetes, and the
innumerable other diseases flesh is heir to. It
should not be necessary to have separate clinics
for the diagnosis of these diseases — whether pri-
vately or publicly supported. With consultation
easily accessible, the profession should be able to
diagnose cancer as early as scientific methods
permit, and we question the practicality or neces-
sity of the establishment of Cancer Diagnostic
Clinics on a wholesale scale.
LIFE INSURANCE FOR STATE
ASSOCIATION MEMBERS
HP HE opportunity for active members of the
Minnesota State Medical Association to add
a $5,000 policy to their life insurances has been
presented in detail to each member. Each mem-
ber would do well to consider the proposition
seriously in view of his particular needs. The
group policy is offered by the Northwestern Na-
tional Life Insurance Company of Minneapolis,
and being a term as well as a group policy, the
rates are low. Term policies are convertible at
any time, the age rate to apply at the time of
conversion.
This proposed group policy is recommended
by the Council of the Association and should
prove particularly attractive to the younger mem-
bers. To them, the cost of adequate life in-
surance is an important item at a time when their
practice is being built up and unfortunate possi-
bilities are ever present. After all, the main pur-
pose of life insurance is protection for depend-
ents in case of death. Endowment policies pro-
tect against the further possibility of reduced in-
come in advanced years and are valuable but more
expensive.
The rates of the proposed group policy are
contingent on 75 per cent of our State Associa-
tion membership taking out a policy. Most mem-
bers should welcome the opportunity to add
$5 ,000 to their life insurance protection. It would
seem that the success of the proposition should
be assured.
991
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
PREPAID MEDICAL AND SURGICAL CARE
FOR MINNESOTA PEOPLE
MR. DON C. HAWKINS
Chairman, Liaison Committee of Insurance
Underwriters
Saint Paul, Minnesota
If there were no differences of opinion, there
would be no problem in providing Minnesota resi-
dents with a plan for budgeting the cost of medi-
cal care. However, there are at least two points
on which there is no disagreement: first, that the
best medical care is and should be available ; and
second, that no matter what method is evolved
for providing this care, the doctor is the one who
is going to render the service.
If one wants a haircut, one goes to a barber;
when one needs his tonsils removed, the logical
procedure is to consult a doctor. And when it
comes to the method of providing medical and
surgical care on a prepayment basis, the question
is one of insurance and one should look to a
recognized licensed insurance company, which is
represented by regular agencies and is capable
of providing reliable coverage. It is through this
method that the greatest good can be done for the
greatest number.
Under a plan utilizing the facilities of recog-
nized insurance companies, coverage provides
payment for care wherever it may be rendered,
irrespective of the nature of the care, thereby
eliminating disappointing experiences arising
from limited coverage in a limited area, as when
coverage can be provided only within state bor-
ders.
The medical profession has always recognized
the fact that they have a duty to perform ; and
every clear-thinking individual should realize that
the social uplifter has, in reality, proved of little
value, and has, rather, impeded progress in the
Mr. Hawkins’ article presents a review of work done by the
Liaison Committees of the Minnesota State Medical Association
and the Insurance Representatives toward setting up a plan for
prepayment of medical and surgical care, underwritten by private
insurance carriers.
992
development of medical care programs. More
attention could well be paid to education, sanita-
tion, housing and the like, while special services
pertaining to medical care could be left to those
who are qualified.
It has been a pleasure and an education to work
with the Liaison Committee of the Minnesota
State Medical Association. In all of this work,
we have not changed from our original objec-
tive. There have, however, been a few changes
which are beneficial to the public and to the medi-
cal profession as well. As the plan progresses,
and with the full co-operation of the members
of the State Medical Association, additional im-
provement will be made; and, while other states
have plans in effect, we in Minnesota have had
opportunity to profit by their mistakes. It may
appear to some that this plan is slow in develop-
ing, but the reverse is true. Minnesota still leads
the field in many phases of the development of
prepayment plans.
In seeking to establish a means of providing
the people of the state of Minnesota with a plan
of prepaid Non-occupational Hospital, Surgical
and Obstetrical insurance, at the lowest possible
cost, there are certain phases of the plan which
are fundamental :
first, it is believed at present that the public
interest is best served through the medium of vol-
untary insurance, underwritten by insurance com-
panies duly licensed by the state insurance com-
.mission.
Second, the Minnesota State Medical Associa-
tion is willing to permit any such licensed insur-
ance company to state that a specific policy or
policies are accepted and approved by the As-
sociation, provided the benefits in such a policy
or policies meet the minimum standards set forth
by the Association and the company will co-oper-
ate towards the attainment of the objectives of the
Association.
In carrying out the instructions of the House
Minnesota Medicine
MEDICAL ECONOMICS
of Delegates, the Liaison Committee of the Min-
nesota State Medical Association has set forth the
following Minnesota standards as a recommenda-
tion to insurance companies operating in this
state :
1. Surgical Expense
Reimbursement for surgeon’s fees up to the amounts
provided in the schedule of surgical benefits offered on
the $150 schedule (schedule offering top benefits of $150
for major surgery) of the former group conference.
2. Medical Expense
The minimum standards for medical service rendered
for employed persons shall be :
$3.00 beginning with the fourth call in the home
$2.00 beginning with the fourth call in the office
$2.00 beginning with the first call in the hospital
$20.00 limit on any one disability
$100 limit in any twelve consecutive months
Minimum standards for dependents’ medical care :
$2.00 beginning with the first call in the hospital
$60.00 limit in any twelve consecutive months
3. Obstetrical Expense
Up to $50.00 for delivery.
4. General Recommendations
(a) There is to be no interference by the insurance
company with the physician-patient relation-
ship.
(b) There is to be no interference by the Associa-
tion in the operation of the insurance company,
although reasonable reports may be requested
from time to time as to claim experience and
enrollment.
(c) The plan must be flexible ; that is, medical ex-
pense benefits may be written without surgical
and obstetrical benefits, and vice versa. Indi-
viduals may be insured without including de-
pendents, but insurance companies would be
expected to have complete coverage available.
(d) Freedom of contract — an insurance company
may use its own forms, may provide higher
benefits than the minimum standards specify,
and may issue other forms in conjunction with
the approved plan.
(e) The Association is to have full control in grant-
ing approval and shall retain reasonable rights to
withdraw approval.
(f) The plan should be competitive as to its pro-
visions with any other plan in the state, and
participating physicians should agree to ac-
cept the fees in the schedule as full payment
for services rendered to the “low income
group.”
(g) Co-ordinating Committee — the Liaison Com-
mittee— is to act as a Committee to consider
problems arising in connection with the plan
and to hear complaints of physicians, the public
and the insurance companies.
In preparing this report, we have not drawn
any unwarranted inferences. There have been
no promises made which cannot be performed.
We have not confused reality with wishful think-
ing. Your insurance companies are continually
interested in the development of constructive pro-
grams for medical care and trust they can at least
keep abreast of the needs of the public, if not
ahead of them.
EMERGENCY MATERNAL AND INFANT
CARE PROGRAM TO END GRADUALLY
By voting just enough funds to wind up activi-
ties, Congress has assured the eventual liquidation
of the Emergency Maternal and Infant Care Pro-
gram, which has been in effect since July 6, 1943.
Appropriations include only those necessary to
permit mothers and babies to complete the medi-
cal and hospital care for which they were eligible
on June 30, 1947.
No one who was not eligible or potentially eligi-
ble for benefits on June 30 can become eligible
after that date. However, an eligible wife, who
became pregnant prior to June 30 may receive
benefits; and her baby can receive medical care
under the program up to the age of one year.
Because babies born to mothers who are still
eligible may receive care until they are a year old,
it is estimated that the program will not be ter-
minated entirely until nearly two years from now.
There is a maximum of twenty-one months of care
possible — nine months maternity care during preg-
nancy plus twelve months for the infant after
birth.
29.840 Mothers, Infants Receive Care
In Minnesota, operation of EMIC has provided
a total of 29,840 wives and infants of servicemen
with the best medical and hospital services avail-
able. Of this number, 22,810 mothers received
prenatal, delivery and postnatal care, while 7,030
babies were provided for when ill and also given
immunizations against smallpox, diphtheria and
whooping cough. The steady decline of maternal
and infant mortality during the period of the pro-
gram’s operation would indicate that this service
has had an important bearing on the saving of
life and health.
As of last December 31, the operation of this
program in Minnesota has -cost the federal govern-
ment in specialists’ and general practitioners’ fees,
as well as hospital charges and nursing services,
September, 1947
993
MEDICAL ECONOMICS
a total of $2,219,062.27. Federal funds have been
administered in Minnesota by the State Depart-
ment of Health, under the direction of Dr. Viktor
O. Wilson, chief of the Section of Special Serv-
ices. Dr. Wilson says that EMIC “storks” costs
in this state have averaged $107.10 a baby, and
$46.92 for each sick infant.
The main objective of EMIC was to provide
necessary medical care for infants and pregnant
wives of men in the four lowest grades of the
armed services (including aviation cadets). Wives
and children of veterans were also eligible when
pregnancy occurred while the men were still in
service.
Program Stirs Controversies
Although no responsible men of medicine ques-
tioned the basic necessity and desirability of the
EMIC program, many of the details of policy
and method were often the subject of heated con-
troversy. The feeling that the program was too
strongly weighted in favor of specialists labeled
it a “specialists’ program.” Too little recognition
was given to the problems of the general practi-
tioner in the rural areas.
The controversy narrowed down to one point,
however, and that was the inability of the physi-
cian attending a case under the program to exer-
cise his own choice of physician for consultation
when complications occurred. The arbitrary poli-
cies laid down by the federal administration in
Washington, the “Blue Book” and the fact that
organized medicine was not consulted at any point
in the designing of the program were all sources
of dissatisfaction and disagreement.
And now the EMIC program is on the way out.
At one time or another the program exemplified
nearly every fault or failing that can be expected
in a nationally sponsored plan for medical care.
A large share of the credit for the ultimate suc-
cess of the program can be given to the patient
co-operation of the physicians of Minnesota, to
the administrative handling of the Health De-
partment, to the services of the professional ad-
visory committee and the Academy of Pediatrics
which worked so hard to iron out difficulties as
they arose.
EMIC has taught many lessons that will be
profitable should a comparable national medical
program be necessary in the future.
FEDERAL FUNDS USED TO PROMOTE
~ COMPULSORY HEALTH INSURANCE
At least six federal agencies in the executive
branch have been found guilty of using Govern-
ment funds in an improper manner for propaganda
activities supporting compulsory national health
insurance.
Unlawful use of federal funds was uncovered
in a recent investigation in Washington of the par-
ticipation of federal officials in forming and con-
ducting health workshops. The investigation was
carried on by a subcommittee of the Committee
on Expenditures in the Executive Department
known as the Subcommittee on Publicity and
Propaganda.
Hearings were held by the Subcommittee on
May 28 and June 18 of this year, which revealed
that employes of the U. S. Public Health Serv-
ice, the Children’s Bureau, the Office of Educa-
tion, the Employment Service, the Department of
Agriculture, and the Bureau of Research and
Statistics of the Social Security Board has been
sent at government expense to a series of “Health
Workshop Conferences” held throughout the
country during the last two years.
These health workshops, planned and conducted
with the aid of federal funds by a key group on
the government payroll, were subtly aimed to
generate public sentiment in behalf of health in-
surance legislation such as the Wagner-Murray-
Dingell Bill.
First Workshop Held in Saint Paul
Following three meetings held to plan the series
of workshop conferences in November and De-
cember, 1945, two in Washington, D. C., and one
at the University of Chicago, the U. S. Public
Health Service launched the series in Saint Paul,
Minnesota, February 6-10, 1946. Eighty persons
attended this first meeting, 15 of whom were gov-
ernment employes representing seven different fed-
eral agencies.
The second health workshop was held in James-
town, North Dakota, September 27-30, with
ninety-eight participating, eighteen of whom were
federal employes representing seven agencies.
Apart from federal personnel, there were no
doctors of medicine in attendance as delegates. No
registered doctor of medicine was invited to par-
ticipate. Other conferences in connection with
the workshop series were held at Fargo, Aber-
994
Minnesota Medicine
MEDICAL ECONOMICS
deen, Great Falls (Montana), and at Minneapolis.
It is evident from the record that most of the
planning for these conferences was done by the
Federal officials in Washington prior to each meet-
ing and that the primary aim was to organize
pressure groups to agitate for compulsory health
insurance then pending in Congress.
Executive Pressure Asserted
That pressure for a national health program
was exerted from the top down within the U. S.
Public Health Service was apparent even before
the current investigation. For concrete evidence
of this, one need look no further than a letter
sent to Health Service officials and employes by
Surgeon General Thomas Parran. The letter re-
ferred to the President’s November, 1945, mes-
sage to Congress, which urged enactment of a
national health program.
Calling the Presidential message “a subject of
highest importance to every citizen,” the Surgeon
General suggested that “every office holder of the
Public Health Service will wish to familiarize
himself with the President’s message and will
be guided by its provisions when making any pub-
lic statement likely to be interpreted as represent-
ing the official views of the Public Health Serv-
ice.”
Through testimony given at the investigation, it
can be seen that Health Service employes and of-
ficials have been consistently intolerant of honest
discussion or debate of issues in their attempts
to high-pressure certain legislation through Con-
gress.
Security Board Pays for Literature
Testimony before the Committee reveals that
the staff and resources of the Bureau of Research
Statistics of the Social Security Board were freely
and frequently lent to the preparation of pam-
phlets and other propaganda literature for the
CIO, the AFL, and the Physicians’ Forum (a
propaganda agency for the Wagner-Murray-Din-
gell Bill). Much of this was in support of the
national health program.
In preparation for the Jamestown Workshop,
the Public Health Service distributed to all dele-
gates a packet of pamphlets published by the
CIO, AFL and Physicians’ Forum, at government
expense, urging that letters be written to Sen-
September, 1947
ators and Representatives advocating immediate
action on the Wagner-Murray-Dingell Bill.
Other evidence before the Committee revealed
that the Bureau of Research Statistics of the
Social Security Board also prepared pamphlets
in behalf of the national health program and sent
them out as Government literature through the
Department of Agriculture’s Interbureau Com-
mittee on Postwar Programs.
Committee Recommends Action
Citing from the United States Code (Section
201, title 18) that the use of federal funds for the
purpose of influencing opinion on legislation be-
fore Congress is unlawful, the Committee brought
its findings to the attention of the Department of
Justice, requesting that the Attorney General at
once initiate proceedings to stop this unauthorized
and illegal expenditure of public moneys.
Its report stated that a comparison of figures of
the Budget Bureau in 1941 and 1946 shows an in-
crease of approximately 300 per cent in federal
expenditures for publicity and propaganda in the
five-year period. Such an increase, the report de-
clared, was a “proper subject for inquiry by
Congress.”
The Committee summarized its purpose in fu-
ture interim reports as follows: “To examine this
expenditure in detail by departments and agencies,
with particular reference to illuminating those ac-
tivities which are directed primarily to influencing
the decisions of Congress on pending legislation.”
UNIVERSITY RECEIVES GRANT
FOR MENTAL HEALTH STUDIES
Expansion of the mental health training pro-
gram of the University of Minnesota will now
be possible following a grant from the United
States Public Health Service of $89,363, made
available under the National Mental Health Act.
Of the total, the University will use $40,241 to
train nurses in the field of psychiatry ; $23,936, for
an advanced mental hygiene program, and $22,786,
for training psychiatric social workers. Another
$2,400 will be used for other psychiatry training.
The Mental Health Act authorizes Congress to
appropriate $7,500,000 for setting up mental
clinics and $400,000 for research and training
throughout the United States.
995
MEDICAL ECONOMICS
MINNESOTA STATE BOARD OF MEDICAL
EXAMINERS
230 Lowry Medical Arts Building
Saint Paul, Minnesota
Julian F. Dubois, M.D., Secretary
Minneapolis Man Sentenced to Three-Year Prison
Term for Criminal Abortion
Re. State of Minnesota vs. Richard Almsted
On August 19, 1947, Richard Almsted, forty-two years
of age, 2017 18th Ave. So., Minneapolis, was sentenced
to a term of not to exceed three years at hard labor in
the State Prison at Stillwater, by the Hon. Lars O.
Rue, Judge of the District Court of Hennepin County.
Almstead had entered a plea of guilty on July 17, 1947,
to an information charging him with the crime of abor-
tion. At that time the Court continued the matter for
sentence and ordered the probation officer to make a pre-
sentence investigation. Following the investigation made
by the probation officer, Judge Rue imposed the three-
year sentence.
Almsted, who has no medical training of any kind
and gave his occupation as a millwright, was arrested
by Minneapolis police officers on July 11, 1947, following
the admission of a twenty-nine-year-old married woman
to Minneapolis General Hospital suffering from the after-
effects of a criminal abortion. In the investigation made
by the Minneapolis Police Department and the Minne-
sota State Board of Medical Examiners, it was learned
that Almsted was paid $100 for performing the abortion.
The defendant used a catheter but the first attempt
was not successful and the procedure was repeated on
two subsequent occasions, the last time being July 5,
1947. On July 9, the patient became seriously ill and
was removed to the hospital. She has since recovered.
Judge Rue refused to place the defendant on probation,
pointing out that the defendant jeopardized the life of
the patient, and in addition, had a previous conviction
for a felony. The records in the office of the Clerk of
the District Court of Hennepin County show that Alm-
sted entered a plea of guilty on June 3, 1940, to a
charge of attempted carnal knowledge. For that offense
he was sentenced to the State Reformatory at St. Cloud
and was released on parole in June, 1944.
Mankato Dentist's License Revoked Following Plea
of Guilty of Abortion Charge
Re. State of Minnesota vs. IV. A. Groebner
On June 21, 1947, the Minnesota State Board of Den-
tal Examiners revoked the license to practice dentistry
formerly held by Dr. W. A. Groebner of Mankato,
Minnesota. The action by the Dental Board was taken
following Dr. Groebner’s plea of guilty on May 24, 1947,
in the District Court of Blue Earth County, to an in-
formation charging him with the crime of abortion.
Dr. Groebner was arrested on March 25, 1947, fol-
lowing the filing of a complaint in the Mankato Muni-
cipal Court charging him with the crime of abortion.
According to evidence obtained in an investigation made
by the legal authorities of Blue Earth County and the
Minnesota State Board of Medical Examiners, Dr.
Groebner was paid the sum of $75.00 to perform an
abortion on March 21, 1947, on a twenty- four-year-old
unmarried Fairmont, Minnesota, woman. The patient
died on March 24, 1947, at Fairmont. A postmortem
examination was conducted by pathologists of the Uni-
versity of Minnesota, who stated the cause of death to
be “acute endometritis and hemorrhagic pneumonia due
to an attempted induced abortion.” Groebner, twenty-
four years of age, graduated from the School of Den-
tistry of the University of Minnesota, in 1944, and was
licensed to practice the same year. At the time Dr.
Groebner was given a suspended four-year sentence in
the State Reformatory at St. Cloud, the Court forbade
Dr. Groebner to practice dentistry either in Mankato or
in North Mankato. However, the action of the State
Board of Dental Examiners revoking Dr. Groebner’s
dental license, precludes his practicing anywhere in the
State of Minnesota.
PROLONGED LABOR
(Continued from Page 948)
a globular shape, the placenta has separated and
should he delivered. The rise of the fundus in
the abdomen is rather the sign of the descent of
the placenta than of a separation, and indicates
the accumulation of clots in the uterus. The prop-
per procedure in expression is for the assistant
to grasp the fundus in his right hand with the
fingers behind and the thumb in front of the
fundus. The uterus is then gently massaged, but
there should be no downward pressure. The left
hand of the assistant is then placed flat on the
abdomen just at the symphysis and pressure is
exerted with the right hand while the left hand
prevents the uterus from entering the pelvis. As
the placenta passes through the cervix, the uterus
is lifted up as far as the umbilicus. With this
method, there is no danger of inversion of the
uterus.
This paper has stressed things that are probably
elementary but nevertheless should be reviewed
from time to time. I have dealt chiefly with
primary inertia and would like to stress chiefly
in summation :
1. Prenatal care as a means of prevention.
2. Use of calcium and vitamin D during preg-
nancy.
3. Care in the use of oxytocics.
4. In postpartum hemorrhage, Pastore’s ad-
vice on expression of the placenta.
5. Murphy’s work with the tocograph.
996
Minnesota Medicine
AMEBIASIS
"The symptoms of amebiasis are
bizarre and simulate other diseases.
■ ' ■
The amebic etiology should not be
overlooked, since it is impossible to
foretell when amebic dysentery
may develop.
>* 1
F he nonirritating, orally administered, high iodine amebacide
— Diodoquin (5,7-diiodo-8-hydroxyquinoline) — "is well tolerated. . . . The
i
great advantage of this simple treatment is that in the vast majority, it
destroys the cysts of E. histolytica and is, therefore, especially valuable in
sterilizing 'cyst-carriers.’ It can readily betaken by ambulant patients
l» 2
1. D’Antoni, J. S.. Amebiasis,
Recent Concepts of Its Prevalence,
Symptomatology, Diagnosis and
Treatment, Internat. Clinics
1.100 (March) 1942.
2. Manson-Bahr, P.. Some Tropical
Diseases in General Practice,
Glasgow, M. J. 27.-123 I May I 1 946.
DIODOQUIN
(5,7-DIIODO-8-HYDROXYQUINOllNE)
In bottles of 100 and 1000 tablets.
Diodoquin is the registered trademark of
G. D. Searle & Co., Chicago 80, Illinois
SEARLE
RESEARCH IN THE SERVICE OF MEDICINE
September, 1947
997
Reports and Announcements
♦
AMERICAN COLLEGE OF ALLERGISTS
The American College of Allergists will hold a full
week of graduate instruction in the many phases of al-
lergy from November 3 to 8, 1947, at the Medical School
of the University of Cincinnati. The course is intended
not only for those especially interested in allergy but for
general practitioners as well. The week will be devoted
to addresses by allergists from throughout the country.
Reservations for the course, fee $100.00, and for hotel
accommodations should be made with Dr. Fred W. Wit-
tich, 423 La Salle Medical Building, Minneapolis 2,
Minn.
VAN METER PRIZE AWARD
The American Association for the Study of Goiter
again offers the Van Meter Prize Award of $300.00
and two honorable mentions for the best essays sub-
mitted concerning original work on problems related to
the thyroid gland. The award will be made at the an-
nual meeting of the Association which will be held in
Toronto, Canada, May 6, 7, 8, 1948, providing essays
of sufficient merit are presented in competition.
The competing essays may cover either clinical or
research investigations; should not exceed three thou-
sand words in length ; must be presented in English ;
and a typewritten double spaced copy sent to the cor-
responding secretary, Dr. T. C. Davison, 207 Doctors
Building, Atlanta 3, Georgia, not later than February 1,
1948.
MINNESOTA SOCIETY OF NEUROLOGY
AND PSYCHIATRY
A meeting of the Minnesota Society of Neurology and
Psychiatry will be held in Duluth, Minnesota, Saturday,
September 13, 1947. The scientific program will be
presented at 10 :00 a.m. in St. Mary’s Hospital, as
follows :
A Case for Diagnosis — J. J. Call, M.D.
Chordoma, with Case Report — A. H. Wells, M.D., and
A. O. Swenson, M.D.
Cerebellar Abscess, Recovery Following Chemotherapy
- — C. M. Jessico, M.D.
Treatment of Involutional Problems — L. E. Schneider,
M.D.
The Use of Xanthydrol to Demonstrate Urea in Brain
Tissue — Wm. V. Knoll, M.D.
Alzheimer’s Disease, with Case Reports — L. R. Gowan,
M.D., and J. E. Seitz, M.D.
Luncheon will be served at 1 :00 p.m. in the Kitchi
Gammi Club, and will be followed at 2 :30 p.m. by
deep sea fishing on the North Shore.
GRANTS FOR SCIENTIFIC RESEARCH
The American Allergy Fund has announced grants in
aid for research, available to investigators in the biolog-
ical sciences, both medical and non-medical, whose
problems meet the requirements of the Scientific Advis-
ory Council. Preference will be given problems with
immediate relationship to allergy, although investigations
in physiology, biochemistry, pharmacology, immunology,
genetics and other basic sciences are solicited.
Applications should contain the following information :
1. Statement of specific research problems and an out-
line of the method or methods of procedure to be fol-
lowed.
2. Description of research facilities in the institution
where investigator will employ the grant.
3. A tentative budget.
4. Statement of the applicant’s research record, ac-
companied, if possible, by publications or reprints.
Grants wifi be made for one year in amounts not to
exceed $3,500.00, and may be renewed from year to
year, if the progress report warrants continuation.
Applications (seven copies) should be addressed to the
American Allergy Fund, 525 Erie Building, Cleveland
15, Ohio, Attention: Scientific Council.
AT YOUR CONVENIENCE,
DOCTOR . . .
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the street floor of the Foshay Tower, 100 South
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With our expanded facilities we will be able
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998
Minnesota Medicine
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September, 1947
999
In Memoriam
ALFRED N. BESSESEN
Dr. Alfred N. Bessesen, a prac-
ticing surgeon of Minneapolis
since 1893, passed away August
19, 1947, at his home.
He was the son of John and
Delia Bessesen and was born Jan-
uary 18, 1870, in Freeborn County,
Minnesota. He attended public
schools in Albert Lea, Minnesota,
and was active in Christian En-
deavor, the Y.M.C.A. and the Lu-
theran church As a student at
Rush Medical College where he
received his M.D. degree, March
28, 1893, he took part in establishing the first Intercol-
legiate Y.M.C.A. chapters.
Dr. Bessesen is said to have been the first intern at
St. Mary’s Hospital, Minneapolis, where he worked un-
der Dr. James H. Dunn.
Along with A. A. McRae and others, he helped
organize the South Side Commercial Club and later
conceived and was active in forming the Commonwealth
Club. He was a charter life member of the Minne-
apolis Club and was also a member of Lodge 19, A.F.
and A.M.
Dr. Bessesen was a life member of the Fairview Hos-
pital United Church Hospital Association, helped or-
ganize, locate, name and build Fairview Hospital, Min-
neapolis, and served on its first Board of Trustees. He
was also the first chief of staff at Asbury Hospital and
was on the staff at Deaconess Hospital. It was he who
interested Mrs. George Christian in building Thomas
Hospital for Fairview, to be devoted to the care of
tuberculosis patients.
He was a member of the American College of Sur-
geons, the Hennepin County Medical Society, the Min-
nesota State and American Medical Associations. He
retired from practice several years ago on account of
ill health but resumed practice during the war on
account of the shortage of physicians.
Dr. Bessesen was married to Dr. Florence E. Hol-
land of Chicago on August 6, 1895. He is survived by
his wife and four children — Dr. Alfred N. Bessesen,
Jr., Dr. Daniel H. Bessesen, Grace and Florence, all
of Minneapolis : three brothers — N. D. Bessesen, H. J.
Bessesen, and Dr. William A. Bessesen, all of Minne-
apolis; five grandchildren, and one great-grandchild.
On the cover page of his first account book was
placed the following which shows better than other
words his character:
My Guide
To respect my country, my profession, and myself.
To be honest and fair with my fellowmen, as I expect
them to be honest and square with me. To be a loyal
citizen of the United States of America. To speak of
it with praise and act always as a trustworthy custo-
dian of its good name. To be a man whose name
carries weight with it wherever it goes.
To base my expectations of reward on a solid founda-
tion of service rendered; to be willing to pay the price
of success in honest effort. To look upon my work as
an opportunity to be seized with joy and made the
most of and not as painful drudgery to be reluctantly
endured.
To remember that success lies within myself, in my
own brain, my own ambition, my own courage, and
determination. To expect difficulties, and to force my
way through them ; to turn hard experiences into capi-
tal for future struggles.
To believe in my own proposition, heart and soul;
to carry an air of optimism in the presence of those I
meet ; to dispel ill temper with cheerfulness, kill doubts
with a strong conviction, and reduce active friction
with an agreeable personality.
To keep my future unmortgaged with debts; to save
as well as earn. To cut out expensive amusement until I
can afford them. To steer clear of dissipation and guard
my health of body and peace of mind as a mo«t precious
stock in trade.
Finally, to take a good grip on the joys of life, to
play the game like a man ; to fight against nothing
so hard as my own weaknesses, and endeavor to grow
in strength, a Christian, a gentleman.
“So I may be courteous to men, faithful to friends,
True to my God, a fragrance in the path I trod.”
GEORGE T. AYRES
Dr. George T. Ayres of Ely died July 17, 1947, at
Halifax, Nova Scotia, while on vacation.
Dr. Ayres was born at Kalida, Iowa, February 1,
1875. He attended Wooster College at Wooster, Ohio,
and the medical school of Western Reserve for two
years before obtaining his M.D. degree from Rush
Medical College in 1897. He interned at Presbyterian
Hospital in Chicago.
Dr. Ayres became associated with the late Dr. Charles
G. Shipman at Ely and when Dr. Shipman retired about
forty-one years ago, Dr. Ayres and Dr. P. M. Parker
took over the Shipman Hospital. When Dr. Parker
retired, Dr. Ayres operated the hospital until 1944
when he retired. For the past year he had resided
in Phoenix, Arizona.
A former member of the Ely city council, Dr. Ayres
was one of the leaders of the Ely Chamber of Com-
merce and was associated with Dr. H. N. Sutherland
for forty-one years. Dr. Ayres was also a member
of the Ely school board, was active in Masonic circles,
the Rotary Club and other fraternal and civic organi-
zations.
He is survived by his wife and a daughter, Mrs.
Victor Roterus of Flint, Michigan.
NORBERT GEORGE BENESH
Dr. N. A. Benesh of Minneapolis passed away June
29, 1947, at the age of thirty-nine.
Born at Ely, Iowa, December 1, 1907, Dr. Benesh
obtained his M.D. degree from the University of Ne-
braska Medical School in 1931. He interned at Asbury
Hospital in Minneapolis.
Dr. Benesh started his general practice on the East
Side in 1932, and worked in that district until the
A. N. Bessesen
1000
Minnesota Medicine
IN MEMORIAM
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
time of his death. He was a member of the staff of
the Deaconess Hospital and was treasurer of the
Lutheran Deaconess Hospital Medical and Surgical
Society.
Dr. Benesh was a member of the Hennepin County
Medical Society, the Minnesota State and American
Medical Associations. He was also a member of the
Cataract Lodge No. 2, A.F. and A.M. and the Calhoun
Beach Club.
Surviving are his wife, Margaret Ann Benesh, and
two brothers, Dr. Louis A. Benesh of Minneapolis and
Lester H. Benesh of Battendorf, Iowa.
Dr. Benesh was an ardent sportsman. He was espe-
cially fond of hunting and fishing and spent his spare
time in South Dakota or northern Minnesota.
JOHN E. CREWE
Dr. John E. Crewe, a practicing physician in Roches-
ter for many years and a former coroner of Olmsted
County, died on his; seventy-fifth birthday, July 22,
1947.
John Crewe was born at Hoboken, New Jersey,
July 22, 1872. He attended the University of North
Dakota at Grand Forks for two years before he at-
tended the University of Minnesota from which he ob-
tained his medical degree in 1896. After interning at
Minneapolis General Hospital and the Deaconess Hos-
pital at Grand Forks, North Dakota, he practiced from
1897 to 1902 at Zumbrota, Minnesota.
He located at Rochester, Minnesota, in 1902, and
September, 1947
served as coroner of Olmsted County for thirty-six
years before his retirement last year. He was a mem-
ber of the Olmsted-Houston-Fillmore-Dodge County
Medical Society, the Minnesota State and American
Medical Associations.
Dr. Crewe is survived by his wife, two daughters,
Mrs. Dorothy Bishop of Minneapolis and Mrs. C. H.
Slocumb of Rochester, and a son, Charles W. Crewe
of Minneapolis.
JOSEPH WILLIAM GAMBLE
Dr. J. W. Gamble, a practicing physician for twenty-
five years at Albert Lea and head of the Gamble Clinic,
died August 6, 1947.
Dr. Gamble was born at St. Cloud, Minnesota, De-
cember 23, 1891. He attended South High School in
Minneapolis and Rochester High School before studying
medicine at the University of Minnesota where he was
graduated in 1918. After interning at the University
Hospital and the U. S. Naval Hospital, Great Lakes,
Illinois, he practiced at Rochester, Minnesota, from 1919
to 1921 and was located at the Veterans Hospital, Min-
neapolis, from 1921 to 1922.
After being located in Albert Lea for two years he
was joined by his two brothers, Dr. Ross M. Gamble
and Dr. Paul M. Gamble, and the Gamble Clinic was
formed. Dr. Gamble was a member of the Freeborn
County Medical Society, the Minnesota State and Amer-
ican Medical Associations. The region of Albert Lea
has always known Dr. Gamble as “Dr. Will.” He has
1001
IN MEMORIAM
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St. Paul 1. Minnesota
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always been intensely interested in civic activities and
has shown leadership in civic betterment projects and
in boys’ work. Since 1929 he had been a director of
the Albert Lea Y.M.C.A. He was a member of nu-
merous other organizations including the American
Legion, the Albert Lea Kiwanis Club, the Chamber of
Commerce, A.F. and A.M., and Toastmasters Interna-
tional. He was also a long-standing member of the
First Baptist Church.
Dr. Gamble is survived by his widow, a son, Elbert
J. Gamble, at present attending the University of Min-
nesota, and a daughter, Mrs. Owen Beard, who, herself,
is a physician and who lives at Little Rock, Arkansas.
Dr. Paul Gamble also survives. Dr. Ross Gamble died
in 1934.
Dr. Will had been in poor health since March of 1947,
when he suffered a coronary occlusion.
KRISTIAN JONASSON
Dr. Kristian Jonasson, a fellow in obstetrics and
gynecology at the Mayo Foundation from 1943 until
1946, died by suffocation from a fire at Reykjavik,
Iceland, on July 27, 1947.
Dr. Jonasson was born May 12, 1914, at Saudarkro-
kur, Iceland. He received his M.D. degree from the
University of Iceland in 1941, interned at several hospi-
tals in Iceland and practiced at Isafiord, Iceland, before
going to Rochester. He practiced at Reykjavik before
his death.
HAROLD E. MARSH
Dr. Harold E. Marsh of Madison, Wisconsin, died
on July 12, 1947.
Dr. Marsh was born October 11, 1892, at Quincy,
Massachusetts ; received the degree of M.D. in 1913
from Tufts College, Boston, Massachusetts; and was
an intern at the Malden Hospital, Malden, Massachu-
setts, from July, 1913, to July, 1914. He entered the
Mayo Foundation as a special student in medicine,
April 1, 1915. From April, 1918, to July, 1919, he served
as first lieutenant in the Medical Corps. He left the
Mayo Foundation May 29, 1920, to practice internal
medicine at the Jackson Clinic, Madison, Wisconsin. Dr.
Marsh was a member of the American Medical Associa-
tion and the Mississippi Valley Medical Society.
REINHART GILBERT OLSON
Dr. Reinhart G. Olson of Minneapolis died July 12,
1947, at his home, aged sixty-seven years.
Reinhart Olson was born at Nicollet, Minnesota, Feb-
ruary 24, 1880. He received his medical degree from
Hamline Medical College in 1908 and served his intern-
ship at Swedish Hospital, Minneapolis. Until 1917,
when he joined the army, he practiced at Nicollet. He
enlisted in World War I and was stationed at St. Ar-
mand, France, and after the Armistice, went to Ger-
many with the Army of Occupation. After discharge
from the army in August, 1919, he became established
in Minneapolis.
Dr. Olson took postgraduate work in eye, ear, nose
1002
Minnesota Medicine
IN MEMORIAM
and throat diseases in Chicago in 1914, and at the
New York Postgraduate Hospital in 1919-1920.
He was a member of the Hennepin County Medical
Society, the Minnesota State and American Medical
Associations, a Knight Templar, and a member of
the Zuhrah Temple of the Shrine. He was also a mem-
ber of the staff of the Swedish Hospital.
Dr. Olson is survived by his wife, and daughter,
Mrs. William C. Droge of Saint Paul.
JOSEPH H. VOGEL
Dr. Joseph H. Vogel, a prominent physician and sur-
geon of New Ulm, died July 21, 1947, from a heart
attack. He was sixty-eight years old.
Born in New Ulm, March 28, 1878, he graduated
from Rush Medical College in 1903 and began prac-
tice at New Ulm. He took postgraduate work in Chi-
cago in 1914 and in Vienna in 1928. A number of years
ago he and Dr. Otto Seifert established the Vogel-
Seifert Clinic.
Dr. Vogel was a member of the Redwood-Brown
Medical Society, the Minnesota State and American
Medical Associations, and the Southern Minnesota Med-
ical Association. He was a staff member of the Union
and Loretto Hospitals.
His hobby was roses, and he was nationally known
as an expert in the growing of roses. In 1941, he was
elected president of the Minnesota Rose Society.
Dr. Vogel had considerable real estate holdings in-
cluding buildings in the heart of New Ulm. He was
president of the Farmers and Merchants Bank of
Mew Ulm and director of the State Bond and Mort-
gage Company and the American Artstone Company.
Otto J. Seifert.
CHARLES D'ARCY WRIGHT
Dr. Charles D’Arcy Wright, a physician for fifty
years in Minneapolis, died July 23, 1947, at his home.
Dr. Wright was born at Chatham, Ontario, Novem-
ber 22, 1863. He attended the University of Wisconsin
before obtaining his medical degree from the University
of Michigan in 1887. He took numerous postgraduate
courses in Paris, London, Berlin, and Vienna, where
he specialized in the special senses.
After practicing in Norway, Michigan, from 1887 to
1895, he became a member of the faculty of the Uni-
versity of Michigan from 1895 to 1897.
Dr. Wright captained the football team at the Uni-
versity of Michigan and became a well-known golfer,
at one time winning the senior golf tournament.
He came to Minneapolis in 1897 and became an
eye, ear, nose and throat specialist. He was a member
of the American College of Surgeons, The American
Society of Ophthalmology, the Hennepin County Medi-
cal Society, and the Minnesota State and American
Medical Associations.
Dr. Wright is survived by a daughter, Mrs. Muriel
Wright Fould, wife of Maurice Fould of France, a
grandson, John D’Arcy Wright, and a brother, G. M.
Wright of Denver.
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Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
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Technique, starting September 22, October 30, No-
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Four-week Course in General Surgery, starting Sep-
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Two-week Course in Surgical Anatomy and Clinical
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One-week Course in Surgery of Colon and Rectum,
starting September 15 and November 3.
Two-week Course in Surgical Pathology, every two
weeks.
FRACTURES AND TRAUMATIC SURGERY— Two-
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GYNECOLOGY — Two-week Intensive Course, starting
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One-week Course in Vaginal Approach to Pelvic Surg-
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OBSTETRICS — Two-week Intensive Course, starting
September 8, October 6.
MEDICINE — -Two-week Intensive Course, starting Oc-
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Two-week Course in Gastro-enterology, starting Oc-
tober 20.
Two-week Course in Hematology, starting September
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TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar, 427 S. Honore St., Chicago 12, 111.
September, 1947
1003-
Of General Interest
Dr. Silas C. Andersen, Minneapolis, has been elected
a trustee of Dana College and Trinity Seminary in Blair,
Nebraska.
* * *
A former fellow in the Mayo Foundation, Dr. Glen G.
Gibson has been advanced to the post of professor and
head of the Department of Ophthalmology, Temple Uni-
versity of Medicine, Philadelphia.
* * *
On July 31, Dr. J. T. Anderson discontinued his medi-
cal practice in Red Lake Falls. At the time he had no
immediate plans for the future beyond a vacation trip
with his family.
* * *
Dr. F. J. Braceland and Dr. P. H. Ffeersema, Mayo
Clinic staff members, attended a meeting of the gover-
nor’s Advisory Council on Mental Health held in Saint
Paul on July 21.
* * *
Dr. George H. Hall, formerly of Minneapolis, has been
named chief of the surgical service at Veterans Hospital
in Fargo, North Dakota. He succeeded Dr. John J.
Tyson, who was transferred to Des Moines, Iowa.
* * *
“The Role of Psychiatry in Probation and Parole
Service” was the title of an address delivered by Dr.
M. N. Walsh, Rochester, at a meeting of the Minnesota
State Probation and Parole Association held in St.
Cloud on July 21.
* * *
Dr. Ellis N. Cohen, who is serving a fellowship in
the Department of Anesthesiology at the University of
Minnesota, was married in Chicago on August 9 to Miss
Sylvia Rosenfeldt, former psychologist in the Division
of Public Institutions for the State of Minnesota.
* * *
In Blue Earth, Dr. J. A. Broberg has resigned as city
health officer after almost forty-five years of service.
First appointed to the office in 1902, Dr. Broberg has held
the position to the present time with the exception of
two short intervals when he was out of the state.
* * *
At the annual meeting of the American Medical As-
sociation, this summer, Dr. Arthur B. Hunt, Rochester,
was elected secretary of the Section on Obstetrics and
Gynecology, and Dr. F. P. Moersch, Rochester, was re-
elected secretary of the Section on Nervous and Mental
Diseases.
* * *
At the meeting of the American Society of Oral Sur-
gery held in Boston in late July, Dr. John B. Erich of
Rochester presented two motion pictures entitled,
“Treatment of Soft Tissue in Facial Injuries” and
“Treatment of Patients with Multiple Fractures of All
the Facial Bones.”
Dr. Charles G. Sheppard, Hutchinson, has been elected
president of the Crow River regional chapter of the
American College of Physicians and Surgeons, while
Dr. Kenneth Peterson, Hutchinson, has been named vice
president, and Dr. J. D. Selmo, Norwood, secretary-
treasurer.
* * *
Physicians from nine southwestern Minnesota counties
met in Worthington on July 23 to discuss organization
of a district public health unit for their area. Represen-
tatives present were from Nobles, Rock, Pipestone,
Murray, Jackson, Cottonwood, Lincoln, Lyon and Red-
wood counties.
* * *
On August 1, Dr. F. B. Schleinitz moved from Battle
Lake to Hankinson, North Dakota, to become the only
physician in that town. Dr. Schleinitz was formerly
associated with Dr. C. A. Boline in Battle Lake, where
he had practiced since 1938. During the war he served
in the army medical corps for four years.
* * *
The Interim Commission of the World Health Or-
ganization has appointed a former fellow in medicine
in the Mayo Foundation, Dr. Thorstein Guthe, to the
secretariat as a specialist in veneral disease. Dr. Guthe,
who was with the Mayo Foundation in 1940, has been
assistant to the surgeon general of public health of
Norway.
* * *
At the Red Wing Chamber of Commerce meeting on
August S, a proposal was made to stage a county-wide
x-ray survey to detect cases of tuberculosis and other
diseases in their early stages. The proposal was re-
ferred for further study to the organization’s Educa-
tion and Public Health Committee, which is headed by
Dr. Royal V. Sherman of Red Wing.
* * *
During August, while Dr. M. G. Flom of Zumbrota
was on vacation, his medical practice was conducted by
Dr. Frederick W. Engstrom of Wanamingo. Dr. Eng-
strom, a graduate of the University of Minnesota Medi-
cal School, recently completed his internship at Detroit
Receiving Hospital in Detroit, Michigan. He is the son
of Dr. and Mrs. F. A. Engstrom of Wanamingo.
* * *
Visiting in the Lffiited States while studying health
conditions and therapeutic methods, Dr. Sigrid Holm,
chief assistant at a chest clinic in Copenhagen, Denmark,
praised the mass chest x-ray survey being conducted in
Minneapolis. “The city is doing a very good job,” stated
Dr. Holm.
The Danish physician said that last year, Copenhagen
x-rayed about 80 per cent of the population in the
fifteen to thirty-four age group, and this year plans are
to x-ray the persons over thirty-four years of age.
1004
Minnesota Medicine
OF GENERAL INTEREST
On August 15, Dr. Merrill E. Henslin of Le Roy
moved to Cresco, Iowa, to enter a partnership with Dr.
Walter Bockhoven of that city. Dr. Henslin did not
completely close his medical practice in Le Roy, how-
ever, for he is maintaining office hours there on Tues-
day and Thursday afternoons and Saturday evenings
each week. His father, Dr. A. E. Henslin, is continuing
to practice in Le Roy.
* * *
Dr. J. E. Henry, who recently completed a fifteen-
month internship at Minneapolis General Hospital, has
joined his brother Dr. C. J. Henry in practice at the
Henry Clinic in Milaca. A graduate of the University
of Minnesota Medical School, Dr. J. E. Henry was
married in Foley on Tune 23 to Miss Dolores Wess-
ner, who has been a nurse at the Henry Memorial Hos-
pital in Milaca for the past three years.
* * *
Dr. B. E. Hall, Rochester, participated in a sympo-
sium on “Radioactive Isotopes in Therapy of Malignant
Disease” at the Chemical Research Conference conducted
by the American Association for the Advancement of
Science in New London, New Hampshire, August 10
to 15. Dr. Hall’s subject was “Radioactive Phosphorus.”
He also participated in a round-table discussion on
“Methods and Results in Chemotherapy of Malignant
Disease.”
% %
Dr. W. Henry Hollinshead, former professor of anat-
omy at Duke University School of Medicine, has joined
the staff of the Mayo Clinic as consultant in anatomy
and professor of anatomy in the Mayo Foundation and
Graduate School of Medicine of the University of Min-
nesota. In addition to directing graduate training in
anatomy, he will continue research on the peripheral
nervous system and mechanisms in the reflex control of
respiration and blood pressure.
* * *
After forty-five years of practice in Saint Paul, Dr.
P. H. Bennion announced in August that he was retiring
from active medical practice and planned to move to
Ismay, Montana, to make his home with his daughter.
A civic-minded person, Dr. Bennion has been active in
the development of the Midway district in Saint Paul.
He has been a staff member of Midway Hospital and a
member of the Osman Temple of the Shrine, the Mid-
way Club, and the Merriam Park library board.
5fj jji
In Mankato, Dr. R. G. Hassett recently announced
that Dr. Norman F. Stone, formerly of Minneapolis,
has become associated with him in medical practice. A
graduate of the University of Minnesota Medical School
in 1944, Dr. Stone served for two years in the navy in
the south Pacific. Upon his release from military service
in July, 1946, he took postgraduate work at the Univer-
sity of Minnesota for one year before joining Dr. Hassett
in Mankato.
jfc
Heron Lake recently acquired another physician when
Dr. Harold Williamson, formerly of Cleveland, Ohio,
joined the Heron Lake Hospital staff and opened a
September, 1947
1909 1947
RHEUMATISM
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1005
OF GENERAL INTEREST
medical practice with Dr. T. Roger Nickerson. The two
physicians are cousins and for many years have planned
to practice medicine together in Minnesota. Dr. William-
son is a graduate of Western Reserve Medical School
and served his internship at Akron City Hospital, Akron,
Ohio. After three and one-half years in the army medical
corps, he returned to be chief resident physician in the
Cleveland City Hospital before accepting an invitation
to practice in Heron Lake.
* * *
Dr. William Black, who recently completed a three-
year Mayo Foundation fellowship in general surgery, is
now associated with Dr. O. J. Seifert and Dr. L. H.
Domeier in New Ulm.
A graduate of Temple University Medical School, Dr.
Black served his internship and a residency at St. James
Hospital in Butte, Montana. He then began his fellow-
ship with the Mayo Foundation but interrupted it to
serve for two years in the army medical corps. Follow-
ing his release from military service, he completed the
surgical fellowship and then joined Drs. Seifert and
Domeier in New Ulm.
* * *
Dr. Alfred G. Sherman, a former naval flight surgeon
with six years of military service, has joined in medical
partnership with Dr. Carleton S. Strathern of St. Peter.
A native of Glencoe, Dr. Sherman received his medical
degree from the Lhiiversity of Minnesota Medical School
and served his internship at Minneapolis General Hospital.
In 1939 he began his medical practice in Ajo and King-
man, Arizona, and in 1941 he entered the navy, specializ-
ing in aviation medicine.
In joining Dr. Strathern in St. Peter, he is replacing his
partner’s father, Dr. F. P. Strathern, who has announced
his semi-retirement from the medical profession.
* * *
Members of the medical and nursing professions, plus
several hundred lay citizens of Cloquet, gathered on
July 24 to pay tribute to Mathilda C. Backes, Cloquet
community nurse, for the outstanding work she had
done since her arrival in the city in 1924. The honor
ceremony took place one week before her departure for
Cold Spring where she had accepted a position as in-
dustrial nurse.
Maste-r of ceremonies for the event was Dr. C. E.
Norberg of Cloquet, while one of the speeches of praise
for Miss Backes was delivered by Dr. N. O. Monserud,
Cloquet, who represented the medical profession. The
nurse was presented with a watch and a purse as tokens
of appreciation of Cloquet residents.
* * *
A new member of the Hedemark Clinic in Ortonville
is Dr. Robert P. Gallagher, who has just completed a
year of postgraduate study at the University of Min-
nesota Medical School.
A Minnesota graduate, Dr. Gallagher served his intern-
ship at Queens Hospital in Honolulu, T. H., and then
spent more than two years in the army medical corps.
After his discharge from military service he returned to
Minnesota for postgraduate training before joining Dr.
Truman Hedemark and Dr. Homer Hedemark in Orton-
ville.
* * *
At a forum at the University of Minnesota on July
31 the medical profession was attacked by Fred Gram,
public relations director for Group Health Mutual, Inc.
“Restrictive state laws urged on legislatures by the
medical profession make it exceedingly difficult for co-
operative health organizations to function,” he com-
plained.
He alleged the medical profession was badly organ-
ized, and stated: “Doctors are afraid to join clinics in
smaller cities and rural areas for fear of facing the
wrath of the American Medical Association.”
He asserted that co-operative medical plans would re-
sult in a healthier population.
The meeting was sponsored by the campus chapter
of the American Veterans Committee.
* * *
At the grand banquet of the International Congress
of Pediatrics, held in New York in July, Dr. Henry F.
Helmholz, former chief of the Section on Pediatrics in
the Mayo Clinic and professor of pediatrics in the Mayo
Foundation, was awarded the Carlos J. Finlay gold medal
by the president of Cuba. During the previous week, at
the Pan American Congress of Pediatrics in Washing-
ton, D. C., Dr. Helmholz was given honorary member-
ship in the Latin American division of the American
Academy of Pediatrics and the Brazilian Pediatrics So-
ciety. The awards were made to the Rochester physi-
cian in recognition of his work in furthering pediatric
education and practice in Latin America by establishing
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Minnesota Medicine
OF GENERAL INTEREST
paid scholarships in various medical schools of the United
States for graduates of Latin American medical schools.
:{C %
In an article in a recent issue of the Journal of the
American Medical Association, Dr. Owen H. Wangen-
steen, head of the Department of Surgery in the Uni-
versity of Minnesota Medical School, stated :
“The public is willing to spend unlimited funds to
conquer the scourge of cancer. . . . Establishment of
cancer detection clinics, staffed by specialists, affords the
best promise of early recognition of cancer. Women
over forty and men past fifty should report regularly
to such clinics.”
In regard to the long-range cancer problem, Dr. Wan-
gensteen advocated the setting up of a cancer commis-
sion to spearhead research. “This commission should
be given adequate funds and authority to draft compe-
tent workers with research experience,” he declared.
* * *
At a reunion of former interns of St. Mary’s Hos-
pital in Duluth, Dr. E. L. Tuohy was honored as the
oldest ex-intern present. A portrait of Dr. Tuohy was
unveiled at a special luncheon meeting, and Dr. W. J.
Ryan of the hospital’s intern committee paid tribute to
the honored physician.
Dr. Tuohy, who is now chief of laboratories at St.
Mary’s Hospital, entered the hospital as an intern in
1905 and remained as a resident in 1906. He was instru-
mental in setting up the hospital’s pathology department
and later organized the hospital’s program of clinico-
pathological conferences.
Among the guests at the honor luncheon was Dr.
Tuohy’s son, Dr. Edward B. Tuohy, former staff mem-
ber of the Mayo Clinic and now professor of anesthesiol-
ogy at Georgetown University in Washington, D. C.
* * *
Community clinics — possibly even traveling clinics —
might help in the control of alcoholism as a social prob-
lem, Dr. Stanley B. Lindley recently suggested. As
superintendent of the Willmar State Hospital, which
was established for inebriates, Dr. Lindley is convinced
that the problem of keeping alcoholism within bounds
is too large to be handled by any state institution.
“Lots of persons who are drinking too much would
never think of coming here for treatment,” he said,
“but they might seize the opportunity to drop in at
a local clinic to get the trouble straightened out.”
Psychiatrists and social workers, operating from such
a clinic, could prevent a large amount of future difficulty
and could ease the daily pressure on courts and jails.
“But the cost would be considerable,” Dr. Lindley
stated. “Men of experience don’t come cheaply. And
one of the essentials would be the selection of a compe-
tent man to head the program.”
* * *
Two Mayo Clinic staff members resigned their posi-
tions this summer to join the faculty of Georgetown
University Medical Center, Washington, D. C.
Dr. Edward B. Tuohy, a member of the anesthesiology
staff of the clinic since 1935, became professor of anes-
thesiology at Georgetown University, while Dr. Paul C.
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Kiernan, a member of the clinic surgical staff for four
years, became an associate professor of surgery at the
school.
Dr. Tuohy received his medical degree at the Univer-
sity of Pennsylvania in 1932 and interned at Roosevelt
and New York Hospitals in New York and at Ancker
Hospital in Saint Paul. He began a fellowship in the
Mayo Foundation in 1933, and in 1936 he received an
M.S. degree from the LTniversity of Minnesota.
Dr. Kiernan, a graduate of George Washington Uni-
versity, Washington, D. C., began a fellowship in surgery
in the Mayo Foundation in 1940 and received an M.S.
degree from the University of Minnesota in 1943.
* * *
Twenty-two physicians who have each completed a half
century of medical practice in Minnesota were honored
by admission to the “Fifty Club” at the annual meeting
of the Minnesota State Medical Association in Duluth on
July 1.
Membership in the club is limited to physicians who
have practiced medicine for at least fifty years in Min-
nesota. The new members admitted this year were Drs.
J. F. Corbett, George B. Hamlin, G. D. Head, A. J. H.
Hammond, all of Minneapolis; L. A. Nelson, Robert
Earl, W. R. Ramsey, of Saint Paul ; Homer P. Dredge,
Sandstone ; J. F. S. Gendron, Grand Rapids ; John A.
Thabes, Sr., Brainerd ; Morrill E. Withrow, Interna-
tional Falls ; George H. Mesker, Cambridge ; William
L. Palmer, Albert Lea ; George F. Reinecke, New Ulm ;
George J. Schottler, Dexter; William E. Wray, Camp-
bell; A. H. Brown, Pipestone; M. A. Brown, Milan; John
E. Crewe, Rochester; S. A. Drake, Lanesboro; Roland
Gilmore, Bemidji, and J. H. Haines, Stillwater.
* * *
A prediction that Tokyo would soon be only twenty-
three hours distant by air was made by Dr. Jan H.
Tillisch in a talk, July 17, before the Rotary Club of
Rochester.
In addition to being assistant professor of medicine in
the Mayo Foundation and consultant in medicine in the
Mayo Clinic, Dr. Tillisch is also medical director of
Northwest Airlines. In his talk to the Rotary Club he
described a trip to the Orient which he had just made
by air to observe personally the physical conditions un-
der which pilots must fly.
Illustrating his words with projected color photo-
graphs, Dr. Tillisch described conditions in Alaska, the
Aleutian islands, Tokyo, Seoul in Korea, Shanghai and
Manila.
“When the Boeing Stratocruiser passenger planes are
put in operation, you’ll be able to fly from here to Tokyo
in as little as twenty-three hours,” he stated. (Present
time, Rochester to Manila: forty- five hours.) “It will
be a very easy trip,” he added. “Ocean flying is much
smoother than flying over land.”
* * *
Captain Louis H. Roddis (MC), USN, Chief of the
Publications Division of the Bureau of Medicine and
Surgery and Editor of the United States Naval Medical
Bulletin , Navy Department, Washington, D. C., has been
awarded the Navy Commendation Ribbon for the ex-
cellent service he rendered in World War II as Senior
Medical Officer of the U.S.S. Relief.
The citation reads :
“For excellent service in the line of his profession
while serving as Senior Medical Officer of the U.S.S.
Relief from 4 March to 9 September, 1944. His pro-
fessional skill and devotion to duty contributed mate-
rially to the smooth and efficient functioning of the
Medical Department. During Fleet concentrations he
rendered invaluable consultation service and dealt with
many medical problems, both in disease prevention and
evacuation of the sick and wounded. Linder his direc-
tion, during the capture of Saipan and Tinian, large
numbers of serious casualties were embarked and trans-
ported, many directly from the beachheads. His per-
formance of duty was outstanding and his conduct was
at all times in keeping with the highest traditions of
.the United States Naval Service.”
Captain Roddis graduated from the University of
Minnesota Medical School in 1913 and entered the Naval
service in 1914. He is considered an outstanding Medi-
cal Historian and has written several books on the
subject. Captain Roddis’ professional specialty is in-
ternal medicine and he is a Fellow of the American
College of Physicians and a Member of the American
Board of Internal Medicine.
* * *
Announcement has been made of eleven recent ap-
pointments to the staff of the Mayo Clinic.
Dr. Edwin D. Bayrd, a graduate of Harvard Medi-
cal School who became a fellow in medicine in the
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Minnesota Medicine
OF GENERAL INTEREST
Mayo Foundation in 1944, has been appointed a con-
sultant in medicine.
Dr. Talbert Cooper, a graduate of Emory University
who entered the Mayo Foundation as a fellow in medi-
cine in 1941, has been appointed a consultant in medi-
cine.
Dr. Edward D. LeLamater, a graduate of Johns Hop-
kins and Columbia Universities who entered the Mayo
Foundation in 1946 as first assistant in mycology and
fellow in dermatology, has been appointed consultant
in mycology in the Section on Experimental Bacteriol-
ogy.
Dr. Albert Faulconer, Jr., a graduate of the University
of Kansas who became a fellow in anesthesiology in
1946, has been appointed to the anesthesiology staff.
Dr. Lloyd E. Harris, a graduate of Rush Medical
College who has been practicing pediatrics in Lafayette,
Indiana, has been appointed to the preventive pediatrics
staff.
Dr. John R. Hodgson, a graduate of the University
of Michigan who entered the Mayo Foundation as a
fellow in radiology in 1943, has been appointed to the
radiology staff.
Dr. Mavis P. Kelsey, a graduate of the University of
Texas who began a fellowship in medicine in 1939,
has been appointed to the staff in general medicine and
surgery.
Dr. Frank D. Mann, a graduate of the Universty of
Minnesota who became first assistant in clinical pathol-
ogy in 1946, has been appointed to the staff in clinical
pathology.
Dr. Gordon M. Martin, a graduate of the Univer-
sity of Nebraska who became a fellow in physical medi-
cine in 1941 and who has been head of the Department
of Physical Medicine at the University of Kansas Medi-
cal School, has been appointed to the staff in physical
medicine.
Dr. John A. Paulson, a graduate of the University
of Minnesota who became a fellow in anesthesiology
in 1942, has been appointed to the anesthesiology staff.
Dr. William G. Sauer, a graduate of the University
of Cincinnati who became a fellow in medicine in 1942,
has been appointed to the staff in general medicine and
surgery.
HOSPITAL NEWS
For the thirty-first consecutive time, Dr. C. L. Sher-
man of Luverne has been re-elected as president of the
Southwestern Minnesota Sanatorium board. Dr. Sher-
man has been president of the board since it was or-
ganized in 1915.
Also re-elected to offices on the board are Edwin
Brickson, Adrian, vice president ; Dr. S. A. Slater,
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Zender, St. James, member of the Executive Committee.
* * *
Miss Margaret Ossendorf left the Staples Municipal
Hospital in July to become superintendent of the Mel-
rose Hospital. Miss Ossendorf had served as first
floor supervisor at the Staples hospital and had been
acting superintendent during the absence of Miss Mar-
celine Lano, the regular superintendent.
* * *
A tax increase to help raise funds for the construc-
tion of new buildings and equipment at Glen Lake San-
atorium, Minneapolis, was voted by the Hennepin Coun-
ty commissioners on July 31. One-half mill of the in-
crease in rate, from 2.75 to 4.30, will provide $146,500
for construction.
He * *
Dr. William C. Heiam, Cook, has announced that a
new autoclave sterilizer has been installed at the Cook
General Hospital. The latest model available, it was
purchased at a price of $700.
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1009
OF GENERAL INTEREST
New chief of staff at Fairview Hospital (Columbia
Heights), Minneapolis, is Dr. H. D. Good, a graduate
of the University of Minnesota Medical School, who
has practiced in Columbia Heights since 1926. Also
recently elected to the hospital staff are Dr. Arthur C.
Skjold, vice chief of staff, and Dr. Donald B. Frane,
secretary-treasurer.
Y * * *
At a recent meeting of the board of directors of
the Union Hospital Association, Inc., in New Ulm,
George D. Erickson was re-elected president of the
board. Other officers are Dr. Albert Fritsche, vice
president ; George Hogen, secretary, and F. H. Retz-
laff, treasurer.
* * *
The twenty-bed Halloran Hospital at Jackson has
been purchased from Dr. Walter H. Halloran and is
now being conducted by the Sisters of Charity of Our
Lady, Mother of Mercy, in the Winona diocese. In-
cluded in the transaction was the modern ten-room
home of Dr. Halloran which has been converted into
a convent for the Sisters.
5*C 5§C
Four Saint Paul businessmen were named members
of the board of governors of Miller Hospital, Saint
Paul, at a meeting of the board on August 12, it has
been announced by Shreve M. Archer, chairman of the
board. The newly appointed members are Frank J.
Anderson, C. F. Codere, Bernard H. Ridder and F. K.
Weyerhaeuser.
* * *
Former assistant superintendent of the University of
Minnesota Hospitals, William K. Klein, has begun his
new duties as superintendent of Hurley Municipal Hos-
pital in Flint, Michigan. A graduate of the University
Business Administration School, Mr. Klein has been a
member of the University Hospitals’ staff for five
years.
* * *
Dr. Paid R. Hawley, head of the Veterans Adminis-
tration Department of Medicine and Surgery, arrived
in the Twin Cities on August 9 to spend a week in-
specting VA hospitals in the area as part of a nation-
wide tour of veterans’ hospital facilities.
With Dr. Hawley on the tour were Miss Dorothy
Wheeler, national director of VA nursing service;
Dr. John Barnwell, chief of the tuberculosis division,
and Dr. Harvey Tompkins, of the neuropsychiatry di-
vision.
ijc :jc
New visiting regulations have been adopted by three
Duluth hospitals, Dr. Mario Fischer, city health direc-
tor in Duluth, has announced.
The regulations, which, Dr. Fischer said, are “in
the interest of better health,” have been approved by
the St. Louis County Medical Society, and are in effect
at St. Mary’s, St. Luke’s and Miller Memorial Hospi-
tals.
Visiting hours both in wards and private rooms are
now between 2 :00 and 4:00 p.m. and 7 :00 and 8:30 p.m.
on week days, Sundays and holidays, with only two
persons permitted to visit a patient at any one time.
Children under fourteen years of age are not permitted
to visit in the hospitals, and all persons under sixteen
years of age are barred from the obstetric floor.
* * *
The Hunt Hospital, founded in' Fairmont thirty-three
years ago by the late Dr. F. N. Hunt and his son,
Dr. R. C. Hunt, closed on July 15.
Since 1940 the hospital has been conducted by Dr.
R. C. Hunt and his son, Dr. Robert S. Hunt, who are
continuing to maintain offices in the building while using
the Fairmont Community Hospital for patients needing
hospital care.
In regard to the closing of the Hunt Hospital, Dr.
R. C. Hunt said, “In view of conditions — which in-
cludes a shortage of nurses — we feel that the inter-
ests of the public will best be served if we centralize
our efforts in one location, where the greatest possible
use of personnel and equipment will be realized.”
^ ^ ^
At a round-table conference at Fort Snelling in July,
leading medical men from six states met with represen-
tatives of the Veterans Administration and the Minne-
sota American Legion to analyze medicine in relation
to the veteran.
Conclusions of the group were that “veterans’ medi-
cine” had advanced tremendously in the past year, that
the future looked “very bright,” but that VA hospitals
were badly overcrowded and new buildings and facilities
were needed.
Dr. Charles W. Mayo, member of the Medical Ad-
visory Committee of the VA, said that the high stand-
ards originally set for the Upper Midwest area are
now being approached generally in the nation. Dr.
Harold S. Diehl, dean of Medical Sciences at the Uni-
versity of Minnesota and chairman of a committee that
aids in selection of medical personnel for the VA,
pointed out that physicians of high ability are now
working with the VA whereas a year ago they tended
to “shy away.”
The meeting was held to bring a better understanding
between the Veterans Administration and veterans’ or-
ganizations.
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Minnesota Medicine
COMMUNICATION
Communication
September 2, 1947
To the Editor :
Those of us who were once accustomed to appreciate
and marvel at the remarkable clinical acumen displayed
by the clinician of two or three decades ago at ward
rounds and at autopsy table, will heartily agree with the
sentiment expressed in the first two paragraphs of the
editorial entitled “Laboratory Abuse” which appeared
in the July issue of Minnesota Medicine. We must
combat the strong tendency toward the dependence which
is more and more being placed on laboratory and x-ray
findings in the care of the patient, at the expense of
clinical observation and judgment, which the young phy-
sician should learn to acquire.
I am not, however, in accord with the statements made
in the third paragraph, wherein the writer, referring to
the uncontrolled use of laboratory facilities, declares that
“one does decry their unstinted use, particularly in the
private hospital and office” and then, commenting on the
need for reducing laboratory expense by some form of
a cushion, asserts that “a practical example of this type
of cushion is the State Board of Health Laboratories.”
Speaking only for the private hospital, it must be re-
membered that in most of them in Minnesota, the
laboratory fees are charged by individual tests, and no
tests are performed without the request from the at-
tending physician, except for the obviously necessary
minimum routine admission procedures and the histologic
examination of surgically removed specimens. I find
the average attending physician to be quite conservative
about the use of the laboratory facilities, even in the
best of the private hospitals, and on many occasions,
the laboratory contributes its services free of charge in
the study of unusual or difficult cases, for the sake of
scientific interest and in order to relieve the financial
burden on the patient. I do not believe that there exists,
to any alarming degree, the laboratory abuse which the
writer deplores, in the majority of the private hospitals.
It is where the laboratory facilities are free and easily
accessible and where the residents and interns are allowed
to assume a greater degree of responsibilities in the
diagnosis and treatment of the patients, as in the public
and teaching hospitals (or perhaps, where a flat rate is
charged for all laboratory tests) that the abuse is
likely to exist.
The high cost of laboratory service is, therefore,
attributable, not so much to the abuse, but largely to
the high cost of maintenance ; that is, the cost of the
equipment and the salaries .of the technicians. The
latter are no longer the mechanical robots of two decades
ago, but college-trained experts who are especially trained
in medical technology, bio-chemistry, bacteriology,
hematology, et cetera, who are equipped to meet the de-
mands of modern medical diagnosis. Their salaries must
be adequate enough to justify their professional training.
This trend, of course, is not peculiar to the laboratory
workers, but shared alike in all phases of medical prac-
tice, in nursing, in anesthesia, in x-ray service, as well
as in all other specialties as, indeed, in all present-day
human endeavors.
Therefore, it is difficult to comprehend how a physician
would single out the practice of clinical pathology and
have the State Board of Health Laboratories perform
clinical laboratory procedures, other than those directly
related to the control of communicable diseases and
public health, in order to bring down the cost of labora-
tory service. Since the performance of laboratory pro-
cedures is primarily a part of the function of the clinical
pathologist who is a practicing physician, the delegation
of this function to the State would be to allow the
state to compete with the licensed physician. If this were
allowed to happen, even in the name of economy, would
it not be logical to suppose that any part of any specialty
of medicine might be taken over by the State in the
name of economy or public health? Could one not imagine
the State taking over a part, if not all, of the nursing
service in order to “cushion” the high cost of medical
care?. Why should not the State go into obstetric prac-
tice and infant care in competition with the physician?
To advocate that the State Board of Health Laboratories
might extend its laboratory service to include routine
diagnostic procedures (including the Rh determination
and tissue diagnosis) would seem as illogical as to sanc-
tion a proposition that the State might “cushion” or
share the expense of the practice by members of any
other specialties of medicine.
Diagnosis by laboratory methods is a sphere of clinical
pathology. A clinical pathologist would view with con-
cern any suggestion that the State Board of Health
Laboratories might “cushion” or share the expense of
any laboratory procedures (other than those dealing
with the control of communicable diseases and public
health) not only for the sake of his own practice, but
for the future of his fellow practitioners, for it may
represent another step toward a deeper and firmer control
by the State upon the practice of medicine in general.
Kano Ikeda, M.D.
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September, 1947
1011
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
MILK AND FOOD SANITATION PRACTICE. H. S, Adams,
B.Sc., Chief, Bureau of Environmental Hygiene, Division of
Public Health, Minneapolis, and Lecturer of Public Health,
University of Minnesota. 311 pages. Illus. Price $3.25. New
York: The Commonwealth Fund, 1947.
This book is a practical text covering in detail the field
of milk and food sanitation. The author states in part,
“It is intended that it should be useful in orienting the
public health student who plans to work in the field of
environmental sanitation, and that it should serve as a
guide for health officers, public health engineers, and
sanitarians whose work in a local health department in-
volves routine but important duties in the sanitary super-
vision of milk and food supplies. The book endeavors to
present essential and fundamental principles of milk and
food control, but it does not attempt to discuss theory
exhaustively.”
The first part of the book is devoted to milk sanitation.
After pointing out that the cash income derived from the
sale of milk is larger than that of any other farm com-
modity including grain crops, and represents twice the
cash return from cotton, the author systematically de-
scribes the steps involved in planning and administering
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a milk control program. Essentials of sanitary milk pro-
duction, undesirable flavors in milk, pasteurization, labora-
tory procedures, and the sanitary control of frozen des-
serts are discussed in a way to be of practical use to
milk sanitarians. A bibliography on milk provides an ex-
tremely valuable source of supplementary reference ma-
terial.
The second part of the book is concerned with the food
control problem, essentials of food establishment sanita-
tion, and instruction and training of food handlers. Prac-
tical helps for the food sanitarian include such items as
a floor plan typifying many desirable features in a me-
dium-sized restaurant; basic features of various kinds
of dish washing machines ; recommended retail storage
temperatures for various fresh fruits, fresh vegetables,
meats, and other products ; and sample review questions
for a health department food handlers’ school. A bibli-
ography on food here also supplies vital reference sources.
An unusual feature of this book is provided by the ap-
pendix, in which there appears a well-organized and
well-presented series of sections which milk and food
sanitarians may use much as they would a field hand-
book. The supplementary source material refers to such
sources as publications of various kinds, and organizations
and commercial institutions interested or engaged in the
milk and food industry. Field equipment for the food
sanitarian is described in detail. Analytical procedures
for detection of cyanide in metal polish, sulphites in meat
products, and arsenic spray residue are typical of the
specific testing procedures outlined. A suggested course
of instruction for food handlers is presented and might
well be studied by all health departments contemplating
or engaged in this vital practice.
This worthwhile book, which certainly cannot fail to
be of value to both student and sanitarian alike, ends
with an index so organized as to fulfill admirably its in-
tended purpose.
Earl H. Rubble, M.S.
Public Health Engineer
Duluth, Minnesota
THE PHARMACOPOEIA OF THE UNITED STATES OF
AMERICA NO. XIII. Easton, Pennsylvania: Mack Printing
Company, 1947. Price $8.00.
The thirteenth United States Pharmacopoeia became
official April 1, 1947. Sheet supplements which may ap-
pear from time to time may be obtained from the U.S.P.
The Birches Sanitarium, Inc.
2391 Woodland Avenue
Duluth 3, Minnesota
A hospital for the care and treatment of
Nervous and Mental disorders. Quiet, cheer-
ful environment. Specially trained personnel.
Recreational and occupational therapy.
Psychiatrists in Charge
L. R. Gowan, M.D. L. E. Schneider, M.D.
1012
Minnesota Medicine
BOOK REVIEWS
headquarters, 4338 Kingsessing Avenue, Philadelphia 43,
Pennsylvania. The United States Pharmacopoeia XII
became official in 1942, but so rapid was the development
in drugs during the war and so many were the supple-
ments needed that another revision was deemed advisable.
For the first time the titles are arranged alphabetically
according to their English titles instead of Latin, and this
facilitates reference.
Revision XIII, as well as recent revisions, represents
an enormous amount of investigation and compilation
which would have been impossible to handle with present
resources had it not been for the gratuitous assistance
given by many groups and individuals. Through the co-
operation of the chairman of the National Formulary
Committee of Revision, it has been possible in these two
official books of standards to develop uniform methods
in related fields.
Each Pharmacopoeia is revised by a general Com-
mittee on Revision, elected at each decennial meeting by
the members of the U.S.P. convention, made up of repre-
sentatives of medical and pharmacal colleges, state and
national medical, dental, chemical, drug and veterinary
associations, Army, Navy, and U. S. Public Health Serv-
ice, and a number of other organizations too numerous
to mention.
Ever since the first Pharmacopoeia was published in
1820, it has been the standard followed by all who have
to do with drugs. If it says so in the U.S.P., it must be
’so !
HOSPITAL CARE IN THE UNITED STATES. American
Hospital Association, 18 East Division Street, Chicago 10,
Illinois. Prioe $4.50.
The American Hospital Association announces publi-
cation August 25 of Hospital Care in the United States,
the complete report of the Commission on Hospital
Care. This 700-page volume, published by the Com-
monwealth Fund, redefines the functions of the general
hospital and outlines a long-range program for the
improvement, development and co-ordination of Ameri-
can hospitals. It summarizes the findings of the Com-
mission’s intensive two-year study of hospital facilities
and lists 181 specific recommendations for the expan-
sion and improvement of hospital care in the United
States.
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TAILORS TO MEN
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T T OMEWOOD HOSPITAL is one of the
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Operated in Connection with
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HOMEWOOD HOSPITAL
Corner Penn and Plymouth Avenues North
Minneapolis Minnesota
SEPTEMBER, 1947
1013
Classified Advertising
Replies to advertisements should be mailed in care of
Minnesota Medicine, 2642 University Avenue, Saint
Paul 4, Minn.
WANTED — Laboratory technician in a general hospital.
Salary is open. For additional information address
E-35, care Minnesota Medicine.
FOR SALE — Complete x-ray equipment, also all Victor
electrical treatment equipment. Very reasonable. Time
to pay, if required. Address E-36, care Minnesota
Medicine.
PHYSICIAN NEEDED — At Isle, Minnesota, situated
100 miles north of Twin Cities, on Mille Lacs Lake.
Offices new — income attractive — practicing area unop-
posed. Address H. S. Nyquist, Isle Civic and Com-
merce Association.
ASSISTANT PHYSICIAN WANTED— Young man
preferred. General practice. Salary basis. Address
Dr. L. A. Benesh, 23 S.E. Fourth Street, Minneapolis
14, Minnesota. Telephone GEneva 9054.
FOR SALE — Practically new diagnostic instruments:
(1) Ruddock peritoneoscope with all supplementary
instruments except biopsy forceps; (2) National body
cavity diagnostic set. Write or telephone Dr. Dan
Goldfish, 424 Medical Arts Building, Duluth 2, Minn.
WANTED — Physician below the age of 40, interested
in general practice with a small clinic in northern
Minnesota. Excellent equipment and opportunity for
eventual permanent association. Write Lynde Clinic,
309 North LaBree, Thief River Falls, Minnesota.
FOR SALE — Because of closing hospital, late model
G-E x-ray outfit and portable unit. Write Drs. Hunt
and Hunt, Fairmont, Minnesota.
EXPERIENCED LABORATORY TECHNICIAN de-
sires position as assistant in doctor’s office. Address
E-34, care Minnesota Medicine.
WANTED — Medical secretary in busy office. Good sal-
ary. Write Dr. Otto J. Seifert, New Ulm, Minnesota.
WANTED — Young general practitioner or man with
some special training in internal medicine to practice
with established physician. Not in cities. Hospital
facilities nearby. No investment. Freedom of individ-
ual practice. Address E-33, care Minnesota Medicine.
GENERAL PRACTITIONER with special interest in
obstetrics, 29 years of age, University of Minnesota
graduate, desires association with small group or
clinic. Address E-37, care Minnesota Medicine.
WANTED — Physician as an assistant in excellent gen-
eral practice, with object of buying practice. Address
E-25, care Minnesota Medicine.
WANTED — Assistant for General Practice in southern
Minnesota with view to permanent association with
another doctor. Very active general practice with
some major surgery. Nothing to sell — just too much
work. If interested, write, giving full particulars about
yourself. Address E-30, care Minnesota Medicine.
FOR SALE — General medical practice in resort town
20 miles from Twin Cities. Execellent opening for
young man. Local and city hospitals available. Will
introduce. Address E-32, care Minnesota Medicine.
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1014
Minnesota Medicine
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
INSTRUMENTS • TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494
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Nine months' course open to high school
graduates or women with eguivalent
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For further information
write
Mrs. Lydia Zielke, Supt. of Nurses
FRANKLIN HOSPITAL
501 Franklin Avenue Minneapolis 5, Minnesota
Orthopedic Braces and
Appliances
Physicians' specifications
followed precisely.
Scientific manufacture
and fitting.
AUGUST F. KROLL
Manufacturer
230 WEST KELLOGG BLVD.
St. Paul, Minn. CE. 5330
Radiological and Clinical
Assistance to Physicians
in this territory
MURPHY LABORATORIES
Minneapolis: 612 Wesley Temple Bldg. - - At. 4784
St. Paul: 348 Hamm Bldg. - Ce. 7125
If no answer, call --------- Ne. 12S1
Hall & Anderson
PRESCRIPTION PHARMACY
BIOLOGIC ALS
PHYSICIANS’ SUPPLIES
SAINT PAUL, MINN.
LOWRY MEDICAL ARTS BUILDING
TELEPHONE: CEDAR 2735
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UNUSUAL LENS GRINDING
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SAINT PAUL
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ORTfldRFWlLLIAM}
Insurance Druggists' Mutual InSUraOTCe Company Pr°mP‘
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Saving Fire - Tornado - Automobile Insurance Service
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September, 1947
1015
.null
pRO‘*°'^*etaw9
**!*»*»
Like Amigen, Protolysate is an enzymic
digest of casein and consists of amino
acids and polypeptides. Like Amigen,
Protolysate supplies the nitrogen es-
sential for maintenance, repair and
growth.
Unlike Amigen, which may be em-
ployed both orally and parenterally,
Protolysate is designed only for oral
use.
The function of Amigen and Protolysate
is to supply the amino acids essential
for nutrition. Both can be given in place
of proteinwhen protein cannot be eaten
or digested, or in addition to protein
when the protein intake is insufficient.
Administered in adequate amounts,
they prevent wastage of protein, restore
previous losses, or build up new body
protein.
'
t U3. NET (454 GM >
PROTOLYSATE
For Oral Administration
^ 'try enzymic digest jf casein containing am
ac'ds and polypeptides, useful as a source of re
^sorbed food nitrogen when given orall)
H tube. Protolysate is designed for adtnin>s*
tion in cases requiring predigested protein'
0<ie administration and the amount
glVM1 should be prescribed by the physici
1 lb. cans at drug stores
MEAD JOHNSON & • CO., EVANSVILLE 21, INDIANA
There is no shortage now of AMIGEN for parenteral use. There is no shortage now of PROTOLYSATE for oral use.
1010 Minnesota Medicine
pillary hemorrhage, defying control by hemostat and ligature,
edily yields to THROMBIN TOPICAL. Seconds after local
dication, the operative field can be cleared of capillary bleeding.
rombin topical affords prompt, on-the-spot clotting action. It
: of a long line of Parke-Davis preparations whose service to the
fession created a dependable symbol of therapeutic significance—
DICAMENTA VERA.
ROMBIN TOPICAL (Bovine Origin) is
ilable in 5,000-unit ampoules, each packed with a
:. ampoule of sterile, isotonic saline diluent.
RKE, DAVIS & COMPANY • DETROIT 32, MICHIGAN
Your Ability to Earn
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Is your disability policy incontestable?
Does it contain the following clause?
“After this policy has been continuously in force two full years
during the lifetime of the Insured it shall become incontestable as
to the accuracy of the representations contained in the application
and as to the physical condition of the Insured on the date thereof
No one would purchase life insurance that was con-
testable. The disability insurance carried on one's
income should certainly be safeguarded by an
incontestable provision.
Your policy should not be a part of the hazard
of disability.
Protect your earning capacity with long term,
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Write or Call
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Ralph H. Brastad, Agency Manager
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MINNEAPOLIS 2, MINNESOTA
1018
Minnesota Medicini
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
/olume 30 October, 1947 No. 10
Contents
*1. Physiologic Approach to Cardiovascular
Roentgenology.
Marry L. Sussman, M.D., New York, New York 1041
rHE Plan of Action for Farm Communities.
Mrs. Charles W. Sewell, Chicago, Illinois 1049
\ Sound Public Health Program.
Haven Emerson, M.D., New York, New York. . 1050
rHE Health Program in Rural Schools.
D. F. Smiley, A.B., M.D., Chicago, Illinois.... 1054
Physical Education in Rural Schools.
Fred V. Hein, Ph.D., Chicago, Illinois 1057
rlospiTAL Facilities for All.
Viktor O. Wilson, M.D., Minneapolis, Minnesota 1060
Rural Medical Service.
Frank J. Hirschboeck, M.D., Duluth, Minnesota 1065
History of Medicine in Minnesota.
Notes on the History of Medicine in Fillmore
County Prior to 1900. (Continued from Sep-
tember issue.)
Not a H. Guthrey, Rochester, Minnesota 1071
President's Letter :
Local Heart Associations 1078
Editorial :
Acres of Diamonds 1080
AMA Fellows 1081
Medical Economics :
Risks of Administering Blood Plasma 1082
Social Security Mission to Japan Questioned. . 1082
AMA “Grass Roots Conference” Hailed as
Decided Success 1083
Minnesota State Board of Medical Examiners. . 1085
Reports and Announcements 1086
Woman's Auxiliary 1090
In Memoriam 1092
■ N
Communication 1094
Of General Interest 1096
I
Book Reviews 1110
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office
in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918.
October, 1947
1019
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
C. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — $3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions — $3.50.
The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
ST. CROIXD ALE ON LAKE ST. CROIX
PRESCOTT. WISCONSIN
MAIN BUILDING— ONE OF THE 8 UNITS IN “COTTAGE PLAN"
A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous and Mental Disorders
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therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
NEUROPSYCHIATRISTS
PRESCOTT OFFICE
Prescott, Wis.
Howard J. Laney, M.D.
Tel. 39 and Res. 76
Hewitt B. Hannah, M.D.
Joel C. Hultkrans, M.D.
Howard J. Laney, M.D.
511 Medical Arts Building
Minneapolis. Minnesota
Tel. MAin 1357
SUPERINTENDENT
Dorothy M. Most, R.N.
Prescott, Wisconsin
Tel. 69
1020
Minnesota Medicin
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Investigated and Recommended by:
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Ramsey County Bar Association
West Central District Dental Society
Hennepin County Medical Society
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St. Louis County Medical Society
Stearns-Benton County Medical Society
East Central Medical Society
11th Judicial Bar Association
St. Paul District Dental Society
)CTOBER, 1947
1021
For Both Medicine and Dentistry, the
value of the first truly scientific dissections
by Galen, the Greek who lived in Rome
(130-200 A.D.), was equaled only by the
scientific method propounded 600 years earlier
by Hippocrates.
Working only with pigs and apes (but urg-
ing his students to be on the alert for human
bones protruding from graveyards), Galen
was first to recognize the different kinds of
nerves, most muscles, the brain as the center
of the nervous system and the fact that arter-
ies, containing blood rather than air, were
somehow connected with the veins (1500 years
before Harvey).
A new concept of the doctor’s legal lia-
bility was evolving then, too. Before, mal-
practice had been punishable only as a crime.
But, under the Lex Aquilia, damages could
be assessed. Malpractice had become a civil,
as well as a criminal, offense.
There Are Few Who Experiment Today
with the risks of unprotected practice. Most
doctors enjoy the Medical Protective pol-
icy’s complete coverage, preventive counsel and
confidential service.
1022
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MINNEAPOLIS Office: Stanley J. Werner, Representative, 816 Medical Arts Building, Telephone Atlantic 5724
*
Minnesota Medici
AMNIOTIN DIVIDEND
AMNIOTIN DIVIDEND
AMNIOTIN DIVIDEND
for the menopausal woman
THERAPEUTIC DIVIDENDS
beyond the relief of
vasomotor symptoms
Therapeutic follow-through : A heightened sense of well-being,
increased strength and vigor, and general relief are inherent in
Amniotin therapy — therapy beyond the relief of vasomotor
symptoms.
Safeguarded by nature: Amniotin therapy does not interfere with
physiologic safeguards regulating estrogen metabolism. Side
effects such as dizziness, fatigue, nausea and vomiting are infre-
quent with Amniotin therapy.
At nature’s pace: Amniotin is administered in essentially the
same manner as the ovary itself elaborates estrogens — in rela-
tively small amounts at a relatively constant rate.
amniotin dividend fdhree convenient forms : Therapy with Amniotin is flexible,
easily adapted to individual therapeusis. Its oral and intramuscu-
lar forms are in potencies readily adjusted to the pace of estro-
genic activity established by the ovary itself. Amniotin is also
available in capsule-suppositories for intravaginal administration.
COMPLEX NATURAL MIXED ESTROGENS
HI
MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858
'CTOBER, 1947
1023
E ye -witness
R e ports. . .
TT is one thing to read results in a
published research. Quite another
to see them with your own eyes.
PUBLISHED STUDIES* SHOWED WHEN SMOKERS
CHANGED TO PHILIP MORRIS SUBSTANTIALLY EVERY
CASE OF THROAT IRRITATION DUE TO SMOKING
CLEARED COMPLETELY, OR DEFINITELY IMPROVED.
But may we suggest that you make
your own tests?
Philip Morris
Philip Morris & Co., Ltd., Inc.
119 FIFTH AVENUE. NEW YORK, N. Y.
*N. Y. State Journ. Med. 35 No. 11,590
Laryngoscope 1935 , XLV, No. 2, 149-154
TO THE DOCTOR WHO SMOKES A PIPE: We suggest an unusually fine
new blend — Country Doctor Pipe Mixture. Made by the same process as
used in the manufacture of Philip Morris Cigarettes.
1024
Minnesota Medici tv
SAVE MINUTES DURING FLUOROSCOPY!
HERE'S WHY you actually save minutes without additional
effort on your part with a G-E Vertical Roentgenoscope.
FASTER POSITIONING
OF PATIENTS!
Suspension -arm -swivel, en-
ables you to swing the
screen out of the way while
positioning patients.
“FINGER-TIP”
SCREEN CONTROL!
This one control
moves the screen
vertically . . . laterally
—regulates shutters
at the same time.
CONTROLS WITHIN
ARMS REACH!
X-ray controls can Be ad-
justed to convenient work-
ing height and rotated to
angle best suited to you.
FASTER MOVING
SCREEN!
Correctly balanced —
one of the lightest
ever designed. Moves
faster . . . takes less
effort on your part.
The more you use this minutes-
saving fluoroscopic unit the
more you marvel at how these
outstanding features enable you
to cut minutes from your daily
examinations and conserve your
energy without trying.
To get an illustrated booklet
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simply clip and mail this coupon
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Please send me Vertical Roentgenoscope Booklet.
Name.
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State or Province _
October, 1947
C-110
1025
Now
. . . a brighter outing f°r
r the child with petit mal
rmi • ■ •
Tndione
(Trimethadione, Abbott)
ABBOTT LABORATORIES
NORTH CHICAGO, ILLINOIS
No longer must the slow and uncertain processes of nature be
depended on to bring relief to petit mal patients. Tridione— discovered
and developed by Abbott Laboratories — offers the prospect of immediate
improvement in the majority of cases. Here’s further evidence added to
the growing literature: In a recent investigation1 Tridione was given to
166 patients suffering from petit mal (pyknoepilepsy), myoclonic jerks or
akinetic seizures. None of the 166 had secured relief from any previous
treatment. With Tridione, 31% became free of seizures; 32% had their
seizures reduced by more than three-fourths; 20% improved to a lesser
extent; 13% were unchanged, and only 4% became worse. Thus 83%
showed definite improvement. In some cases the seizures did not return
after Tridione was discontinued. Tridione has also been reported beneficial
in certain cases exhibiting psychomotor seizures when combined with
other anti-epileptic therapy.2 Tridione is available through your phar-
macy in 0.3-Gm. capsules and in pleasant-tasting aqueous solution con-
taining 0.3 Gm. per fluidrachm. If you wish literature, just drop a line.
1. Lennox, W. G. (1947), Tridione in the Treatment of Epilepsy, J. Amer.
Med. Assn., 134:138, May 10. 2. Dejong, R. N. (1946), Further Observations
on the Use of Tridione in the Control of Psychomotor Attacks, Am. J.
Psychiat., 103:162, Sept.
1026
Minnesota Medicin
outlook on life.
''Premarin" provides effective estrogenic therapy through the oral route and is available
as follows:
Tablets of 2.5 mg bottles of 20 and 100
Tablets of 1.25 mg bottles of 20, 100 and 1000
Tablets of 0.625 mg . bottles of 100 and 1000
Liquid, containing 0.625 mg. in each 4 cc. (1 teaspoonful) . bottles of 120 cc.
CONJUGATED ESTROGENS*
(equine)
•While sodium estrone sulfate is the prin-
cipal estrogen in ■‘Premarin,” other equine
estrogens . . . estradiol, equilin, equilenin,
hippulin . . . are also present in varying
small amounts, probably as water-soluble
sulfates. The water solubility of conjugated
estrogens (equine) permits rapid absorp-
tion from the gastrointestinal tract.
“Premarin”
AY ERST, McKENNA & HARRISON Limited
October, 1947
22 EAST 40TH STREET, NEW YORK 14. N. Y.
1027
WHENEVER THE NUTRITIONAL STATE
MUST BE IMPROVED
The food drink made by mixing Oval-
tine with milk finds frequent applica-
tion whenever underpar nutrition is
encountered. It is equally valuable
whether the need for dietary supple-
mentation arises from the ravages of
acute infectious disease, from dietary
limitations made necessary by surgery,
or from faulty food selection over a
prolonged period.
This nutritional supplement is deli-
cious in taste, readily digested, and
thoroughly bland. It may be taken
either hot or cold, as the patient de-
sires, and is appealing to both children
and adults. It supplies a wealth of vir-
tually all essential nutrients including
ascorbic acid and B complex and other
vitamins. Its proteins are biologically
complete, a feature of importance in
the correction of debility states. Three
glassfuls of this delicious food drink
daily round out even an average diet to
full nutritional adequacy.
THE WANDER COMPANY, 360 N. MICHIGAN AVE., CHICAGO 1, ILL.
Three servings daily of Ovaltine, each made of
Vi oz. of Ovaltine and 8 oz. of whole milk,* provide:
CALORIES
669
VITAMIN A
3000 I.U.
PROTEIN
32.1 Gm.
VITAMIN Bi
1.16 mg.
r a i
31 5 Gm.
RIBOFLAVIN
2.00 mg.
CARBOHYDRATE
NIACIN
CALCIUM
1.12 Gm.
VITAMIN C
30.0 mg.
PHOSPHORUS
0.94 Gm.
VITAMIN D
417 I.U.
IRON
12.0 mg.
COPPER
0.50 mg.
*Based on average reported values for milk.
1028
Minnesota Medici n
UKIOUKJL in propylene glycol
MILK DIFFUSIBLE VITAMIN D PREPARATION
ODORLESS • TASTELESS • ECONOMICAL
The simplicity and conven-
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Drisdol in Propylene Glycol facil-
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early infancy to adolescence.
An average daily dose of
2 drops in milk for infants and
from 4 to 6 drops for children
provides effective low-cost
vitamin D protection throughout
the critical years of growth and
development.
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Minnesota Medicine
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Minnesota Medicini
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Lister’s researches on infection in surgery led him to apply Pasteur’s
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1035
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Job XIV, 1
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Minnesota Medicine
Reminding people of the value of
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To an audience of over 23 million people, in LIFE and other national magazines,
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Minnesota Medicine
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1039
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1040
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30
October, 1947
No. 10
A PHYSIOLOGIC APPROACH TO CARDIOVASCULAR ROENTGENOLOGY
MARCY L. SUSSMAN, M.D.
New York, New York
/TY subject concerns the possibility of and the
"*■ need for the roentgen study of the heart to
be made in terms of pathologic physiology. I do
not mean to deprecate the importance of anatomic
diagnosis but rather to emphasize that since
pathologic anatomy is only an end result of al-
tered dynamics, much of our attention should be
focussed on the disturbed physiology.
The function of the heart is to propel sufficient
adequately oxygenated blood to the tissues and
to handle it efficiently on its return. We are
concerned therefore in the efficiency and adapta-
bility of the heart in maintaining a proper pres-
sure head and volume output. Pressure and vol-
ume are related through Starling’s law15 which
states that, within certain limits, the volume out-
put per beat is directly related to the diastolic
size of the ventricle. To put it another way, the
greater the initial pressure, which is a function
of the length of the muscle fiber, the greater the
pressure developed and therefore the larger the
volume of blood ejected. This law comes into
play when the venous return is augmented, when
the ventricle is unable to empty as the result of
increased pressure in its outflow artery, as well
as when the ability of the myocardium to contract
is impaired. Long continuance of an augmented
contraction based on increased initial length leads
to hypertrophy, which still permits efficient con-
traction until the elastic limits of the fibers are
overstrained. Then the diastolic pressure begins
to rise and, with further increments to diastolic
filling, the output falls.
The Russell D. Carman Memorial Lecture presented at the
annual meeting of the Minnesota State Medical Assocition,
Duluth, Minnesota, June 30, 1947.
The atria probably do not follow this pattern.
If, as is likely, they act like large veins16 there will
be a pressure level below that associated with
clinical failure, at which a slight increase in pres-
sure will cause a marked increase in volume.
The important factors in cardiac dynamics,
therefore, are the pressures in the individual car-
diac chambers, including details of their change
during the cardiac cycle, the changes in the vol-
umes of these chambers, and their output. As
Cournand and his colleagues have shown,7 pres-
sures can be recorded in the right heart and fem-
oral artery in humans, but this technique is not
applicable to all patients. The ordinary x-ray
examination tells us only about the over-all size
of the heart, and this not too accurately because
the upper and lower borders must be guessed and
because the geometric shape varies unpredictably
in different physiologic and pathologic conditions.
Furthermore, the volume of individual chambers
is not given quantitatively except in a condition
like mitral stenosis where the left auricle is un-
usually dense. The only method which regularly
demonstrates individual chambers is angiocardiog-
raphy,20 but this also is a procedure which can-
not be applied universally.
Roentgenkymography, or more recently elec-
trokymography, by recording cardiac pulsations
affords modified data concerning volume change
and, indirectly, pressure change.11,18 This method
is easily applied and, therefore, will be considered
first, using the effects of respiration on cardiac
dynamics as an illustration.
The pressure gradient between peripheral and
central veins is an important factor in right
October, 1947
1041
CARDIOVASCULAR ROENTGENOLOGY— SUSSMAN
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1042
Minnesota Medicine
CARDIOVASCULAR ROENTGENOLOGY— SUSSMAN
atrial filling and, therefore, in the dynamics of
the rest of the circulation. Since this pressure
gradient can be afifected by ordinary and exag-
gerated respiration, we have a simple method
by which to change these conditions. For ex-
ample, roentgenograms made during Valsalva and
Mueller experiments may show a change of 20
per cent or more in the volume of the heart.
It has been shown by direct inspection of the
heart in dogs, that the decrease in intrathoracic
pressure that occurs with deep inspiration results
in augmented right atrial filling,2 and in right
ventricular dilatation.17 According to Starling’s
law, this produces an increase in right ventricular
output. Lauson et al,12 from intracardiac pres-
sure recordings, made similar deductions in the
human. They showed also that for a few beats
there is a decrease in the left ventricular output
in inspiration and an increase during expiration.
However, they emphasize that this basic pattern
can be varied by changes in the following:
depth of respiration, relative duration of inspira-
tion and expiration, respiratory rate, kind of
respiration (abdominal or thoracic), pulmonary
vascular capacity (as the result of disease or
therapy), distensibility of the ventricles in di-
astole (as in pericardial disease), and venous re-
turn as in peripheral or central failure. While,
as I noted, it is difficult to study the absolute
volumes of the cardiac chambers in the human,
the timing and the speed of volume change can
be recorded during the cardiac cycle from the
heart border. Morelli14 carefully investigated this
subject in 1939 using a concentric kymogram.
The electrokymogram, however, permits a rather
more precise analysis, particularly because other
circulatory functions can be simultaneously re-
corded. At present we record heart sounds,
electrocardiogram, electrokymogram and either
the carotid or venous pulse, or the apex beat.
The electrokymogram, as described by Cham-
berlain and his group,11 records the movement
of the cardiac contour through a photocell. As
the contour moves to and fro in front of the cell,
the amount of light from the fluorescent screen
and the current from the photocell vary propor-
tionally. The current is amplified and activates
a recording galvanometer. The final tracing is
much like a pulse tracing. As the right or the
left heart border moves towards the midline of
the chest a downstroke is recorded. Similarly,
movement away from the midline is recorded as
an upstroke. Therefore, when systole occurs, the
left border contracts towards the midline, more
fluorescent light enters the photocell, and a down-
stroke is recorded.
The timing of the events of the cardiac cycle
is obtained from one of the other recorded func-
tions since these have been well known to physi-
ologists and cardiologists for many years. The
timing of systole can be taken from the first sound
or from the carotid pulse. The preliminary vi-
brations of the first sound correspond to' atrial
systole ; the first large component of the sound
corresponds to isometric contraction ; the second
large component to ejection. In the case of the
carotid pulse, a slight presystolic peak may be
seen corresponding to atrial systole. The acute
rise of the anacrotic limb corresponds to ventric-
ular ejection. The semilunar valves close at the
time of the second sound and the dicrotic notch
of the carotid pulse. When the apex beat is
satisfactorily recorded, or more regularly from
the venous pulse, the rapid inflow phase of di-
astole is easily distinguished.
In general, the time relations of mechanical and
electrical activity of the heart are not constantly
correlated. However, when other activities are
not well recorded, and this occurs frequently in
experiments with respiration, the electrocardio-
gram may be the only available frame of refer-
ence.
The electrokymogram is analyzed therefore by
determining when certain phases of the cardiac
cycle have occurred, and deciding from the move-
ment of the cardiac contour what is happening to
the chamber that forms the contour at the point
being investigated.
Case 1 was a normal hypersthenic man of
fifty years. The left ventricular contraction is
larger in expiration than in inspiration (Fig. 1).
Exaggerated respiratory motions demonstrate
profound alterations in ventricular ejection and
filling. In the Valsalva experiment, which is
forced expiration against a closed glottis, systolic
contraction is much more rapid than in expiration
Diastolic expansion is slow and steady until presys-
tole, when there is a sudden sharp filling. In the
Mueller experiment (forced inspiration against
a closed glottis) systolic contraction is very slow,
and diastolic filling, after a fairly rapid start,
progresses slowly to its presystolic maximum.
Lauson et al12 made intracardiac pressure
studies during the Valsalva and Mueller experi-
October. 1947
1043
CARDIOVASCULAR ROENTGENOLOGY— SUSSMAN
meats. Their evidence suggests that the strong
compression of the thoracic contents produced
during the Valsalva impedes venous return and,
as a consequence, the right ventricular stroke
volume decreases. After a short delay, the left
ventricle follows suit. This will explain the slow
diastolic filling of the left ventricle which is
noted in Figure 1. The rapid systolic contraction
is perhaps accounted for by a smaller systolic
residue in the ventricle or by the lower pressure
outside of the thorax than within it.
The Mueller experiment produces a marked
fall in the intrathoracic pressure. Lauson et al12
found here that there was a sharp drop in right
atrial and right ventricular pressures. However,
the net right ventricular pressure was increased,
slowly returning to normal as the effort continued.
This was taken to indicate increased output of the
right ventricle and, therefore, after a few beats,
of the left. Since the right atrial pressure in re-
lation to the extrathoracic veins falls during the
Mueller experiment, we can account for the
steady diastolic filling of the left ventricle by
this increased pressure gradient. The slow ven-
tricular contraction on the left side is more dif-
ficult to understand unless there is a larger
systolic residue and therefore a greater initial
pressure. Perhaps also there are changes in the
activity of the vasomotor centers during this
experiment which alter the systolic pressure and
secondarily the ventricular pressure.
Recording of the right heart border during the
Mueller experiment shows a very rapid filling of
the atrium during ventricular systole (Fig. 1).
The influence of heart rate, and therefore of
the duration of the cardiac cycle, was studied in
a patient with hyperthyroidism and a heart rate
of 120 beats per minute. Intracardiac pressure
recordings,12 suggest that the duration of diastole
may be of some importance in determining the
mode of filling of the left heart. In our pres-
ent case (Fig. 2), diastole was shortened to 0.30
seconds. During the Mueller experiment, the
right atrial filling occurred rapidly and steadily
from shortly after the onset of ventricular systole
until the atrioventricular valves opened. Atrial
systole is well defined; however, during the Val-
salva when the right heart pressure is low, atrial
systole is barely recorded. In both experiments,
nevertheless, as well as in deep expiration, atrial
movements are of large amplitude, which is
probably to be related to the shortened diastole.
1044
The contractions of the left ventricle are much
like those in Case 1 . However, rapid systolic ejec-
tion in both Valsalva and Mueller experiments
is noted. In all likelihood a large systolic resi-
due cannot accumulate in the ventricle during the
Mueller experiment in this case because of the
rapid heart rate. The rather remarkable differ-
ence in the shape of the ejection curve under these
conditions is of great interest. I suggest that the
apparent expansion of the ventricle in late systole
during the Mueller might be due to the decreased
pressure in the intrathoracic vascular structures
as compared with the arteries outside of the tho-
rax, since, while the semilunar valves are open,
they are in free communication with the aorta
and left ventricle. However, such explanations
are mere speculations until, as we intend, simul-
taneous pressure recordings are made. I regret
that space does not permit an elaboration of the
clinical use of this technique. For simplicity, I
have omitted from discussion the effect of the
wringing motion of the heart during contraction,
the side-to-side motion and the pull of the base
towards the apex.
1 shall pass on now to another interesting type
of problem. After an arteriovenous aneurysm
has been corrected or an acute anemia treated, the
heart rapidly becomes smaller. This difference
in size cannot be accounted for by a change in
the stroke output alone. Fahr and Buehler com-
puted9 from observations on a heart-lung prepa-
ration that there would be an increase of about
125 c.c. in the diastolic volume of a normal human
heart (assumed 600 c.c.) when the stroke output
was increased fourfold. This corresponded to
an increase of 7 mm. in the transverse diameter,
whereas I have shown you differences of at least
1 1 mm. in one instance and 24 mm. in the other,
in diseases in which the stroke output was at most
doubled.
To explain this discrepancy, Nylin13 postulated
a change in the systolic residue in the heart.
Cournand3 showed that normally there is a sys-
tolic residue in the left ventricle through pressure
recordings made during an extrasystole. These
showed that although contraction occurred be-
fore filling could have taken place from the
atrium, there was an ejection of blood from the
left ventricle. Angiocardiography shows clearly
that there is residual diodrast in the right ven-
tricle at the end of systole and a smaller amount
ordinarily in the left. This can be seen both
Minnesota Medicine
CARDIOVASCULAR ROENTGENOLOGY— SUSSMAN
from the exposures made at the end of systole
(Fig. 3) and from a motion picture following
the course of diodrast through the heart * Cha-
vez et al3 recently agreed that the right ventricle
as well as simultaneously in the femoral artery.
The catheter is passed under fluoroscopic control
by the roentgenologist. Pressure recordings are
made and blood samples taken for oxygen con-
Fie 3 Systolic residue. No. 1 and No. 2 show the residual diodrast in the right ventricle
at the end of systole; No. 4 and No. 5 show the left ventricular residue. The exposures were
controlled through an electrocardiographic lead (illustrated in No. 1).
does not empty completely in systole. They show
films suggesting that the left does, but I am in-
clined to attribute this to a difference in tech-
nique, such as an unintended Valsalva experi-
ment.
A discussion of systolic residues immediately
leads us back to the problem of pressures, the
importance of which I have repeatedly empha-
sized. Pressure recordings can be made in the
right auricle, right ventricle and pulmonary artery
*The motion picture mentioned was shown after the presen-
tation of this paper at the state meeting.
tent analysis at various points in each chamber.
The oxygen content, along with the oxygen con-
sumption, permits a calculation of the average
stoke output.
When pressure determinations can be corre-
lated with volume measurements, a maximum of
information is available. For this reason, and
also because of the anatomic data which is made
available, angiocardiography also is employed.
In the following cases, therefore, the results of
such a correlation are presented. However, since
we have only recently begun to catheterize the
October, 1947
1045
CARDIOVASCULAR ROENTGENOLOGY— SUSSMAN
heart, while we have performed over one thou-
sand angiocardiographies during the past few
years, I have not hesitated to draw freely from
the literature for the pressure data.
the apex was pointed normally.19 Sometimes the
right ventricle appeared compressed by the large
left ventricle (Fig. 5). However, it is anticipated
that right ventricular dilatation and hypertrophy
Fig. 4. {Left) Carcinoma of the right lower lobe bronchus (AB1). (Right) Angiocardiogram
after right pneumonectomy. Arrow points to stump of right pulmonary artery. The left
pulmonary artery and its branches are not significantly dilated.
PostpneumonectomY
The capacity of the pulmonary vascular bed is
great. Removal of one lung so that the entire
blood flow is through the remaining lung has very
little effect upon right ventricular pressure be-
cause there is no change in vascular resistance.
Cournand6 also found the blood flow normal.
The systolic pressure in the right ventricle was
slightly elevated in' one of his cases where there
was a coincident chronic emphysema. The over-
all size of the heart remains normal, and the
right ventricle, by angiocardiography, is normal
in size (Fig. 4). The pulmonary artery, the
remaining main branch and its smaller branches
are not enlarged, the preservation of normal pres-
sure-flow relations probably being maintained by
an increase in the number and, to a slight extent,
the size of the capillaries in the remaining lung.
Patent Ductus Arteriosus
In spite of the increased pulmonary flow in
this condition, Dexter and Burwell8 found the
mean pressure in the pulmonary artery to be nor-
mal even when, in one case, the shunt through
the ductus was estimated to be eight liters per
minute. We have performed angiocardiography
in about eighty cases of this condition, and the
right ventricle regularly was normal in size ; the
serration of the trabeculae was unchanged, and
will be found if the pressure in the pulmonary
artery rises, as was found in one case by Cour-
nand (55/39 mm. mercury, as against a normal
of 25/8).
Chronic Pulmonary Disease
In four cases of emphysema with a moderate
increase in residual air, Cournand6 found normal
pressures in the right ventricle. In four cases
with a larger residual air, the systolic pressure
was elevated. In both of these situations, the
heart was not definitely enlarged. However,
when right heart failure was present, and this
is defined by Cournand as occurring when there is
diastolic as well as systolic hypertension, dilata-
tion was found regularly. This experience is
comparable to our findings with angiocardiog-
raphy, with this addition. Angiocardiography has
shown how difficult it is to determine the size
of the right ventricle by ordinary x-ray means.8
The first changes take place in the position and
direction of the interventricular septum. The
apex of the right ventricle is rounded instead of
pointed. These changes are wholly undetectable
bv cardiac measurement or by inspection of the
cardiac contours. When enlargement of the heart
occurs, it is found to the left. However, the
pulmonary artery is usually dilated, and this is
demonstrated in the conventional roentgenogram.
1046
Minnesota Medicine
CARDIOVASCULAR ROENTGENOLOGY— SUSSMAN
When there is diastolic hypertension in the right
ventricle, the mean right atrial pressure is ele-
vated and this chamber enlarges. It is then that
frank cardiac enlargement to the right is noted.
Eisenmenger Complex
This case is presented to demonstrate the in-
tegrated type of examination that can now be
made. In this case, a girl of twenty-two, mod-
Fig. 5. Patent ductus arteriosus. Angiocardiograms made in left oblique position. ( Center ) White arrow points to left border
of compressed right ventricle which is otherwise normal in size. Pulmonary artery (two black arrows) is not dilated. ( Right )
Black arrow indicates right border of very much dilated left ventricle.
Mitral Disease
We have been impressed with the finding, by
angiocardiography, that the right ventricle is not
grossly dilated in cases of mitral disease even
when the heart is quite large.10 The right ven-
tricle on the other hand has been found displaced
anteriorly, the pulmonary artery anteriorly and
cephalad, by the large left auricle. The straight-
ened, elongated middle left cardiac contour is
due chiefly to the left auricle and not, as some
have thought, to a dilated elongated pulmonary
conus. It is apparent from angiocardiographic
analysis, that it is very difficult or impossible to
determine the size of the right ventricle in the
usual case of mitral disease by ordinary roentgen
means. The explanation for this is to be found
in a report by Bloomfield et al.1 In a case of
rheumatic heart disease, they found a normal
diastolic pressure in the right ventricle as long
as the patient was not in failure. A systolic
hypertension of 57 mm. mercury was present,
but I have already indicated that significant ven-
tricular dilatation does not take place until the
diastolic pressure rises. The same patient when
in failure revealed pressures of 103/29 in the
right ventricle. It is these pressure changes that
account for the marked change in the size of the
heart that is found when a patient with mitral
disease passes in and out of failure.
erately cyanotic and with progressive impairment
of cardiac reserve, the mean right ventricular
pressure was 22 mm. mercury. The right atrial
pressure also was substantially elevated. The
pulmonary artery could not be catheterized but
the pressure was undoubtedly high because pulsa-
tions were very active fluoroscopically and, when
recorded, suggested pulmonary insufficiency.
Angiocardiography showed considerable dilata-
tion of the right auricle and right ventricle (Fig.
6). A shunt of diodrast from the right ventricle
into the aorta clearly is present but most of the
diodrast passed into the dilated pulmonary artery.
This accounts for the high oxygen saturation of
arterial blood that was found (82 per cent).
In spite of moderate cyanosis and increasing im-
pairment of cardiac reserve, this was not a case
for the Blalock-Taussig operation.
Summary
I have very briefly touched on some of the
phases of cardiac roentgenology which have in-
terested me. I selected for presentation particu-
larly those facets of cardiovascular physiology in
which the roentgen ray can play an important
role. It has been my intention to provoke con-
sideration of these thoughts :
1. It is no longer necessary for roentgenology
1047
October, 1947
CARDIOVASCULAR ROENTGENOLOGY— SUSSM AN
to confine itself to a questionable static analysis
of cardiac topography.
2. The roentgenologist has a tool which is
particularly suited to a physiological approach to
In the preface to his book, Dr. Carmen said,
“Opposing views have been considered with fair-
ness and without conscious implication that the
statements herein recorded should be considered
Fig. 6. Eisenmenger Complex. (Above, left) Conventional roentgenogram shows heart enlarged
to the left, with the pulmonary artery segment convex. (Above, right) A catheter was passed
into the right ventricle but could not be passed into the pulmonary artery. (Below, left) Angio-
cardiogram shows enlarged right ventricle (white arrow) and a dilated pulmonary artery. Diodrast
enters the aorta from the right ventricle (black arrow). (Below, right) Electrokymogram of
the left ventricular pulsations during a Valsalva experiment showed a lateral movement 0.06
seconds after the onset of ventricular ejection.
cardiac dynamics. However, his participation in
a team will permit an integrated study which can-
not be achieved by one individual alone.
3. Newer techniques permit the study of the
individual and his cardiac function. This is the
fundamental development in clinical physiology.
Reliance on prototypes in the postmortem room
or on the experimental animal has become less
necessary than heretofore.
final. Because of the lessons they may teach,
mistakes have been recorded unsparingly, but
these errors should not be regarded as reflecting
on the efficiency of roentgen diagnosis in general.”
Clearly if we follow Dr. Carman’s precepts,
knowledge must advance.
Credit is accorded to the teams with which I have
worked in obtaining the data I have presented : Dr.
(Continued on Page 1081)
1048
Minnesota Medicine
THE PLAN OF ACTION FOR FARM COMMUNITIES
MRS. CHARLES W. SEWELL
Administrative Director, Associated Women of the American Farm Bureau Federation
Chicago, Illinois
T N any discussion of rural health problems, one
is reminded of the ancient recipe for rabbit
stew, which began, “First you must catch the
rabbit.” In this case, the rabbit is public opinion,
and perhaps the most important step in a series
of steps looking toward improvement of rural
health conditions is an awakening of the residents
of a given community and an awareness of the
problems that .exist.
Next in order would be a meeting of interested
people. Farm organizations, extension service,
civic clubs, school authorities, church represen-
tatives and the nursing profession should meet
with their county medical and dental societies
and public health departments, and plan pro-
grams designed to answer three pressing ques-
tions: “How shall the sick be helped?” “How
shall the doctor, dentist, nurse and hospital be
paid?” and lastly, “What can we do in an edu-
cational campaign to institute preventive measures
that will lead to better health?”
The result of such consultation should lead to
a general survey of the rural community. The
number of doctors and nurses, hospital facilities,
condition of the roads, and the average income
of the farm people to be served must be ascer-
tained before intelligent planning can be assured.
When the exact report has been compiled, the
entire community through its local leadership
should be urged to focus general attention upon
the findings. Through organization meetings, ra-
dio, press and pulpit, people can be informed of
the true conditions and urged to assume responsi-
bility in a program that will ultimately effect the
much needed changes.
Read at the Rural Health Conference at the annual meeting of
the Minnesota State Medical Association, Duluth, Minnesota,
July 2, 1947.
It is most likely that it will be found that there
are existing agencies available that are not being
used. Perhaps there is duplication of effort in
some lines and co-ordination is needed. It is
highly possible that a little well directed team
work can bring Federal and State assistance of
funds and personnel to the aid of local health
workers, with remarkable results.
Communities should be made to see that they
can well tax themselves to provide better facilities.
A campaign of health education designed to ex-
plain and extend prepayment plans for medical
care and hospital service will do much to dis-
seminate authentic information on this compara-
tively new and less well-known method of paying
some of the bills. Promising students should be
assisted in preparation for medicine and nursing
through scholarships. Farm organizations and
the county medical societies may well plan work-
shops or discussion groups to carry forward and
perfect the definite programs suggested by the
surveys and “arousement” preliminaries.
America has her greatest stake in a healthful
citizenry. Her economic and cultural advance-
ment as well as her military strength for national
defense are inextricably woven together. Today,
we must meet this great challenge with the best
we have and solve the problem by application
of the time-honored American doctrines of self-
help and individual responsibility. We can no
longer say there is no problem and dismiss it with
a shrug of indifference. If we do not present a
positive approach and apply what we know and
what we have, there are those among us who,
restless and discontented, will seek to fasten upon
us a system of regimentation and compulsion
entirely foreign to American ideas and ideals.
The stake is tremendous. We dare not fail.
October, 1947
1049
A SOUND PUBLIC HEALTH PROGRAM
HAVEN EMERSON, M.D.
Emeritus Professor of Public Health, Columbia University
New York, New York
"D URAL or farm community health is to be
achieved only by interested active sharing
in objectives and methods entered into heartily
by the three parties primarily concerned. These
are, in order of importance, the individuals or
families of the community, the physicians and
dentists in private practice, and the health de-
partment of the local government.
Health is a personal achievement, built upon
good inheritance, upon an understanding of the
laws of living matter, reproduction, nutrition and
growth, that is, the principles of human biology,
and such control of environment and human re-
lationships in work and play as will reduce or
avoid preventable disease.
Without the enlightened and eager self-inter-
est of parents and children, employes, teachers,
ministers, editors and all and sundry persons
and households of the community in attaining a
way of life that is consistent with good health,
neither the professions nor officers of local gov-
ernment can create, maintain or improve the state
of health of village, town or country.
There are no visible limits to the betterment
of health, the enrichment of life, the completeness
of the span of human survival, and the depth,
breadth and happiness of life, if all we now know
of the prevention of disease and the development
and promotion of health at all ages is applied,
with courage, determination and personal and
social unselfishness by people, doctors and their
local government.
Health is largely the result, the payoff, the
reward, of a quality in persons and their way of
life.
No one of the great accomplishments of the
past hundred years, this recent century of sani-
tation, the golden period of the sciences and arts
of human existence, would have been possible
without the trust of people in their family physi-
cians and the personal influence of these doctors
of our nation in the households of our land. Their
necessary role in carrying preventive medicine
to every patient and family is ever more and
Read at the Rural Health Conference at the annual meeting of
the Minnesota State Medical Association, Duluth, Minnesota,
July 2, 1947.
more indispensable in the translation of the facts
of laboratory and hospital, of medical school and
research institution into practical application in
homes, shops, farms and public policies.
Why then must we have the participation of
local government when we admit the prior im-
portance of the people themselves and their
medical and dental advisers?
Because there are some services which can be
offered at less expense and with more effect by
government than if left to private initiative and
individual conscience.
You ask me to describe a sound public health
program with special respect to rural or farm
community existence.
Let us at once define what we mean by public
health sendees. These consist of the application
of the sciences and arts of preventive medicine,
by or with the consent of government, in the in-
terest of the community, as distinct from medical
services for the individual’s personal benefit.
There are four recognized levels of govern-
ment at which health services are conducted. The
international, the national (federal or dominion),
the state or province or department, and the local
level, that is, the village, town, city, county or
multiples of these within the frame of a local
or district government.
We cannot separate ourselves from concern
with the somewhat remote functions of the
World Health Organization or with the duties of
national health agencies, for without their protec-
tion, hazards from other lands and lack of central
authority in commerce and transportation would
certainly deprive us of much of our present health
security. But they do not reach into our homes
or provide persons to protect our water, milk and
food supplies, or supervise the sanitation of our
villages. At the state level we touch closely upon
services that may be, and in Minnesota always
have been, about as intimate and personal as are
those of the local department of health. In fact,
in most of the area of your state and for at least
one-third of your population, the state department
of health has been the only source of protective
health services, outside of the four large cities.
1050
Minnesota Medicine
SOUND PUBLIC HEALTH PROGRAM— EMERSON
But be it always remembered that state, na-
tional and international health services and pro-
grams can be but partial and largely theoretical
unless built upon a structure that brings basic
essential health services to every household,
through the agents of the public health profes-
sions serving each respective community, be it
town, county, city or village.
Let us then picture for our immediate goal as
a function of every local government, whether
separately or in conjunction with adjacent com-
munities within the county, the simplest, most
elementary, economical but efficient services for
health required to make use of the abundant facts
of present day medical knowledge.
It is a privilege enjoyed under your laws for
every unit of local government to establish a
board and department of health. In all common
sense this privilege should be seized upon as an
obligation, a duty of every local jurisdiction of
government that levies taxes and disposes of such
revenue in the public interest. County and lesser
units of local government in Minnesota have
taken their responsibilities too lightly in this
respect, and there are literally hundreds of local
health departments unworthy of the name and but
mere gestures, serving no useful purpose. It is
inevitable that this should be so under the loose
and inadequate provisions of state law which do
not now facilitate the joint action of small com-
munities and sparsely settled counties to combine
for the common purpose of health departments.
I share with all physicians of your state, and
with many other citizens of good will and public
spirit, a deep chagrin and mortification that your
recent legislature allowed a petty political ob-
struction to frustrate the evident demand of the
people for an enabling act permitting the creation
of city-county, county-wide and multi-county
health departments for efficient public health
service at the local level.
But to come back to the substance of the mat-
ter. Of what does a sound public health program
consist? Certainly it does not include medical
care of sickness. It does not invade the recognized
field, the traditional and accepted sphere of pri-
vate initiative and personal relation of family
and family physician. A public health program
must be conceived in view of four administrative
principles. There must be authority under the
law for the performance of certain functions ;
there must be responsibility vested in a profes-
sionally qualified medical officer of health ap-
pointed by elected officials of local jurisdiction;
there must be tax funds authorized and appro-
priated to carry out the health services ; and the
health officer must be free to select and employ
such professional, technical and assistant person-
nel within the specification of civil service require-
ments as may be necessary for the work to be
undertaken.
Authority, responsibility, tax money, person-
nel— these must be assumed if we are to venture
upon a service so vital, so indispensable to living
and a high level of health.
The basic functions of the local health depart-
ment are six in number, each long tested and
each of proved worth, and each so related to the
others as to make a consistent and efficient ad-
ministrative whole. These six functions are :
1. The accounting for all births, deaths and
notifiable diseases, occurring within the local ju-
risdiction : the vital statistics or human family
bookkeeping. This requires verification of each
record for completeness and accuracy, the tabula-
tion, analysis, interpretation and publication of the
facts to be used as a basis for education, for
public policy, for health accounting to the local
public.
2. Control of communicable diseases by the use
of education, persuasion, and, if necessary, the
authority for sanitary law. There is the provi-
sion of specific protective immunity to those not
so served by the family physician, and of such
treatment of infected persons as will shorten the
period of communicability of a disease. These
services, guided by epidemiological intelligence
and resourcefulness, everywhere produce cal-
culable and usually brilliant results.
3. Environmental sanitation including protec-
tion of water, milk, foods, and especially the
guardianship of all employed persons against any
health hazards of their occupation. The control of
insects and animal pests capable of communicating
or causing disease in humans is included under
this part — the sanitary engineering control of
man’s environment on the material, as distinct
from the social or physical, phases of his life.
Housing occupancy, as distinct from housing
construction, falls within the scope of sani-
tation also. The measure of success in this
function of a local health department is, as is
the case in many of the others, the amount of
October, 1947
1051
SOUND PUBLIC HEALTH PROGRAM— EMERSON
educational persuasion, rather than the extent
of police power or sanitary authority that is used
to obtain compliance. The best health services
are those that keep the big stick of authority hid-
den, while teaching has full play to obtain a
willing and interested co-operation.
4. The public health laboratory is the servant
of the sanitarian, the epidemiologist, the health
educator, the health officer within the department
of health, and, even more, the collaborator and
assistant of the physician, the veterinarian, the
dairyman, the food processor and purveyor. The
laboratory gives exactness, promptness, decision
and irrefutable proof of conditions in persons
and in environments that hazard health.
These four functions carry on the earliest basic
conceptions of public health service and are sup-
ported by long established legal sanctions, sup-
ported by the highest courts.
The next two functions involve only educa-
tional methods and express the most modern con-
cepts of the role of civil government as the peo-
ple’s friend and counsellor, rather than their mas-
ter.
5. Only since 1912 have local health depart-
ments had bureaus or divisions of maternity, in-
fant and child hygiene, including concern with
the health protection of school children. This
function, perhaps, in its scope and bearing upon
human happiness and survival is the most far-
reaching and necessary of all the duties of a
health department and might well be thought of
as concerned with human reproduction, replace-
ment, growth and development, the whole field
of the succession of the generations, the quality
and quantity of our offspring, with genetics and
eugenics, with inheritance and the up-bringing of
children within the family. From the pre-marital
state of oncoming youth, through the period of
the expectant mother, the dangerous days of early
infancy, the delightful personality and exuberance
of the runabout, the preschool child, and through
the baffling years of adolescence, through high
school and into college or employment, the health
department stands as a sort of proxy parent to
guide, guard and assist in the achievement of
maturity with the least possible number of handi-
caps to the body, mind and spirit of the child.
Truly the very principle of human biology, if it
becomes part of the way of good life in home
and community.
6. And then latest, as a member of the public
health family, is the function of health informa-
tion, instruction and education in all its infinite
variety.
Health education is a life-long experience, a
sort of biological philosophy, the very essence of
common sense. It has always been a function of
the family physician. It is the particular province
of the visiting and public health nurse. It is a
major concern of every member of every depart-
ment of health from local to international. It
is an art that carries the word of science.
No thought of force or compulsion, no threat
of authority or law can be tolerated in the rela-
tionship between the mother with her children
and the public health nurse who is the very em-
bodiment of a traveling encyclopedia of hygiene.
Whatever the information sought by the public
or specially promoted by the health department in
the public interest, the method must be that of the
educator who speaks with authority in the field
of .human health.
These six, then, are the basic, minimum func-
tions of a local health department : vital statistics ;
communicable disease control ; environmental
sanitation; public health laboratory; maternity,
infant and child hygiene ; health education.
If I did not believe each of these to be a
proven need for my fellow citizens and a proper
and authorized duty of local government to pro-
vide, I should not have come so far from my
home by the sea to persuade you physicians and
you parents of Minnesota to organize your pro-
fessional and public influence and opinion to the
effect that no village, town or county of your
state lacks these. We have had these services in
New York City since 1865.
Full-time, trained professional medical leader-
ship for such health services is as essential as a
lawyer on the bench, an engineer in charge of
your highways, an educator at the head of your
schools.
Part-time physicians, private practitioners, can
no longer play safely the part of local health of-
ficers. They should not be asked to.
Of Minnesota’s 2,714 counties and cities, vil-
lages and townships permitted to set up each a
local health department, only 821 of the 1,881
townships had a health officer. Most of the local
health officers of Minnesota are on a part-time
or fee-for-service basis. Not more than one-
fifth of the local health departments in Minnesota,
1052
Minnesota Medicine
SOUND PUBLIC HEALTH PROGRAM— EMERSON
of which there are some 1,635, even report the
pay of the health officer.
This is an inexcusably loose and inadequate
provision for local health service, for which the
remedy was sought at the last legislature.
The chief errors which have developed unno-
ticed over the recent decades are :
1. Local governmental jurisdictions are too
small to support a competent staff to carry out the
necessary functions of a local health department.
2. Appointment as health officers of part-time
practitioners of medicine and surgery, whose time
and interest are fully engaged in caring for the
sick.
3. A small penuriousness of local government,
which in the main makes wholly insufficient ap-
propriations for human life-saving.
The necessary steps to make Minnesota lead
the states in eradication of tuberculosis and syph-
ilis and maintain its distinction in local health
worthy of its great university schools of medicine
and public health and of its distinguished state
health department are as follows :
1. Secure passage of the enabling act for
creation of consolidated local health units of suit-
able size.
2. Impress elected officers of local government
with their duty to appropriate sufficient tax funds
to support at least the minimum basic local health
services under trained medical direction.
3. Make certain that no less than one public
health nurse is employed for each 5,000 popula-
tion for administrative and educational services.
One for each 2,500 of population will be needed
if they are to be required to give bedside care of
the sick in the home.
4. Give the local health officer authority to
employ other professional and technical personnel
as the population may require.
You will have noted, and perhaps with surprise
and disappointment, that I have made no refer-
ence to the relation of the local health officer to
the administration of hospital, outpatient or home
medical care services for the sick. Your laws
may put the burden upon him, but I assure you
that the program of public health I have out-
lined will require all the ability and time of a
trained health officer and that community health
will suffer if his talents are devoted to manage-
ment of medical care programs for the sick.
It is proper to have the state department of
health charged with its present and expanding
functions in the interest of more and better hos-
pital care, but care of the sick is not a proper
function of the local health officer.
Every local jurisdiction of size to justify a
full-time health department should have a profes-
sional and citizens’ health council to serve as a
forum, a sort of public conscience and planning
body to back up the public health program. One
further omission I have been guilty of inten-
tionally. I have not advised that in the estab-
lishment of local health units and implementing
their half-dozen essential functions there be
undertaken clinic services for the aged, for heart
disease, for diabetics, for the mentally ill, for
multiple sclerosis, for cerebral palsy, for epilepsy,
for Hodgkins’ disease, for cancer, or for arterio-
sclerotic and hypertensive patients.
Only so far as the state of medical knowledge
offers any sound facts which can be safely and
honestly passed on to the general public through
educational publicity, can local health departments
participate in the prevention of these many seri-
ous human ills.
Medical institutions for diagnosis and treat-
ment and research establishments to study origins
and causes of chronic, long-time disabilities have
the present responsibility with respect to these
diseases as causes of individual sickness.
We are deeply ignorant of facts upon which
programs of prevention can be based.
Let us, through our health departments, per-
suade people to obtain competent medical and sur-
gical advice, as the best means of safeguarding
their health by periodic health examinations.
If they are, in fact, unable to meet the cost of
such examination, it is certain that medical insti-
tutions and organizations will find ways of pro-
viding it.
The health department is not the agent of gov-
ernment or the community which should be
charged with establishing clinical facilities for
diagnosis and treatment of the sick, unless the
sickness of the individual threatens communica-
tion to others.
The public health council, the local medical
society, the health officer and his staff should be
the agencies to discover and correct preventable
causes of ill health and create the public spirit of
co-operation among all elements of the population
(Continued on Page 1070)
October, 1947
1053
THE HEALTH PROGRAM IN RURAL SCHOOLS
D. F. SMILEY, A.B., M.D.
Consultant in Health and Physical Fitness,
Bureau of Health Education, American Medical Association
Chicago, Illinois
T T is axiomatic that in a democracy such as ours
-*■ the rural school child should enjoy equal op-
portunities with the urban school child so far as
the protection and improvement of his health is
concerned. When we look at the record, how-
ever, we find this is not the case. Health exami-
nations of rural school children are too often
omitted or only hurriedly done ; arrangements for
following up remediable defects and utilizing all
community resources to bring about correction are
too often lacking'; heating, lighting, ventilating
and cleaning facilities in the rural school are too
often inadequate, and planned and progressive
health teaching too rare.
Correlated with these inadequacies (but prob-
ably not the direct result of them), we find that
though rural and urban children start life with
about the same number of remediable physical
defects, urban children manage to get many more
of their defects remedied during their school life
than do rural children. We also find that the
health habits of rural children, particularly in re-
spect to matters of diet, dental care, and com-
municable disease control, are generally inferior
to those of urban children.
While fresh air, sunshine and physical activity
are health boons almost automatically afforded
rural children, they do not of themselves guar-
antee a high level of health or physical fitness,
nor should their presence be accepted as a reason
for excusing an inadequate health program in the
rural home, school, or community. If a good
home-school health program can be added to what
rural children already have in the way of health-
promoting factors, our rural population should
make rapid strides in improving efficiency, pro-
ductivity and contentment.
The Basic Problem
The basic problem is created by the wide dis-
persal of rural children in the thousands of one-
room schools. Consolidation of these one-room
schools would of course simplify this problem in
many respects, but such consolidation is a long
Read at the Rural Health Conference at the annual meeting
of the Minnesota State Medical Association, Duluth, Minnesota,
July 2, 1947.
and often painful procedure, and the successful
efforts of Grout, Lamkin, Greenleaf, Drenck-
hahn, VanSlyke and many others are proof of the
fact that much can be done to improve the health
programs in our rural schools without waiting
for consolidation.
With perhaps several hundred one-room rural
schools scattered through a typical county it is
easy to see that the county superintendent of
schools will have very limited opportunity to pro-
vide guidance and supervision to the individual
teacher attempting to carry on an effective school
health program. It is just as obvious that the ru-
ral teacher with pupils in perhaps all eight grades,
and with the whole category of responsibilities
extending from planning the school day to super-
vising the recess period, is not going to have very
much time to study the health needs of her pupils
and of the community or to collect interesting new
health-teaching materials or to make home visits
to discuss pupil health problems with the parents.
Some Needed Assistance
If adequate school health programs are to be
provided county wide, then it is apparent that
the overburdened teachers and county superin-
tendents must be given assistance. That assist-
ance may well consist first of a well trained health
education supervisor or health co-ordinator. This
worker will bring new teaching materials to the
rural teachers, work with them to develop teach-
ing units that will be suited to the needs of the
children and adaptable to the limited resources
of the one-room school, and give needed assist-
ance in the maintenance of a hygienic and sani-
tary school room.
Another form of assistance which should be
made immediately available to this overworked
team of county superintendent and rural teacher
is the limited service of a physician and nurse.
Tt is difficult enough for the mother of a family
to be responsible for the health of her small chil-
dren in the isolation of a farm home. She usu-
ally has the father with whom to share the respon-
sibility and she knows that in real difficulty she
can usually find her family doctor at the other
1054
Minnesota Medicine
HEALTH PROGRAM IN RURAL SCHOOLS— SMILEY
end of the telephone line. But to ask the teacher
to be responsible for the health of twenty to thirty
of other people’s children, and without a school
physician for consultation and advice, is both
unfair and unwise.
If the pupils of a school are receiving their
necessary immunizations and health examinations
in the hands of their family physician, I would
be the last to recommend setting up a scheme of
health examinations in the local school. But
even in the ideal situation where the family doc-
tor is providing periodic health examination, it
would seem to me that there is still need for a
regularly appointed school physician to whom
the teacher may turn for advice and counsel in
such matters as suspected communicable disease,
growth and development problems and behavior
problems. Whether such health service is pro-
vided by educational authorities or by local
public health authorities is less important than
that it somehow be provided. Similarly, it
can be said of nursing service that somehow
it must be made available to assist the one-
room rural schoolteacher. But because of the
distances between schools, and the close connec-
tion between disease or infestation of the school
child and disease or infestation in the home, it
would seem particularly desirable that the nurs-
ing service to these rural schools be provided by
the local public health nurses who are author-
ized and equipped not only to work with the child
but to carry the work back into the farm home.
Upon the request of the teacher, the public health
nurse may visit a rural school and, acting upon
standing orders written by the health officer under
whose direction she works, not only eliminate
the pediculosis in the school child but also go
back into the home and eliminate the family in-
festation.
The School Physician
In those rural areas where periodic health ex-
aminations are rarely done by the family physi-
cian, the need for the school physician is even
more urgent. He should not, however, be hired
either by the local school or by the local health
department just to come in once a year, give
every child a rapid examination and then depart
with the feeling that “at least that routine job is
done for another year.” Figures show that school
children are at the healthiest period of their lives ;
in most instances, health examinations done every
three years will be adequate, provided parents
and teachers are alert to refer the child to the
physician when signs of acute illness or handi-
capping defect appear between examinations.
The school physician can therefore make the best
use of his time in the school if he gives first
priority to those children culled out and referred
by the teacher, second priority to health exam-
ination of those entering the first grade, those
entering fourth grade, and those entering seventh
grade. The physician serving the school must
be responsible for establishing professional stand-
ards for the health examination, and he should
refuse to participate in a school health program
which lines the children up and parades them
by the examining physician so rapidly that he
“rarely sees the boy or girl back of the throat.”
Not more than three or four health examinations
should be scheduled per hour, and the time-con-
suming health history, vision testing, hearing test-
ing, and weighing and measuring should already
have been recorded by the teacher and parent
with the guidance and assistance of the nurse.
The advice which the physician gives the child,
and the parent if he is present, at the completion
of the examination, is of the greatest importance,
first because it is based upon the specific needs
of that child, second because it carries the author-
ity of the medical profession behind it. If time
is not taken for this summary and advice, the
physician is failing to utilize his chief opportu-
nity for health education.
The Teacher
The role of the teacher in a one-room rural
school is admittedly a difficult one, and what is
expected of her is frequently far beyond what
any one person can accomplish. It is nevertheless
true that in almost every county in this country
there are rural one-room schools that can be
pointed to with pride by the county superintend-
ent as schools in which health is both taught and
practiced. The atmosphere of the classroom is
cheerful and bright ; each child feels that his
individual needs and desires are being given con-
sideration ; physical activity alternates with mental
activity; health practices jibe with health instruc-
tion ; health instruction is planned and progressive,
and deals with problems, that are found in the
local school, home, or community ; the morning
health review is carefully and consistently done;
the teacher is thoroughly aware of all of the com-
October, 1947
1055
HEALTH PROGRAM IN RURAL SCHOOLS— SMILEY
munity’s resources for recreation, for remedying
defects, for making adjustment to severe handi-
caps.
In order to bring about such a happy situation
it may be presumed that the teacher should have
had in her training days courses in child growth
and development and in the hygiene of the school
child. Most often she has had none. Summer
school courses, teachers’ institutes and health
work shops may have helped many of such
teachers but the majority of successful school
health programs appear to be largely the result
of the teacher’s individual interest and effort.
With the whole community and its health needs
to study, with modern textbooks as tools and with
the help of Hygcia bringing its monthly contribu-
tion of new health facts, every teacher can, if
she has the interest and energy, provide an effec-
tive if not all-inclusive school health program.
Conclusions
1. Though the rural school child as well as
the city child needs and is entitled to an effective
program of health education, health protection
and health promotion, in many instances he is not
getting it.
2. Generally effective school health programs
in rural areas may have to await consolidation of
rural schools.
3. The three chief assisting services that can
be given rural teachers and county superintend-
ents are those of a health co-ordinator, those of
a school physician, and those of a public health
nurse.
4. Every school should have a physician on
call but his time in the school should not be frit-
tered away in doing annual examinations in a
superficial way.
5. The school physician by limiting routine
examining to every three years will have time to
study problem children selected by the teacher
and to offer valuable personal advice upon com-
pletion of the examination.
6. Some teachers in isolated schools manage
to provide effective health programs. Many more
could do so if they were interested, encouraged
and assisted.
7. Medicine now has a tremendous volume of
knowledge as to how to prevent, modify or cure
disease. Much of this knowledge is useless unless
it is in the minds of the general public. The
schools offer the ideal means of putting impor-
tant health facts at the disposal of the public.
It is therefore of vital interest to the medical pro-
fession and all those interested in human wel-
fare that our school health programs, both rural
and urban, function smoothly and effectively.
HYPERTENSION
Of first priority on the list of causes of physical dis-
ability is hypertension, or hypertensive cardiovascular-
renal disease. This is not primarily a vascular disease
but a definite syndrome caused by kidney dysfunction.
It manifests itself in hypertension, cardiac hypertrophy,
secondary degenerative changes in the kidney itself due
to the circulatory changes, and degenerative changes in
other organs, including the brain. Malignant hyperten-
sion is merely a severe and terminal stage of the process.
In evaluating the blood pressure, the diastolic is the
important factor. A persistent diastolic of over ninety
is considered abnormal. Blood pressure may be evalu-
ated most truly just before or after the patient arises
in the morning, or while he is asleep. A normal size
heart is found with the volatile type of hypertension.
An enlarged heart is indicative of a chronic progressive
disease. The eyeground picture reveals the state of the
capillaries. Concentration tests of the urine will tell the
condition of the kidneys. Blood pressure readings alone
should not be the sole criterion for the severity of
cardiovascular-renal disease.
In the management of real hypertension, the commonly
1056
used bromides, barbiturates, and potassium thiocyanate
are not effective enough. Properly done, sympathectomy
is a severe and radical treatment not on a generally rec-
ognized basis. It does not attack the cause of the dis-
ease. Its best use is for the malignant type of disease.
At present, the most gratifying relief of the symp-
toms of headache and “jumping out of one’s skin,”
together with the reduction of the hypertension without
danger and great expense, is the maintenance of the
sodium chloride in the food to approximately 1.2 gm. a
day. With such a low sodium intake the fluid intake
may be as liberal as desired. The sodium intake can be
checked by the chloride content of the urine. It is essen-
tial to keep up the protein intake. Many proteins are
rich in sodium. Protein foods extremely poor in sodium
are being prepared commercially. With the relief
obtained by such a dietary regimen, co-operation of the
patient may be expected.
In the meantime, the important search for the spe-
cific underlying cause of the kidney disease will go on.
— Editorial in The Journal of the Indiana State Medical
Association, October, 1947.
Minnesota Medicine
PHYSICAL EDUCATION IN RURAL SCHOOLS
FRED V. HEIN. Ph.D.
Consultant in Health and Physical Fitness,
Bureau of Health Education, American Medical Association
Chicago, Illinois
TJHYSICAL education, when given its rightful
place in the schools, can be an adjunct of
preventive medicine, a resource for the physiatrist
and orthopedist and an ally of the general prac-
titioner. Mutual understanding, appreciation and
respect for the status, activities and objectives of
closely related professional groups are essential
for co-operative relationships. This is why in-
sight by the physician into' the problems of phys-
ical education and its present professional devel-
opment will aid greatly in bringing about rapport
between the two groups.
The program of health in the schools plays a
major role in conditioning the attitudes of youth
toward health and medical care. The physical
educator’s eminent place in the school health
program makes his relationship with medicine
especially important.
Certain fundamental principles of physical edu-
cation are applicable for rural school programs as
well as for urban education. Physical education
may be thought of as one of the broad subject
areas within the total school curriculum, and phys-
ical educators like physicians have come to realize
that they cannot deal with one aspect of the child’s
development without impinging on the factors
which make up his total personality. This means
that there must be stress on education along with
emphasis on the physical.
Modern physical education is concerned with
education through the physical as well as educa-
tion of the physical. It aims at making a con-
tribution to physical health but is also cognizant
of the potentialities that are inherent in its activi-
ties for desirable social, mental and emotional out-
comes.
Qualities such as loyalty, self-control and co-
operativeness can result from physical education
under skillful guidance, but these things have to
be taught just as arithmetic needs to be taught,
and are not the natural accompaniment of the
activities themselves. Joyous physical recreation
has implications for mental health, in that there
may be considerable relief from the tensions that
Read at the Rural Health Conference at the annual meeting of
the Minnesota State Medical Association, Duluth, Minnesota,
July 2, 1947.
are all too prevalent in the child’s life today.
Children who become skilled at games, sports
and other forms of exercise find opportunity for
self-expression in physical activity and at the
same time gain a sense of achievement through
good performance.
Vigorous, intelligently directed activity can aid
in the development and maintenance of strength,
speed, agility, endurance and skill, in children who
are physiologically sound. Determination of
the program and types of activities in terms of
games, sports, swimming, rhythmics and pre-
scribed activities can be made only after thorough
health appraisal and recommendation by the phy-
sician.
Those who are carefully guided in their school
physical education experiences should enter adult
life with an appreciation of the needed balance
between exercise, rest and relaxation.
At the present time there are over 300 colleges
offering majors or minors in physical education,
health education or combinations of the two.
One accomplishment has been the increase in
the length of these courses, along with those for
other teachers, to' four or five years. But cur-
riculum patterns vary to a considerable degree*
requirements are far from uniform, and faculty
qualifications have not been standardized. In
addition, certification standards for the teaching
of physical and health education have not been
fully developed. But these conditions are no
more difficult than those which prevailed in medi-
cal education only a few decades ago. Vigorous
professional action like that which cleared up the
similar situation in medicine is obviously needed.
Problems of inadequate salaries and unsatis-
factory teaching conditions further complicate the
picture. We cannot expect the needed type of
young people to enter the field until the compen-
sation is somewhat commensurate with the train-
ing required. Genuine interest in the develop-
ment of youngsters keeps many good teachers on
the job but the economic insecurity they suffer
is bound to materially lower their effectiveness.
The medical profession has made great strides
in rooting out the quacks who attempt to foist
October, 1947
1057
PHYSICAL EDUCATION IN RURAL SCHOOLS— HEIN
unscientific methods, worthless devices and harm-
ful remedies upon the people. Physical education
has yet hardly begun the fight against the cultists
who seek to invade its ranks. Muscle for mus-
cle’s sake theories, exercise prescribed through
the mails, useless exercise appliances and “phys-
ical culturists” who have never heard of basic
science may be wrongly identified with physical
education by the public and so undermine the
integrity of a developing profession.
Organized medicine has been largely success-
ful in warding off public pressure for premature
or ill-advised use of the spectacular. But educa-
tion has often been unable to resist public demand
for sports spectacles by the few at the expense
of adequate physical education for the many.
Properly administered spectator sports can have
a wholesome place in education. The skilled per-
formance of varsity groups should motivate wide
participation by our youth on many types and
calibers of teams. But an interscholastic sports
program which stimulates “spectatoritis” among
our boys and girls cannot be classed as educa-
tionally sound.
Over a century of socialization of the schools
of America has not brought solutions to educa-
tional problems in rural areas. There are short-
ages of physicians in many rural districts but
there are shortages of teachers in the same places.
Just as better facilities and more adequate per-
sonnel for medical service are found in urban
areas, so are the personnel and facilities for
education.
Well-developed outdoor play areas, gymnasia,
swimming pools and other equipment which are
the laboratories and clinics of physical education
are almost entirely lacking in the rural areas.
Neither the little red school house nor its coun-
terpart in the hospital has been able to provide
the conditions requisite to an educational program
or medical care of the quality to be found in
metropolitan regions. Recommendations of many
groups indicate that at least a partial answer to
this problem may come about through the consoli-
dated school and the affiliated hospital.
In many rural situations, teachers who might
be called general practitioners in education are
directing instruction. At the elementary school
level in the small schools, the teacher may handle
her own physical education as well as all the
other subjects. In the smaller high schools we
have the P.E. and S. men ; that is, the people who
teach science, physical education and many other
combinations. With adequate background, effec-
tive in-service education and helpful supervision,
acceptable work may be done. But many prac-
tical difficulties stand in the way.
In Minnesota, for example, among about 1,100
men and women teaching physical education,
some 300 had a major in the field and only about
130 had a minor. Another 130 were granted per-
mission to teach part-time in physical education
by reason of completion of a nine-quarter hour
requirement. Over 550 had no certificate but
450 of these attended short-term regional fall
training conferences and subsequently were
granted permission to teach. Obviously the best
prepared of these teachers will be found in the
larger communities where teachers like doctors
seem to find the opportunities greater, equipment
and facilities more to their liking, and living con-
ditions more attractive.
A program for interpretation of physical educa-
tion to the public and to the home is badly needed.
Rural parents may often believe that their chil-
dren secure enough exercise doing the chores at
home and therefore have no need of physical
education in school. Nothing could be further
from the truth. They often need it more than
the city children do. While the country youngster
ordinarlily gets plenty of exercise, he too fre-
quently lacks the skill to play and work well
with others. He is too often xample of poor
co-ordination and awkwardness in the extreme.
His posture and body mechanics are apt to be
very poor, and his home prog ' tm t" exercise but
rarely gives him a background ^joyment of
physical recreation activities.
Understanding physicians, parents ana ichers
are aware that the play life of children just
as important to growth and development ire
work experience and academic learning. T1 ■ .
also recognize the necessity for skillful guid-
ance in these activities if their inherent values
are to be realized. But many of the opportuni-
ties which have been accepted as the natural her-
itage of the city youngster have been denied to
rural youth.
Some teachers and administrators are unsym-
pathetic toward the school health and physical
education program. Persons who are primarily
academic in their thinking may not sense the tre-
mendous educational possibilities that exist in
the wholesome physical education activities which
1058
Minnesota Medicine
PHYSICAL EDUCATION IN RURAL SCHOOLS— HEIN
are so close to the heart of the child. The lip
service that has been given to the health objec-
tive in education must be translated into' action,
and the real life experiences that are available
utilized to their fullest extent.
Courses in teacher education institutions need
to be re-evaluated and, when necessary, the offer-
ings in physical education increased and reorgan-
ized so that elementary teachers will be prepared
to teach physical education effectively under su-
pervision.
In-service education programs, including insti-
tutes such as those which have been conducted
in Minnesota, workshops, summer school courses
and other devices to help teachers in service to
become better qualified for instruction in physical
education, should be developed.
Supervisors, co-ordinators or consultants in
health and physical education need to be provided,
especially in rural areas, to help teachers to plan
and develop worthwhile programs.
At the secondary level people who can teach
health and physical education in our rural high
schools and assume responsibility for co-ordi-
nating rural recreation programs can be prepared.
This combination will make it possible for a
rural community to procure a person with major
training in the field. To go into the reasons for
securing a specialist to do this important job is
unnecessary.
The school program of physical education ac-
tivities must be broad and varied and take into
account the needs and capacities of individual
pupils. Classification of pupils for activity as
the result of a medical examination is a prerequi-
site to desirable physical education. There needs
to be a program for girls and boys who are ca-
pable of enjoying a full schedule of activities, a
modified plan for children whose exercise must
be restricted, and prescribed corrective activities
for those who will benefit from such a routine.
The physician’s advice in respect to the indi-
vidual child’s place in this program is vital to
its success. Then there must be real teaching
which places emphasis on individual needs.
Sufficient time for instruction and enough fa-
cilities, supplies and equipment to1 make possible
an adequate program are essential. The class
period in physical education needs to be regarded
as a time for effective instruction and not as an
occasion for undirected play. There should also
be a chance to practice and enjoy the skills learned
in the classes during leisure time. Informal
games and a broad intramural sports program
within the school, as well as competition against
teams from other schools, can provide all students
with such an opportunity.
All of this will cost money. So will better
medical care, hospitals and public health services.
There are ways of planning intelligently to get
the most for our money but there is no way to
provide the kind of educational program our
children need without reasonable financial outlay.
Physicians are familiar with the expenditures,
present and needed, for medical care, hospitals
and public health. It is interesting to note the
parallels with educational investment.
At the present time in this country we are
spending less than 2 per cent of our annual in-
come on education. Great Britain is engaged in
an educational program that will take between
6 and 7 per cent, and Russia is planning to use
between 17 and 20 per cent of its national income
for educational purposes. Each year in the
United States we spend more for amusements,
tobacco, liquor or cosmetics than we invest in
the education of our youth.
The improvement of physical education in our
rural schools cannot be isolated from the enrich-
ment of education in general, and the betterment
of public health, medical facilities and medical
care. These things can be achieved only when
all the professional and lay groups concerned
plan and work together as a team. Through
wholehearted participation on this team, the
medical profession will place itself in a strategic
position to provide leadership and guidance in
the advancement of rural health and rural living
conditions.
October, 1947
1059
HOSPITAL FACILITIES FOR ALL
VIKTOR O. WILSON. M.D.
Chief, Section of Special Services, Minnesota Department of Health
Minneapolis, Minnesota
Hr HE important health objective of reasonably
'*■ adequate hospital facilities for all the people
has become a realistic possibility with the enact-
ment of the Hospital Survey and Construction
Law. Under this Act the Congress has authorized
an appropriation during each of five years of
$75,000,000, or a total of $375,000,000, to assist
in the building of needed hospitals and public
health centers. Since the law provides that the
Federal share shall constitute one-third of the cost
and the non-Federal funds the other two-thirds,
the law provides for a nation-wide hospital build-
ing program in the amount of $1,125,000,000.
Purpose of the Program
The essential purpose of the law is to provide
Federal financial assistance to the states for the
attainment of “the necessary physical facilities for
furnishing adequate hospital, clinic, and similar
services to all their people”. This purpose is to
be carried out through the following activities :
1. The determination of the hospital and public
health center needs through state-wide surveys.
2. The development of a state-wide plan for
the construction of facilities needed to supple-
ment existing hospitals.
3. The construction of the facilities determined
to be necessary and which conform with the con-
struction program which is part of the approved
state-wide plan.
The law provides for the construction of facili-
ties for all kinds of patients and the types of hos-
pitals which may be constructed under this pro-
gram include general, tuberculosis, mental, chronic
disease and other types of special hospitals but
not those furnishing primarily domiciliary care.
Hospital-related facilities including laboratories,
out-patient departments, nurses’ homes and teach-
ing facilities may be constructed. The building of
public health centers established for the provision
of public health services authorized by state and
local laws, including related facilities such as
laboratories and administrative offices, also may
Presented at the Rural Health Conference at the annual meet-
ing of the Minnesota State Medical Association, Duluth, Min-
nesota, Juiy 2, 1947.
be assisted under the law. The term “construc-
tion” as used in the law is defined to include the
construction of new buildings, the expansion or
remodeling of existing buildings, and the initial
equipment of the constructed facility.
Administration of the Law
The Federal administration of this program is
the responsibility of the Surgeon General of the
United States Public Health Service in the Fed-
eral Security Agency. The Surgeon General issues
regulations governing development and adminis-
tration of state construction plans. The United
States Public Health Service also prescribes mini-
mum standards of construction and equipment of
hospitals and assists through development of
sample plans and the giving of expert advice on
problems. The United States Public Health Serv-
ice has the assistance of a Federal Hospital Coun-
cil composed of eight members appointed by the
Federal Security Administrator of whom four
shall be outstanding authorities in the operation
of hospitals and health activities and four mem-
bers shall represent the consumers of hospital
services and be familiar with the needs in urban
or rural areas. The Federal Hospital Council has
the responsibility of approving the Federal regu-
lations governing the state plan for hospital serv-
ices and the State Hospital Construction Program.
The Council also serves as an appeal body for
consideration of the approval of state plans and
has advisory functions in the Federal administra-
tion of this program.
To qualify for the grant of Federal funds, a
state must designate a single agency to conduct
the state-wide survey and planning, and a single
agency to administer the construction plan. One
agency may serve for both functions which must
be conducted in conformance with the require-
ments of the Federal law and regulations. The
state agency must have the consultation of an
advisory council which shall include “representa-
tives of non-government groups and of state agen-
cies concerned with the operation, construction or
utilization of hospitals including representatives of
the consumers of hospital services”.
1060
Minnesota Medicine
HOSPITAL FACILITIES FOR ALL-WILSON
Surveys and Planning
The Act authorizes the appropriation of three
million dollars to assist the states in surveying
their needs for hospitals and related facilities and
in the development of plans for the construction
of needed additional hospitals and public health
centers. Of this authorized amount, $1,791,000
has been appropriated. This fund will be allotted
among the states on a population basis and shall
be available to defray the cost of state functions
only in the making of surveys and planning dur-
ing the five-year period of the program. Within
its allotment each state will receive Federal grants
equaling one-third of its expenditure for these
purposes. The remaining two-thirds of the survey
and planning costs must be provided by the state.
This program has placed difficult responsibility
on the state. Under the terms of the law and the
Federal regulations, the planning must be con-
cerned with the total number and general method
for equitable distribution of hospitals. All cate-
gories of patients and all areas of the state must
be considered and a plan made to meet the needs
in a balanced and coordinated system of hospital
service. Factors to be studied include the number
and distribution of the population, travel and trade
patterns and the physicians and nurses available to
staff the proposed hospitals. Plans for construc-
tion must be guided by the financial resources
available for construction and for maintenance and
operation. The minimum functions involved in
this work include an inventory of existing facili-
ties, a survey to determine the need for additional
hospitals, the development of a construction sched-
ule and a priority system for the allocation of
the Federal funds in the order of relative need for
the individual project.
For the purposes of the Act facilities are con-
sidered to be adequate in the state if hospital beds
are provided in the various categories according
to the following ratios :
1. General and Allied Special Hospitals — 4.5
beds per 1,000 population.
2. Tuberculosis Hospitals — 2.5 beds per aver-
age annual death from tuberculosis.
3. Mental Hospitals — 5 beds per 1,000 popula-
tion.
4. Chronic Disease Hospitals — 2 beds per 1,000
population.
5. Public Health Centers — 1 bed per 1,000
population.
These allowances are for the state as a whole.
Within the state the Federal requirements intend
that general hospitals be planned on an area basis
to provide a pattern for a co-ordinated hospital sys-
tem. The base area with a large teaching hospital
serves several intermediate areas having smaller
general hospitals. Each of these in turn serves
neighboring rural areas with smaller hospitals.
The ratio of beds to population is graded accord-
ing to the following standards :
Rural Areas — 2.5 beds per 1,000 population
Intermediate Areas — 4 beds per 1,000 popula-
tion
Base Areas — 4.5 beds per 1,000 population
The Construction Program
The $75,000,000 annual construction fund ap-
propriation authorized by the Act for each of the
five years is to be allocated to the states on the basis
of factors of population and per capita income.
This formula will give higher allotments per capita
to low income states. Out of each $75,000,000
appropriated, the Minnesota allotment will be
$1,655,175. Since one-third of the construction
costs may be met from the Federal funds, there
is a possible annual construction program in
Minnesota in the amount of $4,965,525. The Con-
gress has not actually appropriated construction
funds, but late in its last session it did authorize
the activation of the construction work during
the fiscal year 1948 through contractual obliga-
tions for the Federal share in approved projects
within the limitations of state allotments and the
total of $75,000,000 for the country as a whole.
However, before a state may receive federal
grants for construction purposes it must submit to
and have approved by the United States Public
Health Service a state plan for construction of
needed hospitals which must conform to the de-
scribed principles of planning. In addition the
state plan must provide for the adoption of mini-
mum standards of construction which shall not be
less than the Federal requirements and establish
the necessary administrative organization and
methods. Also, the state must provide the funds
to finance the administration.
Project applications may be received for con-
sideration by the state agency only when this
work is completed. When that time comes project
applications are to be processed in the order of
priority of need insofar as local funds are avail-
October, 1947
1061
HOSPITAL FACILITIES FOR 'ALL— WILSON
able for construction and operation of the hospital.
In establishing priorities, consideration must be
given to the relative need in the various categories
of hospitals and, for general hospitals and public
health centers, there shall be emphasis on rural
areas and those with relatively small financial re-
sources. Also, priority is to be given to new hos-
pitals and additions tO' existing buildings, and proj-
ects of a size consistent with efficient and economi-
cal operation.
In addition to priority requirements the individ-
ual project must meet eligibility factors set forth
in the Federal law and regulations. These factors
which are designed to promote qualified commu-
nity hospital service, are as follows :
1. The hospital is needed as shown in the state
plan for hospital services.
2. Public or other non-profit ownership of the
hospital, which means that no part of the net earn-
ings of the constructed hospital may lawfully inure
to the benefit of any private individual.
3. Assurance by the owner that hospital serv-
ices will be provided in the community without
discrimination on account of race, creed, or color.
4. Assurance by the owner that hospital serv-
ices will be provided in reasonable amount to per-
sons in the community unable to pay therefor.
5. Ability of the owner to finance two-thirds
the cost of the construction.
6. Ability of the owner to finance the operation
of the hospital for which evidence must be pro-
vided.
7. Ownership of a suitable site for the hos-
pital. •
8. Development of blue-print plans and speci-
fications for construction of the proposed hos-
pital by a registered architect in conformity with
the state and Federal requirements.
Present Status in Minnesota
Under the provisions of existing statutes, the
Governor of Minnesota designated the Minne-
sota Department of Health to conduct a Hospital
.Survey and Construction Program in cooperation
with the United States Public Health Service.
A State Advisory Council has been appointed and
is functioning in a consultative capacity. An in-
ventory of existing facilities has been conducted
and this information is now being prepared for
use. A study of total needs for hospitals is under
way and it will require a number of months to
TABLE I. NUMBER OF INSTITUTIONS AND NUMBER
OF BEDS IN VARIOUS CATEGORIES
Number of
Institutions
Number
of beds
(complement)
General & Allied Specials
196
12,846
Maternity Homes
32
70
Serve Special Groups
17
706
Nervous & Mental
15
12,107
Tuberculosis & Preventoria
15
1,971
Chronic & Convalescent
128
2,839
Totals
403
30,539
complete this work and develop the construction
schedule and priority system as well as make
other preparations for administering the program
in the state.
The inventory of existing facilities was con-
ducted by the staff of the Minnesota Department
of Health during the period extending from May,
1946, to April, 1947. Although the study of in-
formation collected in this survey is not yet com-
pleted, certain preliminary data are available.
These data relate to the numbers, bed capacities
and uses of the various types of institutions and
certain conditions of staffing, equipment and
physical conditions of these buildings. This infor-
mation is presented in the series of nine tables
included with this report.
Preliminary Information on Existing Hospitals
As shown in Table I, the inventory revealed
403 institutions with a total of 30,539 beds avail-
able for the care of the sick and injured and
for obstetrical cases. Approximately five-sixths
of these beds are about evenly divided between
the general and allied special hospitals and the
nervous and mental group. The allied special
group is made up of the pediatric, contagious,
cardiac, orthopedic and other specialized hospitals
for which a separate listing was not prepared.
The 1,971 beds in fifteen tuberculosis hospitals
are considered quantitatively adequate for the
needs of the state. The 128 institutions with 2,839
beds for the chronic and convalescent include a
few hospitals and the relatively large number of
nursing homes established for the care of these
patients. There are only seventy beds in the dis-
appearing maternity home, which is the 1 to 3
bed facility for normal maternity patients estab-
1062
Minnesota Medicine
HOSPITAL FACILITIES FOR ALI WILSON
TABLE II. TOTAL COMPLEMENT AND NORMAL BEDS
IN GENERAL AND ALLIED SPECIAL HOSPITALS
Beds
Bassinets
Complemenl
Normal
Complemenl
Normal
General
Allied Specials..
12,194
652
11,561
616
2,499 .
1,376
TABLE III. NUMBERS OF HOSPITALS IN CATEGORIES
DISTRIBUTED BY BED CAPACITY
Bed Capacity
Number of
Hospitals
1-24
25-49
50-99
100 &
over
Gen’l & Allied Specials
196
92
49
25
30
Nervous & Mental
15
4
3
0
8
Tbc. & Preventoria
15
0
6
5
4
Chronic & Convales. . . .
128
95
22
7
4
Totals
354
191
80
37
46
lished by a nurse in her own home in a community
without hospital services. The seventeen institu-
tions serving special groups include the infirmaries
and hospitals of institutions such as schools, pris-
ons, and reformatories.
The effect on bed capacities of this period of
high hospital service demand is presented in Table
II. The general hospitals provide more than 600
extra beds as shown by the difference between
a complement of 12,194 available beds and the
total normal capacity of 11,561 beds. While the
hospitals have also set up extra bassinets for new-
born infants, the difference between the comple-
ment and normal bassinet counts as shown in
this table is due largely to the unusually high
floor area standard used in this study for the
determination of normal bassinet capacity.
It is interesting to note in Table III the rela-
tively large number of small hospitals existing in
Minnesota. Of 354 general and specialized hos-
pitals, 191 institutions have bed capacities of
twenty-four or less. This number includes ninety-
five nursing homes in the chronic and convalescent
category. However, of the 196 general and allied
special hospitals, ninety-two have capacities of
twenty-four beds or less and an additional forty-
nine have capacities in the twenty-five to forty-
nine bed group. Seven of the total of fifteen in-
stitutions for nervous and mental patients have
forty-nine beds or less and six of the total of
TABLE IV. NUMBER OF HOSPITALS IN CATEGORIES
DISTRIBUTED BY PER CENT OCCUPANCY
OF NORMAL BEDS
Number
Hospitals
Reporting
Per Cent
Less
than 60
60-79
80 &
over
Gen’l & Allied Specials.
193
62
62
69
Nervous & Mental
15
2
1
12
Tbc. & Preventoria
15
4
4
7
Chronic & Convales
124
21
37
66
TABLE V. HOSPITAL PERSONNEL BY DEPARTMENTS
For 188 general and allied special hospitals
with bed complement of 12,769
Numbers of
Personnel
Numbers of
Personnel
per 100 beds
Administrative
798
7
Dietary
1,563
12
House and Property
2,280
18
Professional
9,868
77
Totals
14,509
114
fifteen tuberculosis hospitals fall in the twenty-
five to forty-nine bed capacity group.
Closely related to the large number of small
hospitals is. the surprising number of institutions
reporting a relatively low percentage of occupancy
during the report year of the study. Of 193 gen-
eral and specialized hospitals giving this informa-
tion, sixty-two reported an occupancy of less
than 60 per cent. In the small hospital this is
due to the uneven flow of the number of daily
admissions and to the inflexibility of accommoda-
tions for care of various diseases and the varia-
tion of patients as to sex and age. Therefore, the
information reported in Table IV does not indi-
cate a surplus of hospital beds.
The data on hospital personnel by departments
as reported by 188 general and allied special hos-
pitals are summarized in Table V. These hos-
pitals with a bed complement of 12,7 60' available
beds reported a total of 14,509 personnel. This
is a ratio of 114 workers per 100 beds. While
hospitals having nursing schools and other teach-
ing programs will have a higher ratio, which
may approach two staff members per bed, it is
significant that the average Minnesota hospital
employs workers in a number more than equal
to its ‘bed capacity.
October, 1947
1063
HOSPITAL FACILITIES FOR ALE-WILSON
TABLE VI. NUMBER OI' HOSPITALS IN CATEGORIES
WITH RESPECT TO DIAGNOSTIC FACILITIES
X-ray in Hospital
Laboratory
in Hospital
Yes
No
Yes
No
General & Allied Specials.
172*
24
139*
57
Nervous & Mental
8
7
10
5
Tuberculosis & Preventoria
14
1
13
2
Chronic & Convalescent. . . .
2
126
3
125
Totals
196
158
165
189
*In hospital 140 *In hospital 107
In Dr.’s office In Dr.’s office
in same bldg.... 32 in same bldg... 32
TABLE VII. NUMBER OF HOSPITALS IN CATEGORIES
GROUPED BY YEAR OF CONSTRUCTION OF
MAJOR BUILDING
.\ umber of
Hospitals
1909 &
before
1910-
1919
1920-
1939
1940 &
after
Gen’l. & Allied
Specials
184
36
54
74
20
Nervous & Mental
15
10
2
3
—
Tbc. & Preventoria
15
—
10
5
—
Totals ....
214
46
66
82
20
The number of hospitals in various categories
without x-ray and laboratory facilities in the
building is presented in Table VI. Twenty-four
general and allied special hospitals do not have
x-ray equipment and fifty-seven of this group are
without laboratory facilities. This preliminary
study does not attempt to analyze the extent of
the equipment or service provided in the hospitals
which do have the facilities. Thirty-two of these
hospitals have the benefit of use of x-ray equip-
ment and laboratory facilities in physicians’ offices
in the same building.
Certain major features of the physical condition
of Minnesota hospitals are presented in Tables
VII and VIII. In forty-six of 214 general and
allied special, nervous and mental and tuberculosis
hospitals, the major building is thirty-seven or
more years old and another sixty-six are twenty-
seven or more years old. Of the total group of
354 general and specialized hospitals, including
those for chronic and convalescent patients, more
than three-fifths are not of fire-resistive construc-
tion and nearly one-half were not built as a hos-
pital. These figures are influenced by the rela-
tively large number of nursing homes estab-
TABLE VIII. NUMBER OF HOSPITALS IN CATEGORIES
DISTRIBUTED BY TWO CONSTRUCTION FEATURES
Fire Resistive
Construction
Built as
Hospital
Yes
No
Yes
No
General & Allied Specials.
81
115
140
56
Nervous & Mental
3
12
11
4
Tuberculosis & Preventoria
8
7
15
—
Chronic & Convalescent...
8
120
18
110
Totals
100
254
184
170
TABLE IX. CONTEMPLATED HOSPITAL BUILDING
PROJECTS IN MINNESOTA
June 1, 1947
New
Hospitals
Replace-
ments
Additions
Remodeling
Total
Gen’l & Allied Spcl..
61
38
58*
18
175
Nervous & Mental. .
9
9
Tbc. & Preventoria. .
3*
3
Chronic & Convales. .
5**
5
Totals ....
61
38
75
18
192
*Includes two nurses’ homes
**Includes three planned in conjunction with general hospitals
fished in dwelling-type buildings. However, only
eighty-one of 196 general and allied special hos-
pitals are classified as of fire-resistive construc-
tion. Also, 50 per cent of these institutions were
not built as a hospital.
Information available to the Minnesota Depart-
ment of Health on June 1, 1947, indicated a total
of 192 contemplated hospital projects in this state.
As shown in Table IX, these include sixty-one new
hospitals, thirty-eight replacements, seventy-five
additions to existing hospitals and eighteen re-
modeling projects with the majority of the plan-
ning in the general hospital category. This infor-
mation covers all sizes of institutions in the va-
rious categories as well as all proposed construc-
tion projects irregardless of the stage of develop-
ment. A number of these hospitals are under con-
struction. This information indicates a state-wide
interest in hospital construction which gives the
hope for the needed effort and funds to provide
the improvements and new hospitals which will
give reasonably adequate hospital facilities for all.
1064
Minnesota Medicine
RURAL MEDICAL SERVICE
FRANK J. HIRSCHBOECK, M.D.
Duluth, Minnesota
A S one reads current periodicals and newspa-
pers, one might gain the impression that the
physicians of this country are in league to debar
the American public from adequate medical treat-
ment. Much passion and prejudice is evinced,
and the onus of inequality of service is placed on
one profession without regard for a sane and dis-
passionate discussion of all the factors involved.
To the credit of the various rural agencies and
the participants in the conferences on rural
health held under the auspices of the American
Medical Association, one is, on the other hand,
impressed by the fair-mindedness of nearly every-
one in attendance at these meetings. It is evi-
dent that so great a problem will require consider-
able survey and analysis before satisfactory re-
sults may be obtained, and I feel it a definite
responsibility to bring this matter before you
for your consideration and review.
At the present time, I believe it cannot be
gainsaid that the type of medical service pro-
vided in the United States of America is superior
to that of any other country in the world, but
it is also admissible that there is, nevertheless,
opportunity for improvement. In a prefatory
way, it should be stated that physicians, in a
large measure, are in full sympathy with any
program tending to foster better medical care in
rural areas. The need is existent and recognized ;
the methods of correction must be explored.
Critical statements that the AMA seeks to keep
the number of medical students at a selfish low
level can be refuted by the dean of any medical
school, as has been indicated in the words of Dr.
Diehl of the University of Minnesota. The prob-
lems of medical education and its significance for
medical practice are manifold, and it should be
remembered that certain obstructive elements,
as inadequate educational facilities, lack of teach-
ers, inadequate laboratories in many instances,
and insufficient internships, all play a part.
An argument for accelerated programs in the
schools may be met by the contradiction that such
programs are not to the best advantage of the
From the Department of Internal Medicine, the Duluth Clinic,
Duluth, Minnesota.
Read at the Rural Health Conference at the annual meeting
of the Minnesota State Medical Association, Duluth, Minnesota,
July 2, 1947.
student nor the public, and may prevent participa-
tion by worthy students who may be obliged to
work for much of their education.
In the Saturday Evening Post of May 17, 1947,
an article by Albert Q. Maisel entitled SO YOU
CAN’T GET A DOCTOR accuses the AMA
and the medical schools of the country of prac-
ticing a cut-back program favoring a deficit of
physicians. He cites Dr. Victor Johnson, of the
AMA staff, appearing before the Senate Commit-
tee on Military Affairs, where it was stated that
the postwar years would require 35,000 additional
physicians to permit an adequate supply, and
that of 40,000 graduates in six years, 24,000
would be replacements for deceased physicians,
allowing only 16,000 to provide for the necessary
35,000. This statement is true insofar as it
relates to this specific factor, but the interplay
of other elements is not quoted.
There is little doubt that medical service was
o
inadequate during the war years and that ade-
quate medical care was not available to all our
citizens. On the other hand, everyone recognizes
the inevitable dislocation in all channels of life
in the greatest cataclysmic upheaval of all time.
It is admitted, I believe, that the armed forces
in enrolling 60,000 physicians, or about 45 per
cent of all those in practice, took more physicians
from civilian practice than may have been neces-
sary, but few of us would quarrel with the
exigencies entailed in a struggle for national sur-
vival. In many areas where only a few physi-
cians were in practice, the enlistment of some
caused medical hardship on the citizenry, but the
Committee of Procurement and Assignment, of
the American Medical Association, performed a
difficult duty with remarkable foresight and suc-
cess, though frustrated no doubt in many in-
stances by voluntary enlistment on the part of
patriotic physicians without due regard for area
needs, which unbalanced the per capita alignment.
In his presidential address at Atlantic City,
President Bortz of the AMA pointed out that the
medical branches of the armed forces have been
separating medical men from the services as rap-
idly as safety permitted, liberating many for the
resumption of practice.
October, 1947
1065
RURAL MEDICAL SERVICE— HIRSCHBOECK
Many medical veterans, having noted certain
advantages of the type of practice in the army
hospitals, particularly with reference to special-
ization, have been imbued with the apparent ad-
vantages of specialization in practice, and on dis-
charge have sought residencies and fellowships
to further a program for ultimate certification by
the specialty boards. Others, planning on return-
ing to general practice, and aided by Federal sub-
sidies, have undertaken graduate training to pre-
pare them more fully for a return to general prac-
tice, recognizing the fact that many aspects of
military experience were also conducive to pro-
fessional stagnation through limitation to cer-
tain types of medicine, notably among healthy
males between the ages of eighteen and forty.
Twenty thousand physicians, it is said, who have
availed themselves of such graduate training, will
in the next few years be searching for a location.
A large number of recent graduates have also
been inducted in the Army, Navy and Air Forces,
a practice which may or may not, depending on
national emergency, be abandoned in a year or
two, further allowing young men to select a site
for practice.
The proper civil reallocation of such personnel
is an immediate and urgent problem, to which the
various state committees should apply themselves.
Unfortunately, partisan expression on both
sides of any problem often leads to discord tlut
defeats the ultimate purpose in view. Proponents
of a greater supply of physicians lose sight of the
fact that an oversupply of doctors may lead to
professional stagnation because of lack of work
and opportunity, and those who believe in a re-
stricted number of graduates are not aware of
the many needs in the rural areas which involve
definite social and economic wants. Flowever,
it would seem that, in the present state of inter-
national relationships and the need of an ade-
quate medical corps, additional increments of
medical men and women are needed, and the
medical colleges should be, and we trust are,
aware of it. A large army, in peace or at war,
will by necessity remove many available men from
practice, and the additional 10,000 doctors grad-
uated during the war years by the accelerated pro-
gram are not enough to make up the deficit. Dur-
ing the war, the medical colleges were free to
admit that there was an insufficient supply of
physicians. Now that a semiemergency still
exists the need cannot have been completely
eliminated, a fact which I am glad to say our
state university has recognized by permitting an
increase in enrollment. It is to be remembered
also that there was not only a dearth of physicians
but, because of the dislocations of warfare, there
was a dearth of personnel in virtually every field
of human endeavor. Postwar adjustments will
correct many of these problems.
Much has been said about the unequal distribu-
tion of doctors in urban and rural areas. Broadly
speaking, and in a general way, there is much in
favor of the view that physicians tend to gravi-
tate to the more metropolitan areas. In years
when there is a relative deficiency in the total
number of physicians, such a migration is likely,
but many of the estimates given in current pop-
ular articles need a more critical review. As
Dr. Dickinson has indicated recently, state and
county boundaries should not be used in consid-
ering the supply of doctors because medical serv-
ice, in a great measure, bears no relation to1 gov-
ernmental boundaries. It is closely akin to trad-
ing areas and extends beyond county or even state
lines.
Before the war, the per capita distribution of
doctors in rural areas was 1 : 1,700 and in cities
1 :650. A ratio of 1 : 1,500 is, I believe, consid-
ered desirable. In rural areas the available hos-
pital beds were 2 per 1,000 instead of 3.5 or 4,
usually considered adequate in a community.
The per capita difference in cities and rural areas
is due to several factors aside from mere choice
of location. Cognizance must be taken of the
fact that the cities are not overwhelmingly sup-
plied with physicians, since many city physicians
are specialists. In Duluth, for example, nearly
50 per cent are specialists who tend to attract
patients from more remote communities. Many
specialists in the cities likewise are not related
intimately to family practice and are engaged in
special types of work such as public health, roent-
genology, pathology, research work and teaching.
On the other hand, many men who are special-
ists perform some elements of general practice,
leading to dilution of practice among the general
practitioners, and the law of supply and demand,
as in other occupations, tends to prevent over-
saturation. Nevertheless, I think it is evident that
until saturation occurs in the metropolitan areas,
rural areas will find it difficult to maintain an
optimal supply of medical personnel.
1066
Minnesota Medicine
RURAL MEDICAL SERVICE— HIRSCHBQECK
In his article, Maisel writes of certain states
and counties having a sad dearth of physicians
but doesn’t discuss any of the qualifying elements
which must prevail in such localities, because phy-
sicians, like everyone else, tend to locate in areas
where their services are likely to be needed and
where they are likely^ to receive adequate compen-
sation for their efforts. I do not know the sit-
uation in the counties in Florida, Virginia and
South Dakota, in which he states there is great
lack of medical care, but I do know something
of our own state as an index. In a recent letter
to the American Medical Association Bureau of
Information, Mr. Rosell, the executive secretary
of the Minnesota State Medical Association, stat-
ed our situation as follows :
“As to physicians’ distribution, Minnesota is quite
well provided for, as far as medical service is con-
cerned. There are no areas in the state at the present
time where physician needs are distressing. In most
areas there are physicians within a radius of twenty
miles, and there are no areas at present where one
must travel much farther for medical service. At the
present time, there are 1,000 physicians, mostly returned
medical officers, who are training in Minnesota, i.e.,
doing graduate work or taking continuation courses, res-
idencies or fellowships. These men will be released
beginning July 1 and for the next two years. We
presume that at least 50 per cent of these men will
remain in this state and will meet whatever urgent de-
mands there are for more physicians.”
Seven counties in our state have less than one
physician per 3,000 people, using the per capita
rate as an example, mostly in the northwestern
part of the state where five or six good clinical
centers exist which may tend to reduce the prac-
tice of local physicians. Mr. Rosell reports that
the Minnesota State Medical Association has had
twenty requests for general practitioners in the
state of Minnesota, eleven of which have come
from areas of less than 500 inhabitants and some
of which, according to personal information re-
ceived, have no need of a physician in the area
as they are well supplied as a community.
Though the problem may not be so acute in
Minnesota, and will very likely be less so in a
few years, it would be provincial to deny that
medical facilities are not always easily attainable
in other states, particularly in -the West and
South. Areas where there is a sparseness in
population, or lack of contact with other physi-
cians and medical centers, as is the case in many
October, 1947
regions in the northwest, central and Rocky Moun-
tain states, would almost of necessity have less
attraction as a choice of location for doctors.
These states also have proportionately fewer
medical schools to supply needed physicians in the
areas. There are only five medical schools in the
vast area of the western plain and Rocky Moun-
tain states. It is well known that graduates
from medical schools tend to locate largely in
areas contiguous to their alma mater. Also it
would seem that there should be more opportunity
for the medical education of negroes, particularly
for the South, where -they are an important part
of the population.
Every well-meaning student of the problem
must realize that the difficulty in providing suit-
able medical care in rural areas evolves not only
upon the dearth of physicians but upon local
factors as well. It is stimulating to note the ef-
forts that are being made in various states to-
find ways and means of solving the problem of
proper medical care, which can be done only by a
consideration of all factors concerned.
Mr. Goss of the National Grange has offered
several fundamental statements indicating the
need of community programs, and one cannot
find fault with his conclusions. He points out the
need of additional physicians and hospital beds
in many of our rural communities. It is also
stressed that, though conditions have improved
among farmers in regard to income in recent
years, financial necessity still precludes the farm-
ers’ paying as much for medical service as other
classes of workers and, in many cases, -often
where there is a sparseness of population and a
lack of good arable land, it is relatively impos-
sible. Conceivably there may be a few areas
where adequate medical care may be impossible
also, because of local conditions. To apply gen-
eral rules to all areas to conform with the needs
of such isolated instances would be unsound
economics.
Mr. Goss also points out the need of better
health measures in rural communities, based on
the increased accident rate among farm workers,
the increased infant and maternal mortality rate,
and the rejection of 41 per cent of farm boys in
the Selective Service as compared to 25 per cent
in urban areas, purely on physical defects.
Wherever the fault may lie, these figures at least
indicate that the preservation of health and life
is better maintained in urban areas, but rural
1067
RURAL MEDICAL SERVICE— HIRSCHBOECK
communities, as has been stated by many, today
need more than doctors in order to solve their
problems. The latter are social and economic, as
well as professional. In order to improve his skill
and supply stimulus for good work, the physi-
cian would choose to live in a community where
good housing facilities, good social and educa-
tional relationships, good health education, good
sanitation, modern living advantages, adequate
laboratory and x-ray facilities, hospital and con-
sultation advantages are available. Otherwise he
would serve poorly. These advantages are avail-
able in many rural areas and towns, but it is in
the smaller and more isolated communities where
the lack of adequate medical facilities is encoun-
tered.
Each community must survey its own problem
by a communion of advisory talent, i.e., by health
councils as advocated by Rural Medical Service
Committees, which should include local represent-
atives, financial advisors, physicians, health au-
thorities, hospital administrators, medical society
representatives of the county and state, nurses
and dentists. This is quite in contrast to a recent
health workshop where twenty-one consultants
were called in, nineteen of whom were Federal
and two state employes !
In isolated areas, where few towns are situated,
the problem of individual care may be difficult
and even impossible of solution. This is apparent
to any of us. Physicians might be induced to
locate in sucb a community if a subsidy were
provided, but this would still not answer the need
for professional contact with other doctors, with
diagnostic centers and hospital facilities. At best,
such physicians could render only relatively in-
adequate medical service.
Probably too much has been said about the
doctors and not enough thought given to their
■waves and children, who are, as members of a
professional group, more critical of social inade-
quacies. Also in such areas public health and
first aid services would be of help, as they have
proved in urban areas. To facilitate better care in
such outlying and sparsely settled districts, good
roads are essential and satisfactory transporta-
tion facilities of great importance. It is frequently
more important to bring the patient to the doctor
in an organized hospital than to try to bring a
doctor to the patient. Ambulance service could
be on a wide community basis and staffed by some-
one skilled in first aid. More seriously sick and in-
jured patients requiring ambulance service usually
need the type of treatment only a hospital can
supply. After the initial outlay, the cost of
maintenance should be relatively small.
The construction of rural health centers, as ad-
vance stations in medical care, is desirable. They
are as necessary to a community as schools. They
would be of educational and therapeutic value.
In some areas on the borderline of economic
balance, physicians might be supplied with of-
fice space and equipped with an available bed for
temporary but necessary care and observation,
pending further disposition. A method of par-
tial subsidy might be invoked.
In such locations, if physician service is to be
maintained, the physicians must be patronized.
In many areas, sick people tend to by-pass their
own community physicians and go to doctors in
a more remote location, and physicians in smaller
towns frequently complain of a lack of loyalty
among their clientele. I think this may be illus-
trated by again referring to the six counties in
the northwestern part of the state where there is
a low per capita rate of physicians and where it
is likely that patients tend to go to the trading
areas where clinics exist for their medical care.
I think this must be an important factor in this
region in view of its noted fertility and financial
competence.
Many areas need better hospital service, and,
on the other hand, many are well supplied. When
the Hill-Burton Act begins to function it is going
to be difficult to separate the communities which
have adequate hospital service, sometimes pri-
vately owned, from those where it is felt that such
service may not be adequate. It is certain that
only an impartial, unprejudiced analysis for al-
location of any funds derived from the Act
will be satisfactory. Such an analysis will have
to consider state needs, county needs, local needs,
transportation facilities, opportunities for con-
sultation and study by the physician, availability
of certain specialists and financial responsibility.
Dr. Buerlce, at the National Conference, stated
that the operation of a hospital entails a yearly
maintenance cost approximating one-third of the
original outlay. This money will have to be
forthcoming from hospital operation and/or local
taxation because niggardly administration in the
operation of a hospital cannot be countenanced.
Local responsibilities, as can be seen, are indeed
heavy.
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RURAL MEDICAL SERVICE— HIRSCHBOECK
The other necessity to any arrangement is a
sufficient supply of medical personnel. Let us
admit that more doctors are needed for the care
of our rural population. I believe that strongly,
especially in this period of semiemergency. The
medical colleges, as for example the University
of Minnesota, should graduate more students, at
least for the present. Control may be practiced
later if necessary. Students should be selected
from the more isolated areas in greater numbers
than is the case at present. Where possible, col-
leges supplying the South and mountain and plain
states should be enlarged, and more applicants
for medical education accepted from such areas,
in the hope they will return to their native state.
It has been suggested that some rural areas might
be wise to enter a contractual relationship with
local students of promise to enable them to study
medicine with the provision that they locate in
certain towns. From time to time, replacements
could be made by more recent graduates working
on a similar plan.
I think it would be expedient to consider re-
quirements for placing recent graduates in general
practice for three years or so before obtaining
residencies. The objection would be raised that
men who have an aptitude for research and
teaching would be wasting valuable years in such
work, but a system of scholarship reward could
be made available to obviate insistence on this
requirement in their cases. It might, however, be
pointed out that even many research men and
teachers might profit by contact with actual prac-
tice, and there is no doubt in my mind that spe-
cialists, who are not teachers or research men,
could profit by experience in general practice. The
opportunity for reaping the many admitted bene-
fits of small town practice might offset the de-
sire for specialization. Specialty boards could al-
low certain credits for such experience, as was
done in the case of military service. There is also
an advantage possibly in creating a residency for
men who might choose to specialize in general
practice, if one may be permitted to use a Celti-
cism.
It is felt that there are too many specialists be-
ing trained. This is probably currently true be-
cause of the demand of the returned medical
veterans, who have been led toward specialties
because of the financial and ranking emoluments
incident to their service. Medical men are pro-
fessionally ambitious and tend to seek the profes-
sional glamor of specialism, a will-o’-the-wisp
which is not always realized. Dr. Weaver, in his
recent report before the Committee of University
Relations, stated, however, that there is a trend
toward favoring general practice in recent classes.
Up to 1946, 80 per cent of the students indicated
a preference for specialization, but in the present
class, only 50 per cent indicated such a desire. I
believe that if medical students were taught the
many undeniable advantages of practice in small-
er communities they would be prompted to choose
such locations more frequently. Discussions by
men in rural practice before the undergraduates
would be helpful and influential.
In rural areas, on the other hand, where hos-
pitals are located with care, specialists’ consulta-
tions should be made available to general prac-
titioners. These hospitals should be uniformly
open to all general practitioners, but certain limi-
tations according to the capacity should be placed
on staff members for the benefit of the public.
Like any other professional group, the adminis-
tration personnel should be specially trained, and
schools are now available for this purpose. Such
administrators are most competent to help in the
selection of material for the physical operation
of the hospital, including medical equipment.
Physicians who locate in smaller communities
should have an opportunity for graduate work
and refresher courses, because the lack of such
facilities would not be to the advantage of either
the medical man or the people who' employ him.
Since the cost of medical care is an important
problem, a summary of projected plans might be
considered. By and large, feeling among doctors
and among most consumers is that the method of
payment by government taxation to supply the
costs is not suited to American methods. It would
be platitudinous and out of place in this discus-
sion to enumerate the various ethical, economic
and social reasons which impel doctors to be out
of sympathy with such a plan involving a huge
bureaucratic control, enormous outlay of funds
out of proportion to need therefor, or the results
obtainable, and the degradation of professional
standards affecting all the phases of practice.
Nor are doctors kindly disposed toward the
belief that consumer control on a prepayment
basis is a satisfactory method, as it is felt that
good medical care can only exist with the pro-
fession unhampered by restriction imposed on
them by lay people whose viewpoint is necessarily
October, 1947
1069
RURAL MEDICAL SERVICE— HIRSCHBOECK
based on economic consideration rather than on
professional standards.
This leaves for evaluation, then, methods of
prepayment which will permit of free choice of
physician and leave the methods of ethical prac-
tice in the hands of those who, by tradition and
training, are best able to judge of the safest
method of practice for the common good. Meth-
ods of prepaid medical care have been in ex-
istence for over sixty years. The more recent
impetus supplied by the Blue Cross Hospital Plan,
with its tremendously successful program, has
brought forward the question of a plan to sup-
ply medical care as well, at a rate commensurate
with the schedule of the Blue Cross. The addi-
tional farm income of recent years has made it
possible to foster ideas, in this respect, for the
rural communities. Physicians in most states, in-
cluding Minnesota, have developed similar plans
which already are or will soon be functioning.
Since each state, or even community, has dif-
ferent problems, some flexibility in application
will be necessary. The potential subscribers need
to be instructed in regard to the insurance plans
to assure popular acceptance. This is a necessity
for its satisfactory operation. Such an organ al-
ready exists through the agency of the Blue
Cross, which in this state has been employed as
sales agents for this program. To work effective-
ly, it needs extensive support, both in the urban
and rural areas, so that the two zones may coun-
terbalance each other in regard to various dif-
ferences which may arise.
Low-income groups may have to be supported
by the tax structure. The plan being launched
in this state has been displayed at this meeting
and it is hoped that you have acquainted yourself
with the details of its operation.
As the popularity of the program expands, the
benefits and costs will have to be changed to
meet the situation. One of the chief difficulties
will be the production of a wide sale of policies
throughout the state so as to allow good actuarial
appraisal and satisfactory operation. It is cer-
tainly as important to insure for health as it is
to insure against financial loss from fire, automo-
bile accident or crop failure.
In summary, therefore, I wish to point out that
the problem of rural service is not one that is
restricted to the community nor to the medical
profession, but it is one which requires a most
careful survey of each community and its needs.
Scarcities in one community may not apply to an-
other, and conclusions based on individual and
specific interpretations of factors may be delusive.
The medical profession has certain responsibil-
ities, and administrative agencies, like the AMA,
medical colleges and the American Hospital As-
sociation, have a great responsibility. On the
other hand, there is an equal responsibility which
is local. It seems to me that at this time the local
responsibility is actually the more difficult prob-
lem to surmount.
A SOUND PUBLIC HEALTH PROGRAM
(Continued from Page 1053)
for the common benefit of all, including as power-
ful associates, labor, co-operatives, management,
the press, the churches and the schools.
Let me repeat that the purpose of a sound local
public health program is such social action as
will bring the richest values and longest enjoy-
ment of life which the inherited qualities of
each of us makes possible.
Local government is the instrument created by
a free and representative democracy to make pos-
sible effective social progress which will be best
measured by the health status of our people.
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Minnesota Medicine
History of Medicine In Minnesota
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester. Minnesota
(Continued from. September issue)
Walter Earl Richardson was born on July 15, 1872, at Elgin, Minnesota,
son of Joseph Richardson and Ursula Miles Richardson, “Yankee farm-
ers,” both natives of Vermont, who in 1858 had come as pioneer settlers to
Wabasha County, Minnesota. Of the seven children of Mr. and Mrs, Joseph
Richardson there were living in 1943 Walter E. Richardson, M.D., of Rush-
ford, and Frank, Lenora (Mrs. Filkins) and Clara (Mrs. Ellsbury), all of
Elgin, Minnesota.
After completing his preliminary education in the schools of Elgin and
by extension work from business and normal schools, Walter E. Richard-
son studied medicine in 1892 and 1893 under the preceptorship of Dr. Frank-
lin Staples and Dr. Edward D. Keyes, of Winona, in preparation for enrolling
at Rush Medical College in Chicago. On his graduation from Rush in 1896
Dr. Richardson began to follow his profession in Preston, Fillmore County.
He was licensed in Minnesota by examination on June 22, 1899, and in 1900
he moved from Preston to Slayton, in Murray County, where for nineteen
years he conducted his own hospital and carried on a general medical and
surgical practice ; from 1919 to 1931 he was in Pipestone, in Pipestone County,
and from 1931 to 1938 at Philip, South Dakota. In 1938 Dr. Richardson re-
turned to Minnesota, to settle in Rushford, Fillmore County.
Always especially interested in ophthalmology, otology, rhinology and
laryngology, Dr. Richardson in 1912 took postgraduate work in these special
fields at the Chicago Policlinic and at the Chicago Eye, Ear, Nose and
Throat College and Hospital in 1918. In Rushford, with offices in his resi-
dence and with the facilities of the Winona General Hospital available to
him, he has been in general practice, placing special emphasis on the diagnosis
and treatment of diseases of the eye, ear, nose and throat.
During World War I Dr. Richardson was a captain in the Medical Corps
of the United States Army, attached to Base Hospital No. 99, American
Expeditionary Forces. He is a member of the Olmsted-Houston-Fillmore-
Dodge County Medical Society, the Minnesota State Medical Association and
the American Medical Association, attends the Presbyterian Church and
is a member of all Masonic bodies. When questioned as to his favorite hobby,
Dr. Richardson wrote, “My family.”
Walter E. Richardson was married on June 18, 1902, to Fatima Whitney,
of Slayton, Minnesota. The four children of Dr. and Mrs. Richardson are
October, 1947
1071
HISTORY OF MEDICINE IN MINNESOTA
Ursula (Mrs. F. C. Eustis, of Williams Bay, Wisconsin) ; Walter Whitney,
a high school superintendent at Jeffers, Minnesota; William H., formerly a
high school instructor, now with the American Red Cross ; and Robert J.
Richardson, M.D., who in 1939 on his graduation from the Medical School
of the University of Minnesota, joined his father in practice at Rushford.
Since the beginning of World War II Dr. R. J. Richardson has been in the
Medical Corps of the United States Army; in August, 1941, he received his
commission as lieutenant and thereafter he took training at Carlisle, Pennsyl-
vania; in September, 1942, he was promoted to captain at Fort Leonard Wood,
Missouri.
Calvin Hubbard Robbins was born in St. Lawrence County, New York,
on December 20, 1840, the son of Marcus Robbins and Fanny Hubbard Rob-
bins, American citizens of English descent. Marcus Robbins, a native of
Wadsborough, Vermont, was a farmer and dealer in real estate and at dif-
ferent times he served as postmaster at Massena, New York, and as customs
clerk at Ogdensburg; his grandfather was Dr. Marcus Robbins, of Brattle-
boro, Vermont, and one of his earlier forebears was George Read, a signer
of the Declaration of Independence. Fanny Hubbard was born at Massena,
New York, and became a teacher; she was a descendant of Theophilus Eaton,
the first governor of Connecticut. Mr. and Mrs. Marcus Robbins were the
parents of five children: Marcus, Frederick, Herbert, Hortense and Calvin.
In 1859 Marcus and Fanny Robbins came with their children to southern
Minnesota, to settle in Fillmore Township of Fillmore County. Their son
Calvin, who had begun his education in the public schools of Norfolk, New
York, continued his studies at Fillmore and Chatfield, completing the avail-
able courses, and for a year or two after finishing his academic schooling he
taught in the rural schools of the community before entering on three years
of medical study in the office of Dr. Luke Miller, of Chatfield.
Calvin Robbins’ medical study was interrupted by his enlistment in the
Fifth Minnesota Volunteer Regiment for service in the Civil War. There
exist two handwritten memoranda over the signature of Oscar Malmros,
Adjutant General during the administration of Governor Alexander Ramsey,
of which the first, dated at the Adjutant General’s Office, Saint Paul, on
October 15, 1863, notified Calvin H. Robbins as follows: “The Governor hav-
ing appointed you Lieutent-Colonel [sic] of the 5th Reg. M. S. M. your
Commission will be countersigned and immediately forwarded upon your
subscribing the enclosed oath of office, and filing the same in this office.”
The second memorandum, Special Orders No. 135, dated on October 29,
1863, read thus: “The resignation of First Lieutenant [sic; no doubt correct]
Calvin H. Robbins the 5th Reg. M. S. M. is accepted to enable him to
accept a field office in the Regiment, said resignation to take effect from the
26th day of October, 1863.” As it happened, he was taken ill en route to join
his regiment and was released from military duty, his certificate of release
being signed by Dr. W. W. Mayo, of Rochester, surgeon on the Board of
Enrollment of the First Congressional District of Minnesota.
In October, 1864, within a year of his release from the army, Calvin Robbins
enrolled at the Medical School of the University of Michigan, in Ann Arbor;
in November of 1865, however, he transferred from Ann Arbor to the Medical
College of Keokuk (Iowa), sometimes, as early as 1884, designated “The
Medical Department of the University of Iowa,” from which he was gradu-
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HISTORY OF MEDICINE IN MINNESOTA
ated in 1866. Long afterward, there was found among his effects a copy
of the twenty-third annual announcement of Rush Medical College, for
1865-1866, perhaps evidence that he had considered matriculation at that
school in his final year. At Keokuk his preceptor was Professor E. J.
Gillett, M.D., D.D. ; the title of his final thesis was “Acute Rheumatism.”
At that time, in some of the medical schools, and the Medical College of
Keokuk was one of them, the faculty determined by vote which students
should be graduated, the decision being based partly on the students’ scho-
lastic records. Only two in Dr. Robbins’ class received more votes than he,
and they were men who had had five years of combined training and actual
medical practice when they entered the college.
In the year of his graduation, 1866, Dr. Robbins began the practice of medi-
cine in the village of Fillmore and became a charter member of the Fill-
more County Medical Society, which was organized in October of that year.
In November of the same year he was married to Rosalia R. Mosher, a
teacher, formerly of Canton, New York. In Fillmore Village Dr. and Mrs.
Robbins made their home for the ensuing nine years. Their five children,
all natives of Fillmore County, were Hortense R., Marcus P., Fanny E.,
Gertrude A., and Calvin Eaton.
Although surgery was his preferred field, Dr. Robbins’ practice was nec-
essarily general. In 1870 his professional card in Western Progress, pub-
lished in Spring Valley, announced him as physician and surgeon. And
that he endorsed vaccination against smallpox is evident from a Fillmore
news item in the same newspaper in March, 1873: “We had a little flurry
about smallpox a few days ago, but we guess the danger is past. ‘Call’ [sic]
has been around jabbing his knife into folks generally.” Of his activities,
professional and nonprofessional, an extract from his diary of 1874 gives
various testimony :*
Jan. 17 Operated for cancer on .
Feb. 9 Gave chloroform to : for Kellogg.**
Feb. 23 Subscribed for Harper’s Magazine.
Mar. 2 Started the supervisor’s report in the evening.
Mar. 10 Attended election. Got 108 votes to D. H. Hoff’s 44 for chairman Board of
County Commissioners.
April 7 Bought 4j4 cords of wood of Marve Eggleston @ $3.25 a cord.
April 9 Got 20 bushels of oats @ $.40 — 8.00. The boys went after horse thieves in the
evening.
April 14 Went to ’s to attend his wife. Head and arm presentation. Every-
thing all right.
April 24 Received $3.00 from town for fees as supervisor.
April 26 Got pint of Female tonic for ’s wife (at Wykoff).
May 21 Met Dr. Ross [John A. Ross, of Preston] at ’s and performed a
craniotomy on child to deliver the woman.
June 2 Met on town board to view the bridge. Resolved to build a new one.
Tune 12 Met on town board. Gave job to build bridge to H. B. Stewart for $174.
June 23 Went to Spring Valley and bought P. O. order for the New York Sun.
In 1875 Dr. Robbins moved from Fillmore to Wykoff, a larger village a
few miles north in the same township, on 4 he railroad and then in the period
of its greatest prosperity, and there in the next twenty years his interests
*The names of patients have been deleted by the writer.
**Evidence has not been found that a Dr. Kellogg resided in the county. This perhaps was Dr. D. W.
Kellogg, surgeon-dentist of Decorah, Iowa, who at intervals made professional trips to Preston and other
points in the county; “all work done in the most skillful and artistic manner.”
October, 1947
1073
HISTORY OF MEDICINE IN MINNESOTA
of all types continued to widen. In Wykoff he owned his home, as he always
did wherever he lived, and in addition to his practice operated a drugstore;
in later years he was certified as a registered pharmacist. After 1878, when
Dr. James H. Phillips settled in the village, Dr. Robbins took the younger
man into partnership with him in the drug store and in general practice, an
association which continued until Dr. Phillips removed to Preston in the
early eighties.
In 1871, while in Fillmore, Dr. Robbins had become a member of the
Minnesota State Medical Society; in 1874 he was one of the seventeen physi-
cians in the state who responded to the request of the Committee on Practical
Medicine regarding the effect of the climate of the Northwest on asthma, and
he “reported two cases not affected by ten years’ residence.” In succeeding
years he was appointed a member of the Committee on Finance in 1879, and
of the Committee on Obstetrics in 1883. After the passage of the act of
1883 to regulate medical practice in the state, Dr. Robbins received certificate
No. 550 (R) given on December 31, 1884. And also during the period of the
eighties (1886 and later) he was a member, with Dr. J. II. Phillips and Dr.
G. A. Love, of the board of examining surgeons for the Bureau of Pensions
of Fillmore County.
A good citizen, friendly and well-disposed, he served the community in
various civil capacities. Politically he was at first a Democrat-Republican,
but later became a staunch Republican and as such, on one occasion, served
as chairman of the Fillmore County Republican Convention. In the early
seventies he was a member of the Board of County Commissioners and of
the “town board.” In 1876 he was elected a representative from his district
to the state legislature. Ide was a member of the Methodist Church and of
several fraternal organizations, among them the Masons (A. F. and A. M.),
Independent Order of Odd Fellows and the Benevolent and Protective
Order of Elks.
In those years of long country drives Dr. Robbins owned a number of
horses in which he took great pride, blooded Morgans, superior lightweight
American-bred animals that were noted for their speed and endurance on
the road. The ability to drive widely through the countryside not only ex-
tended his professional interests but also furthered his most absorbing avo-
cation, the study of geology, especially paleontology. In a territory that has
been well called a geologist’s paradise, he was enabled to observe interesting
formations and to collect fossils, and so intelligent was his research that in
the nineties it brought his name into the section on paleontology of the of-
ficial geological and natural history survey of Minnesota, conducted by the
University of Minnesota. When Newton FI. Winched, State Geologist, and
his colaborers, Wilbur FI. Scofield, Edward O. Ulrich, Tohn M. Clarke and
Charles Schuchert, in carrying on the survey of the lower Silurian deposits
of the Upper Mississippi Province, were in the locality of Wykoff, they
received unfailing courtesy and much practical help from Dr. Robbins. From
his private collection he lent them rare and unsurpassed specimens of various
fossil Crustacea, and in his honor they gave the name Platymetopus robbinsi to a
genus of trilobite found in the middle beds of Galena limestone and the name
Trochonema (Eunema) robbinsi to a genus of gastropod discovered in the Fusi-
spera bed, both sites near Wykoff. Mr. Schuchert, furthermore, in the spring
of 1892 took some of Dr. Robbins’ collection east with him for the Peabody
Museum of Yale LTniversity. Many of Dr. Robbins’ rare specimens are now
1074
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
in the possession of his grandson, Richard Robbins Crandall, of La Canada,
California, a geologist and an alumnus of Leland Stanford University.
In 1895, temporarily discontinuing the practice of medicine, Dr. Robbins
moved to Spencer, Iowa, where for two years he owned and managed the Spencer
Reporter , taking especial pleasure in writing political articles for publication in
that paper. By 1898 he had left the newspaper field and had settled in Austin,
Mower County, where he again successfully followed his profession of medi-
cine and where he was known as “a gentle and courteous physician of the old
school.”
Dr. Robbins died in Austin on February 28, 1900, from angina pectoris.
His brother Marcus, of Grants Pass, Oregon, and his sister Hortense (Mrs.
McKinney), of Chicago, had died previously; his brothers, Herbert, of Oak-
land, and Frederick, of Pomona, California, lived more than thirty years
after him. Mrs. Robbins survived nearly forty years; she died on July 19,
1939, at the home of her daughter, Mrs. S. C. Schmitt, of Los Angeles. In
1943 two of the five children were living: Fanny, wife of Dr. Samuel C.
Schmitt, of Los Angeles (Fanny Robinson Schmitt died on September 21,
1943) ; and Calvin Eaton, a salesman, of Berkeley, California. Those de-
ceased were Marcus ; Hortense, who at the time of her death was principal of
the high school at Marshall, Minnesota ; and Gertrude, wife of Dr. W. G.
Crandall, a dentist of Los Angeles.
In the collections of his daughter, with whom historical and genealogical
research was an avocation, are objects of more than casual interest relating
particularly to Dr. Robbins’ early medical and surgical practice, among them
his surgical instruments, his roll of obstetrical instruments, and his old for-
ceps for extracting teeth, fob like most physicians of the day he was on occa-
sion dentist as well as physician. Among his papers are two of his internal
revenue licenses to sell tobacco, issued at Mankato, one on May 1, 1866, and
one on April 28, 1888, and worthy of note, his diaries, full of information.
John Angus Ross, a native of Scotland, was born in Ross Shire, the Hebrides
Islands, on June 14, 1841. His mother was twice married. Of the first mar-
riage, to Mr. Frazier, there were two children, a son Dan and a daughter
Ann ; of the second marriage, to Mr. Ross, three daughters, Lexie, Isabel
and Jessie, and one son, John Angus.
John A. Ross received his early training near home and his formal educa-
tion in medicine and related sciences at the Universities of Glasgow and Edin-
burgh, from one of which he was graduated in medicine and chemistry. Of
his coming to the United States little is known except that he first was
established in Atlanta, Georgia, perhaps having landed at Savannah, and
that he undoubtedly was the bearer of letters of introduction which gave him
entree to the long-established homes of Atlanta, including that of the gover-
nor of the state, whose daughter was gracious to the young Scotch physician.
Dr. Ross arrived in the South in the troubled period just before the outbreak
of the Civil War and when the crisis came he served the Confederate cause
in one of the military hospitals. Shortly after the close of the war he left
the South for the Middle West and in Chicago continued his scientific study
at Rush Medical College.
The coming of Dr. Ross to Preston, Fillmore County, in early October,
1869, is of itself an interesting story. Dr. LaFayette Redmon and Dr. O. A.
Case, the established physicians of the village, in the course of changing con-
October. 1947
1075
HISTORY OF MEDICINE IN MINNESOTA
ditions of practice found it expedient to improve their professional knowl-
edge— so runs the reminiscence of one who knew the circumstances well —
and were about to go back to school. A request to Rush Medical College to
send Preston a first-class physician was answered by the arrival of Dr.
John A. Ross. Educated in the best medical schools of Britain and America;
tall and fine looking, with clear blue-gray eyes, wavy brown hair brushed
back from the temples and up from the broad forehead, a mustache and a
small flowing beard, narrow and short, that did not conceal the strong lines
of the jaw; carefully groomed, and dressed in the formal costume he always
affected : a fine broadcloth suit with velvet vest and double-breasted coat
and a deep-bosomed white shirt, worn with three studs, stiff collar and dark
tie; wearing a high hat and carrying a beautiful mahogany cane, Dr. Ross
was a new type in the settlement that was made up for the most part of
rugged pioneers. His cane, presented by fellow physicians in Chicago at
a banquet given in his honor just before his departure for Minnesota, had an
ivory handle and bore a gold band that was inscribed in commemoration of
the occasion and in token of his excellent scholastic record. Perhaps the form
of the gift was inspired by the tradition of the gold-headed cane of Dr. John
Radcliffe (1650-1714) ; perhaps a cane was merely the currently favored
accessory of a dignified young physician accustomed to urban life.
In Preston Dr. Ross was well received. From the first the many Scotch
settlers in the community “loved him to death and would not let him leave,”
and he soon won the confidence of all, regardless of nationality or religious
belief. The parish priest within a short time instructed his parishioners to
call only Dr. Ross, for the reason, again a comment in reminiscent vein, that
certain other physicians made mistakes as to their patients’ tenure of life
and caused the priest to administer extreme unction unnecessarily. Dr. Ross,
skilled in diagnosis and prognosis, made few errors. If he considered that
there was hope of pulling a patient through, he would not leave until the
outcome was sure, remaining several days if necessary; if he was convinced
that the case was hopeless, he would not waste time but would go on to
some one who could be helped, and it is remembered that his judgment was
sound and that it was honored.
On May 3, 1869, before Dr. O. A. Case had gone to further his medical
education, as has been told, Dr. Case and a few other local practitioners
organized the Fillmore County Eclectic Medical Society in Preston, and of
this group Dr. Ross soon after his arrival became an active member. For
several years he was its secretary and in 1876 served as vice president ; by
that time the activities of the society were dwindling and soon after the asso-
ciation disbanded. There is no reason to wonder why a man of Dr. Ross’s
training at the medical schools of Glasgow, Edinburgh and Rush and there-
fore ostensibly of the regular school of medical thought, should have allied
himself with an eclectic medical group, especially when the Fillmore County
Medical Society, founded in 1866, was functioning.
In the interest of his profession Dr. Ross, in addition to identifying himself
with medical organization, early began his life-long custom of writing for
medical journals and also acted as preceptor. In 1870 he took into his office
as a student, George A. Fove, who was preparing for matriculation at the
Bennett Eclectic College of Medicine and Surgery in Chicago. There is an
interesting note from the Preston Republican of May 30, 1873, that Dr. Ross,
assisted by Dr. H. Jones, in the presence of Mr. Fove, a medical student,
1076
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
performed a postmortem examination; an infant daughter of local people
had died of cerebrospinal meningitis. “The facts disclosed by the postmortem
examination warrant us in saying that the parents, by overcoming the usual
prejudice, did the public and medical profession a great service by permitting
it to be done.” In 1874, when Dr. Love was graduated, he returned to join
Dr. Ross, as stated previously, in a partnership that was to last two years.
The following card appeared in the Fillmore County Republican of January 8,
1875:
Ross and Love, Physicians and Surgeons, Preston, Minnesota.
Office on Main Street Just in rear of post office.
Open day and night. All calls promptly attended to.
Dr. Ross took a friendly as well as a professional interest in his community,
entering into social and civic activities and joining fraternal organizations,
among them the Masons (A. F. and A. M., Royal Arch Chapter No. 32) and
the Independent Order of Odd Fellows.
The life of this well-endowed physician of great promise was tragically
short. In 1877, after two years of disability and suffering from heart disease,
Dr. Ross died in Preston at the early age of thirty-six years, leaving his young
wife; there were no children. He had been married two years previously,
on March 5, 1875, after a romantic courtship, to Julia Ann Kaercher, the
daughter of John Kaercher, a leading citizen of Fillmore County, in Fillmore,
Chatfield, Preston and Clear .Grit (which he founded). In later years Julia
Kaercher Ross was married to Mr. Dibble ; there were two children of the
marriage, Sarah and Arthur, of whom the latter became a lawyer. After
the death of her second husband she was married to Dr. Hickman. Of the
third marriage there were four children; a son, Beryl, who died in infancy,
and three daughters, Lola, Rachel and Ruth. Ruth Hickman Campbell has
named her son John Angus, in honor of John Angus Ross.
In the histories of Fillmore county published in 1882 and 1912, tribute was
paid to Dr. Ross as an esteemed and valuable citizen of Preston who was
known for his kindness and liberality. “He was honest, plain-spoken, open-
handed and just.”
(To be continued in November issue )
October, 1947
1077
President s £ette\.
LOCAL HEART ASSOCIATIONS
Until June of this year, the American Heart Association was an organization composed of
physicians whose chief purpose was the study and dissemination of knowledge among physi-
cians concerning the science of cardiology and the treatment of cardiovascular disease. It had
conducted an annual scientific meeting each year in conjunction with the American Medical
Association and had published The American Heart Journal. During recent years it had
become apparent to the officials of this organization that the problem of diseases of the
heart and blood vessels must be attacked on a much greater scale and, finally, at meetings
at the various local heart associations, then established, in San Francisco in June, 1946, it
was decided to enlarge the aims of the American Heart Association greatly and to revise its
administrative structure completely. A committee was authorized to prepare a new consti-
tution and to present it to the Board of Directors at the meeting of the American Heart
Association which was to be held in Atlantic City in June, 1947.
When the American Heart Association met this year, the new constitution and by-laws
were adopted. Now, the governing board of the American Heart Association is known as
the “Assembly” and it consists of not more than 150 members. Of this number, not more
than half may be individuals who are not physicians. It is provided that for purposes of
representation the United States and Canada will be divided into six geographic regions and
seventy-five members of the Assembly will be chosen “on a regional basis.” Members of the
Assembly who are physicians and members who are not physicians will have an equal voice
when policies of the Association are being determined. Groups of physicians interested in
special phases of cardiovascular disease, such as peripheral vascular disease, hypertension and
arteriosclerosis, will be accorded representation in the Assembly. For example, it is provided
that five members of the Assembly shall be elected by the American Council on Rheumatic
Fever.
In order to implement the activities of the national body, it was decided that local heart
associations should be formed throughout the country as rapidly as possible. The American
Heart Association prefers that these local units be organized on a statewide basis and that
subdivisions be created in each state in accordance with existing facilities and needs. Many
such local heart associations are being formed throughout the country and hereafter mem-
bership in the American Heart Association will be obtained through membership in the local
heart associations.
The over-all objective of the American Heart Association is to mobilize all resources, on a
national scale, in an attempt to combat diseases of the heart and blood vessels more effectively.
In order to accomplish this purpose, the national organization formulated certain definite
plans. The public must be educated concerning the prevalence of diseases of the heart and
blood vessels. It must be informed concerning prevention of heart disease and concerning
the treatment and management of those who become its victims. It must know enough about
the symptoms of heart disease to be able to consult physicians early. Research must be fos-
1078
Minnesota Medicine
tered, and in order to sponsor research money is needed. A tragically small amount has been
spent heretofore in research. Because of the need for money to accomplish the plans includ-
ing the promotion of research, it is proposed that a national campaign for funds will be
made during the week of Saint Valentine’s Day in February, 1948. That week of each year
will be designated as “Heart Week” and during it nationwide publicity will be sought through
the radio, newspapers, magazines, motion pictures and other publicity mediums. The
American Heart Association calls especial attention to the fact that a “very high percentage”
of the funds which are raised will be retained by the local associations for the purpose of
promoting research and providing facilities for treatment and management of patients suf-
fering from heart disease in the various localities.
An important function of the local associations will be the education of the lay public.
They will show that some forms of heart disease are reversible ; others can be arrested
and many individuals suffering from heart disease can lead useful, comfortable and fairly
long lives, despite their physical limitation. This information will be released through lay
educators, such as teachers, physical education instructors, social workers, public health
nurses and ministers. Physicians will receive advanced instruction by means of refresher
courses and lectures by outstanding authorities. Also the local heart associations will stimu-
late communities to provide an adequate number of beds for patients who suffer from acute
and chronic phases of heart disease. They will see that sufficient nurses and physicians are
available. They will provide for the rehabilitation of patients who have heart disease. This
phase of their activities will require the assistance of occupational therapists and vocational
guidance and often psychologic rehabilitation will be needed. The local heart associations
have been termed the “task forces in this crusade” of the American Heart Association.
In Minnesota much interest has been shown by the American Legion, and farm, labor and
industrial organizations. The Variety Club has provided funds for a heart hospital on the
campus of the University of Minnesota.
The Council of the Minnesota State Medical Association has approved the organization of
the Minnesota Heart Association. Temporary officers were elected at a meeting of repre-
sentatives of industrial, labor and farm organizations and members of the medical profession,
held in Saint Paul on July 24. These officials are preparing articles of incorporation and a
constitution and by-laws at this time which will provide for statewide representation drawn
from members of the medical profession and persons who are not physicians. Soon a per-
manent organization will be established.
P'robably one of the prime functions of this organization will be to enlighten the public
regarding the significance of this program. Soon people will be made to realize that one out
of three people dies of diseases of the heart and blood vessels and that these diseases account
for more deaths than the next six greatest causes of death. It should not be difficult to arouse
public support for this outstanding health program.
President, Minnesota State Medical Association
October, 1947
1079
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
ACRES OF DIAMONDS
T N the October number of Pic appears in
full the famous lecture entitled “Acres of
Diamonds,”* first delivered years ago at the re-
union of Civil War comrades by Dr. Russell
H. Conwell, the philanthropist and founder of
Temple University in Philadelphia. This
inspiring lecture is said to have been de-
livered over 6,000 times and to have been a
source of inspiration to countless individuals
who have heard it.
The title is derived from a story told Dr.
Conwell in 1870 by a guide on the Euphrates
River about a Persian who left his home on
the River Indus in a vain search of wealth,
when the bed of the stream that flowed in
his own yard was covered with diamonds.
This is his thesis — that wealth is at your door-
step in this free country of ours and is the
reward of the industrious and deserving. Pie
decries the idea that there is something in-
iquitous in the search for wealth and points
out that, according to the Bible, “the love
of money is the root of all evil” and not
money itself. With the acquisition of money
comes the power to do good — for your family,
friends, community and the world in general.
He decries anything that stands in the way
of the development and reward of private
initiative, be it employer or union, which by
standardization of wages prevents compen-
sation commensurate with one’s worGi.
Apparently, there was a need for such an
inspirational speech over the period of years
during which Dr. Conwell gave this “Acres
of Diamonds” speech. He died in 1925. Dur-
ing these years, Americans with freedom and
opportunity, some spurred on by this speech,
attained undreamed wealth for themselves and
*The lecture plus the story of Dr. Conwell’s life was com-
piled into book form by Harpers.
their countrymen. Has this period come to
an end?
We have heard of pessimists who as far
back as a hundred years ago predicted that
no longer could wealth be acquired in our
country, only to be proven wrong. We do
not wish to be added to the list.
We believe that the present supplies many
opportunities for acquiring wealth on the part
of those with industry and faith in the future.
We maintain, however, that man-made bar-
riers in recent years have removed much of
the incentive that was formerly present. The
widening of the field of government spend-
ing before the war, greatly increased of neces-
sity during the war, and new fields which have
opened to replace those contracted during the
postwar period — some necessary in the name
of humanity, some indicative of the socialistic
trend in government and some gross extrava-
gance— have necessitated such an increase in
income and inheritance taxes and have re-
sulted in such poor returns from investments
that the money incentive to increase production is
well nigh gone.
We wish everyone could read “Acres of
Diamonds” in order to experience the ex-
hileration it produces in the reader’s soul to
think that he lives in a country like ours, so
rich in opportunities. Certainly, patriotic and
thoughtful readers cannot fail to feel that
everything must be done to maintain our
system of private enterprise in spite of
socialistic tendencies in the rest of the world
to restore the incentive to work by reducing
taxation and government spending. If the
country goes to work, supply will more nearly
meet demand, and the cost of living will begin
to go down, to the benefit of everyone. Con-
cealed or obvious taxes are contained in the
cost of everything we purchase today.
1080
Minnesota Medicine
EDITORIAL
AMA FELLOWS
T)OSSIBLY one in ten physicians in the state
understands clearly the difference between be-
ing a member of the American Medical Associa-
tion and being a Fellow in the Scientific Assembly
of the AMA. Each active member of a county
society is enrolled automatically as a member of
the AMA. He pays county and state dues but
pays no dues to the national organization. Al-
though the AMA has the right, according to its
constitution, to assess each member up to ten
dollars, if necessary, this prerogative, to our
knowledge, has never been exercised. The AMA
derives its income largely from its publications
and the commercial displays at its meetings.
It is, therefore, logical for the AMA to insist
that only those who support the scientific activi-
ties of the Association by subscribing to The
Journal of the American Medical Association or
one of its publications and becoming enrolled as a
Fellow can register or take part in scientific dis-
cussions at the annual meetings. Simply being a
member, with or without subscribing to an AMA
publication does not automatically make one a Fel-
low. Application for Fellowship must be made
by members who are not already Fellows as at-
tested by the Fellowship card received yearly from
the AMA. Fellowship dues, in the sum of eight
dollars, should accompany the application. This
amount includes the subscription price of The
Journal.
Perhaps 20 per cent of members of the Min-
nesota State Medical Association are not AMA
Fellows. Some of these subscribe to The Journal
and can become Fellows without additional ex-
pense by simply applying to the AMA. Those who
do not subscribe to one of the AMA publications
should support the national association by so
doing and should become Fellows.
Aside from qualifying a member to register at
an annual AMA meeting, there are certain addi-
tional advantages to being a Fellow. In case one
moves to another state, a Fellow is eligible to
membership in the component society of his new
location on presentation of a transfer card. If,
however, he does not join the association in the
state to which he moves, he forfeits his AMA
Fellowship. One who has been a Fellow for fif-
teen years, has reached the age of sixty-four and
is an honorary member of his component society,
or the equivalent whereby he does not pay dues,
may be elected to Affiliate Fellowship in the
AMA by the House of Delegates. As an Affiliate
Fellow he will not be required to pay dues ; neither
will he continue to receive the journal, except upon
paid subscription.
A PHYSIOLOGIC APPROACH TO
CARDIOVASCULAR ROENTGENOLOGY
(Continued, from Page 1048)
A. Gordon ; Drs. S. Dack and D. Paley ; Drs. F. H.
King and B. Schwartz ; Drs. A. Grishman and M. F.
Steinberg; Dr. S. Feitelberg and Mr. J. Hay.
References
1. Bloomfield, R. A.; Lauson, H. D.; Cournand, A.; Breed, E.
S., and Richards, D. W., Jr.: Recording of right heart
pressures in normal subjects and in patients with chronic
pulmonary disease and various types of cardio-circulatory
disease. J. Clin. Investigation, 25:639, 1946.
2. Cahoon, D. H.; Michael, I. E., and Johnson, V.: Respira-
tory modification of the cardiac output. Am. J. Physiol.,
133:632, 1941.
3. Chavez, I.; Dorbecker, N., and Celis, A.: Direct intra-
cardiac angiocardiography — its diagnostic value. Am. Heart
J., 33:560, 1947.
4. Cossio, P., and Berkonsky, I.: El primer ruido cardiaco y
el soplo persistolico en las estrechez mitral con fibrilacion
auricular. Rev. argent, de cardiol., 10:162, 1943.
5. Cournand, A.: Discussion at the New York Acad. Med.,
(May) 1947.
6. Cournand, A. : Recent observations on the dynamics of
the pulmonary circulation. Bull. New York Acad. Med.,
23:3, 1947.
7. Cournand, A.; Lauson, H. D. ; Bloomfield, R. A.; Breed,
E. S., and Baldwin, E. de F. : Recording of right heart
pressures in man. Proc. Soc. Exper. Biol. & Med., 55:34,
1944.
8. Eppinger, E. C. ; Burwell, C. S., and Gross, R. E. : Ef-
fects of patent ductus arteriosus on the circulation. J.
Clin. Investigation, 20:127, 1941.
9. Fahr, G., and Buehler, M. S. : A physiologic definition of
acute congestive heart mucle failure. Am. Heart J., 25:
211, 1943.
10. Grishman, A.; Steinberg, M. F., and Sussman, M. L. :
Angiocardiographic analysis of the cardiac configuration in
mitral disease. Am. J. Roentgenol., 51:33, 1944.
11. Henny, G. C. ; Boone, B. R., and Chamberlain, W. E. :
Electrokymograph for recording heart motion; improved type.
Am. J. Roentgenol., 57:409, 1947.
12. Lauson, H. D.; Bloomfield, R. A., and Cournand, A.: The
influence of the respiration on the circulation in man. Am.
J. Med., 1:315, 1946.
13. Lysholm, E. ; Nylin, G., and Quarna, K.: The relation
between the heart volume and stroke volume under physio-
logical and pathological conditions. Acta radiol., 15:237,
1934.
14. Morelli, A. C. : Roentgen kymographic study of the alter-
ations in the pathological heart during Valsalva and Muller
tests. Radiology, 33:131, 1939.
15. Patterson, S. W. ; Piper, H., and Starling, E. H.: The
regulation of the heart beat. J. Physiol., 48:465, 1914.
16. Ryder, H. W. ; Molle, W. E., and Ferris, E. B., Jr.: The
influence of the collapsibility of veins on venous pressure
including a new procedure for measuring tissue pressure.
J. Clin. Investigation, 23:333, 1944.
17. Shuler. R. H.; Ensor, C. : Gunning, R. E. : Moss, W. G.,
and Johnson, V. : The differential effects of respiration on
the left and right ventricles. Am. J. Physiol., 137:620, 1942.
18. Stauffer, H. M. : Electrokymography. Bull. Hosp. Univ.
Minnesota, 18:462, 1947.
19. Steinberg, M. F. ; Grishman, A., and Sussman, M. L. :
Angiocardiography in congenital heart disease. III. Patent
ductus arteriosus. Am. J. Roentgenol., 50:306, 1943.
20. Sussman, M. L. ; Steinberg, M. F., and Grishman, A.:
Multiple exposure technique in contrast visualization of the
cardiac chambers and great vessels. Am. J. Roentgenol.,
46:745, 1941.
21. Sussman, M. L. ; Steinberg, M. F., and Grishman, A.: Con-
trast visualization of the heart and great vessels in emphy-
sema. Am. J. Roentgenol., 47:368, 1942.
October, 1947
1081
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
RISKS OF ADMINISTERING
BLOOD PLASMA
Possibilities of disease transmission by the in-
jection of human blood derivatives is re-empha-
sized in a recent report from the American Red
Cross.
The report, released through the Minnesota
Department of Health, comes from the Commit-
tee on Blood and Blood Derivatives of the Amer-
ican National Red Cross Advisory Board on
Health Services, which recently reviewed ac-
cumulated reports on the administration of sur-
plus dried blood plasma.
Although the Committee does not advocate the
discontinuance of its use, it does recommend that
all physicians consider carefully the potential risk
to the patient in the administration of pooled
plasma. Because of the possibility of disease
transmission, plasma should be used chiefly for
serious emergencies, the report says, when a need
for it is clearly indicated and when safer agents
such as whole blood or serum albumin are not
available.
No Other Restrictions
There are no other restrictions on the use of
dried human blood plasma. This plasma, derived
originally from blood given by thousands of do-
nors throughout the country, to help in the war
emergency, has been returned as surplus to the
American Red Cross. By agreement with the
American Medical Association and the Associa-
tion of State and Territorial Health Officers, it
has been distributed to all state health depart-
ments for use in this country.
No longer needed for soldiers and sailors, this
plasma is now intended to help save the lives of
the people who so generously gave blood origi-
nally. It is available to all who request it, as long
as it lasts. No charge is allowed for the plasma
itself ; and to avoid confusion, the Health Depart-
ment suggests that hospitals might bill patients as
follows :
Blood plasma — No charge
Plasma administration — (Prevailing fee)
The plasma is not intended solely for admin-
istering to indigents; nor is it to be kept in re-
serve for disasters. An ample reserve has been
set aside for both of these purposes.
15,829 Units Distributed
Since March, 1946, the Minnesota Department
of Health had distributed a total of 15,829 units
of dried human blood plasma to physicians and
hospitals throughout the state. Approximately
11,481 units of 500 c.c., and 4,348 units of 250
c.c. have been supplied between March, 1946, and
August 1, 1947.
Co-operation of physicians is urgently sought
both in reporting cases of disease apparently
spread through plasma administration and in
preventing any further spread.
According to the Red Cross Committee, physi-
cians who see patients with hepatitis should make
a habit of inquiring about the possibility of their
having been injected with blood or its derivatives
during the preceding six months and of reporting
such cases to the state or territorial department of
health.
Furthermore, the Committee recommends, no
matter how well a person looks or feels, he should
not serve as a blood donor if ( 1 ) he has been hos-
pitalized during the previous six month, partic-
ularly if he has received injections of human
blood, blood plasma or serum within that period
and if (2) there is a history of jaundice among
members of his family or household within the
preceding six months’ period.
SOCIAL SECURITY MISSION
TO JAPAN QUESTIONED
Motives prompting the dispatch on August 28
of certain officials from the Federal Security Ad-
ministration and the U. S. Public Health Service
1082
Minnesota Medicine
MEDICAL ECONOMICS
to Japan “to advise the Japanese government with
reference to the co-ordination and application of
social security measures” are under heavy fire in
Washington.
The big question being asked is this : Does this
social security mission to Tokyo represent simply
a response to a normal request from the Supreme
Command for the Allied Powers in Japan for
help in rebuilding the Japanese Government on
a sounder basis, or is it an attempt to “put over”
a socialistic system in that country ?
This question is being posed by the same in-
vestigating subcommittee which, under the guid-
ance of Representative Forest A. Harness (Re-
publican, Indiana), recently uncovered a misuse
of funds by six agenciees of the executive branch
of the U. S. Government for propaganda activ-
ities supporting compulsory national health in-
surance.
Defenders of the mission to Japan maintain
there is a very simple explanation for the whole
procedure. It all began, they relate, with a re-
quest last April from General Douglas Mac Ar-
thur, Supreme Commander for the Allied Pow-
ers, that Mr. Arthur J. Altmeyer, Commissioner
of the Social Security Administration, be invited
to head a six-man mission to Japan for a period of
thirty to ninety days to evaluate and make recom-
mendations for achieving a sound social security
system for Japan.
To Help Draft Health Bill
These men are to consult with the Public
Health and Welfare Section of the Occupational
government (the SCAP) and will offer technical
guidance to the Japanese Committee on Social
Insurance and the Japanese Council on Medical
Care, presently engaged in drafting a co-ordi-
nated national health bill.
Apparently General MacArthur did make this
request, although the Harness Investigating Com-
mittee insists that they have never seen such a
request. What arouses suspicion is the fact that
the persons being sent to Japan by the War De-
partment are merely, in the General’s own words
“presumed to be qualified” since they are “respon-
sible public officials.”
This fact has prompted the Harness Committee
to probe further into their backgrounds. Each
man who will work with Altmeyer is known,
according to the Harness Committee, to have an
“ideological attachment” to a national health pro-
gram of the Wagner-Murray-Dingell type. The
inference from this is that they were picked for
their political convictions and not for their profes-
sional competence as health or social security
advisers.
Four members of the mission have already been
flown to Japan by the War Department. Mr. Alt-
meyer and two other men will join them later.
The advance guard includes Dr. Joseph W. Moun-
tin and Mr. Burnet M. Davis of the U. S. Pub-
lic Health Service; Mr. Barker S. Sanders, So-
cial Security Administration, and Mr. Francis A.
Staten, Public Housing Authority.
See Danger to Medicine
The Harness Committee sees imminent danger
in this social security mission, pointing out that if
it is carried through, it may establish a precedent
for controlling the medical profession in other
countries. The selection of the experts by persons
known to favor the nationalization of medicine
leads the Committee to suspect an attempt is be-
ing made to find a “likely spot” to plant the seeds
of a socialistic system in view of the fact that such
plans have so far failed in this country.
The Committee doubts that MacArthur had any
real knowledge of the composition of the mission
or of the reputation of its members. It may be
that he was guided by recommendations from the
War Department, which may in turn have been
guided by someone else — someone with strong so-
cialistic leanings. Such is the contention of the
Investigating Committee. For this reason, the
Committee requested that the departure of the
mission be delayed pending further investigation.
The request was denied, and the mission left as
scheduled.
AMA "GRASS ROOTS CONFERENCE"
HAILED AS DECIDED SUCCESS
The first national meeting of county medical
society officers, held in connection with the AMA
Centennial Convention in Atlantic City, has been
hailed as a decided success. The conference,
which has been aptly named the “Grass Roots
Conference,” has been accorded the wholehearted
approval of the AMA House of Delegates, and a
continuation of these conferences has been rec-
ommended.
Employing the question-and-answer method of
discussion, with the county officers themselves
supplying the questions, delegates exchanged ideas
October, 1947
1083
MEDICAL ECONOMICS
on a variety of medical economic subjects. A pan-
el of experts was on stage to provide facts in an-
swer to the specific questions and to keep the dis-
cussions going.
The enthusiasm shown by the delegates and
their active participation in the discussions re-
sulted in the coverage of only seventeen major
questions from a list of seventy-eight submitted
by the county officers.
Receiving most attention were the questions
dealing with rural medicine, with the status of the
general practitioner in relation to the hospital and
the specialist, and with the public relations of the
county medical society.
Discuss Physician Shortage
The shortage of physicians, particularly in the
rural areas, it was agreed by the delegates, is a
number one problem, the remedy of which is the
dual responsibility of the public and the profes-
sion. The growing interest on the part of rural
people to do something about it was noted, to-
gether with the firm resolve of organized medicine
itself to do its share, by Dr. L. W. Larson
of Bismarck, a member of the panel by reason of
his work on the AMA Committee on Rural Med-
ical Service.
“Medical schools,” Dr. Larson pointed out,
“have emphasized specialization in the years past,
but there is now evidence to show that the trend
is swinging back to more emphasis on the gen-
eral practitioner. The tendency on the part of the
larger rural hospitals to extend their facilities to
surrounding territory is also in the right direc-
tion.”
None of these things alone will solve the prob-
lem, he said. He expressed the belief that doctors
themselves can do something within the county
medical societies in rural areas, and he recom-
mended that physicians help encourage bright
young men who might be interested in medicine to
get into the field and to settle in rural areas. The
county medical society might also foster the de-
velopment of local health councils in the county.
Still another suggestion was the offering of practi-
cal help to the rural practitioner — that of making
him feel that he, too, is important and that he has
friends in the larger centers who stand ready to
give him whatever advice or consultation he may
need.
Dr. Norman M. Scott, medical director of the
New Jersey Medical Surgical Plan, also a panel
member, cited another problem particularly appli-
cable in rural areas, that of rural enrollment in
prepayment medical care plans. His conclusion
was that since such insurance is most successful
when written on the group basis, that the solution
for the spread of these plans in rural areas is to
organize farmers into groups.
Preserve the Family Doctor
If we do not protect the status of the general
practitioner our whole system of organized medi-
cine is threatened. This statement was made by
Dr. L. H. Bauer of Hempstead, N. Y., during the
discussion of the specialist-general practitioner re-
lationship, and it seemed to summarize the feeling
of the entire group.
Various ways of preserving “the family doctor”
were discussed. Suggestions included increasing
hospital facilities to make general practice
easier, revamping specialty boards, the establish-
ment of general practice services in hospitals and
increasing the number of postgraduate courses,
slanted toward the needs of the general practi-
tioner.
Indicative of the line of thought of the confer-
ence delegates were such statements as : “Hospi-
tals are for the use of and not the convenience of
the specialist” ; “The general practitioner has no
fight with the specialist — we need him as much
as he needs us” ; and “Credit should be given on
the basis of proved ability to practice.”
Some doctors objected to the name “general
practitioner,” advocating such titles as “general
physician” or a return to the name “family doc-
tor.” The question of a specialty board for gen-
eral practitioners was also brought up, but there
was disagreement as to need for such a board or
the advisability of it, since the original idea of a
specialty board was not to make it difficult for a
man not in a specialty, but to arrive at comparable
standards for different specialties. To avoid un-
happiness in the profession from inequality of op-
portunity, the House of Delegates has already
recommended and the Hospital Association has
accepted this statement as a guide in the matter
of the specialty board: “The individual shall be
qualified for a particular place by reason of his
particular training and not because he has been
certified by a board.”
Public Relations Discussed
The proper share of public relations activity
which should be assumed at the county society
1084
Minnesota Medicine
MEDICAL ECONOMICS
level provided a subject for very active discussion
at the Conference. A member of the panel, Dr.
L. F. Foster, secretary of the Michigan State
Medical Society, cited the development of social
consciousness as an important consideration. The
rugged individualism, typical of the medical pro-
fession, is being discarded, he said.
“Doctors are, in the eyes of the patients, great
fellows,” Dr. Foster said. “But these same pa-
tients seem to feel that medical associations exist
for the doctors’ own good and not to help the
public. But as a corporate institution we are con-
cerned with public welfare and must get this
across to the public.”
Mr. Thomas A. Hendricks, secretary of the
AMA Council on Medical Service, a firm believer
that “public relations begin at home,” listed for
the delegates what he called “the seven sins” to
be avoided by a functioning local society: “iner-
tia, reaction, cliques, discord, provincialism,
smugness and defeatism.”
“To offset these,” he said, “the seven' character-
istics that mark a good medical society are : en-
terprise, progress, friendship, harmony, vision,
leadership and courage.”
PNEUMONIA IMMUNIZATION CUTS DEATH RATE
OF OLDER PERSONS
A group of New York investigators who made a
six-year study of pneumonia in elderly patients, suggest
immunization against the disease where high incidence
rates prevail, as in epidemics, in institutions, and in
persons with a tendency to recurring pneumonia.
Writing in the current issue of the Archives of In-
ternal Medicine, published by the American Medical As-
sociation, the investigators — Paul Kaufman, M.D., at-
tending physician, Goldwater Memorial Hospital and
New York City Home; C. O’Brien, M.D., resident phy-
sician and H. Stein, M.D., resident physician, New York
City Home — state that they undertook their study in the
older age group for several reasons :
First, they have a high incidence of pneumonia, mor-
tality and case fatality rate. Second, repeated attacks
of pneumonia occur frequently. Third, there was pos-
sibility for continuous observation, hospitalization, and
re-examination, since the patients were from the New
York City Home and the Medical Division of the former
Central and Neurological Hospital and the Goldwater
Memorial Hospital, where higher age groups are treated.
During the six-year study, 1937 to 1943, 5,750 patients
were immunized against pneumonia, while 5,153 control
patients were observed for comparison. Among the im-
munized group, 99 developed pneumonia, an incidence
rate of 17.2 per 1,000, of which 40 died, a mortality rate
of 6.2 per 1,000. There were 227 cases of pneumonia
among the nonimmunized patients, an incidence rate of
44 per 1,000 with 98 deaths, a mortality rate of 19
per 1,000.
The antigen used in these experiments for immuniza-
tion is made from a fraction of the pneumococcus, the
organism responsible for pneumonia. The antigen, which
incites production by the body cells of a substance to
fight the bacteria, is a polysaccharide. — American Medi-
cal Association News, July 11, 1947.
October, 1947
MINNESOTA STATE BOARD OF MEDICAL
EXAMINERS
230 Lowry Medical Arts Building
Saint Paul, Minnesota
Julian F. Dubois. M.D., Secretary
Elkton, South Dakota, Man Sentenced to Three-year
Prison Term for Abortion
Re. State of South Dakota in. Herman V. Feenstra
On August 19, 1947, Herman V. Feenstra, seventy-
three years of age, of Elkton, South Dakota, entered a
plea of guilty in the Circuit Court at Brookings, South
Dakota, to a charge of performing an abortion. Feenstra
was sentenced to a three-year-term in the South Da-
kota State Prison, and is to receive credit for three
months that he was confined in the Brookings County
Jail following his arrest in May of this year.
Feenstra, who formerly represented himself as a
chiropractor, was arrested on May 20, 1947, follow-
ing the hospitalization of an eighteen year-old Lake
Benton, Minnesota, girl at the Hendricks, Minnesota,
hospital. The matter was immediately called to the at-
tention of the Minnesota State Board of Medical Exam-
iners, and through the splendid co-operation of the
attending physicians, it was learned that the patient had
gone to Feenstra on May 2, 1947, for the purpose of
having an abortion performed. Feenstra inserted a
catheter and was paid $50.00 for his services. The
patient became seriously ill and was hospitalized on
May 9, 1947, in the Hendricks Hospital.
Feenstra is well knowm to the South Dakota and
Minnesota authorities. On August 10, 1938, Feenstra
was sentenced to a four-year prison term in the District
Court at Glencoe, Minnesota, following his plea of
guilty to a charge of criminal abortion. On November
21, 1938, Feenstra was returned to the District Court
at Glencoe, Minnesota, from the State Prison, and
sentenced to a term of two to eight years because the
investigation, at that time, disclosed that Feenstra had
a prior conviction in the Circuit Court at Brookings,
South Dakota, for a similar crime. The records of the
Circuit Court at Brookings, South Dakota, also show
that Feenstra forfeited a $2,500 cash bond in that
Court, on January 19, 1938, at which time he was
under arrest on a charge of rape. Feenstra has resided
at Elkton, South Dakota, for the past thirty years.
Prior to that time he operated a cafe at Lake Benton,
Minnesota. He then worked as a painter, following
which he claims that he studied chiropractic at Daven-
port, Iowa. Feenstra has never held any license to
practice any form of healing in the State of Minne-
sota.
The Minnesota State Board of Medical Examiners
wishes to acknowledge the very fine co-operation that
it received in this case from the physicians who took
care of the patient while she was hospitalized at Hen-
dricks, Minnesota. The Medical Board also wishes to
make known the prompt and efficient services rendered
by Mr. W. R. McCann, States Attorney, and Sheriff
J. M. Rishoi, both of Brookings, South Dakota.
1085
♦ Reports and Announcements ♦
RESEARCH FELLOWSHIPS
The Surgeon General of the U. S. Public Health
Service has been authorized to establish and .maintain
research fellowships intended to promote the training
and development of investigators in the field of
medicine and related sciences. Between January 1,
1946, and August 31, 1947, a total of $10,214,174 was
made available to investigators in twenty-three different
study sections. Research in syphilis received $1,669,793;
in cancer, $1,241,510; in physiology, $676,836; in
biochemistry and nutrition, $682,358 ; in malaria,
$543,208 ; in virus and rickettsial diseases, $509,556 —
to cite the largest grants-in-aid.
The sums are devoted to fellowships, ranging from
$1,200 to $3,000 per year, awarded to those with
bachelor’s, master’s or doctor’s degrees. The fellow-
ships are for one-year periods, but may be renewed.
Application forms for research fellowships may be
obtained from the Division of Research Grants and
Fellowships, National institute of Health, Bethesda 14,
Maryland. Applications must be supported by a state-
ment from the department head of the university under
whom the fellowship work is to be conducted.
MARKLE FOUNDATION POST-FELLOWSHIP GRANTS
The John and Mary R. Markle Foundation, 14 Wall
Street, New York City, has announced that grants of
$25,000, payable at $5,000 per year for five years, will
be available beginning in the school year 1948-49 to
accredited medical schools for the specific purpose of
aiding embryo research workers in preclinical and
clinical subjects. The grants will total $1,250,000 over
the five-year period.
The purpose of the program is to meet the need
for financial assistance for young medical students
who have completed residencies and have the desire
and ability to enter research and teaching. Candidates
will have had training in some special field to qualify
them to receive a faculty appointment and to conduct
original research.
The program is the result of a survey which showed
that while there are scholarships and other forms of
financial aid for the student in the course of his
scientific training and for the scientist once his name
is made, there are few sources of help at the
beginning of the career of the man who chooses
academic medicine.
Persons interested in being considered as candidates
are referred to the deans of accredited medical
schools for further information.
UROLOGY AWARD
The American Urological Association offers an annual
award of $1,000.00 (first prize of $500.00, second prize
$300.00 and third prize $200.0) for essays on the result
of some clinical or laboratory research in urology.
Competition will be limited to urologists who have been
in such specific practice for not more than five years
and to residents in urology in recognized hospitals.
The first prize essay will appear on the program of
the forthcoming meeting of the American Urological
Association, to be held at the Hotel Statler, Boston,
Massachusetts, May 17-20, 1948.
For full particulars write the secretary, Dr. Thomas
D. Moore, 899 Madison Avenue, Memphis, Tennessee.
Essays must be in his hands before March 1, 1948.
AMERICAN ACADEMY OF ALLERGY
The American Academy of Allergy will hold its an-
nual convention at Hotel Jefferson, St. Louis, Missouri,
December 15-17, inclusive. All physicians interested in
allergic problems are cordially invited to attend the ses-
sions as guests of the Academy by registering without
payment of fee. The program, the scientific, and tech-
nical exhibits have been arranged to cover a wide varie-
ty of conditions where allergic factors may be important.
Papers will be presented dealing with the latest methods
of diagnosis and treatment as well as the results of
investigation and research. Round table conferences
will be held on Monday afternoon, December 15, 1947.
Advance copies of the program may be obtained by
writing to the chairman on arrangements, Charles H.
Eyermann, M.D., 634 North Grand Boulevard, St. Louis,
Missouri.
AMERICAN COLLEGE OF SURGEONS
Thirty-two Minnesota physicians were accepted into
fellowship in the American College of Surgeons at its
thirty-third convocation in New York on September 12.
The Minnesota initiates are Doctors B. Marden Black,
Rochester; Theodor E. Bratrud, Thief River Falls;
C. Kenneth Cook, Saint Paul ; Henry C. Dahleen,
Rochester; Charles T. Eginton, Saint Paul; Benjamin
A. Gingold, Minneapolis; Gilman H. Goehrs, St. Cloud;
Harry P. Harper, Minneapolis; Albert T. Hays,
Minneapolis; Gustaf A. Hedberg, Nopeming; Arthur
B. Johnson, Minneapolis; Carl E. Johnson, Saint Paul;
.Edward S. Judd, Jr., Rochester; Leonard L. Kallestad,
Brownton ; Bernard G. Lannin, Saint Paul ; Clarence
M. Larson, Minneapolis ; Paul R. Lipscomb, Ro-
chester; Donald C. MacKinnon, Minneapolis; Orval
L. McHaffie, Duluth; John C. Mickelson, Mankato;
Daniel J. Moos, Minneapolis ; Harvey Nelson, Minne-
apolis; Maynard C. Nelson, Minneapolis; Arthur H.
Pedersen, Saint Paul; Nathan C. Plimpton, Jr.,
Minneapolis; Harold A. Reif, Minneapolis; Frank H.
Russ, Rochester; Oliver E. Sarff, Duluth; James S.
Spang, Duluth ; David State, Minneapolis ; William
B. Stromme, Minneapolis, and H. Herman Young,
Rochester.
(Continued on Page 1088)
1086
Minnesota Medicine
today:
Anatomic illustrations were crude;
knowledge of the anatomy and the treatment of
diseases of the heart and thoracic organs
were extremely limited.
SEARLE AMINOPHYLLIN*
is widely employed in selected cardiac
cases, bronchial asthma, paroxysmal dyspnea
and Cheyne-Stokes respiration.
G. D. Searle & Co., Chicago 80, Illinois
*Searle Aminophyllin contains at least
80% of anhydrous theophylline
SEARLE
RESEARCH IN THE SERVICE OF MEDICINE
REPORTS AND ANNOUNCEMENTS
(Continued from Page 1086)
OMAHA MID-WEST CLINICAL SOCIETY
The fifteenth annual assembly of the Omaha Mid-
West Clinical Society will be held October 27 to 31,
1947, at the Hotel Paxton in Omaha.
This midwest medical meeting has become one of the
larger and more important sectional meetings of the
country. Distinguished visitors will participate in the
extensive program which includes the various
specialties.
A program may be obtained from Dr. J. M.
Thomas, Secretary, 1031 Medical Arts Building, Omaha
2, Nebraska.
SOUTHERN MINNESOTA MEDICAL ASSOCIATION
Dr. C. L. Sherman, Luverne, was elected president of
the Southern Minnesota Medical Association at the
annual meeting held in New Ulm on September 8.
Other officers elected at the meeting were Dr. Lewis
I. Younger, Winona, first vice president, and Dr. Carl
Fritsche, New Ulm, second vice president. Dr. W. A.
Merritt, Rochester, was re-elected secretary-treasurer.
Winona was selected as the convention city for 1948.
SOUTHWESTERN SOCIETY
The August 25 meeting of the Southwestern Medical
Society was preceded by a dinner at the Worthington
Country Club, attended by members of the society and
their wives. After the dinner, the women were enter-
tained at the home of Dr. and Mrs. B. O. Mork, Jr.,
while the society members conducted the regular
meeting at the club. The principal features of the
evening program were reports by Dr. S. A. Slater,
Worthington, and Dr. D. J. Halpern, Brewster, who
were delegates to the annual meeting of the Minnesota
State Medical Association in Duluth in June.
WASHINGTON COUNTY SOCIETY
At the monthly meeting of the Washington County
Medical Society, held in Stillwater on September 9,
the guest speaker was Dr. Benjamin Sommers, Saint
Paul, who spoke on “Treatment of Congestive Heart
Patients.”
Dr. Edgar C. Burseth, an associate of Dr. George M.
Ruggles of Forest Lake, was elected a member of
the society. A visiting gnest at the meeting was
Dr. Lucien Culver, Saint Paul, who formerly practiced
in Stillwater.
MINNESOTA SOCIETY OF ANESTHESIOLOGISTS
All physicians interested in ansethesia and related
subjects are invited to attend the second meeting of
this Society Saturday evening, November 15, 1947, in
Minneapolis.
For exact time, place and program, address Dr. J. W.
Baird, Committee Chairman, University Hospitals,
Minneapolis 14, Minnesota.
BROMURAL
( a Iphabromisovalery /carbamide)
A well tolerated hypnotic,
inducing a restful sleep.
Two tablets upon retiring
or in wakefulness during
the early morning hours.
Contains no barbiturate.
5 grain Tablets and Powder.
BILHUBER0 KNOLL""'
ORANGE,, - - NEW JERSEY
1088
Minnesota Medicine
Brown & Day, Inc.
62-64 East 5th St.
ST. PAUL. MINN.
October, 1947
WOMAN’S AUXILIARY
North Shore
Health Resort
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
Winnetka, Illinois
on the Shores of
Lake Michigan
WOMAN’S AUXILIARY
Upper Mississippi Auxiliary
The Woman’s Auxiliary to the Upper Mississippi
Medical Society were hostesses to the auxiliary mem-
bers of the Northern Minnesota Medical Society at
the convention on September 6, 1947. Approximately
sixty members and friends registered and were guests
of the Brainerd doctors at a luncheon in the main
dining room of Breezy Point Lodge, where the con-
vention was held.
In the afternoon the ladies participated in bridge and
a social hour, and were served refreshments by the
Brainerd doctors’ wives. Mrs. J. A. Thabes, Sr.,
president of the state auxiliary, was an honored guest.
There was a banquet in the evening for the doctors
and their wives, at which Governor Youngdahl was
the principal speaker.
Range Auxiliary
Members of the Range Medical Association Auxiliary
held a joint session with members of the Medical As-
sociation at a dinner meeting in the Elks Club, at Eve-
leth in September. Auxiliary guest speaker was Mar-
garet Moore, who gave a talk on her recent trip to
Mexico, illustrated with motion pictures.
Mrs. Robert L. Bowen, president of the Auxiliary,
represented her group at a tea which the women’s or-
ganizations of Eveleth sponsored, following a public
relations talk on various phases of socialized medicine
given at the Little Theater of the Memorial Building
on October 9. In the evening the Range Medical As-
sociation and Auxiliary members were hosts at a dinner
for the St. Louis County Medical Society.
October 23 has been slated for the Auxiliary rum-
mage sale to raise funds for the nursing scholarship at
Hibbing General Hospital, which the organization is
sponsoring. The Range Auxiliary embraces members
from Hibbing, Chisholm, Buhl, Nashwauk and Kee-
watin.
SICKNESS STATEMENTS FOR RAIL WORKERS
Physicians throughout the nation are being asked to
furnish medical evidence to substantiate the claims of
railroad workers who may now draw cash sickness bene-
fits under the Railroad Unemployment Insurance Act.
The Railroad Retirement Board pointed out that unless
an application is mailed not later than the seventh day
after the first day of sickness claimed, it may not be
received within the legal time limit for filing applications.
As a result, the employe may lose one or more days’
benefits. Physicians are asked either to return each com-
pleted Statement cf Sickness to the patient, or mail it
promptly to the office of the Board to which it is ad-
dressed.
1090
Minnesota Medicine
Replacing turmoil with serenity for women under-
going menopausal disturbances has become a matter
of comparatively specific therapy
Choice of an estrogenic product in this condition
is likewise well charted. For optimum relief
of symptoms, the competent physician selects a
product whose manufacturing history he need
never question.
VtRIcV
MEDICAL
! ASSN
This, perhaps, may account for the wide use of
Solution of Estrogenic Substances, Dorsey. Made by
Smith-Dorsey Company, whose plant facilities,
personnel and procedure are above reproach, these
products merit the continuing confidence of
careful doctors.
Dorse
October, 1947
THE SMITH-DORSEY COMPANY, Lincoln, Nebraska
BRANCHES AT LOS ANGELES AND DALLAS
1091
•""I
In Memoriam
JOHN A. DUFFALO. JR.
Lieutenant Commander John A. Duffalo, Jr., died
suddenly at Oakland, California, on July 6, 1947, at the
age of thirty-one.
Born in Minneapolis, Dr. Duffalo graduated from the
LTniversity of Minnesota Medical School in 1940 and
joined the navy in 1942. He took part in battles at
Okinawa, Iwo Jima, Leyte and Luzon as flight sur-
geon aboard the escort carrier, LT.S.S. Lunga Point.
Dr. Duffalo is survived by his parents, his wife, Ellen,
and a son, Bruce.
HAROLD F. DUNLAP
Dr. H. F. Dunlap, formerly of the Mayo Clinic, died
July 22, 1947, at Indianapolis, Indiana.
Born in 1895 at IOuncannon, Pennsylvania, Dr. Dun-
lap received his M.D. degree from Indiana University
in 1920 and entered the Mayo Foundation as a fellow
in medicine, January 1, 1922. In 1932, he left the
Foundation and after a year of practice in New Jersey,
went to Indianapolis, where he had practiced and served
as associate in medicine at the Indiana University School
of Medicine since 1934.
ROBERT K. GREEN
Dr. Robert K. Green, head of the Department of
Bacteriology at the University of Minnesota medical
school and well known nationally for his research work
in virus diseases and cancer, died September 6, 1947, at
the age of fifty-two.
Dr. Green was born at Wadena, Minnesota, January
11, 1895. He attended school at the University of Val-
paraiso (Indiana) and at International Falls before at-
tending the University of Minnesota. There he received
the degree of B.A. in 1919, M.A. in 1920, and M.D. in
1922. He was a member of Sigma Xi and an Honorary
Fellow in the New York Zoological Society.
A decade ago, Dr. Green was credited with having
saved the nation’s fox industry by developing a vaccine
to prevent fox encephalitis. A year ago, he introduced
a revolutionary theory on the cause of cancer. At the
time of his death, he was working on what he hoped
would be a successful vaccine against poliomyelitis and
an agent to immunize against cancer. He left his per-
sonal laboratory equipment to the University of Minne-
sota for the continuation of research.
Dr. Green’s wife, the former Beryl Bertha Sparks,
whom he married in 1917, died in 1941. A daughter,
Gale, two brothers and five sisters survive him.
Dr. Green was a member of Hennepin County Medi-
cal Society, the Minnesota State and American Medical
Associations, the Society of American Bacteriologists,
the American Society of Mammalogists, the American
Association of Immunologists and the Minnesota Acad-
emy of Medicine.
JULIUS F. GENDRON
Dr. Julius F. Gendron, a practitioner in Grand Rapids,
Minnesota, since 1904, died September 11, 1947, at the
age of seventy-nine.
Dr. Gendron was born at St. Francis de Montmagny
in the province of Quebec on March 31, 1868. After
studying law at Laval University, he came to Minnesota
and decided to study medicine. He graduated from
Hamline University medical school in 1896. He prac-
ticed medicine at Centerville, Minnesota, from 1896 to
1898; at Saint Paul, as an associate of Dr. Marquis from
1898 to 1899; at Crookston from 1899 to 1900; at Red
Lake Falls from 1902 to 1904, when he located in Grand
Rapids. He was health officer for Grand Rapids for
a number of years before his death.
Dr. Gendron was well known in Canadian literary
circles as a poet, doing his writing in French. He was
once poet laureate of Canada. In 1928, he published
a symbolic poem in French entitled “D’Oil.” Several
works in both verse and prose were never published.
In 1930, he became a member of the Society of French
Canadian Poets.
A member of the St. Louis County Medical Society,
the Minnesota State and American Medical Associations,
he served as a captain in the medical corps of the army
in World War I. He is survived by his widow and a
son, Bertrand Gendron, a druggist at Brainerd, Minne-
sota.
WILLIAM GINSBERG
Dr. William Ginsberg, for thirty years a practitioner
in Saint Paul, died at the age of fifty-seven on Sep-
tember 21, 1947, at his home. He had retired from
active practice three years previously because of ill
health.
Born in Saint Paul, December 11, 1889, he was the
son of Jacob and Mollie Ginsberg. He attended the
Lhiiversity of Minnesota where he received his B.S.
degree in 1914 and his M.D. degree in 1915. During
World War I he served overseas as a first lieutenant
in the Medical Corps. He had maintained his reserve
commission as a major since that time.
After his return to practice, Dr. Ginsberg was a staff
member of St. Luke’s, St. Joseph’s and Miller Hospi-
tals. Early in his career he manifested a broad untiring
interest in medical, civic and philanthropic activities,,
and although he included the entire gamut of commu-
nity life, he had the sincerity and patience to master
the details of the many institutions and causes with
which he was affiliated. Nothing which was socially
progressive or helpful was alien to his sphere.
He was one of only two life members of the Jewish
Educational Center, of which he was one of the princi-
pal founders and first president. For many years he
was active in Boy Scout Circles, serving as a member
of the Executive Committee of the Boy Scouts of
America, Saint Paul Area Council, and as chairman of
(Continued on Page 1094)
1092
Minnesota Medicine
Gelfoam* was developed by the Ijpjuun research laboratories
to fill an important spot in surgical hemostasis. Gelfoam sup-
plements the clamp, the clip, and the suture, affording biochem-
ical arrest of bleeding with an absorbable organic agent which
rnay be left in situ. This unique gelatin sponge simplifies the
problem of clearing oozing surfaces, of staunching capillary
bleeding, the trickling from small vessels, and the annoying hem-
orrhage from such tissues as liver, kidney, spleen, and tumors. In
general practice, Gelfoam is an aid in the control of epistaxis,
hemorrhage from lacerations, and postextraction bleeding.
•Trademark
Upjohn
FINE PHARMACEUTICALS SINCE 1888
Gelfoam
Gelfoam is made in sponges 28 x 60 x 7 mm. in size. Four sponges are packed in each jar
October, 1947
1093
COMMUNICATION
IN MEMORIAM
(Continued from Page 1092)
the Leadership and Training Committee of the Saint
Paul Area Council, Boy Scout Regional Executive
Committee.
His memberships indicated the diversity and generos-
ity of his interests. These included the Ramsey County
Medical Society, Minnesota State Medical Association,
American Medical Association, B’nar B’rith lodge of
which he was a Past President, Masonic Lodge, Ameri-
can Legion, Jewish War Veterans, and Veterans of
Foreign Wars. He was also a member of the St. Paul
Refugee Service Committee, Refugee Affidavit Com-
mitte and the Conference of Christians and Jews. He
was a member of the Board of Directors of the lewish
Home for the Aged, the Temple of Aaron Congrega-
tion, Central Hebrew School, St. Paul Zionist Organiza-
tion, Jewish Welfare Board, United Jewish Fund and
Council, Central Community House, Council of Jewish
Social Agencies, the American Jewish Congress and
chairman of the Local Theological Seminary.
On April 28, 1947, Dr. Ginsberg was chosen to rep-
resent the St. Paul Jewish physicians by signing a
goodwill certificate which was sealed in the corner-
stone of the new tuberculosis hospital, a unit of Hebrew
Lhiiversity Hospital on Mount Scopus, Jerusalem.
He received an award from the Jewish War Vet-
erans, naming him the outstanding Jewish citizen in
1942, recognition of a life of communal service and
benefaction which won him the highest esteem, confi-
dence and admiration of all.
He is survived by his sons, Dr. Robert L. Ginsberg
and Tames P. Ginsberg of Saint Paul and Stanley
Thomas Ginsberg of Oshkosh, Wisconsin, and three
sisters, Annie and Lily Ginsberg and Mrs. Alex Mains,
all of Saint Paul, and a brother, Dr. S. Theodore Gins-
berg of Marion, Indiana.
BENJAMIN F. SMITH
Dr. B. J. Smith, formerly superintendent of the State
Hospital at Rochester, Minnesota, died August 17, 1947,
at Jackson, Louisiana, where he was superintendent of
the Louisiana State Hospital.
Dr. Smith was born March 3, 1895. He received
his B. A. degree from the LTniversity of Missouri
in 1917 and his M. D. degree from Tulane University
in 1919.
He came to Minnesota in 1922 as assistant physician
at the St. Peter State Hospital and was superintendent
of the Willmar State Hospital from 1927 to 1935 when
he was appointed superintendent of the Rochester State
Hospital. He left here in 1942 and later was super-
intendent at a hospital in Missouri before his appoint-
ment to the Louisiana State Hospital.
On June 15, 1920, at Neosho, Missouri, Dr. Smith
married Stella G. Walters, who with three sons, Dr.
B. F. Smith, Jr., of St. Louis, William, and George,
survive.
Communication
To the Editor:
Dr. Kano Ikeda’s criticism* of the edito ial “Lab-
oratory Abuse’’ is gratefully acknowledged by the
author.
The title of the editorial is unfortunate. It was
not the author s choice. There was no allegation of
abuse. Dr. Ikeda heartily agrees with the observation
that the multiplicity of laboratory procedures may be
a distinct danger to the clinical approach.
He does not agree with the idea of the partition of
the economic load nor does he like the illustration
of a cushion, i e., the State Board of Health Lab-
oratories.
Besides the present multiplicity of laboratory pro-
cedures we add as an example the oncoming rush of
requests for hormone levels in the blood or urine,
the vitamin levels in body fluids, the various enzyme
systems. Who is going to pay the technicians able
to do these biochemical assays?
Again, every hospital the author has contact with,
and every physician of his acquaintance uses the State
Board of Health Laboratories for diagnostic purposes.
The reason for this is obvious. Lack of facilities
or economic pressure, or both, are the factors which
have brought this about.
It was in that sense the author used the word
“cushion.”
Henry L. Ulrich
Associate Editor
*See page 1011, September, 1947, issue.
SHOULD BUSINESS AND PROFESSIONS
JOINTLY OPPOSE WELFARE STATE?
Industrialists and manufacturers show little inclination
to oppose Federalization of medicine. The banker may
think it is no worry of his if medicine is socialized.
The physician may conclude he has nothing to lose if
the Federal Government sets up sickness insurance bene-
fits by diverting railroad unemployment insurance funds
into strange channels. But the banker, the physician, and
the manufacturer would do well to inquire if they are
not all being threatened by various manifestations of a
single movement. Schemes for socialization do not
operate in an economic vacuum. They are well planned ;
they strike on many fronts. No one can predict which
part of the economy will be taken over first when the
Welfare State is established. — Insurance Economics Sur-
veys, September, 1947.
1094
Minnesota Medicine
is a proud profession
. . . and rightfully so. For next to the doctor in service rendered stands
the present-day nurse. Into her hands is entrusted the care of the sick,
and often the success of the doctor’s work depends directly upon her skill.
GLENWOOD HILLS HOSPITAL— through its
School of Nursing — is anxious to cooperate with you
in your effort to increase the number of nurses in your
community. A student from your locality will result
in increased nursing assistance to you in the near
future.
Your help is greatly needed in recruiting candidates
for this profession. A one-year course in psychiatric
nursing is currently being offered to eligible appli-
cants. Tuition is free. Regular classes begin in Jan-
uary, June and September.
TEACHING STAFF
Margaret Chase, R.N., B.S Director
Mrs. Virginia Bowers, R.N., B.S Assistant Director
Julius Johnson, M.D Case Study
Robert Meller, M.D Psychiatry
C. O. Erickson, M.D Psychiatry
Donald Reader, M.D Neurology
N. J. Berkwitz, M.D Psychiatry, Neurology
Grace, Johnson, O.T.R
Occupational & Recreational Therapy
June McChord, B.A Dietetics
Marian Tucker, B.S.M.T. (ASCP) Bacteriology
M s. Mabel Pelletier Vocal Music
Mrs. Louise Neilon, B.A Psychology
SCHOOL OF PSYCHIATRIC NURSING
Candidates for the January class should make reservations at once.
School and health records must be reviewed prior to acceptance.
For full information, write
Miss Margaret Chase, R.N. B.S.
DIRECTOR
SCHOOL OF NURSING
u
e nib mod
1 S DS
]i a s
3501 Golden Valley Road : Route Seven
October, 1947
Minneapolis, Minn.
1095
Of General Interest
On September 25 the Freeborn County Medical
Society met at Albert Lea and heard Dr. J. W. Pender,
Rochester, speak on “New Drugs and Techniques for
Anesthesia.”
* * *
On August 27, Dr. B. M. Spock, Rochester, spoke
on “The School-Aged Child” at a meeting of the
Minnesota Conference of Child Caring Institutions, in
Saint Paul.
% % J(:
President of the Northern Minnesota Medical
Association is Dr. Charles W. Vandersluis, Bemidji,
who was elected at the annual meeting at Breezy Point,
September 6.
* * *
Dr. Lyman R. Critchfield and Dr. Edwin C. Burk-
lund have announced their association in the practice
of pediatrics and the removal of their offices to 1517
St. Clair Street, Saint Paul.
* * *
“Ulcerative Disease of the Bowel” was the title of a
paper presented by Dr. P. W. Brown, Rochester, at a
meeting of the Champaign County Medical Society in
Champaign, Illinois, on September 18.
* * *
At a meeting of the British Association for the
Advancement of Science, held at Dundee, Scotland, on
September 1, Dr. Charles F. Code of Rochester spoke
on “Man’s Reaction to Centrifugal Force.”
After practicing medicine in Northome for a year,
Dr. B. G. Nelson closed her offices in that city on
August 8. She planned to vacation for several weeks
before opening a medical practice elsewhere.
* * *
The Minnesota Chapter of the American Medical
Technologists elected Jack O. Kirkham, of the Estrem
Clinic in Fergus Falls, president of the organization
at the annual meeting in Minneapolis September 6.
2|C jjC S|S
Ten lectures entitled “Ophthalmology in General
Medicine” were given by Dr. H. P. Wagener, Rochester,
at an instructional course that started September 2 and
was sponsored by the Ophthalmological Study Council
at Portland, Maine.
* * *
In Chicago on September 8, Dr. J. Arthur Myers, pro-
fessor of public health at the University of Minnesota,
delivered an address at the Mississippi Valley Tuber-
culosis Conference. Dr. Myers was the retiring
president of the organization.
* * *
A bust of Walter Reed will be placed in the New
York University Hall of Fame, probably in May, 1948,
when the Fourth International Congresses of Tropical
Medicine and Malaria meet in Washington, D. C. At
that time the British will pay honor to their great
malariologist, Sir Ronald Ross.
* * *
It has been announced that Dr. Ralph R. Sullivan has
resigned as director of venereal disease control and
acting director of medical services for the Minne-
apolis Health Department. Dr. Sullivan will become
venereal disease control director for Oregon.
* * * •
Community Health Association in Two Harbors re-
cently announced that Dr. E. Bryant Woods, an ob-
stetrician and gynecologist from Tampa and Tarpon
Springs, Florida, had arrived in the city to join the staff
of the North Shore Clinic in Two Harbors.
:jc s}1 ♦
Dr. O. W. Scholpp, Hutchinson, has purchased a
corner lot in that city where he plans to have a new
office building constructed sometime in the future. One
feature of the new building will be a large x-ray room,
arranged for ease and efficiency of operation.
* * *
At a tuberculosis conference in Chicago early in
September, Dr. Ernest S. Mariette, superintendent of
Glen Lake Sanatorium, participated in a panel dis-
cussion on ways and means of making nursing more
interesting to prospective students.
* * *
Dr. Charles W. Rogers, former practitioner in
Heron Lake, who recently completed postgraduate
training in pediatrics at the University of Minnesota,
is now specializing in pediatric practice as a member
of the Winona Clinic in Winona.
* * *
“Exchange Transfusion” was the subject discussed
by Dr. William Heilig, Northwestern Hospital, Minne-
apolis, at a meeting of the Twin City Society of
Medical Technologists held in Saint Paul on September
10.
* * *
While Dr. M. H. Larson, Nicollet, was trying to
dodge hurricanes and do some deep-sea fishing during
his September vacation along the Gulf of Mexico, his
medical practice back home was conducted by Dr.
Leander Sjostrom of St. Peter.
* * *
“Emotional Conflicts and Their Relation to Sterility”
was the topic presented by Dr. Gordon R. Kamman,
Saint Paul, at the meeting of the American Congress
of Obstetrics and Gynecology held in St. Louis,
Missouri, on September 9.
* * *
Dr. G. M. Kelby, Minneapolis, has announced the
association of Dr. Harry W. Mixer in the practice
(Continued on Page* 1098)
1096
Minnesota Medicine
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niiuniuiiiitiiiaiiiiiiiM
1098
(Continued from Page 1096)
of radiology. Dr. Mixer, who is also an instructor in
radiology at the University of Minnesota Hospitals,
began his work with Dr. Kelby on August 15, 1947.
V •I"
Dr. R. G. Tinkhman, who had been associated with
Dr. John Eiler of Park Rapids in the practice of
medicine and surgery since December, 1946, withdrew
from the partnership in August but at the time was
undecided as to where he subsequently planned to
locate.
* * *
Dr. M. J. Schirber, who recently completed a two-
year residency at St. Joseph’s Hospital in Chicago, has
become associated in the practice of medicine with Dr.
M. J. McKenna, Dr. R. V. John, and Dr. A. V. Griqley
in Grand Rapids. Dr. Schirber is a graduate of
Northwestern University.
' * * *
On August 23, Dr. Roger G. Hassett, Mankato,
suffered two fractured ribs when the automobile in
which he was riding was struck by another car at a
street intersection in Mankato. The only person injured
in the accident, Dr. Hassett was believed to have been
thrown forward against the dash board.
* * *
Two Thief River Falls physicians, Dr. Harold C.
Johnson and Dr. C. A. Haberle, have announced their
withdrawal from membership in a local clinic and have
jointly engaged in general practice in a combined office
in that city. They plan later to erect a clinic building
in the business district of Thief River Falls.
* * *
In Sandstone on September 5, Dr. H. P. Dredge
celebrated the forty-fourth anniversary of his arrival
in the city. Forty-four years ago, Dr. Dredge stated,
he arrived in Sandstone in a freight car, sleeping on
a cot, surrounded by his household goods and a team
of horses, but eager to open his medical practice.
if: j|c sfc
At a meeting of the Cancer Institute, a division of
the Iowa State Department of Health, held in Des
Moines on September 23, Dr. D. O. Ferris of Rochester
presented two papers, entitled “Carcinoma of the Kidney,
Ureter and Bladder” and “Carcinoma of the Uterus.”
The meeting was sponsored by the Iowa State Medical
Society.
* * *
Dr. Richard P. Griffin, who has been associated for
the past year with Dr. I. L. Oliver at Graceville, re-
cently opened a practice in the office of Dr. Oscar
Daignault in Benson. A graduate of the University of
Iowa in 1944, Dr. Griffin interned at Santa Rosa
Hospital in San Antonio, Texas, before entering the
navy for one year.
* * *
Recently discharged from the ar,my, Dr. Gerald E.
Bourget has become associated in practice with Dr.
L. H. Rutledge and Dr. C. W. Moberg in Detroit
Lakes. A graduate of the University of Minnesota
Minnesota Medicine
OF GENERAL INTEREST
in 1944, Dr. Bourget served his internship at Western
Pennsylvania Hospital in Pittsburgh before entering the
army.
* * *
Results of the chest x-ray survey in Blue Earth
County and North Mankato were reported at the annual
meeting of the Blue Earth County Public Health
Association by Dr. Hilbert Mark, director of the
Tuberculosis Division of the State Board of Health,
who was the principal speaker at the September 24
meeting in Mankato.
* * *
Dr. Robert E. Rocknem, who recently completed an
internship at Minneapolis General Hospital, was
married in Minneapolis early in September to Miss-
Margery Lou Hill, formerly of Veblen, South Dakota.
A graduate of the University of Minnesota, Dr.
Rocknem expected to be called to active duty in the
army in late September.
;}«
An emergency health board was organized in Hibbing
at a meeting on August 27. The group will work
within the framework of the Community Fund to supply
funds for emergency health cases where needy patients
are concerned. Among the members of the board are
Dr. Carlyle Tingdale, Dr. T. A. Estrem, and Dr. C. N.
Harris, all of Hibbing.
* *
On October 1, Dr. W. W. Canfield returned to
Houston after almost four years of absence, and opened
offices for his medical practice. Dr. Canfield formerly
practiced in Houston from 1929 until January, 1944,
when he entered military service. After his discharge
from the army, he practiced medicine for a short time
at Forest Lake and at Winona.
Dr. Percy T. Watson, Minneapolis, suffered bruises
and an injury to his eye on the morning of September 8
when his automobile was struck on a highway near
Rosemount by a car coming out of a blind crossing.
Dr. Watson’s car rolled over twice, bruising the
physician and another occupant. The two occupants
of the other car were not injured.
* * *
In White Bear, Dr. A. L. Wurdemann, formerly of
East Orange, New Jersey, has opened offices for the
general practice of medicine. Dr. Wurdemann, a
graduate of the University of Iowa, served her intern-
ship at East Orange General Hospital in New Jersey
and later became associated in an obstetrics and
gynecology practice in East Orange.
j}c j{:
Rochester physicians who presented papers at the
annual session of the Michigan State Medical Society,
at Grand Rapids, September 23 to 26, included Dr. S. W.
Harrington, Dr. W. E. Herrell, and Dr. Paul A.
O’Leary. Dr. Harrington spoke on “Surgical Treatment
of Carcinoma of the Breast,” Dr. Herrell on “The
Present Status of Sulfonamide and Antibiotic Therapy,”
and Dr. O’Leary on “The Use of Penicillin in the
Treatment of Syphilis in General Practice.”
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October, 1947
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Word has been received that Dr. Donald T. Anderson,
former Red Wing resident now on the staff of the
Veterans ‘Hospital in St. Cloud, has been promoted to
the rank of captain in the Lb S. Army Medical Corps.
* * *
An annual fall chest clinic was held in Faribault on
September 22, at which time Dr. Karl H. Pfuetze,
superintendent of Mineral Springs Sanatorium, inter-
viewed former patients of the sanatorium and ad-
ministered free Mantoux tests to all interested residents
of the area as part of the campaign against tuberculosis.
* * *
Newly appointed to the staff of the University of
Minnesota pediatrics department as an associate pro-
fessor is Dr. Charles D. May, formerly of Boston.
Graduated from Harvard University Medical School
in 1935, Dr. May was director of the outpatient
department at the Children’s Hospital in Boston when
he accepted the Minnesota appointment.
* * *
Dr. Charles D. Freeman, Jr., has opened offices at
1160 Lowry Medical Arts Building, Saint Paul, for
the practice of dermatology and syphilology. After
graduating from the University of Minnesota Medical
School in 1942, Dr. Freeman spent three and a half
years in the army medical corps in Puerto Rico, in
Kentucky, and on the European front.
* * *
Dr. Erling G. Hestenes, resident physician at St. John’s
Hospital, Saint Paul, has accepted a call to establish
a medical mission and public health service in Africa.
Recently discharged from the army, Dr. Hestenes will
assume his new duties early next year. It will be the
first time that an American physician has been per-
mitted to practice in British South Africa.
* * *
Dr. Charles W. Fogarty, Jr., has opened offices at
1019-1021 Lowry Medical Arts Building, Saint Paul, for
the practice of internal medicine, with special emphasis
on arthritis and allied rheumatic disorders and periph-
eral vascular diseases. Dr. Fogarty was a member of
the class of 1938 of the University of Minnesota Medi-
cal School. He has since spent four years at the Mayo
Clinic and four years in the army.
* * *
After practicing in Lakeville since January, Dr. Paul
A. Wagner closed his office on September 15 and left
for Portland, Oregon, to complete his war-interrupted
postgraduate training in a hospital there. A graduate
of the University of Minnesota, Dr. Wagner served for
three years in the army, stationed in Burma for part
of the time. Following his discharge, he opened practice
in Lakeville.
* * *
The Dearholt Medal for distinguished service in
combating tuberculosis has been awarded to Dr. S. A.
Slater, superintendent of the Southwestern Minnesota
Tuberculosis Sanatorium. The medal, named for the
late Dr. Roy Dearholt of Milwaukee, pioneer tuber-
culosis fighter, was presented to Dr. Slater at a recent
dinner meeting of the Mississippi Conference on
Tuberculosis.
1100
Minnesota Medicine
OF GENERAL INTEREST
Under the leadership of Dr. J. W. Duncan, a com-
mittee in Moorhead is staging a county-wide drive to
raise funds for the building of the Mayo Memorial
medical center at the University of Minnesota. Plans
are to establish a quota and work out a method for
covering the entire county during the drive. In Moor-
head the aid of local service organizations is being
enlisted to cover the city.
* * *
Dr. John J. Bittner, University of Minnesota cancer
research head and president of the American Association
for Cancer Research, was a member of the nine-man
United States delegation to the Fourth International
Cancer Research Conference held in St. Louis, Missouri,
September 2 to 7. About 200 scientists from more
than thirty countries attended the conference, the first
since the war ended.
The Southern Minnesota Spastic Club had Dr. John
F. Pohl of Minneapolis as its guest speaker at a meet-
ing held in Mankato on September 19. Dr. Pohl, who is
attending orthopedic surgeon for the Michael Dowling
School for Crippled Children, medical supervisor for
the Elizabeth Kenny Institute, and a member of the
medical advisory committee of the Minnesota Society
for Crippled Children, discussed problems in the care
and rehabilitation of cerebral palsied children.
* * *
Formerly of Minneapolis, Dr. Theodore Rasmussen
has been appointed professor of neural surgery at the
University of Chicago. A graduate of the University
of Minnesota Medical School and a former fellow
in the Mayo Foundation, Dr. Rasmussen has been
doing neurosurgical work at the Montreal Neurological
Institute for the past several years. During the war
he was neural surgeon for the Fourteenth Evacuation
Hospital in Burma.
* * *
On September 16, Dr. Donald W. Hastings, professor
and head of the department of neuropsychiatry at the
University of Minnesota, spoke at a meeting held in
the Fort Snelling armory by the 110th General Hospital
Organized Army Reserve.
A colonel in the Army medical reserve, Dr. Hastings
discussed problems of military personnel in regard to
neuropsychiatric fitness. Dr. Hastings is a member of
a national ten-man commission studying that topic.
* * *
Dr. Curtis J. Lund, associate professor of obstetrics
and gynecology at the University of Minnesota Medical
School since 1943, has become head of the University
of Louisiana s department of obstetrics and gynecology
at New Orleans.
Dr. Lund, who received his medical degree at the
University of Wisconsin in 1935, has been engaged in
research work at the University of Minnesota and,
previously, at the University of Wisconsin.
* * *
Dr. Elliot C. Cutler, Moseley Professor of Surgery
at Harvard and surgeon-in-chief at the Peter Bent
October, 1947
1101
OF GENERAL INTEREST
1909 1947
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Graduate School of Medicine
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SURGERY — Two-week Intensive Course in Surg-
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Four-week Course in General Surgery, start-
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Two-week Course in Surgical Anatomy &
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One-week Course in Surgery of Colon and
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TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar, 427 S. Honore St., Chicago 12, 111.
Brigham Hospital in Boston, died at his home on
August 16, 1947. During World War II, Dr. Cutler
was a brigadier general in the Medical Department of
the Army, serving as chief consultant in surgery and
later as chief of professional services in the Office of
the Chief Surgeon, European Theater of Operations.
He was an honorary consultant to the Army Medical
Library.
:fc
Washington County will be one of the first areas
in Minnesota, after the Twin Cities, to have a mass
chest x-ray survey conducted, it was recently announced.
No definite dates for the survey have yet been set,
but it is expected that the program will get under
way early in the fall of 1948. Funds to finance the
survey will come partly from the .sale of Christmas
seals and partly from money raised by popular sub-
scription in the county. Chairman of the survey is
Roy Sakrison of Bayport.
a{c J|e
Included in the new advisory board of the
Diagnostic Clinic for Rheumatic Fever in the Wilder
dispensary, Saint Paul, are Dr. Thomas E. Broadie,
Dr. R. B. J. Schoch, Dr. George W. Snyder, Dr. Edward
L. Stre,m, Dr. Robert Rosenthal, Dr. Harold Flanagan,
Dr. James N. Dunn, and Dr. Paul F. Dwan.
Dr. Evelyn Harris is medical director of the clinic,
which is sponsored by the Saint Paul section of the
National Council of Jewish Women. Any Saint Paul
child up to the age of eighteen years is eligible for
the clinic’s services.
* * *
Dr. Donald E. Hoaganson, a former Bemidji resident
who has been practicing with Dr. H. R. Tregilgas in
Saint Paul, recently moved back to Bemidji and be-
came associated with Dr. Charles W. Vandersluis of
that city.
A graduate of the University of Minnesota Medical
School in 1944, Dr. Hoaganson served his internship
at St. Joseph’s Hospital in Saint Paul before entering
the armed services. Following his discharge from the
army in March, 1947, he joined Dr. Tregilgas in Saint
Paul.
s|s sf:
Formal recognition for his contributions to medicine
and public health has been given to Dr. William A.
O’Brien, director of postgraduate medical education at
the University of Minnesota, by the House of Delegates
of the Minnesota State Medical Association. A reso-
lution recently passed by the House of Delegates
commented on Dr. O’Brien’s radio health broadcasts,
and read in part : “Resolved that this House express
its deep appreciation and thanks to Dr. O’Brien for
the unique contribution he has made through his work
to medicine and the public health in Minnesota.”
* * *
Dr. Richard Virnig, who was released from naval
service in June, has joined his brother, Dr. Mark P.
Virnig, in medical practice in Wells.
The brothers are having the first floor of a build-
ing in Wells remodeled into a fourteen-room office suite.
1102
Minnesota Medicine
OF GENERAL INTEREST
The new offices will include waiting room, recovery and
physiotherapy room, two private offices with adjoining ■
treatment rooms, x-ray room, darkroom, laboratory, :
secretary’s office, and a minor surgery room. :
Dr. Richard Vimig is a graduate of the University :
of Minnesota. He interned at the Naval Hospital in
Philadelphia and then served for five years in the
navy. He was discharged on June 25.
^
A new member of the Marshall Medical Center is
Dr. P. C. Hedenstrom, formerly at Bethesda Hospital
in Saint Paul. The staff of the Marshall clinic is now
comprised of Dr. W. W. Yaeger, Dr. J. E. Murphy and
Dr. Hedenstrom.
I 5*C j}l :}{
Following a flood in Hibbing in the week of
September 7, Dr. Carlyle Tingdale, local health officer,
stated that citizens who had been exposed to insanitary
sewer conditions should consult their local physicians in
regard to typhoid innoculations. In his newspaper
message, Dr. Tingdale said that there was no imminent
danger but that the preventive health measure should
be observed.
sf:
Dr. Clifford G. Grulee, Jr., an instructor in pediatrics
at the University of Minnesota since 1946, has ac-
cepted a position as assistant professor of pediatrics
at the University of Texas, Galveston. Dr. Theodore
G. Panos, head resident physician in pediatrics at the
University of Minnesota, will also move to Galveston
to become an instructor in pediatrics at the University
of Texas. He has been at Minnesota since 1945.
Both Dr. Grulee and Dr. Panos will be associated
with Dr. Arild E. Hansen, head of the pediatrics
department at the University of Texas, who was
formerly an associate professor of pediatrics at the
University of Minnesota.
* * *
After five years of medical practice at Erskine, Dr.
J. H. Cameron has joined the staff of the Northwestern
Clinic at Crookston, where he will be associated with
Dr. C. L. Oppegaard in the Eye, Ear, Nose and Throat
Department.
A graduate of the University of Saskatchewan and
McGill University of Surgery at Montreal, Dr.
Cameron took postgraduate work in surgery at
California Hospital in Los Angeles and at New York
Polyclinic Hospital. Before opening his practice at
Erskine in 1942, he practiced in Bagley for four years.
Dr. Cameron is a past president of the Red River
Valley Medical Society.
* * *
Approved residencies in internal medicine and general
surgery will soon be available at the Veterans
Administration Center, Dayton, Ohio, it was recently
announced. The residency training program is being
conducted under the auspices of the University of
Cincinnati College of Medicine and will follow the
pattern of residencies in the Cincinnati General Hospital.
There are 1,004 general medical and surgical beds at
the VA institution and 2,500 domiciliary beds. Ap-
plication for residency should be made to Dr. D. E.
October, 1947
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* * *
For two weeks in September Dr. Ira O. Wallin,
Saint Paul, conducted the practice of Dr. W. J. Lund
in Staples while Dr. Lund was a patient in the Northern
Pacific Hospital in Saint Paul.
* * *
On August 23, Dr. Linus F. Leitschuh, a former
resident of Minneapolis, was married to Miss Helen
Patricia Carroll in Portland, Oregon, where Dr.
Leitschuh is on the staff of Providence Hospital. A
graduate of the LTniversity of Minnesota in 1937,
Dr. Leitschuh was at Minneapolis General Hospital for
three years, after which he practiced at Red Lake
Falls for one year. He then served in the army for
five years. After January 1, 1948, he will be established
in an obstetrics and gynecology residency at St. Mary’s
Hospital, Minneapolis.
* * *
Two talks on tuberculosis were given by Dr. Kathleen
Iordan, Granite Falls, at meetings held in Virginia and
Ely on September 23. In the afternoon, Dr. Jordan,
whose husband is Dr. Lewis S. Jordan, superintendent
of Riverside Sanatorium in Granite Falls, addressed
a gathering of school superintendents, physicians and
nurses in Virginia, leading a discussion on Mantoux
testing in schools of the area. Dr. Mario Fischer,
Duluth city health director, presided at the meeting.
In Ely, at a dinner meeting that evening, Dr. Jordan
spoke on “The Eradication of Tuberculosis.”
Both meetings were part of the anti-tuberculosis pro-
gram being conducted by the St. Louis County Tuber-
culosis and Health Association.
* * *
Announcement has been made that Dr. Milton D.
Starekow, for the past six years associated with the
Lynde Clinic in Thief River Falls, has purchased the
clinic from Dr. O. G. Lynde, and that Dr. Frank
Fraser, formerly on the staff of St. Vincent’s Hospital
in New York, has become associated with Dr. Starekow
in the practice of medicine and surgery.
A graduate of the Medical College of New York
University, Dr. Fraser served his internship and a
surgery residency at St. Vincent’s Hospital, New
York. He then studied surgery for eighteen months
under Dr. L. K. Ferguson in Philadelphia. During
the war Dr. Fraser served in the navy for three and
one-half years.
* * *
For his aid in planning medical evacuations during
the Normandy invasion, Dr. Einar C. Andreassen, chief
of medical service for the Veterans administration
branch at Fort Snelling, has been awarded the Order
of the British Empire by the king of England.
Dr. Andreassen, who was chief of medical operation
for the U. S. Army in southern England during the
war, will go to Washington to receive the award from
the British ambassador.
Dr. Andreassen, a graduate of the University of
Minnesota in 1917, was a Navy lieutenant during
1104
Minnesota Medicine
OF GENERAL INTEREST
The Birches Sanitarium, Inc.
2391 Woodland Avenue
Duluth 3, Minnesota
A hospital for the care and treatment of
Nervous and Mental disorders. Quiet, cheer-
ful environment. Specially trained personnel.
Recreational and occupational therapy.
Psychiatrists in Charge
L. R. Gowan, M.D. L. E. Schneider, M.D.
World War I. After six years in China as a doctor
with the Lutheran Board of Missions, he set up practice
in Minneapolis. He was called to active military duty
with the Minnesota National Guard in 1941.
* * *
Honorary fellowship in the American Medical
Association has been granted Dr. C. P. Robbins,
Winona, who is now in his fifty-fourth year of medical
practice.
Dr. Robbins, a graduate of Jefferson Medical College
in Philadelphia in 1894, first opened his medical practice
in Winona in 1896 after a year in Los Angeles and a
year of postgraduate surgical study in New York.
During his years in Winona he twice traveled to
Europe for a year of study in Vienna, Berlin and
London. In his earlier years of practice he was a
steady contributor to several medical journals.
Dr. Robbins has been the official Winona County
physician for ten years. He is a life member- of the
Winona County Medical Society and an honorary life
member of the Minnesota State Medical Association.
^ ^
As a one-man commission for the Rockefeller
Foundation, Dr. Irvine McQuarrie, head of the
pediatrics department of the University of Minnesota
Medical School, left for Japan on September 16 to
conduct a three-month survey of medical education
and practice.
Dr. McQuarrie will visit twenty-seven Japanese medical
Homewood hospital is one of the
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schools, inspecting laboratory facilities, clinics, libraries
and hospitals. His report will aid the Rockefeller
Foundation in determining its future support of
Japanese medical training. Dr. McQuarrie also will be
a special consultant to General MacArthur on medical
education.
During his absence, Dr. John M. Adams, associate
professor, will be acting head of the pediatrics de-
partment.
=k * *
Ten orthopedic clinics are being conducted throughout
the state this fall by the State Division of Social
Welfare.
The clinics include examinations by orthopedic
surgeons, diagnosis and recommendation for treatment,
consultation with the patient’s physician, and vocational
advice for children more than sixteen years old. The
service is made possible by state and federal funds and
is part of the crippled children’s service of the welfare
division.
Each clinic conducted in the state serves several
different counties in the area surrounding the site of
the clinic. Cities at which clinics are being conducted
are the following: Winona, ‘ Fergus Falls, Bemidji,
Virginia, Cambridge, Little Falls, Mankato, Crookston,
Willmar, and Marshall.
Organizations co-operating in the program are the
Minnesota-Dakota Orthopedic Society, Northwestern
Pediatric Society, Gillette State Hospital for Crippled
October, 1947
1105
OF GENERAL INTEREST
Children, Division of Vocational Rehabilitation, Minne-
sota Public Health Association, and the Minnesota
State Medical Association.
* * *
Twice within the past year an International Falls
eye, ear, nose and throat specialist has had the unusual
task (for his geographic area) of removing a filaria
parasite from the eye of a patient.
The patient, an ex-missionary, contracted filariasis
between 1925 and 1932 while living in the Belgian
Congo. Not until several years after her return to
the United States did she become aware of the in-
fection. At that time a California physician removed
a filaria parasite from one eye. A year ago, while
living in International Falls, she again noticed a
“wriggling sensation’’ in her left eye. Her local
physician removed an inch-long parasite from the super-
ficial tissues of her eyeball. In August of this year,
she again experienced the same symptom, and for the
second time the International Falls physician hooked out
a filaria parasite, this one 22 millimeters long and
embedded in the lower lid of her left eye.
sj:
Fifty-nine years of medical practice lie behind Dr.
Ward Z. Flowers, Gibbon, who has at last retired in the
community he served for three decades.
After graduating from the University of Illinois
School of Medicine in 1886, Dr. Flowers came to
Minnesota for a brief visit with his sister in Sibley
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County. His love of hunting was so satisfied by the
abundant wild life in that area that he decided to stay
and practice medicine for one year. After twelve
months in Gibbon, he gave up plans to study in Germany
and decided to make Gibbon his home. The hunting
was too good to leave.
Hunting has always been Dr. Flowers’ favorite
recreation. From 1896 until 1940 he never missed an
open season for deer in the United States and Canada.
Though less active now at the age of eighty-six, he still
keeps his guns free from rust for each fall season.
Dr. Flowers practiced in Gibbon for thirty-three
years, and then moved to Minneapolis for another twenty
years of professional work. When his wife died in 1940,
he returned to Gibbon, reopened his practice, and served
the community until 1946. During the past summer,
while Gibbon was without a resident physician, Dr.
blowers was still on call for emergency cases.
* * *
Attorney General J. A. A. Burnquist on September 5
ruled that a school board has power to abolish the
position of school physician but it, has no authority to
contract with a hospital to furnish professional ser-
vices of a physician.
The legal question came up when a school board
in St. Louis County employed a school physician for
the year 1946-47, then in August abolished the position
and made a contract with a local hospital to furnish
physicians to serve the school. The physician whose
position was abolished claimed veterans preference
right to employment and contended his contract was
still in force.
“It was for the school board to decide whether it
would have a school physician,” stated Burnquist. “It
decided to have one for the year 1946-47. The board
had the power to continue or discontinue the employ-
ment. When the board abolished the position, it
determined a policy.”
In regard to the hospital contract, however, the
attorney general emphasized that “a hospital is not a
person and is not licensed to practice medicine.” He
went on, “I fail to understand how in the case under
consideration a hospital can assume to furnish the
services which the law contemplates will be performed
by physicians. In other words, the hospital cannot
practice medicine.”
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Minnesota Medicine
OF GENERAL INTEREST
REST HOSPITAL
A quiet, ethical hospital with therapeutic facilities
for the diagnosis, care and treatment of Nervous
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PSYCHIATRISTS IN CHARGE
Dr. Hewitt B. Hannah
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The attorney general then ruled : “So far as the
board attempted to contract with a hospital to furnish
the professional services .of a physician, it is ,my
opinion that the contract was without effect and, in
fact, was not a contract.”
5}c if:
DR. M. A. BURNS HONORED
Dr. M. A. Burns of Milan was the guest of honor
at festivities held at the Kviteseid Lutheran Church at
Milan, Minnesota, on September 14, 1947. Friends and
townsfolk gathered in large numbers to celebrate ap-
proximately fifty years of faithful and conscientious
service contributed by Dr. Burns to the community.
The idea of the appreciation day festival for the doc-
tor originated among his friends and was carried out
by action of the Milan Commercial Club.
The program started at 2:30 p.m. with Rev. Frank M.
Salveson as master of ceremonies. Rev. R. R. Syrdal,
Madison, former pastor at Milan, pronounced the invo-
cation. This was followed by a song by the Gay Nineties
Quartette of Montevideo. Dr. William A. O’Brien, Min-
neapolis, delivered an address, dwelling on some of the
great advances made in the science of medicine during
the past fifty years.
Dr. Leon G. Smith, Montevideo, told how he and
Dr. Burns have been working pleasantly together in the
practice of their profession. He also presented the
guest of honor with a pin awarded by the Minnesota
October, 1947
State Medical Association for fifty years of medical
practice. Miss Solveig Anderson brought a greeting
from the Milan school in appreciation of the many years
Dr. Burns has served as a member of the local board
of education.
The Rev. Mr. Salveson read a paper written by Dr.
Arnold Anderson of St. Petersburg, Florida, but for-
merly of Milan, telling of many interesting incidents
of the early days in Milan.
A gift in the form of a gold watch was then pre-
sented by the Rev. Mr. Salveson to the honored guest.
It bore the inscription : “Dr. M. A. Burns, 50 Years
of Faithful Service, 1898-1948, Milan Community.”
After Dr. Burns had expressed his appreciation of
the honors shown him, refreshments were served in the
church parlor. In passing down the line to greet the
guest of honor, each person deposited a gift of money
in a large bowl which, with its contents, was later pre-
sented to Dr. Burns.
It was generally agreed that the celebration was a
great success from beginning to end, and served its pur-
pose of expressing the appreciation of the community
to Dr. Burns.
* * *
AMERICAN CONGRESS OF PHYSICAL MEDICINE
Physical medicine stepped into the spotlight on Sep-
tember 2 when the American Congress of Physical
Medicine opened its twenty-fifth annual meeting in the
Radisson Hotel in Minneapolis. An estimated 500 spe-
1107
OF GENERAL INTEREST
cialists in physical medicine attended the five-day ses-
sion which extended through September 6.
On the first day of the meeting a prediction was made
by Dr. Max Newman, head of the physical medicine
''ection at Wayne University, Detroit, that within the
next ten years even small general hospitals in the
United States will expand to include physical and
occupational therapy departments. The new president
of the organization, Dr. H. Worley Kendall of the
University of Illinois, pointed out the great strides that
physical medicine has been making in the rehabilitation
of war veterans and in the return to productivity of
persons injured in industry. “Physical medicine has
become one of the vital agents in keeping American
production in high gear,” he stated.
Among the mechanical devices exhibited at the meet-
ing was an electrical apparatus developed by Dr. Donald
L. Rose, University of Kansas, and Dr. Sedgwick Mead,
Massachusetts General Hospital, that measures the level
of a patient’s ability to withstand pain. It is hoped
that the device will lead to research which will produce
apparatus to stimulate muscles without pain or dis-
comfort of any kind.
Dr. Allan Hemingway, University of Minnesota, dem-
onstrated to the group the value of an oximeter in the
treatment of poliomyelitis, while the essentials of atom
smashing and the development of radioactive elements
were displayed by Dr. Frederic T. Jung of the AM A
Council on Physical Medicine.
Artificially induced fever was shown to be of some
value in the treatment of chronic rheumatoid arthritis
by three Mayo Clinic physicians, Dr. Frank H. Krusen,
Dr. K. G. Wakim, and Dr. E. C. Elkins. Physical exer-
cise, started while tuberculosis patients are still con-
fined to bed, was advocated by Dr. Edwin R. Levine
of Michael Reese Hospital, Chicago.
The importance of games and exercise in the treat-
ment of mental disease was emphasized by Dr. J. E.
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Davis, Veterans Administration chief of corrective physi-
cal rehabilitation, who cited numerous examples to show
that the proper use of games and exercise helps restore
mental balance by developing confidence in the patient
or respect for his fellow men.
At the annual dinner of the organization on the eve-
ning of September 4, the gold key award of the Con-
gress was presented to Dr. A. C. Ivy, physiology pro-
fessor and vice president, University of Illinois; to
Major General Norman T. Kirk, former surgeon general
of the army, and to Lord Thomas Horder, president
of the British Association of Physical Medicine. Dr.
Ivy was the only one of the three present to receive
the citation.
Dr. O. Leonard Huddleston, Los Angeles, was named
president-elect of the Congress, and Dr. Earl C. Elkins,
Rochester, was elected first vice president.
HOSPITAL NEWS
The American College of Hospital Administrators
named Ray Amberg, Rosetown, second vice president
of the organization at a convention held September 22
in St. Louis. Mr. Amberg is superintendent of the
University of Minnesota Hospitals.
* * *
While in Minneapolis in August, Dr. Paul R. Haw-
ley, chief medical director of the Veterans Administra-
tion, stated that the proposed $6,000,000 addition to the
Fort Snelling Veterans Hospital will make the institution
one of the most modern medical centers in the nation.
He said that the hospital already is “one of the out-
standing plants of the world,” including private hospi-
tals, and that much of the credit for the rating must
go to the University of Minnesota for placing its medi-
cal resources behind the hospital.
The new addition will be a centrally placed struc-
ture connected to the other buildings in a spoke-like
arrangement. It will house surgery and clinical depart-
ments and will allow the addition of 300 beds, to give
the hospital a total of 1,100 beds.
* * *
One of the speakers at the forty-ninth annual conven-
tion of the American Hospital Association, held in St.
Louis, September 22 to 25, was Dr. Victor Johnson,
director-elect of the Mayo Foundation for Medical Edu-
cation and Research. Dr. Johnson spoke on “Medical
Education in the Tax-supported Hospital.”
* * *
Rising hospital expenses were explained to the Min-
neapolis public on September 4 by Dr. William A.
O’Brien, chairman of the Minnesota Hospital Associa-
tion’s Council on Public Education, who pointed out that
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Minnesota Medicine
OF GENERAL INTEREST
the hospitals are continually trying to find ways to
cut costs while still maintaining high standards of
service.
Dr. O’Brien described a ten-year cost study at an
“average” hospital which showed that most expenses
have more than doubled in the last decade.
“In 1938 the cost of operating this hospital was $6,400
a month,” he said, “while today it is $13,730. Nursing
service has increased from $1,750 a month in 1938 to
$6,312 in 1947, dietary service from $1,087 to $2,768,
laundry from $450 to $750, housekeeping from $390 to
$824, administration from $904 to $1,598, and plant main-
tenance from $1,123 to $1,384 per month. Likewise,
the hospital’s payroll in 1938 amounted to $4,841 a
month for sixty-five employes, but today totals $17,700
for 125 employes.”
Classified Advertising
Replies to advertisements should be mailed in care of
Minnesota Medicine, 2642 University Avenue, Saint
Paul 4, Minn.
WANTED — Physician as an assistant in excellent gen-
eral practice, with object of buying practice. Address
E-25, care Minnesota Medicine.
WANTED — Medical secretary in busy office. Good sal-
ary. Write Dr. Otto J. Seifert, New Ulm, Minnesota.
FOR SALE — Because of closing hospital, late model
G-E x-ray outfit and portable unit. Write Drs. Hunt
and Hunt, Fairmont, Minnesota.
FOR SALE — Complete x-ray equipment, also all Victor
electrical treatment equipment. Very reasonable. Time
to pay, if required. Address E-36, care Minnesota
Medicine.
POSITION WANTED — Vocational practical nurse,
twenty-four, desires position in Minneapolis doctor’s
office. Willing to learn. Telephone ALdrich 1987,
Minneapolis.
WANTED TO BUY — A recent x-ray machine with
table and Bucky, in excellent condition ; also could
use some office equipment and desk. Address E-42,
care Minnesota Medicine.
FOR SALE — Office building, equipment and medical
practice at Benson, Minnesota. Splendidly located,
modern, one-story brick building, erected about fifteen
years ago; designed for a physician. Reason for sell-
ing— ill health. For additional information, write T.
W. Harding, Benson, Minnesota.
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PRACTICE FOR SALE — Ideal, unopposed general
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equipped. Abundant obstetrics and surgery. Easy
terms. City had three physicians before the war.
Reason for leaving — ill health. Address E-39,
care Minnesota Medicine.
ASSISTANT OR ASSOCIATE WANTED— Busy
Minnesota eye, *ear, nose and throat office. Fine
opportunity. Address E-38, care Minnesota
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FOR SALE — Unopposed, well-established southern Min-
nesota practice. Population. 600. Large territory, good
roads and school. Specializing. Address E-41, c/o
Minnesota Medicine.
LOCUM- TENENS WANTED— Very liberal offer for
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Address E-40, c/o Minnesota Medicine.
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1109
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
INFANT NUTRITION. Fourth Edition. A Textbook
of Infant Feeding, for Students and Practitioners of
Medicine. P. C. Jeans, A.M., M.D., Professor of
Pediatrics, College of Medicine, State University of
Iowa; and Williams McKim Marrioll, B.S., M.D.,
late Professor of Pediatrics, Washington University
School of Medicine; Physician in Chief, St. Louis
Children’s Hospital. 516 pages. Illus. Price, $6.50,
cloth. St. Louis : C. V. Mosby Co., 1947.
OFFICE TREATMENT OF THE EYE. Elias
Selinger, M.D., Attending ophthalmologist Mount
Sinai, Cook County and Michael Reese Hospitals.
542 pages. Illus. Price, $7.75, cloth. Chicago : Year
Book Publishers, 1947.
SYNOPSIS OF ALLERGY. Second Edition. Harry
L. Alexander, A.B., M.D., Professor of Clinical
Medicine, Washington University School of Medicine,
St. Louis ; editor of Journal of Allergy. 255 pages.
Illus. Price $3.50, cloth. St. Louis: C. V. Mosby
Co., 1947.
COMMUNICABLE DISEASES. Second Edition.
Franklin H. Top, A.B., M.D., M.P.H., F.A.C.P.,
Medical Director Herman Kiefer Hospital, Clinical
Professor of Preventive Medicine and Public Health,
Wayne University College of Medicine, etc. 922-
pages. Illus. Price $8.50, cloth. St. Louis: C. V.
Mosby Co., 1947.
A HISTORY OF THE AMERICAN MEDICAL
ASSOCIATION, 1847 to 1947. Morris Fishbein,
M. D. 1226 pages. Illus. Price $10.00, cloth. Phil-
adelphia : W. B. Saunders Co., 1947.
SYNOPSIS OF OBSTETRICS. Third Edition.
Jennings C. Litzenberg, B.Sc., M.D., F.A.C.S.,
Professor Emeritus of Obstetrics and Gynecology,
University of Minnesota Medical School, Minneapolis.
416 pages. Illus. Price $5.50, cloth. St. Louis:
C. V. Mosby Co., 1947.
RYPINS’ MEDICAL LICENSURE EXAMINA-
TIONS. Sixth Edition. Topical Summaries, ques-
tions and answers. Walter L. Bierring, M. D.,
F.A.C.P., M.R.C.P. Edin. (Hon.), editor. 690 pages.
Price $6.00, cloth. Philadelphia : J. B. Lippincott
Co., 1947.
FUNDAMENTALS OF PSYCHIATRY. Fourth
Edition. Edward A. Strecher, M.D., Sc.D., LL.D.,
Litt.D., F.A.C.P., Professor of Psychiatry and
Chairman of Department, Undergraduate and Grad-
uate Schools of Medicine, University of Medicine,
University of Pennsylvania ; psychiatrist to Penn-
sylvania, Philadelphia and Germantown Hospitals,
etc. 325 pages. Illus. Price $4.00, cloth. Phil-
adelphia : J. B. Lippincott Co., 1947.
THE HOSPITAL ACT AND YOUR COMMUNITY. U. S.
Public Health Service, Division of Hospital Facilities. Wash-
ington 25, D. C. : Government Printing Office, 1947. Single
copies, Free. Quantities to 100 copies, 10c each; 100 or
more, $7.50 per hundred.
For those interested in the hospital program, autho-
rized last year by the Hospital Survey and Construction
Act, this booklet tells in simple terms what the Act
means to the individual, the community and the State. It
should be especially valuable to any group or commu-
nity that wants to build a hospital but does not know
how to go about getting Federal aid for construction.
Single copies are available free on request to the U. S.
Public Health Service, Washington 25, D. C. Larger
quantities may be purchased at 10 cents a copy of $7.50
per hundred from the Superintendent of Documents,
Government Printing Office, Washington 25, D. C.
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1111
IT DOES HAPPEN HERE
Severe rickets still occurs — even in sunny climates
Vitamin D has become such an accepted practice in infant feeding that it is easy to think that
rickets has been eradicated. However, even deforming rickets is still seen, as witness the above three
contemporary cases from three different sections of the United States, two of them having well
above the average annual sunshine hours for the country. In no case had any antiricketic been given
during the first two years of life. It is apparent that sunlight did not prevent rickets. In other cases of
rickets, cod liver oil was given inadequately (drop dosage) and even this was continued only during
the winter months.
To combat rickets simply, inexpensively, effectively —
OLEUM PERCOMORPHUM
This highly potent source of natural vitamins A and D, if administered regularly from the first weeks
of life, will not only prevent such visible stigmata of rickets as pictured above, but also many other
less apparent skeletal defects that might interfere with good health. What parent would not gladly
pay for this protection ! And yet the average prophylactic dose of Oleum Percomorphum costs less
than one cent a day. Moreover, since the dosage of this product is measured in drops, it is easy to
administer Oleum Percomorphum and babies take it willingly. Thus there is assurance that vitamin
I) will be administered regularly.
OLEUM PERCOMORPHUM WITH OTHER
FISH-LIVER OILS AND VIOSTEROL
* Potency, 60,000 vitamin A units and 8,500 vitamin D'
units per gram. Supplied in 10 cc. and 50 ee. bottles;
and as capsules in bottles containing 50 and 250.
MEAD JOHNSON & COMPANY, Evansville 21, Indiana, U. S. A
1112
Minnesota Medicine
dci/l/t flte/f/ spotlights the slender, nimble
undulating form of Treponema pallidum to establish
a diagnosis of syphilis. The prognosis may be dark if the patient fails
to receive adequate therapy.
MAPHARSEN is a dependable arsenical, with
years of clinical experience and millions of administered doses
testifying to its effectiveness.
MAPHARSEN is one of a long line of Parke-Davis preparations
whose service to the profession created a
dependable symbol of significance in medical therapeutics —
MEDICAMENTA VERA.
MAPHARSEN ( Oxophenarsine Hydrochloride)
in single dose ampoules of 0.04 gm. and
0.06 gm.; boxes of 10 ampoules. Multiple dose,
hospital size ampoules of 0.6 gm., in boxes of 10.
PARKE, DAVIS & CUMPANY • DETROIT 32, Ml U HID AN
Your Ability to Earn
is your
Greatest Asset
Many disability policies contain the following
clauses:
(1) Standard Provision No. 16 which reads:
“ The Company may cancel this policy ait any time,
etc.” or —
(2) “This policy may be renewed WITH THE CON-
SENT OF THE COMPANY from term to term.”
If a disability policy has one of the above clauses,
you may not have coverage when you most need it.
Don't make your policy part of the hazard of dis-
ability^
Protect your earning capacity with long term, non-
cancellable, incontestable disability insurance.
Write or Call
MASSACHUSETTS INDEMNITY INSURANCE COMPANY
Ralph H. Brastad, Agency Manager
1400 RAND TOWER GENEVA 8319
MINNEAPOLIS 2, MINNESOTA
1114
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 November, 1947 No. 11
Contents
Epidemiology and Recent Developments in Polio-
myelitis.
Joseph G. Molner, M.D., Detroit, Michigan 1145
The Sick Child in Poliomyelitis.
Erling S. Platou, M.D., Minneapolis, Minnesota. . 1149
The Treatment of the Muscular After-effects
of Poliomyelitis.
Miland E. Knapp, M.D., Minneapolis, Minnesota 1152
Recent Advances in the Management of Ear,
Nose and Throat Problems.
Olav E. Hallberg, M.D., Rochester, Minnesota. . 1156
Amebic Abscess of the Liver With Broncho-
hepatic Fistula.
B. I. Heller, M.D., and IV. E. Jacobson, M.D.,
Minneapolis, Minnesota 1161
Clinical Use of Folic Acid.
Marcus A. Keil, M.D., Minneapolis, Minnesota. . 1167
Clinical-Pathological Conference :
Diagnostic Case Report.
Karl W. Emanuel, M.D., Malcolm Gillespie,
M.D., and Arthur H. Wells, M.D., Duluth,
Minnesota
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. (Continued from October
issue.)
Nora Id. Guthrey, Rochester, Minnesota 1178
President’s Letter :
National Physicians’ Committee Calls Confer-
ence of the Professions 1186
Editorial :
Socialism or Free Enterprise? 1188
Typhoid in Minnesota 1189
Topical Sulfa N.G 1190
AMA Directory Information Card 1190
Tuberculosis and Christmas Seals 1190
Medical Economics :
North Central Conference Meets in Saint Paul,
November 23 1192
State Division Rehabilitates 590 Handicapped Per-
sons 1192
Conference Studies National School Health Pro-
gram 1193
Minnesota State Board of Medical Examiners .. 1 195
Minnesota Academy of Medicine :
Meeting of April 9, 1947 1197
The Surgical Treatment of Carcinoma of the
Right Part of the Colon.
Charles W. Mayo, M.D., Rochester, Minne-
sota 1197
Minnesota State Medical Association :
Summary of Proceedings, House of Delegates,
Duluth Session 1202
Woman’s Auxiliary 1208
Reports and Announcements 1210
Of General Interest 1212
Book Reviews 1220
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917. authorized July 13, 1918.
November. 1947
1115
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
G. L. Oppegaard, Grookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — $3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions — $3.50.
The right is reserved to reject material submitted for editorial or advertising columns. The
Editing and Publishing Committee does not hold itself responsible for views expressed either in
editorials or other articles when signed by the author.
Classified advertising — five cents a word; minimum charge, $1.00. Remittance should ac-
company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
ST. CROIXD ALE ON LAKE ST.
PRESCOTT. WISCONSIN
CROIX
MAIN BUILDING— ONE OF the 8 UNITS IN “COTTAGE PLAN”
A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous and Mental Disorders
Located on beautiful Lake St. Croix, eighteen miles from the Twin Cities, it has the advantages of both
City and Country. Every facility for treatment provided, including recreational activities and occupational
therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
NEUROPSYCHIATRISTS
PRESCOTT OFFICE
Prescott, Wis.
Howard J. Laney, M.D.
Tel. 39 and Res. 76
Hewitt B. Hannah, M.D.
Joel C. Hultkrans, M.D.
Howard J. Laney, M.D.
511 Medical Arts Building
Minneapolis. Minnesota
Tel. MAin 1357
SUPERINTENDENT
Dorothy M. Most, R.N.
Prescott, Wisconsin
Tel. 69
1116
Minnesota Medicine
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(Available first time in medical districts not listed below.)
CASWELL-ROSS AGENCY
The Commercial Casualty Insurance Company
1177 Northwestern Bank Bldg. • Minneapolis
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Investigated and Recommended by:
Minneapolis District Dental Society
Minnesota State Dental Society
Minnesota State Pharmaceutical
Minnesota State Bar Association
Hennepin County Bar Association
Ramsey County Bar Association
West Central District Dental Society
Hennepin County Medical Society
Ramsey County Medical Society
St. Louis County Medical Society
Stearns-Benton County Medical Society
East Central Medical Society
11th Judicial Bar Association
St. Paul District Dental Society
November. 1947
1117
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WITH
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IS ASSURED
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Immediate Delivery!
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Protractor eliminates technical errors
Write for free descriptive booklet
C. F. ANDERSON CO., Inc.
Surgical and Hospital Equipment
901 MARQUETTE AVENUE MINNEAPOLIS 2. MINN.
1118
Minnesota Medicine
Facts regarding
of PENICILLIN in oil and wax
When penicillin in oil and wax is to be used once daily, the most important
consideration is the maintenance of therapeutic blood levels for 24 hours.
For easy administration and adequately sustained blood levels, the
formula must be neither too viscous nor too fluid . . . the penicillin crystals of
correct size, shape and density . . . the container appropriate to the use
intended. The following should also be recognized:
1 For administration from multiple-dose vials, the mixture should be sufficiently
fluid to permit easy withdrawal, accurate measurement and easy injection.
2 In all fluid preparations, however, the penicillin has a tendency to settle out.
Unless the container has adequate air space and volume to permit resuspen-
sion of the settled penicillin by shaking, 24 hour blood levels may not be
maintained. Either overdosage or underdosage may result.
3 When injected from individual-dose cartridges, the penicillin in oil and wax
suspension should be of slightly thicker consistency. If it is not, and the
penicillin settles out, it cannot be resuspended by shaking, because (a) the
volume is too small, and (b) the cartridge has no air space.
4 The slightly heavier type of suspension can be easily injected in accurate
dosage with a minimum of discomfort to the patient. It is essentially free-
flowing at room temperature, and each cartridge contains a full 1 cc. (300,000
unit) dose, which eliminates the need of measuring.
In keeping with Squibb policy of making the form of the product appropriate
to the use, two forms of Squibb Penicillin G in Oil and Wax are available.
Each offers the advantages of proper formula and consistency.
For easy, individual injections in home, office and emergency:
SQUIBB PENICILLIN G IN OIL AND WAX
Essentially free-flowing at room temperature: in Double-cell Cartridges for
use with B-D* disoosable or permanent syringe.
X *T. M. REG. BECTON, DICKINSON & CO.
For easy, mass injections in clinic, hospital, or office, the neiv 10 cc. vial of
SQUIBB LIQUID PENICILLIN G IN OIL AND WAX
Resuspension readily attained; easy to inject; no withdrawal difficulties.
November. 1947
1119
For all doctors whose practice includes Ob-
stetrics, Internal Medicine, Dermatology, Pedi-
atrics or Orthopedics.
The Hanovia Luxor Alpine Lamp is especi-
ally designed and manufactured for maximum
production of the complete ultraviolet spec-
trum including short, medium and long wave
lengths. These are recognized as the most ef-
fective for all therapeutic purposes.
DOCTORS...
UJsl fornmnumd,
thsL Thw
HANOVIA
LUXOR
ALPINE LAMP
Among the many beneficial applications of
ultraviolet radiation are:
Skin Diseases — Surgery — Rickets — Infantile
Tetany — Erysipelas — Tuberculosis of the Bone
— Secondary Anemia — Etc.
Complete information mill be furnished upon request.
Write for our Hanovia Catalog No. MM-1147
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
MINNEAPOLIS MINNESOTA
1120
Minnesota Medicine
ethics of the medical profession and the
temptations of the market place in the field of anatomical supports. Here the stand-
ards of the businessman must be elevated to the standards of the doctor because the
customer of the businessman is the patient of the doctor. Anything else is “merchan-
dising quackery.” We at Camp have for many decades controlled our distribution
throughout the recognized retail institutions which, like the doctor have earned the
respect and confidence of their home communities. No appeal is used in our adver-
tising approach to the consumer which fails to meet the precepts of the profession.
\
We serve the physician and surgeon by living up to our chosen function of supplying
scientific supports of the finest quality in full variety at prices based on intrinsic
value. We try to insure the precise filling of prescriptions through the regular
education and training of fitters. In cooperation with medical and edu-
cational public health authorities we play the role our resources
permit in promoting better posture and body mechanics.
That is our idea of the practical ethical standards which
permit the businessman to solicit the recommen-
dation of the doctor. Camp Anatomical Sup-
ports have met the exacting
test of the profession for four
decades. Prescribed and recom-
mended in many types for prenatal, post-
natal, postoperative, pendulous abdomen, vis-
ceroptosis, nephroptosis, hernia, orthopedic and
other conditions. If you do not have a copy of the
Camp “Reference Book for Physicians and Surgeons” ,
it will be sent upon request.
C/yyVP ANATOMICAL SUPPORTS
S. H. CAMP & COMPANY • Jackson, Michigan • World’s Largest Manufacturers of Scientific Supports
Offices in CHICAGO • NEW YORK • WINDSOR, ONTARIO • LONDON, ENGLAND
'November. 1947
1121
"don’t smoke”.
IS ADVICE HARD FOR
PATIENTS TO SWALLOW!
May we suggest, instead,
Smoke “Philip Morris ” ?
Tests* showed 3 out of every
4 cases of smokers’ cough
cleared on changing to
Philip Morris. Why not
observe the results for
yourself?
* Laryngoscope, Feb. 1935, Vol. X LV , No. 2, 149-154
TO THE PHYSICIAN WHO SMOKES A PIPE: We suggest an unusually fine new blend — COUNTRY
Doctor Pipe Mixture. Made by the same process as used in the manufacture of Philip Morris Cigarettes.
1122
Minnesota Medicini
"AMERICAN
MEDICAL
::d COWS' MSl>
of Milk f at, Milk Suq«!
*0©mON OF »
W FHQSPH^tC AHO iSOW ,
Successful in Infant Nutrition
= FORMULA
7Vi FLUID OUNCES
20 CALORIES
PER OUNCE
LACTOGEN +
1 LEVEL TABLESPOON
40 CALORIES
(APPROX.)
FORMULA
2 FLUID OUNCES
20 CALORIES
PER OZ. (APPROX.)
DEXTROGEN
1 FLUID OUNCE
50 CALORIES
+ WATER
l’/2 OUNCES
2 OUNCES
No advertising or feeding directions, except
to physicians. For feeding directions and pre-
scription pads, send your professional blank to
Nestle’s Milk
Products, Inc.
155 EAST 44th ST., NEW YORK, 17, N. Y.
November. 1947
1123
PYOKTANIN SURGICAL GUT
Plain and 'Jomalijed
Manufactured Since 1099 by
The Laboratory o( the Ramsey County Medical Society
Packaged dry in hermetically sealed glass tubes in accord-
ance with the new requirements of the U. S. Pharmacopoeia.
I • •
Price iUt
PLAIN TYPE A NONBOILABLE
AND
FORMALIZED TYPE C NONBOILABLE
Sizes 000 — 00 — 0—1 — 2 — 3
28 inches per dozen strands $2.00
60 inches per dozen strands $3.00
Special discount to hospitals and to the
trade. Cash must accompany the order.
« I •
Address
LABORATORY RAMSEY COUNTY MEDICAL SOCIETY
Lowry Medical Arts Building, St. Paul, Minnesota
FOR SALE BY SURGICAL DEALERS AND DRUGGISTS
1124
Minnesota Medicine
Outstanding clinical endocrinologists, both here and abroad, have commented on the brighter
mental outlook displayed by women receiving "Premarin." Not only does "Premarin, impart a
feeling of "well-being" but it offers many other advantages as well.
It is orally active.
It is well tolerated.
It is promptly effective in controlling the menopausal syndrome.
"Premarin" is supplied in three potencies —tablets of 2.5 mg , 1.25 mg. and 0.625 mg. It is also
available in liquid form containing 0.625 mg. in each 4 cc. (l teaspoonful).
While sodium estrone sulfate is the principal estrogen in "Premarin," other equine estrogens . . .
estradiol, equilin, equilenin, hippulin . . . are also present in varying small amounts, probably as
water-soluble sulfates. The water solubility of conjugated estrogens (equine) permits rapid ab-
sorption from the gastrointestinal tract.
Mi
.
CONJUGATED ESTROGENS
(equine)
AYE RST, McKENNA & HARRISON Limited
22 EAST 40th STREET • NEW YORK 16, N. Y.
November, 1947
1125
He sees that first-downs are measured accurately, but he lets his diet be measured
by the whims of his appetite. Sooner or later he faces the penalty of sub-
clinical vitamin deficiency — along with a host of other self-made victims: food-
faddists , excessive smokers, alcoholics, those on self-imposed and ill-advised
reducing diets, patients "too busy” to eat properly, to name only a few.
When such patients come to you, dietary reform is your first thought.
Your second may well be a suitable vitamin supplement. For these cases,
consider the advantages of specifying Abbott Vitamin Products: known
quality . . . assured potency . . . wide variety to fit every vitamin need — in
supplemental or therapeutic levels of dosage, in oral or parenteral
forms, in single or multiple vitamin preparations. Abbott Vitamin
Products are readily available at all prescription pharmacies.
Abbott Laboratories, North Chicago, Illinois
p *
f 'f
f»*°
1126
Minnesota Medicine
SUBSTANTIATE YOUR DIAGNOSES
with this G-E PORTABLE X-RAY
ENERAL (g) ELECTRIC
-RAY CORPORATION
General Electric X-Ray Corporation
Dept. 2690, 175 W. Jackson Blvd.
Chicago 4, Illinois
Send me G-E "Portable X-Ray” booklet
This powerful, 100 per cent shock-
proof x-ray, atop your office desk or
in the home of your inambulant
patients — provides you with a sure
way of obtaining information you
desire to substantiate your diagnoses.
It’s easy to operate. With its sim-
plified control you can easily and
quickly make examinations of pos-
sible fractures, gross pathologies and
foreign bodies with satisfying results.
It’s the lightest unit of its compact-
ness and flexibility ever built— comes
in a neat carrying-case ... is easy to
assemble and disassemble. And be-
cause of its low cost is well within
reach of every practicing physician.
To learn all the advantages
of owning this popular G-E
Portable X-Ray, clip this cou-
pon now . . . mail it today.
Name.
Address.
City.
State or Province.
Clll
November. 1947
0 0 9#
1127
HH
(j 'me/iwiT
THE
Music provides a retreat
from the anxieties and cares of
the moment, where, in imagina-
tion, you live in a world care-
free and gay.
The superb new Capehart
offers you preferred passage
to this wonderland of music.
This magnificent instrument re-
creates the living presence of
the artists and instruments
themselves as it flawlessly re-
produces the recorded music
of your choice.
.
Model illustrated is the
Capehart Georgian
McGowans
23 W. SIXTH ST.
ST. PAUL 2, MINN.
1128
Minnesota Medicini
The development of Streptomycin Calcium Chloride
Complex Merck constitutes an important advance in
Streptomycin therapy. This improved form of Streptomycin
provides these noteworthy advantages:
Anmuncma
NEW
IMPROVED
FORM OF
STREPTOMYCIN
• INCREASED PURITY
• MINIMUM PAIN ON INJECTION
• UNIFORM POTENCY
STREPTOMYCIN
CALCIUM CHLORIDE COMPLEX
MERCK
MERCK & CO., Inc. *A(a*n*fizctutinp c€/ienu&fo RAHWAY, N. J.
In Canada: MERCK & CO., Ltd. Montreal, Que.
LITERATURE AVAILABLE
ON REQUEST
November. 1947
1129
ii
■ y
.
mm
1 Extensive clinical experience
• has established that the com-
bined use of an occlusive dia-
phragm and a spermatocidal
jelly affords the optimum in pro-
tection to the patient.
2 A comprehensive report
• shows an overwhelming
preference for the diaphragm-
jelly technique of conception
control. In a survey comprising
36.955 cases, clinicians pre-
scribed this method for 34,314
or 93 per cent1
3 Warner,2 in a study of 500
• cases in private practice,
concludes that the combined
technique is the most efficient
JULIUS SCHMID, INC. 423 W. 55th ST. • NEW YORK 19, N. Y.
/S83
The word "RAMSES” is a registered trademark ol Julius Schmid, Inc.
tActive ingredients: Dodecaethyleneglycol
monolaurate 5%; Boric Acid 1%; Alcohol 5%.
method; there was no case of
unexplained failure.
4 For the optimum of protec-
• tion and simplicity in use
we suggest the "RAMSES" Pre-
scription Packet NO. 501 ... a
complete unit, containing a
"RAMSES" Patented Flexible
Cushioned Diaphragm of pre-
scribed size, a "RAMSES" Dia-
phragm Introducer of corre-
sponding size, and a large tube
of "RAMSES" Vaginal Jelly.t
Available through all prescrip-
tion pharmacies. Complete lit-
erature to physicians on request
‘Human Fertility 10: 25 (Mar.) 1945.
Earner, M. P.: J.A.M.A. 115: 279 (July
27) 1940.
mm
■
r ' * f*
sMm
IS
PRESCRIPTION PACKET
Gvtn&es
NO. 501
1130
Minnesota Medicine
Recent statistics indicate that more than
10 per cent of all peptic ulcers occur in
persons past the age of 60. Except for
a greater tendency to bleed, ulcers in
the aged are no different from those in
younger persons and require essentially
the same therapeutic program of rest,
diet and acid neutralization.
Creamalin, the first aluminum hydroxide
gel, readily and safely produces sus-
tained reduction in gastric acidity. With
Creamalin there is no compensatory
reaction by the gastric mucosa, no acid
"rebound/' and no risk of alkalosis.
Through the formation of a protective
coating and a mild astringent effect,
nonabsorbable Creamalin soothes the
irritated gastric mucosa. Thus it rapidly
relieves gastric pain and heartburn, and
helps in the healing of peptic ulcers as
well as in the prevention of a recurrence.
( Creamalin® )
First Brand of Aluminum Hydroxide Gel
Supplied in 8 fl. oz., 12 fl. oz. and 16 fl. oz. bottles
November. 1947
The businesses formerly conducted by Winthrop Chemical Co., Inc.
and Frederick Stearns & Co. are now owned by Winthrop-Stearns In:.
1131
MEAT
Md Protein Deficiency
While protein deficiencies per se are difficult to recognize in their
incipiency, conditions which lead to negative nitrogen balance are
well known. The presence of any of the following states which
characteristically exert an adverse influence on nitrogen balance,
calls for immediate measures to prevent serious protein depletion:
i. Diseases of the digestive organs, which impair proper
digestion and absorption.
a. Wasting diseases, infections and thyrotoxicosis, which
increase protein breakdown and need far above normal
levels.
3. Hemorrhage, burns, and chronic exudative processes,
causing excessive loss of protein.
A high protein diet, whenever possible, is considered to be the
most effective method of protein administration in the prevention
and correction of protein deficiencies.
Meat, which readily is eaten two or more times daily, is an
excellent component of the high protein diet. Meat is an out'
standing source of protein for the following reasons. The protein
of meat is biologically complete, capable of satisfying the body’s
protein needs. The percentage of protein contained in meat makes
it one of man’s most important protein foods. And, all meat is
highly digestible— 96 to 98 per cent — an important consideration
especially in the presence of disease.
The Seal of Acceptance denotes that the nutri-
tional statements made in this advertisement
are acceptable to the Council on Foods and
Nutrition ofthe American Medical Association.
AMERICAN MEAT INSTITUTE
MAIN OFFICE, CHICAGO . . . MEMBERS THROUGHOUT THE UNITED STATES
1132
Minnesota Medicine
Yes, and experience is the best teacher in smoking too!
EXPERIENCE during the wartime cigarette
shortage taught smokers the differences in
cigarette quality. In those days, people smoked
— and compared — many different brands. That’s
the experience from which so many smokers
learned that Camels suit them best. As a result,
more people are smoking Camels than ever
before.
Try Camels ! Let your taste and throat tell you
why, with millions who have tried and compared.
Camels are the choice of experience !
According to a Nationwide survey.
More Doctors smoke Camels
R. J. Reynolds Tobacco Company, Winston-Salem, North Carolina
than any other cigarette
November. 1947
1133
TABLETS
PURODIGIN®
MYSTALU* CHClTOKtN
C*uriO» T« b. Mt, b, ». ,
<*» pivKnpbM tJ a ptTS(U» OSKIoxul
OM vUI b> u^plxtf Is m,UDMl os ,w
reisoN
WYETH INCORPORATED
For oral use 0.2 mg. tablets — vials of 30, bottles of
100 and 500; 0.1 mg. tablets — bottles of 100 and
500 • For intravenous injection: 1 cc. ampuls, 0.2 mg.
1
Purodigin has these advantages:
PRECISE DOSAGE: Purodigin (Digitoxin Wyeth) is absolutely
uniform . . . standardized by weight, prescribed by weight.
LACK OF IRRITATION: Purodigin is concentrated — dosage is
only one thousandth that of digitalis leaf. Nausea is rare.
ABSORPTION of Purodigin is virtually complete. Almost no
irritating residue is left in the digestive tract.
SUSTAINED ACTION: Purodigin remains in the body as long
as digitalis.
Try Purodigin — especially for those patients who do not easily tolerate
digitalis leaf. Without interrupting treatment, simply prescribe 0. 1-0.2
milligram Purodigin in place of 0. 1-0.2 gram digitalis.
PURODIGIN'
CRYSTALLINE DIGITOXIN
WYETH INCORPORATED . PHILADELPHIA 3, PA.
1134 Minnesota Medicine
Replacing turmoil with serenity for women under-
going menopausal disturbances has become a matter
of comparatively specific therapy
Choice of an estrogenic product in this condition
is likewise well charted. For optimum relief
of symptoms, the competent physician selects a
product whose manufacturing history he need
never question.
This, perhaps, may account for the wide use of
Solution of Estrogenic Substances, Dorsey. Made by
Smith-Dorsey Company, whose plant facilities,
personnel and procedure are above reproach, these
products merit the continuing confidence of
careful doctors.
Dorseij
Solution of Estrogenic Substances
November, 1947
1135
THE SMITH-DORSEY COMPANY, Lincoln, Nebraska
BRANCHES AT LOS ANGELES AND DALLAS
recent definitive findings on
Benzedrine Sulfate
in the treatment of overweight
A conclusive study* on the action of
amphetamine in weight reduction
brings out four significant points:
1. With Benzedrine Sulfate "the
obese subjects lost weight when
placed on a diet which allowed them
to eat all they wanted three times a
day . . Later, these same over-
weight subjects continued to lose
weight when allowed to eat — if
they so desired — before retiring.
2. . . amphetamine definitely de-
creased the intake of food. . .”
3. ". . . amphetamine-induced loss
of weight is almost entirely due to
anorexia.”
4. "No evidence of toxicity of the
drug as employed in these studies
was found.”
*Harris, S.C.; Ivy, A.C., and Searle. L.M.:
The Mechanism of Amphet amine- Induced
Loss of Weight: A Consideration of the
Theory of Hunger and Appetite. J.A.M.A.
734:1468 (Aug. 23) 1947.
Smith, Kline & French Laboratories, Philadelphia
Benzedrine Sulfate
( racemic amphetamine sulfate , S.K.F.)
tablets capsules elixir
Accepted by the Council
on Pharmacy and Chemistry of the AMA
tor use in treatment of overweight.
Minnesota MEmciNF.
• _ •
sensitive
when milk
becomes "forbidden food"
• When children (infants and
adults, too) are unable to tolerate
the animal proteins in cow’s
milk, MULL-SOY— the emulsified soy
concentrate— is the replacement
of choice. It is highly palatable, and
easily digestible, without the
offending proteins of animal origin
• MULL-SOY is a biologically
complete vegetable source of all
essential amino acids. In standard
1:1 dilution, it also provides
the other important nutritional
factors of fat, carbohydrate and
minerals in quantities that closely
approximate those of cow’s milk.
• To prepare MULL-SOY, simply
dilute with equal parts of water.
BORDEN’S PRESCRIPTION PRODUCTS DIVISION
350 MADISON AVENUE, NEW YORK 17, N. Y.
In Canada write The Borden Company , Limited , Spadina Crescent, Toronto
S'mTiM'lwr.lmlS
mull-soy
MULL-SOY is a liquid hypoallergenic food prepared from water,
soy flour, soy oil, dextrose, sucrose, calcium phosphate, calcium
carbonate, salt and soy lecithin,- homogenized and sterilized.
Available iji 1 5/x fl. oz. cans at drug stores everywhere.
November. 1947
1137
Safeguard If cut
Professional Reputation
USE MERCHANDISE OF DEPENDABLE QUALITY
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Kalman & Company, Inc.
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ST. PAUL MINNEAPOLIS
AT YOUR CONVENIENCE,
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1138
Minnesota Medicinf
"(Parenteral) Amino acids find their greatest usefulness preoperatively
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"Complete parenteral feeding has the advantage of producing com-
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Parenamine
PARENTERAL AMINO ACIDS STEARNS
FOR PROTEIN DEFICIENCY
PARENAMINE i$ a 15 per cent sterile solution of all the
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FOR USE alone or as a supplement to high protein diets
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ADMINISTER diluted with three or four parts of 5 per cent
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SUPPLIED AS Solution 15% in 100 cc. rubber-capped bottles.
1. Editorial: J A. M. A. 121:346, 1943 Trade-Mark Parenamine Reg. U. S. Pat. Off.
2. Nadal, J, W.: Northwest Med. 46:444, 1947
3. Sprinz, H>f. M. Clin. North America 30: 363, 1946
4. Brunschwig, A., Clark, D. E.. and Corbin, N.: Mil. Surgeon 92:413, 1943
November. 1947
1139
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Minnesota Medicine
“Beginner’s luck”
isn’t always good
The good luck so often attributed to beginners can’t be counted on in
infancy. Here the "beginners" often meet insurmountable oostacles which
have raised the proportion of infant deaths within the first 30 days to
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proper selection of the first fonnula is therefore of vital importance.
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'Dexin* Reg, Trademark
Literature on request
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November. 1947
1141
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A completely equipped sanitarium for the care of
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offering all forms of treatment, including electric shock.
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Human Convalescent Serums
are available lor prevention or treatment
HYPER-IMMUNE PERTUSSIS
MUMPS SCARLET FEVER
POLIOMYELITIS MEASLES
POOLED NORMAL SERUM
Address or telegraph communications or
requests to
Human Serum Laboratory
West-108, University Hospital
Minneapolis 14, Minn.
Main 8551, Ext. 276 24-hour Service
BROWN & DAY, INC
St. Paul 1. Minnesota
1142
Minnesota Medicine
No. 208 in the “See Your Doctor” series
. . . published in behalf of the medical profession
° in a sen?
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Prescribed
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To an audience of over 23 million people, in LIFE and
other national magazines, Parke- Davis presents the mes-
sage shown below.
A reproduction in full color will be sent on request.
Write to Parke, Davis & Company,
Detroit 32, Michigan.
November, 1947
1143
TfcTJ/ut 1 \fmmv UmiBtm . . .
Medicine and Dentistry rhank Belgium's Vesalius (1514-1564) for the first accurate
knowledge of human anatomy. Galen’s knowledge of monkeys, dogs and pigs had
been gospel for 1,350 years. But what of the human body? Vesalius, who at 23 held Padua’s
first chair of anatomy, robbed scaffolds of charred criminals until he could name every
human bone, even when blindfolded.
His great book (printed, like the Copernican theory, in 1543 — 11 years after Jordan’s
book on teeth and a year before Ryff’s on the correct number of tooth roots) showed no
vena cava arising from the liver, no imputrescible heart bone, no opening between the
2 ventricles, etc. He had brought honest observation to anatomy.
A doctor’s responsibility was greater, too, after 1200 A.D. Under Europe’s "modern”
Roman Law, he was liable not only for intentional injury, but for use of less than "stand-
ard" knowledge or skill.
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1144
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30
November, 1947
No. 11
EPIDEMIOLOGY AND RECENT DEVELOPMENTS IN POLIOMYELITIS
JOSEPH G. MOLNER, M.D.
Deputy Commissioner and Medical Director, Detroit Department of Health
Detroit, Michigan
POLIOMYELITIS as a disease has attracted
the attention of lay individuals, laboratory
workers and members of the medical profession
for well over a century and a half. The recogni-
tion of the existence of the disease is noted by
many as dating back to 1600 B.C. Actually, the
first good clinical description of the disease is
made by Underwood in a paper entitled "Debility
of the Lower Extremities” published by J. Mat-
thews in London, England, in 1789.
In recent years a great deal of interest has
been manifest in this disease. This interest has
centered around the mode of transmission of the
disease, prevention and treatment. A great deal
of progress has been made in these particular
fields, but the sum total of our knowledge of the
disease is still rather limited — limited at least from
the point of view of practical application.
Etiology. — Although there are proponents of
the bacterial etiology of the disease, it is generally
recognized that the causative agent is a virus.
There is also general agreement that the polio-
myelitis virus is a neurotropic virus which prob-
ably is disseminated through the body by passage
along the nerve fibers. More specifically, Toomey
16,17 believes that the virus travels best along non-
medullated or gray nerve fibers,.
In 1909 Flexner and Lewis7 described a virus
as the etiological agent in this disease and de-
scribed in detail their experimental work with the
M. Rhesus monkey. By cerebral inoculation of
Read in Symposium on Management of Poliomyelitis at the
annual meeting of the Minnesota State Medical Association,
Duluth, Minnesota, July 2, 1947.
November. 1947
macerated spinal cord tissue, experimental ani-
mals developed a disease closely simulating in-
fantile paralysis. The isolation of this virus and
experimental work herein described have been re-
peated many times since.
The Portal of Entry. — Although it is generally
agreed that the virus of poliomyelitis is a neuro-
tropic virus which enters the central nervous sys-
tem by traveling along nerve tracts, there has
been no agreement as to ways and means by which
this virus reaches the nerve tracts. There are two
concepts which may be mentioned as to the portal
of entry of the virus, namely, the nasopharynx
and the intestinal tract.
Toomey16’17 is the principal proponent of the
gastrointestinal route of entry. By experimental
inoculation of the virus into the gastrointestinal
tract, Toomey was able to produce a disease in
monkeys which simulated poliomyelitis. Llowever,
he was obliged to create severe stagnation of the
gastrointestinal tract before he could promote the
development of this condition in his experimental
animals. Other investigators are of the opinion
that such unusual stagnation is probably non-
existent normally, and therefore the gastrointes-
tinal work of Toomey and his associates should
be looked upon as additional good scientific in-
formation without a great deal of practical appli-
cation value.
Sabin and his associates15 are proponents of the
olfactory route of entry. This theory probably has
more supporters than any other theory. Propo-
nents of the theory point out that the virus has
1145
RECENT DEVELOPMENTS IN POLIOMYELITIS — MOLNER
been isolated from the nasopharynx of patients and
apparently healthy carriers ; further, that the epi-
demiological characteristics of the disease sug-
gests a droplet type of infection. Supporters of
this theory also point out the ease with which
entrance into the olfactory system might be
brought about through the nasopharynx. Certain-
ly the virus has been isolated in acute cases from
the nasopharynx. All of these facts taken together
are strongly suggestive of the nasopharyngeal
route of entry of the virus.
Escape. — The escape and liberation of the virus
from the human body have been repeatedly studied
and innumerable publications are available for
study.11 The virus of poliomyelitis has been iso-
lated from the stools and nasopharynx of appar-
ently healthy carriers as well as persons acutely ill
with the disease. The virus in the nasopharynx
is usually present only for relatively short periods
of time. The virus, however, may be present in
the gastrointestinal tract weeks before the onset of
clinical symptoms5 and for months after the acute
symptoms have subsided. There is, of course, a
question which arises in the minds of investigators
as to whether or not the primary localization of the
virus is in the upper respiratory tract and that
the gastrointestinal localization is secondary and
is brought about by the swallowing of sputum
contaminated with the virus.
Reservoirs. — Although extensive research work
has been directed at the recognition of reservoirs
of this virus, there is but one definite reservoir
known, namely, that of the human being. The
reported recovery of the virus of poliomyelitis
from a mouse found dead in a home where there
had been a case of poliomyelitis only adds greater
confusion to an already confused situation. To
the best of the speaker’s knowledge, this finding
has not been repeated. Fowl, birds, rodents and
various other animals have been examined but
without a satisfactory recognition of the polio-
myelitis virus.
The virus has been isolated from sewage12 and
it has been shown that it will resist10 the effect
of chlorine in concentrations of 0.5 per 1,000,000
parts for over a half hour. There have been
variously reported outbreaks which, according to
the epidemiological evidence, would tend to in-
criminate food and milk, but all of these factors
are affected by missing links of information and
certainly it has been repeatedly pointed out that
the pattern of behavior of poliomyelitis is such
that it does not correspond with the characteristic
behavior of food- or water-borne infections.
The recognition of the virus in the nasopharyn-
geal secretions of persons affected with the disease
and the recognition of the virus in sewage12’13’14
and its presence in the stools of apparently healthy
persons11 lend emphasis to the significance of the
human reservoir. The repeated recognition of the
virus in apparently healthy human carriers and
the rapid development of the carrier state is re-
ported by Brown, Francis and Pearson. Certainly
the report of the recognition of the virus of polio-
myelitis in the stool of an apparently healthy in-
dividual, nineteen days before the development of
clinical symptoms,5 is a notable contribution to the
knowledge of poliomyelitis.
Mode of Transmission. — There is no definite
agreement as to the mode of transmission of this
disease. The virus of poliomyelitis has been iso-
lated from the nasopharyngeal washings of ap-
parently healthy individuals as well as those suf-
fering from the disease. It has been isolated
from sewage, from food and from the gastro-
intestinal tract of flies. This wealth of confusing
facts only lends further confusion to the possible
ways and means by which this disease is trans-
mitted. It has also been proposed, only because
of some epidemiological evidence, that possibly
the disease is transmitted by insect vectors.
Certainly the epidemiological characteristics of
the disease are such that they do not coincide with
water- or food-borne diseases. Water- and food-
borne epidemics are usually explosive in nature
and affect large numbers of people simultaneously.
Usually epidemics of poliomyelitis are progressive,
develop gradually, show evidences of radial spread
and reach their peaks within several weeks from
the date of onset. The distribution of cases within
the area affected is scattered with occasional ag-
gregation, while in water-borne epidemics the
distribution is somewhat more uniform. The at-
tack rate of poliomyelitis in urban epidemics sel-
dom exceeds one per thousand, and in rural epi-
demics the attack rates seldom exceed three per
thousand. In food- and water-borne outbreaks
the attack rate among exposed persons is usually
much higher.
One cannot too emphatically discount the food
1146
Minnesota Medicine
RECENT DEVELOPMENTS IN POLIOMYELITIS— MOLNER
and water bases as the modes of transmission be-
cause, as has been noted many times, the rate of
infection with poliomyelitis virus probably far
exceeds the incidence of reported cases. Pro-
ponents of the food- and water-borne mode of
transmission therefore have this very important
argument in their favor.
Probably the oldest and the best theory of the
mode of transmission of poliomyelitis is that of
person-to-person contact and droplet infection.
Certainly the number of persons succumbing to
the disease who have had contact with other cases
is statistically significant. In investigation which
has been carried on, evidence of contact with
cases has been reported as high as 601 to 80' per
cent. There are contradictory points to this meth-
od of transmission. The low secondary attack
rate, intra, and extra-familially, is certainly sug-
gestive of some important extrinsic or intrinsic
factors limiting the occurrence of secondary cases.
There is also the important fact that additional
cases in families and households may develop in
subsequent years in persons who escaped the first
exposure.
Age, Sex, and Race Distribution. — The disease
affects primarily persons between the ages of five
and fourteen years of age, with a reasonably high
incidence under four and with greatest concentra-
tion of cases between five and nine years. The
disease, however, does affect persons of all ages,
and the writer has had the experience of seeing
a patient seventy years of age and has seen polio-
myelitis in a newborn infant.
By sex, the distribution of the disease shows a
somewhat greater incidence among males than
among females, the ratio being approximately 1.4
males to one female. A great deal has been said
and written about the racial distribution of polio-
myelitis, depending almost entirely upon the sec-
tion of the community or section of the country
which is affected. The writer and his associates
have not been able to show any difference in the
race distribution of poliomyelitis. In individual
epidemics difference of significant amount has not
been noted, and over a period of many years the
attack rate among Negroes and whites is approxi-
mately the same. The differences which have been
noted in attack rate by race were due to geographic
or area location of the epidemic.
The rural as against the urban incidence of the
disease is noteworthy. In the most severe urban
outbreaks the incidence of the disease seldom ex-
ceeds one per 1,000 population while in rural areas
when epidemics occur the attack rates are two or
three times as great as in urban areas. As a matter
of fact, the actual incidence of the disease is much
greater in rural areas than in urban. The rural
incidence of poliomyelitis is so much greater that
it is frequently referred to as primarily a rural
disease. The Henderson County outbreak of 1945
in Tennessee is a good illustration of this observa-
tion.
There is a definite seasonal variation of the
disease. It has been repeatedly noted that polio-
myelitis has an apparent selective occurrence both
as to season and individuals. Epidemics seem tO'
occur in summer and early fall, and, as pre-
viously noted, clinical poliomyelitis affects but a
very few persons who live in the epidemic area.
Seasonal Variation. — The seasonal variation is
of significant epidemiological importance because
coupled with this seasonal variation is the fact
that the incidence of paralytic disease in areas
where seasonal changes are not so radical is con-
siderably lower than in the more temperate cli-
mates where the seasons change and change radi-
cally. This has brought about the prognostication
that possibily there is something in the physiology
of the human being which in part at least is re-
lated to the possibility of successful and clinical
invasion of the virus. In other words, the prog-
nostication is that a certain percentage of the
people in these areas fail to make adequate physio-
logical adjustments with the varying climate and
season, with the end result that the infection with
poliomeylitis virus results in clinical disease. On
the other hand, the person whose physiology fol-
lows a more favorable pattern of adjustment is
infected but escapes clinical disease.
Predisposing Factors. — There is a great . deal
of evidence to suggest that there is a hereditary
predisposition to poliomyelitis and that the clinical
disease is prone to recur in families. This fact
is proposed along with drawing attention to the
fact that the incidence of secondary cases in
households during the same epidemic is rather
infrequent. In a survey of the incidence of polio-
myelitis in families, Aycock pointed out that 51
per cent of the patients gave a history of disease
among relatives while only 5 per cent of his
controls gave a similar history.2’3
November. 1947
1147
RECENT DEVELOPMENTS IN POLIOMYELITIS— MOLNER
Furthei investigations by other workers, not-
ably Adair and his associates,1 confirm this familial
predisposition to poliomyelitis. There have been
attempts by Aycock and Draper to associate the
disease with endocrine imbalance and to point out
that certain institutional types4 are more apt to
acquire clinical poliomyelitis than are others.
Aycock further suggests that susceptibility may
reside in a subclinical endocrine difference, and,
more particularly, a subclinical difference between
periods of growth and development. These
theories, needless to say, cannot be completely
ignored but evidence to the contrary is proposed
by other investigators.
Aycock also points out that there appears to
be a predisposition to attacks of poliomyelitis
among pregnant women. He noted that poliomy-
elitis is associated with pregnancy about four
times as frequently as it would be expected in
nonpregnant individuals. The closer examination
of this relationship shows that the greatest risk
occurs in the second and third trimester of preg-
nancy.18
Here again Aycock draws attention to the fact
that this may be associated with some endocrine
disturbance. Experiments have been attempted
by Jungblut to associate the incidence of the dis-
ease with Vitamin C deficiency. Helm9 has pro-
posed that Vitamin B deficiency is the major
factor accounting for increased susceptibility to
the virus and Weaver in turn19 in his experimenta-
tion with cotton rats was unable to show any
relationship between Vitamin B deficiency and the
poliomyelitis virus.
It is conceivable therefore that the endocrines
and vitamins, or the lack of endocrines or vita-
mins, are associated with susceptibility to clinical
poliomyelitis. Tf there is an intimate association,
the method of its operation is not clearly under-
stood.
Certainly from the overwhelming amount of in-
formation which is available, it is obvious that
the indidence of infection with poliomyelitis virus
far exceeds the reported incidence of clinical
disease.
It has also been noted by some investigators
that trauma, overexertion and exhaustion are
predisposing to clinical poliomyelitis. One must
question this proposition because although trauma
may be very -definite, the degree of shock may be
variable, or at least the interpretation placed upon
the severity of such trauma by the investigator
is variable. Also, exhaustion and overexertion are
relative terms. In the Detroit studies virtually no
correlation existed between these factors and the
incidence of the disease. The increased incidence
of severe poliomyelitis following recent tonsillec-
tomy is quite significant. For example, there is
evidence to indicate that children who have re-
cently undergone tonsillectomy develop bulbar
poliomyelitis much more frequently than those
who have not.6 There are, of course, persons who
do not agree with this. But the evidence is over-
whelmingly in favor of the proponents of the
predisposing effect of tonsillectomy to the devel-
opment of bulbar poliomyelitis.8
Carriers. — As has been previously noted, the
incidence of infection with poliomyelitis virus far
exceeds the incidence of clinical cases.5’11 The
writer and his associates were able to show that
in one outbreak, involving an institution caring for
children between infancy and ten years of age,
several individuals without any clinical symptoms
were found to be carriers of the virus of polio-
myelitis. A nurse and a physician, in addition to
several of the children, who had intimate contact
with cases, were found to be positive. It seems
quite possible that those with abortive and sub-
clinical disease may carry the virus for varying
periods of time. Brown and his associates, for
example, were able to show that a person who
developed clinical poliomyelitis had actually har-
bored the virus of poliomyelitis in his stools nine-
teen days before the onset of the first clinical
symptoms.
Prevention. — The principles of prevention of
poliomyelitis have varied many times even within
the past decade. Vaccines have been developed
which have been most unsuccessful. Prophylactic
spraying of the nasopharynx with various and
sundry chemicals has proved to be a total failure.
As a matter of fact, there are observers who be-
lieve that both the vaccine and the nasal spraying
had actually the opposite effect of that which was
expected.
The closing of schools, the avoidance of crowds
and the isolation of the patient and contacts
appear to have the effect of only a placebo. Cer-
tainly the wide and general distribution of the
virus in nature and among humans particularly
(Continued on Page 7191)
1148
Minnesota Medicine
THE SICK CHILD IN POLIOMYELITIS
ERLING S. PLATOU, M.D.
Minneapolis, Minnesota
npHE 1946 outbreak of poliomyelitis furnished
a serious challenge to the physicians of Min-
nesota. The physician became the initiator and
co-ordinator of medical care, nursing care, phys-
ical therapy, psychotherapy, and orthopedic care
in 2,877 cases between May and December. Al-
though 222 (7.7 per cent) of these patients died,
the untiring efforts of the medical and nursing
profession saved many lives and ameliorated great
suffering.
It is the purpose of this presentation to discuss
some of the more important responsibilities of
the physician in the care of the sick child with
poliomyelitis. The opinions of contemporary
workers in this field have been drawn on freely.
As Stimson9 has pointed out, “In the average
spinal case with involvement of a leg or an arm,
co-ordination of the patient’s care becomes a
matter of relative routine. A schedule of rest
and relaxation, of proper nursing care, and of
measures to combat increased muscle tension
should be quickly and adequately instituted” in
the hands of well-trained personnel. The man-
agement of special manifestations in this disease
requires experience, judgment and the skill of
many workers. The symptoms of greatest im-
portance are those seen in the patient with bulbar
or intercostal paresis or paralysis.
In 1946 between May and December, 107 cases
were admitted to the University Hospital and 265
cases were admitted to the Minneapolis General
Hospital, a total of 372 patients, in whom a
greater or lesser degree of bulbar involvement
was exhibited. In addition to symptoms such as
fever, prostration, and toxemia, these patients had
dysphagia, nasal regurgitation, voice change, pala-
tine weakness with lost gag reflex, pooling of
mucus in the oropharynx and the airways, pulse
changes, hypertension, and pallor associated with
varying degrees of cyanosis.
Grulee,2 reviewing the cases at the University
Hospital, emphasized the fact that heretofore at-
tention had been primarily focused on morbidity
From the Pediatric Department of the University of Minnesota
and Minneapolis General Hospital.
Read in Symposium on Management of Poliomyelitis at the
annual meeting of the Minnesota State Medical Association,
Duluth, Minnesota, July 2, 1947.
November. 1947
instead of mortality in poliomyelitis when practi-
cally all of the deaths occur in the bulbar group.
He correctly stressed the proper management of
the bulbar patient since almost 100 per cent of the
polio deaths occurred in the bulbar group, which
comprised only 23 per cent of the total patients.
In contrast, almost all of those with bulbar in-
volvement who survived recovered completely.
In the care of bulbar cases, the factors deserv-
ing special consideration may be listed as follows:
1. Psychological reassurance.
2. Fluid and electrolyte balance.
3. Optimum nutrition.
4. Prevention of aspiration.
(a) Posture
(b) Suction
(c) Tracheotomy
(d) Avoidance of respirator except in the high
spinal type.
5. Oxygenation.
6. Adjuvants.
(a) Avoidance of bladder and bowel retention.
(b) Reduction of intracranial pressure.
(c) Prophylaxis against infection.
(1) Superimposed contagion (measles, pertus-
sis, streptococcal, et cetera).
(2) Pneumonia, genito-urinary, et cetera.
(d) Supportive measures, i.e., caffeine, et cetera.
Anoxic patients were especially in need of re-
assurance and the inspiring influence of a doctor.
Dr. Albert Schroeder,15 fellow in pediatrics at
the University and Minneapolis General Hospital,
one of the many who worked day and night dur-
ing the outbreak, has summarized the psychologi-
cal needs and care in a recent report. “To aid in
providing good psychological environment, pa-
tients having a like involvement were grouped in
wards, and a serious effort was made to become
familiar with each patient. These children were
not allowed to dwell on their weakness, stiffness,
or paralysis, but their interest was transferred to
other thoughts of environment and ward activity.
By explanation and demonstration it was found
possible to teach all but a few of the patients to
use a bulb syringe or water suction to aspirate
secretions pooled in the pharynx. With more in-
struction some patients learned to pass their own
gavage tubes. These achievements and others, such
’149
SICK CHILD IN POLIOMYELITIS— PLATOU
as initial accomplishment of swallowing, main-
tenance of recumbancy during packing, and co-
operation in exercises, were generously praised by
the nurses and physicians before the patient’s
ward mates.”
Disturbances of fluid equilibrium in the sick
child with poliomyelitis are especially important
during the acute stage. This is true because of
the relatively greater susceptibility of children to
the effects of changes in volume and character of
body water.
Optimum nutrition, meaning an optimum of
calories, food elements, minerals, and vitamins
have recently been stressed in disease. Cannon1
and others have shown that by omitting essential
amino acids, antigenic response is inhibited and
even abolished. Spies,7 Smith,6 and Stare8 have
demonstrated that body stores cannot meet the
nutritional demands of starvation. In bulbar
poliomyelitis, relative starvation is inevitable and
more or less a part of the disease.
At the onset of the epidemic, the dysphagic pa-
tients were provided with fluids and part of their
nutritional requirements parenterally. However,
the inadequacy of this treatment became more and
more apparent and its use induced apprehension
on the part of the children and made them less
co-operative to the physical therapy.
The problem of nutrition in patients who were
unable to swallow for long periods of time Was
of major importance. The use of a gavage tube,
using No. 12 to No. 16 French tubes, proved to
be an easy solution, since the patient with dys-
phagia and a depressed gag reflex experienced no
particular discomfort from the passage of the
tube. The procedure was explained to the chil-
dren before the initial insertion, and they were
assured that it was only for temporary expediency.
Gavage feedings were instituted on patients who
had marked dysphagia or complete inability to
swallow. Most of the patients co-operated in the
procedure, and many were proud of their ability
to pass the tube themselves. The dangers often
referred to in the use of the gavage tube, such as
aspiration pneumonia and aspiration asphyxia
were not encountered in this series.
Special formulas, high in calories and adequate
in protein, minerals, and vitamins were admin-
istered by tube in four daily feedings. The high
carbohydrate and protein content in the feeding
which might be expected to produce an alimentary
disturbance seemed to improve elimination which
is prone to be sluggish in this disease. With the
slow partial return of the function of swallowing,
oral supplements of liquids and then pureed and
soft foods were added to the gavage feeding.
In those children where difficulty was en-
countered in gavaging by an easily aroused gag
reflex, and in all who were deeply lethargic or
comatose, infusions of plasma and amino acid-
glucose (fortified Hartmans, et cetera) solutions
were used in preference to the tubing.
The initial swallowing of liquids was best ac-
complished by keeping the child in a supine posi-
tion. After fluid from a rubber-tipped dropper
had been injected into his mouth, the child was
instructed to close his lips tightly, breathe through
his nose, hold his nose, and then swallow. He
was encouraged and praised by the staff for this
accomplishment, and then was allowed to try
pureed foods in the same manner after a period of
time. The upright position worked best for this
latter achievement.
Loss of body fluids due to the profuse sweat-
ing caused by the hot packs, also resulted in the
need of sodium chloride. Replacement was best
accomplished by proctoclysis, using 5 per cent
glucose in normal saline. Since this disease is
accompanied by intestinal atonia, this was readily
accomplished, and 400 to 800 c.c. daily were re-
tained.
Manifestations of respiratory disturbance, char-
acterized by the restriction of respiration and oxy-
genation, are briefly outlined as follows :
1. Damage to the respiratory center.
2. Pharyngeal or laryngeal paralysis with its resultant
accumulation of mucus in the airways.
3. Muscular “tightness” in the thoracic area which
interferes with normal expansion and contraction.
4. Impaired peripheral respiratory innervation with
anoxia as found in respiratory muscle paralysis (dia-
phragm and intercostals) seen in the high cervical
involvement.
Since these factors may occur singly or in com-
binations, it is important for the physician to
evaluate the needs of the patient. It is at, this
point that the judicious use of the respirator is
of prime importance. The bulbar patient who can
neither cough nor swallow will not benefit but
will be placed in jeopardy by the use of the
respirator. On the other hand, the high spinal
patient with an extensive loss of innervation of
1150
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SICK CHILD IN POLIOMYELITIS— PLATOU
the muscles of breathing often owes his life to
the use of artificial respiration.
Posture and careful aspiration of mucus, ad-
ministration of oxygen, tracheotomy, and occa-
sional use of the respirator were methods which
were used. Early recognition of anoxia by clini-
cal means and more accurately later by oximeter
were the most valuable weapons in directing
therapy. Sabin4 has stated that encephalitis is
practically nonexistent in poliomyelitis and actu-
ally is a symptom-complex due to anoxia of the
brain. Adequate oxygenation through a tracheot-
omy tube or cleared normal airways frequently
brought about rapid and marked changes in the
sensoriums.
Tracheotomy was one of the life-saving meas-
ures in combating anoxia and the trend during
the course of the epidemic was to do this more
often in well-selected cases. Criteria cited by
Priest3 and Goltz were :
1. Respiratory distress as evidenced by recurrent
cyanosis, coarse rales in the chest and laryngeal
stridor.
2. Excitement and unmanageability causing the patient
to resist pharyngeal aspiration strenuously.
3. Stupor of degree sufficient to make the patient
oblivious to accumulation of secretion in his airway.
4. Inability to cough effectively.
5. Pharyngeal pooling of mucus, vocal cord paralysis,
or intralaryngeal hypesthesia demonstrable by laryn-
goscopy.
Forty-two tracheotomies were done on patients
at the University and Minneapolis General Hos-
pital, of whom twenty-five died. Most of those
with fulminating course are included in this fatal
group. Of 372 dysphagic patients, 284 lived.
The dramatic saving of life by means of suc-
tion, tracheotomy, and oxygenation was impres-
sive in this series of almost 400 seriously ill pa-
tients. The newer ideas in physical therapy con-
tinued to be meritorious. Round-the-clock vigi-
lance of the physician, the expert service fur-
nished by the nurse and physiotherapist in con-
serving the physiological functions necessary to
life, though not acclaimed in the public press,
should be permanently documented as a tribute to
the younger men of medicine who participated in
this formidable task. Their teamwork resulted
in the best care known for the sick child with
poliomyelitis. Completely equipped centers with
well-considered plans, staffed by personnel who
have experience and a co-operative spirit, are the
places of choice for the management of the critical
case that it has been my privilege to discuss.
Referencees
1. Cannon, Paul R. : University of Chicago, Manuscript.
2. Grulee, Clifford G., and Panos, Theodore C. : Acute polio-
myelitis in children. Staff Meet. Bull. Hosp. Univ. Minnesota,
18:251, (Feb. 14) 1947.
3. Priest, Robert, and Goltz, Neill: Tracheotomy in bulbar
poliomyelitis. Journal-Lancet, 67:196-198, (May) 1947.
4. Sabin : Personal communication.
5. Schroeder. Albert: Nutritional and psychological aspects of
the care of the patients with bulbar poliomyelitis. Journal-
Lancet, 67 : 199, (May) 1947.
6. Smith, H. P. : Bile salt mechanism. Control diets, methods,
and fasting output. J. Biol. Chem., 80:659-669, 1928.
7. Spies, Tom D. : Principles of diet in the treatment of dis-
ease. J.A.M.A., 122:497-502, (June 19) 1943.
8. Stare. Frederick J. : Protein: its role in human nutrition.
J.A.M.A., 127:985-989, (April 14) 1945.
9. Stimson, Philip M. : J. Pediat., 28:309, (March) 1946.
ASKS AID IN NURSING CRISIS
Katharine J. Densford, president of the American
Nurses’ Association, has urged the governors of all
forty-eight states to call state-wide conferences “at the
earliest possible date” to consider concrete measures to
resolve the nursing crisis created by increased demands
for nursing service now facing the American public.
Pointing out that the nursing profession is united on
a program of action, Miss Densford, in telegrams to
each governor, called for effective action in every state
of the union. Her message follows :
“I made a nation-wide telephone roll call from Min-
neapolis on October 20 to get the support and co-opera-
tion of the forty-eight presidents of the state nurses’
associations. The ANA, representing 155,000 profes-
sional registered nurses, received whole-hearted sup-
port from the state association presidents on three
major points of the ANA’s program: (1) Make nurs-
ing care equally available to all by intensifying efforts
of the ANA’s counseling and placement service for the
best possible use of available nursing service, and pro-
vide a continuing supply of nurses by promoting re-
Ncvember, 1947
cruitment ; (2) improve nurses’ working conditions, rates
of pay, personnel practices, and see that nurses share
in the administration of nursing services; (3) protect
the public by adequate legal control of nursing prac-
tice, both professional and practical.
“We in ANA are doing everything in our power to
rouse the public to a clearer understanding of the nurs-
ing crisis, because nurses cannot singlehandedly solve
the problem. Effective action is needed at once in every
state of the Union. As president of the American
Nurses’ Association I am respectfully requesting the
governors of each state to co-operate with us.
“Specifically, I ask you to call on the president of
your state nurses’ association and the head of every
group interested in public health and public service, to
meet at a state-wide conference under your auspices
at the earliest possible date to consider concrete meas-
ures resolving the nursing crisis now facing the Ameri-
can public. I shall deeply appreciate a prompt reply
from you indicating what co-operation you can give this
public situation.”
1151
THE TREATMENT OF THE MUSCULAR AFTER-EFFECTS OF POLIOMYELITIS
MILAND E. KNAPP. M.D.
Minneapolis, Minnesota
A CUTE anterior poliomyelitis • is a disease
which runs a rather short febrile course,
usually lasting only a week or two; but during
that febrile course enough damage may be in-
flicted upon the central nervous system so that
there may result serious muscular after-effects
requiring treatment for months or years, and per-
manent disability may ensue. These after-effects
cannot be removed by medication, and at present
we know of no effective methods for preventing
them. Therefore, their treatment resolves itself
into the solution of various mechanical problems.
Each individual case is a problem unto itself and
must be solved mechanically for that individual.
There is no routine treatment which is uniformly
successful. The basic mechanical factors which
must be considered in solving these problems are
three in number : namely, muscle shortening,
muscle weakness or paralysis, and loss of muscu-
lar efficiency, often called incoordination.
Muscle Shortening
Muscle shortening is not an accurately descrip-
tive term. Sometimes the muscle is actually
shortened so that flexion contractures are present,
but more commonly the condition could be de-
scribed as a loss of normal extensibility of the
muscle. In the past it has often been ascribed
to muscle imbalance. Contrary to the situation
implied by the ordinary concept of muscle im-
balance, muscle shortening in my experience seems
to have no relationship to muscle strength or weak-
ness. It often begins very early in the course of
the disease, even as early as the first day, and
it may continue forever if not treated. On the
other hand, muscle shortening sometimes appears
slowly over a long period of time — as much as a
week or more in some instances. It may be present
in a relatively strong muscle, in a relatively weak
muscle, or in the opponent of either a strong or
a weak muscle. Muscle shortening in the neck,
back, and hamstrings seems to have no relation-
Dr. Knapp is Clinical Associate Professor of Physical Medicine
at the University of Minnesota.
Read in Symposium on Management of Poliomyelitis at the
annual meeting of the Minnesota State Medical Association,
Duluth. Minnesota, July 2, 1947.
ship to the number of cells in the spinal fluid. In
the early stages of the disease, this shortening
seems to be of neurogenic origin since it can be
relaxed temporarily by spinal anesthesia and
other anesthetics which induce muscular relaxa-
tion. After some months have passed, however,
the shortening apparently changes from a neuro-
genic type to a peripheral type, so that it is prob-
able that fibrotic changes have occurred in which,
at this time, anesthesia does not produce relaxa-
tion. We have learned by experience that in
order to obtain the best results, this muscle short-
ening must be combated at the earliest possible
date, long before fibrosis has occurred. We begin
the treatment immediately after the diagnosis has
been made, even while the temperature is still
elevated, and we have learned that the more
vigorously we treat this symptom, the more likely
we are to succeed in overcoming it.
The essential element in the treatment of
muscle shortening is motion. If the patient has
sufficient muscle strength to allow him to perform
voluntary motion against gravity, activity alone
will often cause relaxation of the muscle short-
ening. However, in those patients who are too
weak to carry out motion actively, the motion
must be performed for them passively. At first,
attempts should be made to cause relaxation by
motion within the limits of pain. However, if
relaxation is not accomplished by such mild de-
grees of motion, it becomes necessary to use
forced motion or stretching. This may be done
even in the stage of isolation. It is important,
however, that the physical therapist should have
enough experience to be able to differentiate be-
tween forced motion, which is improving the range
of motion, and forced motion which is decreasing
the range of motion, because it is not infrequent
that the pain associated with forced motion will
cause an increase of shortening and therefore be
harmful rather than helpful.
If pain is a potent factor and especially during
the early stages of the disease, hot packs are a
useful adjunct in the treatment of muscle short-
ening. They should be as hot as possible, but
1152
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AFTER-EFFECTS OF POLIOMYELITIS— KNAPP
also dry enough so that there are no droplets of
water to cause burns. Experimentally, we have
found that the packs can be applied at a tem-
perature of 130-140° F. on the wards. They cool
off rapidly, so that within five minutes after ap-
plication the temperature of the pack is down to
about 102°, after which it shades off gradually so
that within fifteen minutes the temperature is ap-
proximately that of the body. These packs should
be repeated as often as necessary for the individ-
ual patient. In fairly mild cases, in the early
stages, the packs are usually changed once an hour ;
in the less severe cases, once every two hours ; in
the very severe cases, the packs may be changed
as often as every two or three minutes.
One thing that should be stressed is that the
packs should be extremely hot, hot enough so
that the patient squirms, in order to be effective.
It seems quite obvious to me that this is not a
heat application in the true sense of the word ; it
is really a reflex stimulus, and it should be pos-
sible to obtain this reflex stimulus by simpler
means. Research is being carried out to try to
find these simpler means. There is some evidence
to indicate that in some stages stretching alone
may be as effective as hot packs plus stretching.
It should be emphasized that hot packs alone
will not cause relaxation of the muscle shortening.
In fact, hot packs may sometimes increase muscle
tightness, rather than relax it. There are certain
individuals in whom this has been shown very
definitely to be true. The percentage of these in-
dividuals is rather small, but it is important that
this possibility be recognized in a patient who is
continually tightening in spite of apparently ef-
ficient treatment. If hot packs seem to increase
the tightness, other types of heat may be used,
such as hot baths, paraffin, fever therapy, or oc-
casionally infra-red radiation or diathermy.
Several drugs have also been used for the pur-
pose of relaxing muscle tightness. Prostigmine
has been found to be useful in certain cases that
do not respond to other types of therapy. It must
be remembered, however, that prostigmine is not
the complete answer to the relaxation of muscle
tightness in poliomyelitis; its usefulness is def-
initely limited, and it is impossible to predict
whether improvement will be obtained in any in-
dividual case. I do not recommend the routine
use of prostigmine.
Curare has also been used and advocated for
the relaxation of muscles in poliomyelitis. Curare
November, 1947
is a drug which acts upon the myal side of the
myoneural junction to prevent acetylcholine from
causing contraction of the muscle. Therefore, it
produces relaxation of muscle. For this reason it
has been used extensively in surgery in order to
get maximal muscle relaxation with a minimal
amount of anesthetic. Its use in poliomyelitis has
been advocated by Ransohoff and others in the
last few years. Its usefulness has been predicated
upon the fact that it relaxes normal muscle. In
the case of poliomyelitis, however, there are ap-
parently other processes entering into the causa-
tion of muscle tightness which are not always
affected by curare. Therefore, we have found
that curare often relaxes all the muscles except the
ones which we want relaxed. However, it may be
a useful adjunct in preventing the normal muscle
fibers from resisting forced motion so that
stretching may be more effective in the curarized
muscle.
Some other drugs also have a similar effect.
Among these are quinine, quinidine, and atropine.
However, the side effects of these drugs are so
pronounced that their usefulness is extremely
limited, and they have not been investigated thor-
oughly as regards their effect in poliomyelitis.
If the attempts at relaxation of muscle tight-
ness are unsuccessful, even though continued ade-
quately for many months, it may become neces-
sary to resort to more forceful procedures. Among
these are the use of neurotripsy, with an air-
hammer-like instrument, to break up the fibrosis
in the muscle under anesthesia, or the use of
stretching manipulation under anesthesia, or the
use of tendon lengthening and other surgical pro-
cedures. It is my opinion, however, that these
procedures should be used only as a last resort.
It may seem illogical that so much stress should
be placed upon the restoration of adequate muscle
length, especially in view of the fact that a majori-
ty of untrained normal individuals are unable to
pass the required flexibility tests. It is essential
that adequate muscle length be obtained in order
to have maximal function of those muscles which
are weak. If the antagonist of a weak muscle is
short, it acts as a brake upon the weak muscle
and may not allow the weak muscle to move the
part through a full range of motion. It may thus
make useful function impossible. As an example,
may I quote the situation as regards the knee joint.
It is commonly found that the hamstrings are
shortened and the quadriceps is weak. This makes
1153
AFTER-EFFECTS OF POLIOMYELITIS— KNAPP
a situation which is incompatible with locomo-
tion unless braces are used. A person with normal
strength in the quadriceps may walk with his
knee bent, but a person with a weak quadriceps
cannot walk unless his knee is completely straight,
in fact, unless it is slightly beyond a straight line
so that there is a small amount of what may be
termed normal recurvatum present in the knee.
Thus it is imperative that the tightness of the
hamstrings be completely released in order that
such a patient may walk without a brace. This
situation is not taken into account by the brace-
makers at the present time. Nearly all such braces
are made with the knee flexed slightly, only a few
degrees, it is true, but that few degrees is enough
so that if the patient wears a brace for a long
enough time to allow tightening of the posterior
capsule to occur, that patient can never walk with-
out the brace, sometimes in spite of fair strength
in the quadriceps.
Muscle Weakness
Muscle weakness may be due to destruction of
anterior horn cells, to temporary loss of function
of the motor nerve cells due to the presence of
inflammation or other types of damage, or to fac-
tors of conduction higher in the central nervous
system which interfere with normal function. If
the anterior horn cell is destroyed, it never re-
generates. If the anterior horn cell is damaged, it
usually recovers function spontaneously. There is
no known treatment which will increase the num-
ber or the activity of the lower motor neurons.
Therefore, treatment of the anterior horn cell is
of no avail.
There is no successful method of increasing
the number of muscle fibers present in the body.
We are born with the maximum number of muscle
fibers that we will ever have. We may die with
fewer muscle fibers, but not with more. There-
fore, there is no way to increase muscle strength
by increasing the number of muscle fibers.
The only method left by which muscle strength
can be increased is to produce hypertrophy in
those muscles which still have innervation. In
order to accomplish this, it is necessary that the
muscle contract actively, and the best method is
by the normal nerve pathway. Electrical stimula-
tion has never been found to be as effective as nat-
ural stimulation. The most effective method of
causing hypertrophy of muscle fiber has been
found to be the use of heavy resistance exercises.
making the patient contract the muscle against
a nearly maximal load. It is better to carry out
such a motion only once or twice a day than to
carry out an unresisted motion many times a day,
for this purpose. Of course we must realize that
in poliomyelitis there is an unusual situation where
frequently the muscle itself is unable to lift even
the weight of the extremity, let alone any load
placed upon it. Therefore, maximal heavy resist-
ance exercise may be performed merely by moving
the extremity itself. Thus, walking with the ex-
tremely weak muscles is frequently the best type
of heavy resistance exercise. It must be remem-
bered, however, that the natural tendency of polio-
myelitis is toward improvement; therefore, we
must be very conservative in ascribing improve-
ment in strength to any particular treatment.
Mention may be made here of a possible method
of increasing muscle strength by nerve-crushing
or neurotripsy as introduced by Billig and Van
Harreveld. This is an attempt to use the well-
known phenomenon of branching-out growth of
nerve fibers following injury to produce re-inner-
vation of previously denervated muscle fibers. It
is not yet fully evaluated but some results have
been promising.
Muscular Efficiency
The factor of muscular efficiency is difficult to
define and difficult to explain, but in my opinion
is extremely important, even more important than
the development of muscle strength. Co-ordinated,
rhythmic, muscular movements are produced by
the interaction of many muscles, some stabilizing
the part, some carrying out the motion, others re-
laxing gradually to pay out slack. This is all con-
trolled by the central nervous system, and though
a great deal of the control is exercised by the
cerebellum, there is probably also a considerable
amount exerted through the spinal cord. And of
course the connections between the cerebellum and
the anterior horn cells are mediated by other cells
in the spinal cord. There is never less than a
three-neuron arc between the cerebrum and the
muscle, which means that there must be at least
one internuncial cell involved in every motion. The
so-called motor pattern is produced by this inter-
action of correlated neurons so that rhythmic
movements are possible. This motor pattern is
produced by the carrying out of motion, either
passively or actively. At first great mental effort
is required to carry out any skilled motion. As
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AFTER-EFFECTS OF POLIOMYELITIS— KNAPP
the motion is repeated over and over, it eventu-
ally becomes automatic, and then co-ordination
has been secured to a maximum degree.
In poliomyelitis we have a knockout of certain
cells controlling muscular action. We may also
have some of the internuncial cells which are con-
nected with co-ordination destroyed. The entire
neuromuscular setup has been disturbed ; there-
fore, the entire neuromuscular setup needs re-
training. There has been a great deal of con-
troversy concerning the function of various in-
dividual muscles, and many books have been writ-
ten to detail the function of these muscles. How-
ever, from a practical point of view, in the re-
training of the patient, it is necessary only to
carry out the motions as desired. Muscles do not
work independently, but in combination with
each' other in varying degrees. Therefore, if the
part is used in the manner which is desired, the
various correlating muscles and neurons will learn
to interact with each other in such a manner as
to produce the action which has been practiced.
This constitutes rhythmic co-ordinated motion.
On the other hand, if the patient is allowed to
substitute any muscle or muscle group in an ab-
normal manner, he will develop power in the
stronger muscles and use these stronger muscles
to excess. For instance, he may walk with his
foot everted, and never develop power in the in-
verters because he is not using them. The best
example of this situation is in flexion at the hip.
The iliopsoas is ordinarily considered to be the
prime flexor of the hip. However, the hip can be
flexed with the sartorius, rectus femoris, and the
adductors as well. Under normal circumstances,
the psoas performs most of the function. How-
ever, with increased resistance, all of the other
muscles are brought into play so that, if the flexor
of the hip is strongly resisted, every muscle will
be working to its maximum. In poliomyelitis, we
frequently have the iliopsoas very weak. Then in
order to move the weight of the extremity, the
sartorius, rectus femoris, and adductors may
come into play much more prominently than nor-
mal. It is true that these muscles can flex the hip
and many people rely upon increasing their power
in order to use the hip flexion to its maximum.
However, it is also true that if the psoas is not
exercised, it will not increase its strong! h. There-
fore, it is my opinion that the training should be
done to decrease emphasis on the muscles other
than the psoas and to try to increase the emphasis
on the weak psoas, thus promoting increase in
strength of the weak psoas which would not oc-
cur if effort were not made to move it.
I feel that the carrying out of motion in the
nearest possible approach to the normal manner is
the most important part of the treatment, and I
am perfectly willing to sacrifice the development
of maximal strength in order to have smooth,
rhythmic function in as normal a manner as pos-
sible. Artificial support and braces are to be
avoided in so far as possible. Occasionally it may
be necessary to use some form of support in order
to prevent an excessive back-knee or in order to
prevent rotation of the foot in such a manner that
walking is impossible. However, the number of
braces to be used will be very, very small, if
proper attention is paid to the foregoing factors.
NATIONAL HEARING WEEK. NOVEMBER 9-15
Three million children in the United States have a
hearing loss, and millions of adults are already hard
of hearing, according to Dr. C. Stewart Nash, presi-
dent of the American Hearing Society, Washington,
D. C. The national organization was joined by its
120 local chapters throughout the country in the ob-
servance of National Hearing Week, November 9-15.
“Authorities estimate that one out of every ten per-
sons in America has a hearing loss, ranging from a
slight loss to almost total deafness. The social and
mental effects of ' this hearing loss can do much to
warp the personality of a growing child, and in addi-
tion may prove an effective bar to the child’s making
a success of later life,” says Dr. Nash. He points
out the necessity for parents and teachers to watch
children carefully for any signs of hearing loss, es-
pecially after illness involving the nasal passages, ears
or throat.
“Prompt attention by a competent otologist is neces-
sary where such a hearing loss is suspected,” Dr. Nash
declares. “Inattention, falling grades in school, a tend-
ency to shun the company of other persons are often
indications of a beginning hearing loss. The majority
of people with serious hearing defects need never have
reached that stage if the trouble had been checked in
its incipient state.”
Dr. Nash recommended a vigorous hearing conserva-
tion program to be put in effect in the schools. This
program includes periodic hearing tests, medical exami-
nations followed by prompt medical attention if any
impairment is discovered, and adequate education and
rehabilitation for those with handicapping hearing loss.
November. 1947
1155
RECENT ADVANCES IN THE MANAGEMENT OF EAR. NOSE AND
THROAT PROBLEMS
OLAV E. HALLBERG, M.D.
Rochester, Minnesota
V\ 7 E ARE all familiar with the benefit otology
* * has obtained through the use of sulfona-
mides and antibiotics. Let us first look into the
problem of the more commonly called “sulfa"
drugs. They made their entry about ten years
ago, and are now used for all kinds of infectious
diseases, including infections of the ear. How-
ever, they should not be used indiscriminately.
Infections of the Middle Ear
Hadjopoulos and Bell4 stated that there are
two types of infections of the middle ear. One of
them is caused by an obligate aerobe, and produces
an infection limited by the amount of oxygen
present in the spaces of the middle ear when
inflammatory swelling closes the eustachian tube.
Such an infection often is characterized by a vio-
lent onset of pain in the affected ear. Spontaneous
rupture or myringotomy results in almost im-
mediate subsidence of symptoms, and the secre-
tions dry up within a few days without any treat-
ment.
Probably, however, in the majority of cases,
the infection is of the second type ; that is, it
arises by invasion of a facultative anaerobe which
might reach the middle ear and mastoid process
either directly through the tube or along the sub-
mucosal lymphatic vessels of the eustachian tube.
This type of organism is able to multiply in the
presence of a very low oxygen tension, and it
produces a more dangerous infection of the middle
ear and mastoid process than might otherwise oc-
cur. At the onset, there might be marked tender-
ness over the mastoid. If it looks as if mastoid-
itis might develop, both sulfonamide compounds
and penicillin should be administered immediately.
The medication should be continued for several
days after the discharge has stopped.
During the past several years there has
been no severe mastoid disease, and the tendency
is to give the sulfonamide drugs and penicillin all
the credit for this situation. We know, however,
that streptococci and pneumococci may vary in
virulence from year to year. Results of studies
Read before the meeting of the Kossuth County Medical
Society, Algona, Iowa, April 30, 1947.
From the Section on Otolaryngology and Rhinology, Mayo
Clinic, Rochester, Minnesota.
carried out by Kopetzky and Hadjopoulos7 would
tend to support this view. They found that in
acute mastoiditis caused by hemolytic streptococci
variations in the severity of the infection and also
in the mortality rate occurred from year to year.
For a period of several years the variations were
characterized by regular periodicity, and the au-
thors suggested that a major cycle consists of a
period of five to six years.
For example, at the Mayo Clinic we have late-
ly seen several patients with surgical mastoiditis
arising from influenza and measles contracted
during a local epidemic. The mastoiditis in these
cases became so severe as to require surgical treat-
ment in spite of adequate sulfonamide and peni-
cillin therapy that had been instituted at the very
onset of the infection. So far as biologic resistance
is concerned, it is now an established fact that
immunity to infection does not develop when the
infection is terminated by chemotherapy or anti-
biotic agents. I am sure we all have experienced
this sad fact. It is especially annoying when it oc-
curs among babies with infections of the upper
part of the respiratory tract. As soon as one in-
fection has been terminated by these means, an-
other one starts right away.
I should like to make a plea that physicians do
not consider patients all but cured after hav-
ing started to administer chemotherapy and an-
tibiotics. At the Mayo Clinic, we feel that we
have encountered more patients with serious mas-
toiditis and complications than previously. Many
of these patients had been receiving adequate sul-
fonamide therapy and then began to receive peni-
cillin. The “masking” effect of these drugs is an
important thing to recognize. “Masking” is a poor
term ; perhaps we should say “change of symp-
toms,” a change which must be recognized by the
surgeon. Other workers, such as Kopetzky6 have
observed that since sulfonamide drugs have been
available, many more patients come to hospitals
suffering from epidural abscesses than was pre-
viously the case.
Otitic meningitis is caused by either acute or
chronic infections in the middle ear or mastoid
process. Before the advent of chemotherapy this
1156
Minnesota Medicine
EAR. NOSE AND THROAT PROBLEMS— HALLBERG
disease had a very poor prognosis. Now the
chance of cure is almost 100 per cent if the
treatment is not started too late. Septicemia
caused by infection of the ear or its complication,
thrombophlebitis of the sigmoid sinuses, now can
be attacked successfully by combined chemo-
therapy and surgery. Abscess of the brain secon-
dary to disease of the ear also has a better prog-
nosis than formerly.
Meniere's Disease
Meniere’s disease has received much attention
lately. At the Mayo Clinic, Dr. H. L. Williams
prefers to designate this disease as “endolymphat-
ic hydrops” because in some reported cases gross
dilatation of the endolymphatic system and degen-
erative changes of the organ of Corti were the
main findings at necropsy. I shall not burden you
with etiology except to say that Meniere’s dis-
ease probably has an allergic background. The
reaction is not of the antigen-antibody type ; the
condition might belong in a group of the so-
called physical allergies which is intimately con-
nected with disturbed permeability of cell mem-
branes and disturbed electrolytic metabolism.
Histamine is still used in the treatment of Me-
niere’s disease. Horton treated 270 patients with
histamine (1 grain or 0.065 gm. of histamine base
in 250 to 500 c.c. of isotonic solution of sodium
chloride). Seventy per cent obtained complete
remission, with improvement of hearing in 40
per cent. Many of these patients suffered remis-
sions when treatment was discontinued in a
month to a year. Lately, at the clinic, we have
used a combination of nicotinic acid and potassium
nitrate, with good effects. All treatments aim at
control of fluid metabolism, correction of balance
in the tissue fluids and production of vigorous
vasodilation.
When medical management does not control
the dizziness, surgical treatment can be attempted.
For a long time, only section of the eighth cranial
nerve was done. In this type of surgery there
is always a certain risk, since the surgeon must
proceed intracranially in order to reach the nerve.
Lately, transmastoid labyrinthotomy has come into
favor. This operation was suggested by Lake9
in 1906. Since then, sporadic reports of it ap-
peared until Day2 and Cawthorne1 reported a
series in which labyrinthotomy had been done for
Meniere’s disease. At the Mayo Clinic nineteen
patients who had Meniere’s disease have under-
gone labyrinthotomy as outlined by Day.
In the selection of patients for surgery only
those whose hearing in the diseased ear is not
useful should be chosen, since in our cases the
hearing disappeared entirely in the operated ear.
Patients who have almost normal or fairly normal
hearing should have the benefits of long and fair
trial of conservative measures. The operation it-
self is fairly simple. We use a postauricular
incision. As much of the mastoid process is
exenterated as is possible, so as to provide enough
operative room. The horizontal semicircular canal
is exposed to view all the way anteriorly to the
junction with the anterior vertical canal. With an
electrically driven burr, a small hole is made in
the horizontal canal about 2 mm. posterior to the
ampulla. A thin, curved electrode is inserted
into the vestibule and light cautery is used.
Transitory facial palsy often develops among these
patients. It disappears within two weeks to a
month. Penicillin is used during convalescence
to prevent infection.
Meniere’s disease can occur in. all age groups,
but it is more common in the later decades of life.
We had one patient recently whose condition was
very interesting. Gooch and I3 have reported the
case. The patient, a deaf-mute, had had episodes
of dizziness all his life, and had tried all kinds of
treatment, without result. Bilateral destructive
labyrinthotomy was done, since we did not know
which ear was responsible for the dizziness. The
operation was performed about a year ago and
so far the patient has been doing remarkably well.
He is carrying on his work satisfactorily as a
printer.
Otosclerosis
The greatest advance in the treatment of a
certain type of deafness is the fenestration op-
eration for otosclerosis. This operation is indi-
cated only in certain selected cases of otosclerosis
in which bone conduction is good and in which
there is little if any damage to the acoustic nerve.
The diagnosis of otosclerosis has to be made by
exclusion. The onset of loss of hearing usually
is very insidious ; most often hearing begins to
diminish when the patient is between ten and
twenty years old. These patients often hear better
in noisy places. A familial history of deafness can
be obtained in about 40 per cent of cases. Oto-
November. 1947
1157
EAR, NOSE AND THROAT PROBLEMS— HALLBERG
sclerosis is a disease in which pathologic changes
occur in the auditory capsule. Osteoclasts destroy
the bone of the auditory capsule and the de-
stroyed region is rebuilt in a disorderly manner by
osteoblasts. When this process causes ankylosis of
the stapediovestibular joint, deafness will result.
Otosclerosis is primarily a disease of bone, and
stapedial ankylosis is an incidental complication
that occurs occasionally. In a study of the tem-
poral bone, it was found that stapedial ankylosis
occurred in only ten of eighty-one ears examined
in which otosclerosis was present. Otosclerosis is
only a histologic diagnosis, and if the diagnosis is
to be made for the living patient, the term must
he modified to “clinical otosclerosis.” The diagno-
sis of clinical otosclerosis can be arrived at with
reasonable accuracy by exclusion, on the basis
of the history and results of examination, of all
other conditions likely to produce' a conduction
type of deafness.
The fenestration operation is applicable only to
patients who have clinical otosclerosis and in
whom the hearing reserve is so great that release
of it will rehabilitate the patient socially. Lem-
pert, who perfected the fenestration operation, re-
ported that up to the time of his report 33 per
cent of patients who had been operated on six
years or more previously had been rehabilitated
socially and economically through restoration of
hearing to normal conversational levels. Because
of recent improvement in technique, he considered
that in approximately 70 to 75 per cent of cases
restoration of hearing to normal conversational
levels could be secured in the ear on which op-
eration is performed. The fenestra rarely
closes if it has remained open for a year. In 347
fenestration operations performed at the Mayo
Clinic, we have been able to secure good early
results in about 90 per cent of the cases. It would
seem that about 70 per cent of the patients will
have permanent good results, although it is still
a little too early to be certain, because we started
to employ this type of surgery only about two and
a half years ago. In approximately 3 per cent of
the cases the ability to hear may be decreased by
the operation, and in about 1 per cent complete
deafness may develop in the operated ear. The
latter result, we feel, is caused mostly by hemor-
rhage into the labyrinth or by an infection.
It might be asked, how does the fenestration
operation improve hearing? It has been known
for many years that in conduction deafness the
draining ofif of a portion of the perilymph, so
that mobility of both perilymph and endolymph
is increased, would produce immediate improve-
ment in the ability to hear; this improvement is
again lost when the perilymph refills the perilym-
phatic space. The hypothesis has been presented
that the fenestration operation makes the tympanic
membrane more responsive to vibrations by means
of removal of the head of the malleus and leaves
the tympanic membrane attached to a thin tlap
of membrane which is used to cover and main-
tain patent a new opening into the perilymph, so
that a permanent condition is produced in which
the endolymph is more mobile and is stimulated by
the more vigorous vibrations of a more mobilized
tympanic membrane. Therefore, in order to se-
cure good results, the tympanic membrane must
be intact and capable of increased response to
sound waves. This theory is not entirely satis-
factory, however, since l have seen several pa-
tients with badly torn eardrums and flaps in whom
marked improvement in hearing nevertheless
develops. It is possible that the eardrum does not
have much to do with the good result obtained
from the fenestration operation.
I feel that the sound waves might enter the
round window, and that the excess acoustic trauma
then normally escapes through the oval window,
the whole chain of ossicles then being a protector
for the cochlea, so that very loud noises might
be screened out. After fenestration operations,
the sound waves might escape through the new
window. It seems that in such an instance the
normal protector mechanism with the ossicular
chain is gone, and therefore deterioration of
hearing might be expected if the patient so treated
has a prolonged exposure to loud noises. In
practice, this conclusion does not seem to hold
true ; at least, I know of one patient who was ex-
posed to continuous gunfire during the war, but
he did not experience any deterioration of hearing.
As a general rule, patients, after successful fen-
estration surgery, should not expose themselves
to continuous acoustic trauma.
It might also be asked if this operation can be
performed in all cases in which a presumptive
diagnosis of clinic otosclerosis can be made. There
appears to be an increased number of cases of
clinical otosclerosis in which atrophy of the fibers
of the cochlear nerve or cells of the organ of
Corti occurs. It is not known whether this atrophy
is one of disuse secondary to immobilization of
1158
Minnesota Medicine
EAR, NOSE AND THROAT PROBLEMS— HALLBERG
the stapes or secondary nerve degeneration. When
secondary nerve degeneration occurs, the proba-
bility of obtaining a good result from surgery is
diminished. If the nerve degeneration affects only
the higher tones above the range of speech, it is
perfectly advisable to proceed with surgery, but
if it is suspected that the nerve degeneration af-
fects the range of speech, the chance of success
of the operation in restoration of hearing is in-
versely proportional to the degree of degeneration
present.
It has been found that the 30 decibel line is the
critical level for conversational speech. At 5
decibels above this line, a person will have little
difficulty in understanding speech, whereas at 5
decibels below this line, the person is severely
handicapped. The two most important frequen-
cies for the understanding of speech are 1,024
and 2,048 double vibrations per second.
Lempert has stated that the average improve-
ment in hearing, measured in decibels, which is
produced by a successful fenestration operation is
about 20. The object of fenestration surgery is
to bring the hearing above the 30 decibel line.
Therefore, a patient who has a loss of hearing
of 50 decibels or more must expect much less than
the average probability of a good result from
surgery.
What are the usual causes for failure ? I shall
only enumerate them: (1) faulty diagnosis, (2)
osteoma (I have seen two patients with such
lesions), (3) closure of window with regenera-
tion of bone, in which event the surgeon must be
very careful so that all bone chips are removed
from the window, (4) infection with development
of labyrinthitis, (5) late infection with fibrosis of
the endolymphatic duct, (6) hemorrhage into
the labyrinth after surgery, and (7) poor surgery.
If the patient who seeks aid is found to have
clinical otosclerosis of an operable type, he is first
informed as to the possibility of obtaining a good
result for his particular condition. We tell him
that surgery is optional and that it is accompanied
by a risk which, however, is small. The patient
must weigh this risk against the results obtained
by use of a hearing aid, which instruments now-
adays are efficient and give promise of even fur-
ther improvement.
Conditions of the Nose and Throat
About fifteen or twenty years ago surgical
treatment for a variety of nasal conditions was
radical ; almost everything that protruded was
excised from the nose and the end result for the
patient would be a so-called lead-pipe nose. Mod-
ern surgical treatment generally has been directed
toward retention of the normal physiology of the
nose. Penicillin did much to better the therapy
of diseases of the nose and throat. The sulfona-
mide drugs, however, did not prove to be so ef-
fective as was hoped in the treatment of infec-
tions of the paranasal sinuses.
Williams and Popp12 reported in 1940 on
roentgen therapy for acute sinusitis. I feel it is
worth while to mention their views again herein.
Roentgen therapy reduces pain promptly, prob-
ably by rendering secretions more liquid. Oc-
casionally, roentgen therapy shrinks the mucous
membrane sufficiently so that when the next in-
fection occurs there is either no pain at all or it
is very slight.
In the treatment of chronic sinusitis much can
be done with conservative surgical treatment with
penicillin as an adjunct. Penicillin alone will not
cure chronic disease of the sinuses. If penicillin
is administered the condition of the nose often
will improve, but as soon as the use of penicillin
is stopped, the infection will recur.
In the treatment of chronic pansinusitis with-
out bronchiectasis, surgery and penicillin are the
agents of choice. The treatment of chronic pan-
sinusitis with bronchiectasis is somewhat different :
often by the clearing up or amelioration of the
condition in the lungs first, remarkable improve-
ment is seen in the nose, and occasionally no
further treatment need be directed to the nose.
Sometimes the infection extends into the bone,
in which instance osteomyelitis arises. The so-
called spreading type of osteomyelitis has been
dreaded by otolaryngologists. This type of in-
fection occasionally starts after an intranasal op-
eration. I reported two such cases, in which the
infection was situated in the maxilla.5 Both pa-
tients recovered after a combined treatment with
radical surgery and penicillin. These infections
usually are caused by an anaerobic streptococcus,
and in spite of everything that could be done — -
that is, before the advent of penicillin — the mor-
tality rate was almost 100 per cent. Lillie10 also
has reported several such cases.
Nasal allergy still is one of the unsolved prob-
lems of rhinology. Nasal allergy includes sea-
sonal hay fever and so-called vasomotor rhinitis,
November 1947
1159
EAR, NOSE AND THROAT PROBLEMS— HALLBERG
which is characterized by sneezing and watery
discharge in the morning. Of the newer treat-
ments, I should mention that involving histamine.
The physiologic effects of histamine are known
to be : (1) contraction of smooth muscle, (2) con-
striction of arterioles, (3) dilatation and increased
permeability of the capillaries, with localized
edema, and (4) increased secretion by the secre-
tory glands. Because there is a similarity between
the action of allergy and that of histamine, small
doses of histamine are administered in an attempt
to desensitize the patient. Histamine and nicotinic
acid can be tried, but in my experience, especially
in respect to nicotinic acid, the results have been
rather disappointing.
Benadryl (beta-dimethylaminoethyl benzhydryl
ether hydrochloride), which is an antihistaminic
substance, has been tried much lately. In vasomo-
tor rhinitis it helps only in about 20 per cent of
the cases. Moreover, the side effects — drowsiness
and nervousness — are most annoying.
A newer drug, pyribenzamine hydrochloride
( N'- pyridyl - N' benzyl-N-dimethyl-ethylene dia-
mine hydrochloride), seems to affect vasomotor
rhinitis more satisfactorily ; 50 to 60 per cent
of patients derive benefit from this drug. The
side reactions are not so noticeable as are the
side effects of benadryl. At least, this was the
opinion of McBean,11 who recently studied the
subject.
Of the newer treatments, I might also mention
that involving the use of streptomycin — the new-
est of the antibiotic agents. Since Klebsiella
ozaenae, a bacterium which is sensitive to strep-
tomycin, often is found in ozena, treatment of this
disease with streptomycin has been- tried. These
experiments were started only recently by Dr. K.
M. Simonton, and it is still too early to be able
to say whether the patients have derived lasting
benefit from it.
Finally, I shall mention the use and misuse of
nasal vasoconstrictors. These points recently were
stressed by Lake.8 For a long time it has been
known that overuse of vascoconstrictors eventual-
ly leads to difficulty in nasal function. Scarcely a
day goes by during which some of us in the Sec-
tion on Otolaryngology and Rhinology do not see
one or two patients who are the victims of mis-
use of nose drops. We often call this condition
“rhinitis medicamentosa.” The usual story is as
follows : “My doctor gave me nose drops for
‘sinus trouble.’ After a few weeks they did not
give me relief any more and 1 got hold of some
stronger ones. Now they don’t help me much,
either.”
Every attempt should be made to alleviate the
original condition which led to the use of vaso-
constrictors. An explanation of the normal phys-
iology of the nose frequently is helpful in re-
lieving the patient’s mind concerning certain mis-
conceptions that he has entertained regarding
his nose.
There are certain indications for the use of
nose drops. First, strong vasoconstricting agents
are necessary in preoperative preparation and an-
esthetization of the nose. Second, nose drops can
be used for not more than two days, during the
first stages of an acute cold, when certain patients
experience complete blockage of the nares. Third,
nose drops can be administered to the nursing
infant who has a cold, so that he may be enabled
to breathe well enough to take his feeding.
Otherwise, the habit of the use of nose drops
should be strongly discouraged.
References
1. Cawthorne, T. E. : The treatment of Meniere’s disease. J.
Laryng. & Otol., 58:363-371, (Sept.) 1943.
2. Day, K. M.: Diagnosis and surgical treatment of Meniere’s
disease (hydrops of labyrinth). Ann. Int. Med. 23:41-47
(July) 1945.
3. Gooch, J. O., and Hallberg, O. E. : Surgical treatment of
Meniere’s disease in a deaf-mute. Proc. Staff Meet., Mayo
Clin., 22:2 52-254, (June 25) 1947.
4. Hadjopoulos, L. G., and Bell, J. W. : Direct versus inter-
mediate pathways in infections of the mastoid. Arch.
Otolaryng., 25:601-617, (June) 1937.
5. Hallberg, O. E.: Spreading osteomyelitis of the maxilla.
Minnesota Med., 28:126-127, (Feb.) 1945.
6. Kopetzky, Samuel: Discussion. Arch. Otolaryng., 30:913-
914, (Dec.) 1939.
7. Kopetzky, S. J., and Hadjopoulos, L. G. : The relationship
of upper respiratory and alimentary tract flora to mastoid
infections, with particular reference to the epidemiology of
mastoiditis. Laryngoscope, 42:661-673, (Sept.) 1932.
8. Lake, C. F. : Rhinitis medicamentosa. Proc. Staff Meet.,
Mayo Clin., 21:367-371, (Sept. 18) 1946.
9. Lake, Richard: A case of operation on the vestibule for the
relief of vertigo; together with a description of the flap
employed in order to obtain a better view of the parts
during operation; with remarks on the history of the op-
eration. Lancet, 1 :26- 28, (Jan. 6) 1906.
10. Lillie, H. I.: Osteomyelitis of the maxilla secondary to
suppurative maxillary sinusitis. Ann. Otol., Rhin. & Laryng.,
55:495-507, (Sept.) 1946.
11. McBean, J. B.: Observations on the management of vaso-
motor rhinitis. Minnesota Med., 30:399-402, (April) 1947.
12. Williams, H. L., and Popp, W. C. : Roentgen therapy for
acute sinusitis. Ann. Otol., Rhin. & Laryng., 49:749-754,
(Sept.) 1940.
1160
Minnesota Medicine
AMEBIC ABSCESS OF THE LIVER WITH BRONCHOHEPATIC FISTULA
Report of a Case and Discussion of Emetine Cardiotoxicity
B. I. HELLER. M.D.. and W. E. JACOBSON. M.D.
Minneapolis. Minnesota
A MEBIASIS with all its protean manifesta-
tions presents a problem of great importance.
This disease has never been considered a strictly
tropical problem for it has been discovered wher-
ever careful surveys have been conducted. The
over-all infection rate for the United States has
been estimated to be about 10 per cent.1 The in-
cidence in tropical and subtropical regions and in
areas of poor hygienic standards is much higher.
Klatskin10 has estimated the incidence of ame-
biasis among American troops stationed in India
during the recent war to be between 20 and 40
per cent. This is comparable to the incidence of
23 per cent infection among troops in Calcutta
and 18.3 per cent infection among troops in Myit-
kyina, Burma, as quoted by Karl and Sloan.9
The return of troops from those and other endem-
ic areas increases the significance of this dis-
ease to the physician and the public. Several
authors1,9’10 have recently stressed the danger of
producing a definite public health problem in-
cident to the return to this country of a large
number of undiagnosed and unsuspected cases
of amebiasis. The chronicity of the disease, espe-
cially in asymptomatic “cyst passers,” can be ex-
pected to manifest itself in exacerbations and
complications in the patient and by the spread
of the disease to previously uninfected persons.
These problems can be expected to arise in the
Upper Midwest as frequently as might be ex-
pected in other portions of the country. A con-
stant awareness of the possibility of this disease
is the most important factor which will lead to a
proper diagnosis and successful treatment. It is
imperative that the physician be acquainted not
only with the intestinal signs of amebiasis but
also with the numerous other clinical manifesta-
tions and complications of the disease. We are
presenting a case of amebic abscess of the liver
with pleuropulmonary complications.
From the Department of Internal Medicine, University of
Minnesota Hospitals and Veterans Administration Hospital,
Minneapolis, Minnesota. Published with permission of the Med-
ical Director, Veterans Administration, who assumes no re-
sponsibility for the opinions expressed or conclusions drawn by
the authors.
November. 1947
Fig. 1. Roentgenogram of chest, February 13, 1947. Eleva-
tion of the right diaphragm and evidence of pleural effusion.
Case Report
R.B, a twenty-year-old World War II veteran, was
admitted to the Minneapolis Veterans Administration
Hospital on February 11, 1947. He dated the onset of
his present illness to December, 1946, when he noted
the onset of fever, cough, shortness of breath, soreness
in the right shoulder, and pain in the right lower chest.
He attributed his symptoms to a recurrence of malaria
and took quinine sulfate for several days. The symp-
toms persisted and he was admitted to a local hospital
on December 30, 1946, with an admitting diagnosis of
recurrent malaria and right lower lobe pneumonia. He
was treated with quinine sulfate, sulfadiazine, penicillin,
and streptomycin ; however, his symptoms persisted.
On February 2, 1947, while still in the hospital, he sud-
denly coughed up a large amount of a “chocolate pud-
ding-like” material ajid subsequently coughed up bitter,
bile-stained material. The diagnosis of amebiasis with
hepatic abscess and bronchohepatic fistula was made at
that time, and he was started on emetine therapy. He
received seven intramuscular injections of emetine prior
to transfer to the Veterans Administration Hospital.
During the course of this illness he lost about 30
pounds in weight.
Ihe past history was significant in that he had first
developed bloody diarrhea about a year prior to ad-
mission while stationed on Luzon in the Philippine
Islands. At that time he received nonspecific therapy
and the diarrhea subsided in about four days. Two
months later while en route to the United States he
1161
AMEBIC ABSCESS OF THE LIVER— HELLER AND JACOBSON
Fig. 2. Roentgenogram of chest, posteroanterior view, March Fig. 3. Roentgenogram of chest, lateral view, March 10, 1947.
10, 1947. Marked increase in the parenchymal lesion on the Doming of the anterior portion of the right hemi-diaphragm.
right.
developed a second episode of bloody diarrhea. He also
had chills and fever, and examination of the blood
smear revealed the presence of malaria parasites. He
was treated only with quinine and all his symptoms sub-
sided. Following this he had recurrent episodes of
bloody diarrhea every four to eight weeks. At no time
during this entire year was his stool ever examined
for ova or parasites; however, on numerous occasions
he received nonspecific therapy for the diarrhea.
Physical examination on admission revealed a well-
developed, poorly nourished young white man who ap-
peared chronically ill. His temperature was 99° F.,
his pulse 120 per minute, and his respirations 20 per
minute. There was no icterus of the skin or sclerae.
Examination of the chest revealed limited expansion on
the right and there was dulness to. percussion over the
lower third of the right lung field posteriorly and
laterally. The right diaphragm was immobile. The
breath sounds were diminished over the area of dulness.
Many coarse rales were present in the lower right lung
field. The heart was not enlarged and the heart tones
were normal. The blood pressure was 120 mm. mer-
cury systolic and 68 mm. mercury diastolic. There was
marked tenderness to pressure in the right upper ab-
dominal quadrant, and the liver mass was thought to
extend just below the costal margin. There was com-
pression tenderness elicited over the liver area. The
remainder of the physical examination was otherwise
essentially negative.
Laboratory Data. — Blood study on admission revealed
a hemoglobin of 14.2 grams per cent, a red blood count
of 4,870,000, and a leukocyte count of 13,700, with a
differential of 56 per cent neutrophils, 30 per cent lym-
phocytes, 3 per cent monocytes, and 11 per cent eosino-
phils. The erythrocyte sedimentation rate was 45 mm.
per hour. The serological test for syphilis was nega-
tive. Blood chemistry studies revealed a blood sugar of
84 mg. per cent, a blood urea nitrogen of 14 mg. per
cent, total plasma proteins of 8.3 grams per cent, with
5.5 grams per cent albumin and 2.8 grams per cent
globulin. The total serum bilirubin was 0.4 mg. per cent.
Urinalysis on admission revealed a slightly acid re-
action, a specific gravity of 1.025, negative tests for al-
bumin and sugar, and 2 to 3 white blood cells per high
power field. Examination of the blood smear failed to
reveal malaria parasites. Numerous examinations of the
sputa were all negative for bile, and no endameba his-
tolytica were found. No ova or parasites were found
in the feces on repeated studies. The bromsulfalein test
revealed 10 per cent retention at the end of forty-five
minutes. The cephalin cholesterol flocculation test was
negative after twenty-four and forty-eight hours. Liver
function studies repeated on April 2, 1947, the fiftieth
hospital day, revealed no retention of bromsulfalein at
the end of forty-five minutes, a negative cephalin
cholesterol flocculation test, a total serum bilirubin of
0.3 mg. per cent, and an alkaline phosphatase activity
of the serum of 8 King- Armstrong units.
Roentgenologic examination of the chest shortly after
admission (Fig. 1) showed an elevation of the right
diaphragm and evidence of pleural effusion on the right.
On fluoroscopic examination the right diaphragm was
noted to be almost immobile, although slight paradoxical
movement could be seen on deep inspiration.
Hospital Course. — On the fourth hospital day the
patient was started on intramuscular injections of eme-
tine in doses of 1 grain daily. He was also started on
diodoquin, 10 grains three times a day. The patient
1162
Minnesota Medicine
AMEBIC ABSCESS OF THE LIVER— HELLER AND JACOBSON
Z-J3-47 Z-J9-47 3-16-47 3-31-47
Fig. 4. Roentgenogram of chest, April 10, 1947. Almost com-
plete resolution of the process on the right.
was kept on strict bed rest, the blood pressure was
checked frequently, and electrocardiagrams were taken
every other day. On the third day of emetine therapy
a marked decrease in the amplitude of the T waves was
noted in all leads and on the fifth day there was a flat
Ti and diphasic T2, T3, and Tcf4 (Fig. 5b) : In view
of the progressive electrocardiographic changes from the
normal pretreatment tracing (Fig. 5a) emetine was dis-
continued after a total of 6 grains had been given. The
diodoquin was continued for a total of twelve days. On
this regime he improved subjectively and by the thir-
teenth hospital day the erythrocyte sedimentation rate
was down to 5 mm. per hour. However, the leukocyte
count remained elevated between 13,000 and 14,000. On
the eleventh and fifteenth hospital days, thoracenteses
were attempted but no fluid was obtained at either
time. In order to prevent secondary infection following
attempted thoracentesis, penicillin was given prophylac-
tically from the twelfth through the seventeenth hos-
pital days. Except for occasional elevations to 99° F.
the patient’s temperature remained essentially normal
during the early phase of treatment.
On the twentieth hospital day the patient again be-
came rather acutely ill; his temperature rose to 100° F.,
and the leukocyte count rose to 16,759, with 71 per cent
neutrophils. The emetine treatment was renewed in
doses of one grain daily given intramuscularly and con-
tinued for five days. His temperature remained between
99° and 100° F., for seven days, the leukocyte count
rose to 19,600, and the erythrocyte sedimentation rose to
86 mm. per hour. Penicillin was again started prophy-
lactically on the twenty-first hospital day. Postero-
anterior and lateral chest x-rays, taken on March 10,
1947 (Figs. 2 and 3), the twenty- seventh hospital day,
revealed a doming of the anterior portion of the right
Fig. 5. (a) Pretreatment electrocardiogram interpreted as
within normal limits.
(b) T wave changes noted after 5 grains emetine hydro-
chloride intramuscularly over five-day period.
(c) Marked T wave changes after third course of only
3% grains emetine hydrochloride. Course preceded by short
rest period, and thus the electrocardiogram shows cumulative
effect of emetine.
(d) After 15-day rest period the electrocardiogram shows
complete return to normal.
diaphragm, which was interpreted to be the forma-
tion of a new liver abscess or reaccumulation of fluid
in the previous abscess cavity. In spite of the fact that
the patient had not had a sufficient rest period, a third
course of emetine was started preparatory to attempted
aspiration of the abscess. The emetine was given in doses
of grain intramuscularly every eight hours for four
doses preoperatively. Following this the patient was
taken to the operating room and aspiration was at-
tempted from three approaches : lateral, anterolateral,
and anterior. All attempts failed to yield pus and the
procedure was discontinued. Emetine was continued
postoperatively in doses of */-> grain intramuscularly
daily. The electrocardiogram showed progressive
changes with tendency to inversion of all T waves (Fig.
5c), and thus emetine was discontinued after a total pre-
operative and postoperative dose of Z]/2 grains had
been given. In spite of the failure to aspirate pus from
the liver, the patient improved rather remarkably. His
temperature returned to normal, the leukocyte count
and the erythrocyte sedimentation rate gradually return-
ed to within normal range, and subsequent roentgenologic
studies showed disappearance of the doming and clear-
ance of the pulmonary lesion. On the forty-ninth hos-
pital day the leukocyte count was 9,600 with 56 per cent
neutrophils, and the erythrocyte sedimentation rate was
2 mm. per hour. The electrocardiogram at that time
was within normal limits with normal positive amplitude
of all T waves (Fig. 5d). In view of the severity of
the original infection, it was deemed advisable to give
November. 1947
1163
AMEBIC ABSCESS OF THE LIVER— HELLER AND JACOBSON
the patient another small course of emetine. There had
been a rest period of sixteen days since the last emetine
had been administered. The final course consisted of
Yi grain daily for eight days. At no time during this
course did the electrocardiogram become abnormal ;
however, on the seventh day of therapy there was a
very slight decrease in the upright amplitude of the T
waves.
Subsequent roentgenologic (Fig. 4) and fluoroscopic
studies showed a remarkable clearing of the pulmonary
lesion and almost normal movement of the right
diaphragm. The liver was still palpable 3 cm. below the
costal margin in the mid-clavicular line but it was no
longer tender. On the sixty-fifth hospital day the pa-
tient was up and about the ward. His weight was 148
pounds as compared with an admission weight of 131
pounds. He was discharged on the seventy-second hos-
pital day.
Discussion
Amebic hepatitis and amebic abscess of the
liver are the most important extra-intestinal man-
ifestations of this disease. In Klatskin’s series11
of 748 cases of amebiasis there were sixty-nine
cases (9.2 per cent) with liver involvement, and
in the 360 cases reported by Karl and Sloan9
there were thirty cases (8.3 per cent) with liver
involvement.
The symptoms, and signs of hepatic amebiasis
have been stressed in a number of recent arti-
cles.1’9’10’11,13’14’15’18, 18 Pain over the liver area is
the most common symptom and is almost univer-
ally present. The pain is usually anterior and
subcostal in location but may also be present over
the lower chest posteriorly. Not infrequently the
pain may occur over the entire lower right chest
and may be aggravated by coughing. This may
direct one’s attention to the chest and suggest the
erroneous diagnosis of pleurisy or early pneumo-
nia. Fever is probably the next most common
symptom and is an almost constant feature of
abscess, but may be absent in presuppurative le-
sions of the liver. In the event of abscess for-
mation chills are not infrequent. Nausea and
vomiting are said to occur in about one-third of
the cases.10 Anorexia, cough, and jaundice are
other less common symptoms. Sodeman and
Lewis18 report the presence of jaundice in five
cases (15.1 per cent) of a series of thirty-three
patients with amebic hepatitis. Diarrhea may or
may not be present during the development of
hepatic involvement. In the thirty-three cases re-
ported by Sodeman and Lewis18 only nine patients
had diarrhea at the onset of the hepatitis, al-
though another seven gave a history of previous
episodes of diarrhea.
The most constant and significant physical
findings include liver tenderness and hepato-
megaly. Klatskin10,11 places considerable em-
phasis on the importance of compression tender-
ness over the liver area. Corroborative laboratory
evidence will usually include a moderate leuko-
cytosis and an elevated erythrocyte sedimentation
rate. The finding of cysts or trophozoites of en-
dameba histolytica in the feces is not essential to
the diagnosis of hepatic amebiasis. In the sixty-
nine cases of amebic hepatitis reported by Klat-
skin,10 endameba histolytica was found in the
feces in 80 per cent of the cases. In the series re-
ported by Sodeman and Lewis18 the organisms
were found in the feces in only 54.5 per cent of
thirty-three cases. Roentgen-ray studies may give
further aid to the diagnosis by the demonstration
of a mass bulging under the diaphragm. Eleva-
tion of the right diaphragm and immobilization
are other frequent findings.
The absolute diagnosis of hepatic amebiasis
depends upon the aspiration of “anchovy-sauce”
pus and the demonstration of endameba histolytica
in the material. However, to wait for this evi-
dence in all cases would be unjustified. With the
aforementioned signs, symptoms, and laboratory
findings, one can make a presumptive diagnosis of
hepatic amebiasis, and a trial of emetine therapy
is indicated. A satisfactory response to this treat-
ment adds further weight to the correctness of the
diagnosis.
Pleuropulmonary involvement constitutes one
of the most important complications of amebic
abscess of the liver. This manifestation of the
disease has been considered in some detail by
Ochsner and DeRakey. 13,14,15 A few of the more
pertinent facts mentioned by these authors will
be discussed here. Occasionally pulmonary ame-
bic abscess may occur without evidence of liver
disease, or may occur independent of the liver
infection. However, pleuropulmonary involve-
ment is most commonly the result of direct ex-
tension of the disease from the liver through
the diaphragm.
Of the 2,490 cases of the amebic hepatic ab-
scess collected by Ochsner and DeBakey,13 198
(7.5 per cent) had pleural complications and 209
(8.3 per cent) had pulmonary complications.
Thus pleuropulmonary complications occurred in
1164
Minnesota Medicine
AMEBIC ABSCESS OF THE LIVER— HELLER AND JACOBSON
15.8 per cent of the cases. In their own series
of 181 cases of amebic hepatitis and hepatic
abscess there were twenty-six cases (14.4 per
cent) of pleuropulmonary involvement.14,15 In
the series of fifty-eight cases of hepatic amebic
abscess reported by Sodeman and Lewis19 there
were twelve cases (20 per cent) in which the
presenting signs and symptoms were those of
pleural pain, pleural effusion, or pneumonitis.
Of the twenty-six cases of pleuropulmonary in-
volvement reported by Ochsner and DeBakey14'15
there were nine cases (34.6 per cent) of empye-
ma, nine cases (34.6 per cent) of pulmonary
abscess, and eight cases (30.4 per cent) of bron-
chohepatic fistula.
The symptoms and signs of pleuropulmonary
complications depend to a large extent upon the
type of involvement. Chest pain and cough are
almost constant symptoms. The former may fre-
quently be referred to the shoulder area as a re-
sult of diaphragmatic irritation. The expectora-
tion of “anchovy-sauce” pus is considered to be
pathognomonic of the disease. The demonstra-
tion of endameba histolytica in the sputum of
course establishes the diagnosis. Roentgenologic
examination of the chest may frequently reveal
in the lower lung field a triangular shadow with
the base directed toward the liver and the apex
directed toward the hilum of the lung. However,
roentgen-rays may only demonstrate evidence of
a pleural effusion or empyema.
The prognosis depends upon the type of com-
plications and the type of therapy used. In the
collected series of Ochsner and DeBakey13 there
was a mortality of 56.1 per cent among cases of
pleuropulmonary involvement not receiving eme-
tine. In cases receiving emetine the mortality was
8.2 per cent. Open drainage increased the mor-
tality even when combined with emetine. The
total mortality in the collected series was 41.1 per
cent. In the twenty-six personal cases reported
by Ochsner and DeBakey14,15 the total mortality
was 30.8 per cent. The development of an em-
pyema has the worst prognosis while the forma-
tion of a bronchohepatic fistula offers the best
prognosis. Of the twenty-six cases of Ochsner
and DeBakey14’15 there were six deaths (66.6 per
cent) among the nine cases of empyema, two
deaths (22.2 per cent) among the nine cases of
pulmonary abscess, and no deaths among the eight
cases of bronchohepatic fistula.
Emetine Cardiotoxicity
The therapeutic problem which arose when the
patient manifested electrocardiographic evidence
of emetine cardiotoxicity was of extreme con-
cern to us. Though the cardiotoxic effects of
emetine have been known12 since 1916, considera-
ble difference of opinion still exists as to its
clinical significance. The experimental basis for
emetine cardiotoxicity has been universally ac-
cepted.2,4,12,13 In 1916 Levy and Rowntree12
demonstrated that the intravenous injection into
dogs of 4 to 18 mg. of emetine per kilogram of
weight produced death by ventricular fibrillation.
The authors stated that the principal pathological
lesion was a hemorrhagic gastroenteritis, but no
discussion is given of the myocardial pathology.
In 1922 Chopra and Ghosh4 reported cloudy
swelling, atrophy, and myocardial necrosis in rab-
bits that had been poisoned by doses of emetine.
Rinehart and Anderson16 reported that in rabbits
and cats a single dose by mouth of 15 to 20 mg.
per kilogram produced death in more than 50 per
cent of the animals in two to eight days. Lethal
or sublethal doses of the drug caused severe in-
jury to the heart muscle. Those animals that died
in less than forty-eight hours showed interstitial
edema of the myocardium. In animals surviving
for more than three days there was found a ne-
crosis of some fibers and a degenerative swelling
of the remainder. Focal proliferation of plasma
cells, polymorphonuclear cells, and eosinophils
was present. A more chronic intoxication with
divided lethal doses caused small cellular scars in
the myocardium, the scars being centered about
necrotic fibers.16 As will be suggested later this
is of considerable clinical significance in evaluat-
ing the cumulative effect of emetine upon the
myocardium. More recently striking electrocar-
diographic changes have been noted in dogs and
cats following the intravenous administration of
emetine in a dose of 37 mg. per kilogram.2 The
earliest alteration consisted of widening of the
initial QRS complex. This was noted to occur as
early as 20 to 30 seconds after the injection and
was not accompanied by prolongation of the PR
interval, T wave changes, or unusual change in
the heart rate. A second injection caused further
intraventricular block and auricular extrasystoles.
A third injection usually caused the heart to stop
in diastole. Paroxysmal auricular tachycardia was
frequently noted. Ventricular tachycardia was
less common and often changed to ventricular
November. 1947
1165
AMEBIC ABSCESS OF THE LIVER— HELLER AND JACOBSON
fibrillation. None of the dogs showed an ab-
normal increase in the PR interval ; however, two
cats were noted to have complete heart block.
The electrocardiographic alterations usually dis-
appeared within forty-five minutes if the dose did
not exceed 37 mg. per kilogram. The striking ef-
fect of the cumulative action of emetine is noted
by the response to a second or third injection of
the drug. Thus it has been shown that emetine
is capable of producing marked cardiotoxicity in
experimental animals, although it is recognized
that the doses employed are far in excess of those
used therapeutically. It remained for clinical in-
vestigation to establish that emetine cardiotoxicity
may also occur with the usual therapeutic doses.
The difference of opinion which challenges this
concept is felt to be due to a different clinical ap-
proach to the problem.
In 1935 P>rown,3 in summarizing his experience
with 544 cases of amebiasis treated at the Mayo
Clinic with emetine, reported no evidence of car-
diovascular disease. It is noted, however, that no
electrocardiograms were reported. In the same
year Sayid17 reported two cases of auricular
fibrillation following the subcutaneous administra-
tion of emetine. One might challenge the arrhyth-
mia in his first case since it occurred in a pa-
tient with mitral heart disease. The second case
is thought to be significant since the patient had
no evidence of heart disease prior to emetine
therapy. In 1943 Heilig and Viveswar8 reported
a series of forty-five unselected cases of amebia-
sis in whom emetine was given by both the in-
tramuscular and intravenous routes. It was noted
that these authors were dealing with chronically
ill, malnourished patients, a large majority of
whom had abnormal electrocardiograms prior to
institution of therapy. In one of fourteen cases
treated intramuscularly, electrocardiographic
changes consisted of lowered QRS voltage and
flattening of the T2 after therapy. In six of six-
teen cases treated intravenously, prolongation of
the PR interval, diminished QRS voltage, and
flattening of the T wraves were noted. Fifteen
cases treated with intravenous emetine were sub-
jected to an exercise tolerance test, and lowered
voltage of the R waves was noted in six instances
and lowered T waves in nine instances. In all of
the above-mentioned series, the dose consisted of
1 grain daily for twelve days. The authors’ con-
clusion that a moderate cardiac lesion is no con-
traindication to emetine would seem, in view of
the above-noted electrocardiographic changes, to
be open to some criticism.
In 1944 Hardgrove and Smith,7 in a series of
seventy-two cases treated with Zz grain of emetine
twice a day for ten days, noted depression of T
waves varying from lowering to frank inversion
in thirty-three cases (45.8 per cent). In nine
cases it was noted that the PR interval increased
although still remaining within normal limits. In
four cases there were noted auricular or ventric-
ular extrasystoles. In 1945 Cottrell and Hay-
ward5 reported a series of thirty-two cases treated
with 1 grain of emetine intramuscularly for ten
to twelve days. Lowering of the QRS was noted
in seven cases and diminution of the T waves in
one or more leads in twenty-five cases. In twelve
cases the PR interval increased from .02 to .04
seconds but still remained within normal limits.
The blood pressure was observed in twenty-one
cases ; no change occurring in thirteen, a transient
fall from 15 to 20 mm. mercury occurring in six,
and a persistent fall in two cases. Recently Dack
and Moloshok6 reported nine cases of amebic
dysentery in whom toxic cardiac manifestations
developed after treatment with emetine. Dysp-
nea, tachycardia, or palpitation were observed in
seven cases. Electrocardiographic abnormalities
consisting of T wave changes were reported in
all nine cases. The authors stress the fact that
electrocardiographic abnormalities may first ap-
pear one or two weeks after cessation of treat-
ment.
From the bulk of evidence it would seem safe
to conclude that emetine is capable of producing
clinically significant toxic effects on the heart.
The electrocardiographic changes noted in our
case were interpreted as evidence of early emetine
cardiotoxicity and indications for at least tempo-
rary cessation of emetine therapy. The length
of the rest periods between courses of emetine
was shorter than we would have liked to observe ;
however, our desires in this regard were modified
by the severity of the infection and the dire need
for specific therapy.
Summary
1. A case of amebic abscess of the liver with
bronchohepatic fistula is reported. The diagnostic
criteria have been discussed.
2. Amebiasis and its complications present a
(Continued on Page 1177)
1166
Minnesota Medicine
CLINICAL USE OF FOLIC ACID
MARCUS A. KEIL, M.D.
Minneapolis, Minnesota
/T UCH has been written on the clinical use
of folic acid (pteroyl glutamic acid). The
results of the various investigations have been
quite similar, and consequently there is fair agree-
ment as to indications and contraindications for
its use. The purpose of this paper is to review
briefly some of the literature and to add the
results of the use of folic acid by the Department
of Medicine at the University of Minnesota Hos-
pitals during the past year.
Studies on Nutrition of the Monkey
Berry and Spies5 and Spies43 have published
the most complete reviews of the literature. Time
permits only a brief review here. Probably it is
most logical to first review the studies done on
the nutrition of the Macacus Rhesus monkey.
Wills and Bilimoria50 in 1932 showed that mon-
keys fed a diet similar to that eaten by pregnant
women in Bombay, India, developed anemia, leu-
kopenia, and had a megaloblastic bone marrow.
Yeast extract corrected the condition. In 1935
Day, Langston, and Shukers15 performed a sim-
ilar experiment, noted that the animals developed
in addition gingivitis, diarrhea, and expired in
twenty-six to ninety-three days. They also
noted16 that 10 grams of brewer’s yeast or 2
grams of a liver stomach preparation daily pro-
moted a normal state of nutrition. This unknown
substance was designated vitamin “M,”17 the “M”
for monkey. Known vitamins were noted to be
ineffective in the condition and liver extract was
shown to be effective.29 In subsequent experi-
ments19’38’39’46’51 beneficial effects in the deficiency
syndrome were obtained with yeast residue, crude
liver extract, a norit eluate fraction of liver, and
a highly purified L. caseii factor. Finally, crystal-
line folic acid was shown to correct the condi-
tion.18
Work on L. Caseii Factor — "Folic Acid"
In 1941 Stokstad44 isolated a factor from solu-
bilized liver which was necessary for the growth
of Lactobacillus caseii. At about the same time,
Mitchell, Snell, and Peterson31 reported isolation
of a growth factor for Streptococcus lactis R
Dr. Keil is a Fellow in the Department of Medicine, Uni-
versity of Minnesota Hospitals.
November. 1947
(Streptococcus faecalis) from spinach. This they
termed folic acid because of the source. A num-
ber of investigations have followed. Very briefly
these have demonstrated that these factors were
probably related and that hydrolysis of crude
compounds produced substances equal in activity
for both organisms. One of the biggest problems
in studying folic acid is that the only method of
quantitation is by bio-assay with either L. caseii
or Streptococcus faecalis. At best it is not a
very satisfactory method.
The various investigations have revealed there
are at least four different compounds from various
sources which have “folic acid” activity. The
Lactobacillus caseii factor from liver has been
synthesized1 and its formula is :2
COOH 0
H00C-CH2CH2-Ch-NH-C^ VNH-i
The folic acid factor from yeast has the same
ring structure but differs in the number of mole-
cules of glutamic acid, and is pteroylhexagiuta-
mylglutamic acid.35 The fermentation L. caseii
factor has been described by Hutchings et al as
pteroyldiglutamylglutamic acid.26
Studies in Chick Nutrition.- — Hogan and Pa-
rott25 in 1939 following studies on the nutrition
of the chick, reported that a water soluble extract
of liver was necessary to maintain growth and
a satisfactory level of hemoglobin. He desig-
nated this substance as vitamin Be, the “c” for
chick, and showed that none of the known vita-
mins would replace it. In 1943 Pfiffner et al36
reported they had isolated a crystalline substance
from liver which was active for the chick and
very active for L. caseii. This they felt was
the same as the previously described “Eluate fac-
tor” and “folic acid.” In subsequent reports8’9’37
this same group of investigators showed that by
enzymatic digestion of the yeast extract the sub-
stance was equally active for L. caseii and Strep-
tococcus faecalis and also was as equally active
as the liver factor. Much confusion has arisen
1167
CLINICAL USE OF FOLIC ACID— KEIL
in connection with the studies of chick nutrition
also but it appears that Briggs and Lillie10 an-
swered most of the problems by feeding chicks
what appeared to be a diet deficient in folic acid
and adding the synthetic substance. This pro-
moted normal growth in all respects whereas
the chicks not fed the synthetic product began
to develop signs of the deficiency syndrome.
Folic Acid Deficiency in the Rat. — There are
two reviews5’12 of this work which do not inter-
est us greatly here except that these studies were
responsible for the original use of folic acid at
the University of Minnesota. Two papers27’45
appeared which reported that rats fed on a puri-
fied diet plus sulfaguariidine or sulfasuxidine
developed agranulocytopenia and aplasia of the
bone marrow. This was corrected in three to
ten days by liver fractions known to contain folic
acid, even when the control conditions were con-
tinued. A similar response13 was obtained with
crystalline L. caseii factor. In a subsequent re-
port28 L. caseii factor was repeatedly able to
correct the granulocytopenia of rats on the defi-
cient diet.
Possible Folic Acid Deficiency in other Ani-
mals.— A number of studies on deficiency states
in other animals have been reported. Most of
these have been reviewed by Spies.5 It appears
at this time that they do not add anything to our
knowledge of folic acid and its relationship to
human nutrition.
Studies on Folic Acid in Man
It is impossible to know where such a review-
should begin; perhaps with the use of liver ex-
tract in pernicious anemia, perhaps with the use
of yeast in macrocytic anemia of pregnancy. In
any event, both liver and yeast have been used
successfully and extensively in the treatment of
various anemias and sprue. Whether their bene-
ficial effects have been due to their folic acid
content is not definitely apparent at this time.
Again, the subject is reviewed by Spies.51
One of the first clinical studies was reported
in 1944 when a Be concentrate was given to ten
patients with anemia which would not respond
to the usual therapy. A dose of 1500 gamma per
day failed to> give a response.40
In 1945 Watson et al49 reported giving folic
acid concentrate orally to eight patients with re-
fractory anemia. No response was noted. In
six cases with leukopenia resulting from intensive
roentgen ray therapy for carcinoma of the cer-
vix, definite elevations of the leukocyte count were
noted. One patient with polycythemia vera, re-
ceiving total body radiation, exhibited a rise in
the leukocyte count. No effect was noted in one
patient with Hodgkins disease who was receiving
radiation therapy. Also in 1945 Berry, Spies,
and Doan6 obtained transitory rises in the leu-
kocyte counts in patients with leukopenia asso-
ciated with a general vitamin B complex defi-
ciency. A more recent report34 stated that agran-
ulocytosis appeared in a patient receiving pro-
pylthiouracil while 30 mg. of folic acid was
being given daily.
Vilter, Spies, and Koch47 reported a study on
fourteen cases of macrocytic anemia treated with
synthetic folic acid. Five of these were Addiso-
nian pernicious anemia, six were classified as
nutritional anemias, and three were of indeter-
minate type. Thirteen of the patients responded
with a satisfactory reticulocytosis, rise in hemo-
globin, and erythrocyte count. The response was
considered to be equal to that expected from
liver extract and was independent of the route
of administration.
Moore, Bierbaum, Welch, and Wright32 report-
ed a small group of cases treated with synthetic
folic acid. Included were two patients with
Addisonian pernicious anemia, one patient with
nontropical sprue, and one patient with pernicious
anemia of pregnancy. All obtained excellent hem-
atological remissions.
Spies41 more recently summarized treatment
of forty-five patients with various anemias. He
obtained hematological responses in five cases of
nutritional macrocytic anemia, five cases of Addi-
sonian pernicious anemia, eight cases of sprue,
three indeterminate macrocytic anemias, three
pernicious anemias of pregnancy, one macrocytic
anemia and alcoholism, one macrocytic anemia
and carcinoma of the stomach. Ten patients did
not respond at all. These included three with
aplastic anemia, three with leukemia, three with
hypochromic anemia, and one with an indeter-
minate macrocytic anemia.
Arnall and Wright3 noted that pernicious ane-
mia responded to folic acid.
Other articles of interest have appeared. Zuil-
zer and Ogden53 noted that nine of twelve infants
with macrocytic anemia responded to folic acid.
1168
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CLINICAL USE OF FOLIC ACID— KEIL
Berman et al4 reported a series of eleven cases
in which response was obtained in each instance
where the bone marrow was megaloblastic.
Doan20 found folic acid failed in macrocytic
anemia of cirrhosis. He also states that minor
neurological signs and symptoms in patients with
pernicious anemia in relapse have responded as
promptly and completely following L. caseii fac-
tor supplement as with potent liver extract. Gold-
smith21 reported that familial hemolytic anemia
did not respond to folic acid therapy. Moore
et al33 found that 100 mg. of folic acid given
rectally to a patient with Addisonian pernicious
anemia gave a submaximal response. There are
four writers who disagree with Doan’s view so
far as the effect of folic acid on subacute com-
bined degeneration is concerned. Spies48 reported
follow-up studies on a series of twenty-six pa-
tients. After five to eight months of treatment,
four patients developed paresthesias and unsteady
gait. Fifty to 500 mg. of folic acid orally per
day for ten to fourteen days did not benefit the
patients but five cubic centimeters of liver extract
parenterally gave improvement in ten days.
Hall22 in a study of fourteen cases of pernicious
anemia noted that the spinal cord lesions pro-
gressed. Meyer30 noted progression of neuro-
logical lesions in three of eleven patients treated.
Heinle and Welch24 considered the possibility that
folic acid caused a more rapid development of
cord lesions in one patient.
Folic acid has also been used in the treatment
of sprue, perhaps witth more success than in any
other disease. Darby and Jones14 treated suc-
cessfully two patients suffering from tropical
sprue with synthetic folic acid. More complete
studies followed, but Spies et al42 reported treat-
ment of nine tropical sprue patients with excel-
lent hematological responses, decrease in the vol-
ume and the number of stools, and improvement
in the patient’s sense of well-being.
Results of Our Studies with the Use of Folic
Acid* — Our studies with folic acid (pteroylglu-
tamic acid) have included administration to pa-
tients with a variety of conditions. Our results,
in general, agree fairlv well with what has been
previously reported.
We have treated seven patients with pernicious
^Synthetic folic acid, Lederele’s “Folvite”’ was used in this
study and was supplied by Dr. Stanton M. Hardy of Lederle
Laboratories, Pearl River, New York.
anemia in relapse, six at this hospital and one
at Ancker Hospital.
Case Reports
Case 1. — E. M., a woman aged sixty-three, was given
folic acid 200 mg. intravenously over a period of sixteen
days. The hemoglobin was 10 grams and the erythrocyte
count was 2.4 million at the beginning of treatment. On
the twenty-seventh day the hemoglobin was 15.7 grams
and the erythrocyte count was 4.9 million.
Case 2. — J. B., a man aged sixty-six, was given 140
mg. of folic acid in ten days (60 mg. intravenously, 60
mg. intramuscularly, and 20 mg. orally), and on the
tenth day, the hemoglobin had risen from 6.4 grams to
8.1 grams. Maximum reticulocyte response was 15.5
per cent on the sixth day. Liver extract parenterally
failed to give a secondary reticulocytosis. Bone marrow
study on the seventh day revealed an almost completely
normoblastic marrow whereas before therapy it had
been megaloblastic.
Case 3. — M. B., a woman aged forty-one, was given
15 mg. folic acid orally for twenty-four days and 15
mg. intramuscularly for the first three days. The hemo-
globin rose from 3.9 grams to 10.6 grams, and the
erythrocyte count from 850,000 to 3 million. Maximum
reticulocytosis appeared on the sixth dhy when the
count reached 35 per cent. Folic acid therapy was con-
tinued in this case from September 10, 1946, to Novem-
ber 15, 1946, the dosage being 15 mg. orally daily and
30 mg. intramuscularly every week. It is, however, not
certain just how much of the medication the patient
received. On November 15, 1946, the hemoglobin was
15.6 grams and the erythrocyte count was 4.8 million.
The cell indices were normal, whereas before therapy
there had been a marked macrocytosis.
Case 4.- — E. J., a woman aged sixty-seven, was given
folic acid 15 mg. intramuscularly and 15 mg. orally daily
for eighteen days. The hemoglobin rose from 5.4 to
8.1 grams, and the erythrocyte count rose from 1.9 to
3.4 million. The maximum reticulocyte count appeared
on the tenth day, when it was 10 per cent.
Case 5. — U. D., a man aged fifty-one, received folic
acid 15 mg. intramuscularly daily for ten days, and
10 mg. orally daily for eighteen more days. The hemo-
globin rose from 9.6 to 15.2 grams and the erythro-
cyte count rose from 2.5 million to 4.6 million in this
interval. The reticulocyte count was maximal at the
seventh day, when 11.3 per cent was recorded.
Case 6. — M. J., a woman aged seventy-three, was given
20 mg. of folic acid intravenously for ten days and 20
mg. orally for ten more days. The hemoglobin rose
from 7.3 to 10.5 grams and the erythrocyte count from
1.4 million to 2.5 million. The maximum reticulocyte
count was 16.2 per cent on the seventh day of therapy.
Case 7 . — This patient, a woman aged eighty-five, was
given 15 mg. of folic acid intramuscularly for ten days
November, 1947
1169
CLINICAL USE OF FOLIC ACID— KEIL
and 5 mg. orally thereafter. On the eighth day, the
reticulocyte count was 25 per cent. The hemoglobin
rose from 3.8 grams to 7.8 grams at the end of 20
days of therapy.
The hematological responses in these patients
compares quite favorably with the responses fol-
lowing liver therapy. In Case 3, where the intake
of extrinsic factor was very poor, folic acid ap-
parently was capable of maintaining normal blood
levels for the period of time the patient was
treated.
In June, 1946, we felt it would be very
desirable to place a group of patients with treated
pernicious anemia on folic acid in order to de-
termine, if possible, whether the neurologic
lesions of subacute combined degeneration would
appear while folic acid was being given. We
also wished to study the effect of folic acid on
the cord lesions present at the time therapy was
begun. We selected twenty-two patients, nine-
teen of whom we were able to follow for the
period of study. Eleven of these patients had no
neurological signs at the beginning of treatment,
and their hemoglobin levels were well maintained
by parenteral liver extract. Two of these eleven
patients received 30 mg. of folic acid intramus-
cularly every two weeks. Two more received
30 mg. intramuscularly every two weeks for two
months and were then given 5 and 10 mg. orally
daily, respectively, for another four months. The
remaining seven patients of this group of eleven
were given 5 mg. folic acid orally for five to six
months. Hemoglobin values and erythrocyte
counts on these patients remained at relatively
normal levels and the neurological pictures were
unchanged.
There were nine patients of the group of twen-
ty-two who had variable neurological symptoms
and signs at the beginning of the study. Seven
in this latter group were old cases which were
stable on liver. Three of these had moderate neu-
rological changes which did not progress during
five months of treatment with folic acid. A
fourth patient left the clinic before the study
could be completed. A fifth patient had moderate
neurological findings which did not progress.
Two patients had severe cord changes when the
study was begun. In one of these there was no
apparent progression of the lesions during five
months of study. The other demonstrated no
changes at the end of five months and was again
given a moderately refined liver extract. One
month later, however, she had definite evidence
of progression of the neurological lesions. She
has shown no improvement after six weekly in-
jections of crude liver extract. The other two
patients in this series are difficult to evaluate,
but in neither were any significant changes demon-
strated neurologically. The amount of folic acid
given to these nine patients varied from 5 mg.
orally daily to 30 mg. intramuscularly every two
weeks. In all of the nineteen patients the hemo-
globin and erythrocyte values were maintained at
satisfactory levels but there was no definite in-
crease over the values obtained while the patients
received liver extract.
Cases 3 and 6, above, deserve further considera-
tion in regard to neurological lesions. Case 3
had evidence of extensive cord involvement at
the time she was first seen. Reflexes were hyper-
active. Babinski reflexes were present bilaterally.
Position sense was poor and vibration sense was
absent bilaterally on the lower extremities. At-
axia and scissor gait were present and she walked
only with support. After the initial hospital-
ization of twenty-four days she was given folic
acid 15 mg. orally per day and 30 mg. intra-
muscularly weekly by her local doctor. On
October 8, 1946, one month after discharge,
she returned to the out-patient clinic and several
examiners felt that her gait was more unsteady.
She also complained of inability to control her
urine. After unsuccessful attempts to place her
in a rest home, she was hospitalized on Novem-
ber 15, 1946. At that time she was psychotic,
exhibited marked malnutrition, had a flaccid
paralysis of the lower extremities, was incon-
tinent, and had no vibration or position sense in
the legs. She also had several large decubiti and
there were a number of erythematous areas over
the feet and legs which were felt to be due to
pellagra. As was pointed out above, her blood
values were normal. ‘She was treated intensively
with a high caloric diet, crude liver extract, and
vitamins. The skin lesions subsided rather
promptly and two months later she was mentally
clear, was no longer incontinent, and there was
some evidence of improvement in the neurological
lesions.
Case 6 was maintained on folic acid 10 mg. per
day after she developed sensitivity to liver ex-
tract. She had definite evidence of neurologic
1170
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CLINICAL USE OF FOLIC ACID— KEIL
involvement at the time treatment was begun and
was poorly nourished. After about seven months
she complained bitterly of paresthesias and man-
ifested evidence of progression of the neuro-
logical lesions with hyperactive reflexes, a Babin-
ski reflex on the right, and loss of vibratory
sense in her legs. She has not improved signifi-
cantly after two months of intensive therapy
with liver extract and vitamins.
Other Conditions Treated
Folic acid has also been tried in a variety of
other conditions. One patient with idiopathic
hypochromic anemia failed to respond after a
month of treatment with 30 mg. of folic acid daily
orally. Four patients with hyporegenerative
(aplastic) anemias failed to respond. One pa-
tient eighty-five years old with a macrocytic
anemia due to undetermined cause failed to re-
spond. Another sixty-one-year-old man with a
macrocytic anemia and a macronormoblastic mar-
row failed to respond. A fifty-nine-year-old man
who had had a gastrectomy in 1941 developed a
macrocytic anemia which did not respond to
folic acid orally. The bone marrow before therapy
was macronormoblastic.
Results of treatment in one case are very in-
teresting. This patient had a macrocytic anemia
with free hydrochloric acid on gastric aspiration.
Intermittent diarrhea was present. Liver therapy
had been carried out for a prolonged period in
adequate amounts, and liver injections were con-
tinued while folic acid was given. Flowever, after
twenty -three days on 10 mg. of folic acid orally
daily, the hemoglobin had risen from 8.5 to 10.6
grams. A reticulocyte response was obtained and
reached 14.6 per cent on the sixth day. It is
probable that this patient had sprue, but labora-
tory proof was not available.
Six patients with neutropenia or agranulocy-
tosis have been treated. Three of these were as-
sociated with hyperthyroidism in patients receiv-
ing various medications including thiouracil or
propylthiouracil. In one patient, a marked re-
sponse occurred simultaneously with the admin-
istration of 10 mg. of folic acid intravenously
daily. The patient also received pyridoxine and
penicillin. The same situation prevailed in the
other two cases where there was a less marked
rise in the leukocyte count, and again the re-
sponses may have been due to other medications.
One five-year-old girl with a severe neutropenia
of undertermined cause failed to respond and
another patient, also with an agranulocytosis of
undetermined etiology, demonstrated no ap-
parent response to folic acid. In one patient with
a sulfonamide leukopenia the leukocyte count
rose from 3,650 to 9,400 cells after three days
of treatment. The percentage of polymorpho-
nuclear cells rose from 20 to 68 per cent. This
result may well have been due to discontinuing
the sulfonamide.
Two patients with nonspecific ulcerative colitis
were given folic acid 40 mg. daily for eleven
and 100 days, respectively, without a definite im-
provement in the number or character of their
stools. Another patient with nonspecific ulcera-
tive colitis who had had repeated resections of
portions of her small bowel in addition to the
colon because of extension of the disease failed
to respond after fourteen days of therapy. One
patient with steatorrhea may have had a response
to folic acid but the clinical picture was com-
plicated by hemorrhage from an esophageal diver-
ticulum, and no conclusions can be drawn. One
patient with pernicious anemia and an unex-
plained diarrhea was treated. No improvement
in the diarrhea was noted. A temporary improve-
ment was noted in one patient with steatorrhea
thought to be due to sprue.
Amounts and Administration
We have used folic acid intravenously, in-
tramuscularly, and orally. When diluted with
10 c.c. of saline, as much as 40 mg. of folic acid
has been given intravenously without reaction.
Intramuscular injections produce temporary dis-
comfort. No reactions have-been noted to oral
administration. Doan20 reports that 125 to 150
mg. given intravenously produce unpleasant his-
taminelike reactions.
Discussion
The role of folic acid in human nutrition is
not at all clear, nor is it established that it is an
essential substance as it is in the nutrition of the
monkey. Our knowledge at this point permits
us to say that given parenterally, orally, or rectal-
ly to patients with pernicious anemia and other
megaloblastic anemias it produces an apparently
complete remission of the blood picture. It ap-
parently fails to exert any beneficial effect on the
associated cord lesions of pernicious anemia. The
folic acid content of liver has been studied.11
November. 1947
1171
CLINICAL USE OF FOLIC ACID— KEIL
by bio-assay methods and the amount of free
folic acid present is less than 10 micrograms per
cubic centimeter. Oral liver preparations also
give a low assay value. Many studies have been
reported in which the amount of folic acid in liver
and yeast (as determined by bio-assay methods)
could be increased by acid or base hydrolysis, or
enzymatic digestion, but the amount obtained is
not significantly increased.
The above findings have led Spies5 to postu-
late that folic acid in food occurs as a conjugate,
and patients with megaloblastic anemias are un-
able to liberate the active substance because of
lack of enzymes. He further postulates that liver
extract may provide an enzyme capable of liberat-
ing folic acid from the conjugated form. The
work of Bethell7 and Heinle23 tend to support
this theory.
Case 3, above, presents another feature which
1 believe is significant. The question might well
be asked if folic acid deficiency plays any part in
producing the clinical picture of pellagra. This
patient developed what was felt to be pellagra
while she was being given folic acid, and re-
sponded rather promptly when nicotinamide was
given.
Doan20 has described folic acid as “an essen-
tial panhematopoietic stimulus,” and Wright and
Welch52 regard folic acid as part of the vitamin
P> complex. I should like to point out that in
several of our patients an unexplained feeling
of well-being followed folic acid therapy. In one
instance this effect was later secured by giving
placebos. In others it may have been due to a
dislike for intramuscular injections of liver ex-
tract. The improvement in one patient’s epigas-
tric distress and bowel habits may have been
related to change in bacterial flora of the bowel
since folic acid is an essential growth factor for
the lactobacilli group and also streptococcus
faecalis. It is, however, to be noted also that
several patients felt better after liver extract
therapy was resumed.
Tn the present state of our knowledge it does
not appear possible to state clearly the indications
for the clinical use of folic acid. Certainly it ap-
pears that folic acid should be given to every pa-
tient who appears to have sprue. There appears
to be sufficient evidence to warrant its continued
use and evaluation in neutropenias and agranu-
locytosis, particularly those due to sulfonamides.
In some of the megaloblastic anemias where spinal
cord lesions are not present it may be made more
desirable than liver extract, particularly where
there is sensitivity to the latter. It also seems quite
possible that it may be an essential vitamin.
Conclusions
From our studies it seems fair to draw the
following conclusions :
1. Folic acid (pteroylglutamic acid) parenteral-
ly is capable of inducing a complete remission in
Addisonian pernicious anemia and, given orally
or parenterally, is capable of maintaining normal
blood values for a period of at least five months.
2. It appears to exert no beneficial effect on the
spinal cord lesions of subacute combined degener-
ation.
3. Macrocytic anemias in which a megaloblas-
tic marrow could not be demonstrated did not
respond to folic acid.
4. It does not appear to be of any benefit in the
other conditions in which it was tried, with the
possible exception of the sulfonamide leukopenias.
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41. Spies, T. D.: Treatment of macrocytic anemia with folic
acid. Lancet, 1:225, 1946.
42. Spies, T. D.; Milanes, F. ; Menendez, A.; Koch, Mary B.,
and Minnich, V. : Observations on the treatment of tropical
sprue with folic acid. J. Lab. & Clin. Med., 31:227, 1946.
43. Spies, T. D. : Experiences with Folic Acid. Chicago: Year-
book Publishers, 1946.
44. Stokstad, E. L. R. : Isolation of a nucleotide essential for
the growth of Lactobacillus caseii. J. Biol. Chem., 139:
475, 1941.
45. Spicer, S. S.; Daft, F. S. ; Sebrell, W. H., and Ashburn,
L. L. : Prevention and treatment of agranulocytosis and
leukopenias in rats given sulfanilylguanidine or succinylsul-
fathiazole in purified diets. Pub. Health Rep., 57:1359, 1942.
46. Waisman, H. A., and Elvehjem, C. A.: The role of biotin
and “folic acid” in nutrition of the Rhesus monkey. J.
Nutrition, 26:361, 1943.
47. Vilter, C. F. ; Spies, T. D., and Koch, M. B.: Further
studies on folic acid in the treatment of macrocytic ane-
mias. South. M. J., 38:781, 1945.
48. Vilter, C. F. ; Vilter, R. N., and Spies, T. D.: The occur-
rence of combined system disease in persons wilh pernicious
anemia during treatment with folic acid. Proc. Cent. Soc.
for Clin. Res., 19:26, 1946.
49. Watson, C. J.; Sebrell, W. H. ; McKelvey, J. L. ; Daft,
F. S., and Hawkinson, V. : Possible effectiveness of the L.
caseii factor (“folic acid”) concentrate on the refractory
anemias and leukopenia with particular reference to leu-
kopenia following radiation therapy. Am. J. M. Sc., 210:
463, 1945.
50. Wills, L., and Bilimoria, H. S.: Studies in pernicious ane-
mia of pregnancy; production of macrocytic anemia in
monkeys by deficient feeding. Indian J. M. Research, 20;
391 1932
51. Wilson, H. E. ; Doan, C. A.; Saslow, S., and Schwab, J. L. :
Reactions of monkeys to experimental respiratory infections.
V. Hematological observations in nutritional deficiency
states. Proc. Soc. Exper. Biol. & Med., 50:341, 1942.
52. Wright, L. C., and Welch, A. D.: The metabolism of folic
acid. Am. J. M. Sc., 206:128, 1945.
53. Zuilzer, W. W., and Ogden, F. N.: Folic acid for megalo-
blastic anemias. Am. J. Dis. Child, 71:211-243, 1946.
PRACTICE BY APPOINTMENT
Criticism of the individual members of the medical
profession is encountered in every survey and test
being made to find answers to problems of public rela-
tions. Laymen complain that “they are being pushed
around by the doctors.” Just today we were told of
a patient trying to find a doctor in one of our larger
towns. The patient had an earache too severe for
ordinary remedies, but could see the otologist only by
appointment, and the first available date was two weeks
ahead. Too often the doctor’s appointments are made
up as far as six weeks in advance.
Industrialists complain that if a worker has to go to
a doctor during working hours it takes at least three
hours, and causes too many lost man-hours. And the
patients that do get in to see the doctor complain that
the appointment is crowded into so little time that they
feel as though they are on an assembly line.
Tens of thousands of our doctors have returned
from military service where they became used to fixed
hours, and shorter hours for their work. Labor and
the government have impressed upon all of us the ideal
of a forty-hour week. Doctors, especially the younger
ones, are adjusting their practices to short hours
filled with appointments, and these are made far in
advance. Such a regime makes for the complaint that
doctors are hard to find ; that there are too few of them.
During the war many of our busy doctors found that
they were not rendering the best possible service by
the appointment system, and opened their offices to all
comers; first come, first served. The office doors would
be closed at a designated hour, and the doctor would
care for all who remained before leaving. People
complained of having to wait sometimes a long while,
but they did get medical care. This plan should ap-
peal to some doctors in each community.
If doctors continue to practice by appointment, and
since the public is really entitled to medical attention,
we would suggest that every day of appointments in-
clude one hour or a specified time for patients without
appointments. — Editorial, Journal Michigan State Medi-
cal Society, October, 1947.
November, 1947
1173
CLINICAL-PATHOLOGICAL CONFERENCE
DIAGNOSTIC CASE REPORT
KARL W. EMANUEL. M.D.. MALCOLM GILLESPIE, M.D., and ARTHUR H. WELLS. M.D.
Duluth, Minnesota
Dr. K. W. Emanuel : Mrs. E. P., aged thirty-nine
years, consulted me on Tune 4, 1947, complaining of
diarrhea, occasional vomiting, and some cramp-like ab-
dominal pain associated with her diarrhea beginning
May 7. The diarrhea had stopped at the time I saw
her, and her chief complaint was itching of the skin
associated with some areas of papular dermatitis. The
physical examination was essentially negative through-
out, with normal blood counts and routine urine analysis.
On Tune 6, she again came to my office, stating that
her skin had become very yellow during the preceding
two days. She had also noticed some weakness and
itching. Her icterus index was 70 units. The red blood
cell sedimentation rate was 75 mm. in one hour (Wester-
gren) and there was a 2 plus bile in the urine. The white
blood cell count was 12,250. Her pulse and temperature
were normal. The examination was otherwise essentially
negative. There were no clay-colored stools. Hospitali-
zation was advised, but refused. She was, therefore,
placed on proklats and ketochal. On June 11, her icterus
index had dropped to 69 units. The red blood cell
sedimentation rate was 65 mm. and the urine had 1 plus
bile. Besides jaundice and associated itching, she was
beginning to feel definitely weaker. Her appetite was
fair, and there was no nausea or vomiting. The stools
were normal in color and in frequency. Hospitalization
was again urged, but refused. On June 16, her icterus
index had dropped to 60 units. The sedimentation rate
was 55 mm. and the urine showed a trace of bile. The
jaundice had receded slightly but there was still con-
siderable itching. Her weakness was more profound
than on previous visits. The hemoglobin was 94 per
cent and the red blood cell count was 4,480,000. Her
stools were lighter in color but not clay-colored.
Because of her profound weakness, she consented to
enter the hospital on June 22. While at home she had
noticed some chills and a slight fever for a couple
of days. There had also been a loss of from 5 to 10
pounds in weight since the onset of the present illness
which she felt to be due to loss of appetite.
She was a well-developed and well-nourished white
woman with a grade III jaundice. There were marked
deformities of the hands and feet due to rheumatoid
arthritis. The blood pressure was 130/80. Temperature,
pulse, and respiration were normal. The abdomen had
no tenderness whatever. The gall bladder and other
masses could not be seen or felt. The cardiac, lung,
pelvic and rectal examinations were essentially neg-
ative.
From the Department of Pathology, St. Luke’s Hospital,
Duluth, Minnesota.
The family history was not contributory. She had
five children, living and well. All her pregnancies had
been normal. She had had no operation. She had had
pneumonia once and had suffered from rheumatoid
arthritis for many years.
Laboratory findings : A four-day stool was negative
for urobilinogen. A twenty-four hour urine specimen
contained bile, but no urobilinogen. The blood choles-
terol was 267.0 and cholesterol esters 51.5 mg. per cent.
A cephalin flocculation test on June 24 was negative,
and on June 27 it was 1 plus. The alkaline phosphatase
was 40.6 units (K.A.). The direct Van den Bergh
was 16.4 mgm. per cent and the indirect Van den Bergh
was 1.85 mgm. per cent. The benzoic acid excretion
test revealed 3.33 gm. excreted in three hours. There
were 6,400 white blood cells with a normal differential
count. The red blood cells totaled 3,970,000 and the
hemoglobin was 14 gm. The red blood cell sedimen-
tation rate was 97 mm. in one hour ( Westergren). A
red blood cell fragility test was normal. X-ray studies
showed a nonvisualization of the gall bladder and no
changes in the stomach or duodenum.
Dr. A. H. Wells: The case is now open for diagnosis.
Physicians : Choledocholithiasis, acute hepatitis, car-
cinoma of the liver.
Dr. E. L. Tuohy: The absence of urobilinogen in the
stool and urine plus normal results with liver function
tests even after a month of jaundice make this an al-
most certain case of carcinoma blocking the common
duct.
Dr. F. J. Hirschboeck : More specifically, this is a
case of carcinoma of the papilla of Vater. This type
of cancer is much more likely to result in a fluctuating
jaundice than carcinoma of the pancreas.
Dr. M. G. Gillespie : Through a mid-right rectus in-
cision, exploration revealed a distended gall bladder and
common duct without stones. Dake’s smallest dilator
passed through the ampulla without much difficulty.
However, we opened the duodenum vertically to expose
a tiny nonpalpable mass on the papilla. A Whipple op-
eration was performed, with resection of the head of the
pancreas, the first and second portions of the duodenum,
the pyloric end of the stomach and the terminal end of
the common duct (Fig. 1). The remainder of the
head of the pancreas was sutured into the end of the
first part of the jejunum and the common duct joined
1174
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CLINICAL-PATHOLOGICAL CONFERENCE
end to side with the same loop a few centimeters dis-
tally. The patient had a completely uncomplicated con-
valescence. A T-tube left in the common duct came
out about two weeks after the operation, and its sinus
tract closed immediately.
Dr. A. H. Wells : The lesion involved the very mar-
gins of the orifices of the common duct and duct of
Wirsung, and extended distally on the duodenal mucosa
for 5 mm. (Figs. 2 and 3). There was a severe dilatation
of the two ducts with thickening of their walls. Micro-
scopically (Fig. 4) the adenocarcinoma appears to
have had its origin from the epithelium of the two
ducts at their transitions to the duodenal mucosa. No
extension into the head of the pancreas or through the
duodenal musculature could be found. I predict a com-
plete cure.
Frequency
In a group of 464 cases of carcinoma of the gall
bladder extrahepatic ducts, and the major duodenal
papilla, there were 291 cases originating in the bladder,
119 in the ducts, and 54 in the papilla. Carcinoma
of the latter represented 1.13 per cent of the cases of
carcinoma found in 26,306 necropsies.15 Cancer of the
papilla is reported in a ratio of from 2:1 to 6:1 pre-
dominance in males. Although this malignancy may
occur at any period of adult life, the mean age is
approximately 56 years.16
Etiology
The most convincing theory6’7’16 as to the etiology of
carcinoma of the papilla concerns the little known, yet
remarkably frequent tendency for the normally promi-
nant valvelike folds of the epithelium inside the orifice
of the papilla to form adenomatoid hyperplastic polyps. It
is generally accepted that this pathologic manifestation is
a common precursor of cancer in the rest of the
gastrointestinal tract. Recurrent inflammation may be
the instigator of the polyps.7 Gallstones occur in 50
per cent of the cases of carcinoma of the gall bladder,
in 31 per cent of the cases of cancer of the extrahepatic
ducts and in only 17 per cent of the malignancies of the
papilla.8
Pathology
Carcinomas of the papilla may have their origin from
seven possible epithelial structures: (1) common duct,
(2) pancreatic duct, (3) the confluence of ducts (am-
pulla), (4) Lieberkuehn’s glands of the duodenum,
(5) Brunner’s glands, (6) aberrent pancreatic glands
and (7) Dradinski’s mucous glands of the papilla. In
most instances, tumors of these different sources can-
not be differentiated and for practical purposes are
grouped as adenocarcinomas of the major duodenal
papilla, caruncula major, or papilla of Vater. Since an
ampulla does not exist in 43 per cent of the papillas16
and the tumors can be demonstrated in some instances
to arise from most of the above normal sources, the
frequently used term of carcinoma of the ampulla of
Vater should be discarded as inadequate.
Very rarely other malignant tumors including mela-
noma, lymphosarcoma, and spindle cell sarcoma have
been described.9’11 Rarely, benign neoplasms have been
found causing clinical manifestations.1 They include
papilloma, adenoma, lipoma, fibroma, neuroma, gran-
uloma, melanoma, and carcinoid. Benign duodenal ulcers
rarely occur on the papilla.1
The epithelial malignancies are nearly all adenocar-
cinomas. They have a decided tendency to become pap-
illary and are frequently described as infiltrating and
ulcerating. Rarely they form much mucus. They tend
to be of low histologic grade. They range up to 3 cm.
in diameter, and are frequently too small for the sur-
geon to palpate through the duodenal walls. The fact
that less than half of the cases have metastasized even
at the time of death makes this malignancy unique
among the cancers of the gastrointestinal16’17’18 tract.
Metastases do occur late in the adjacent lymph nodes,
pancreas, and liver in some cases.
Cited as the reasons for the rapid exitus which aver-
ages seven and a third months from the onset of symp-
toms in untreated cases are : cholemia, cholangitis, liver
abscess, empyema of the gall bladder, acute peritonitis,
suppurative pylephlebitis, exsanguination from intraduo-
denal hemorrhage, duodenal obstruction, cachexia, and
pneumonia. Other anatomical complications result from
blocking the common duct and Wirsung’s duct, in-
clude a dilatation of the gall bladder (possibly 90 per
cent), dilatation of intrahepatic bile ducts, hydrops of
the gall bladder and extrahepatic ducts, cholecystitis,
dilatation of the major pancreatic duct (majority), pan-
creatic fibrosis and atrophy.
Clinical Manifestations
Dr. K. W. Emanuel: The early occurrence of signs
and symptoms of malignancies of the papilla of Vater
depend primarily upon their strategic location and al-
most universal obstruction of the flow of bile and to a
less extent on the frequent obstruction of the pancreatic
duct. The consequent jaundice is nearly always present
and is the chief complaint in the majority of cases.
In the majority of patients the jaundice is constantly
present with some fluctuation and slow progression.21 A
few cases with intermittent icterus are explained upon
the basis of ulceration and necrosis of the obstructing
malignancy. Occasionally the jaundice is continuous
and progressive without fluctuation and rarely there is no
jaundice.
Contrary to the general belief, these patients do not
have a painless jaundice, but over 50 per cent have a
colicky or continuous pain in the epigastrium right upper
quadrant or elsewhere in the abdomen.17 The pain is
generally not severe and may decrease in severity.
Pruritis, rapid loss of weight, anorexia and progres-
sive weakness are outstanding and frequent complaints.
Chills and fever occur in over 50 per cent and simulate
these symptoms in common duct calculus. Light colored
or acholic, tarry and steatorrheal stools have been de-
scribed. Nausea, vomiting, diarrhea, severe constipation,
bloating sensations and eructations are occasionally noted.
In some hands distended gall bladders are palpable in
over one half of these patients.21 Courvoisier’s law is
proved correct in 83 per cent of the cases at the time
of laparotomy.18
November. 1947
1175
CLINICAL-PATHOLOGICAL CONFERENCE
A barium meal and roentgren study may reveal some
deformity in the second part of the duodenum and prove
helpful in ruling out other gastrointestinal diseases.
An abdominoscopic examination has been considered of
use.22
Fig. 2. (left) Arrow points to the duodenal mucosal surface
of the carcinoma on top of the papilla of Vater.
Fig. 3. (right) Arrows point to the early carcinoma about the
margins of the dilated (in order) common duct and duct of
Wirsung, also an extension down on the duodenal mucosa.
The literature on carcinoma of the papilla of Vater
is dominated by surgical interests which may explain
the great paucity of data concerning exact measure-
ments of physiologic processes. When the figures are
known, we predict that the laboratory can be of con-
siderable help; first in differentiating obstructive (sur-
gical) from intrahepatic (medical) jaundice and second,
in aiding in the determination of the exact location of
the lesion. The patient we have presented is an illus-
tration of how the various liver function tests (cephalin
flocculation, galactose tolerance, benzoic acid excretion,
blood cholesterol and cholesterol esters) are negative
for diffuse disease of the liver and how the complete
absence of urobilinogen of the stool and urine leads to
the clinical diagnosis of carcinoma obstructing the com-
mon duct. Other aids are found in the fact that occult
blood occurs in the stools in a majority of patients with
cancer of the papilla. Also blood amylase and lipase
may be increased due to the pancreatic duct obstruction.
Duodenal aspiration of blood with little or no bile is
considered helpful.21
One must clinically differentiate carcinoma of the
major duodenal papilla from : cancer of the pancreas,
common duct calculus, stricture of the common duct,
cholecystitis, cirrhosis of the liver, hepatitis, empyema of
the gall bladder, duodenal ulcer, carcinoma of the liver
and others. The most important of these, carcinoma of the
head of the pancreas, is less likely to have occult blood
Fig. 4. Photomicrograph showing an adenocarcinoma at the
margin of the common duct with beginning infiltration of the
normal duodenal mucssa covering the outside of the papilla of
Vater.
in the stools and is more likely to have a rapidly de-
veloping to complete and continuous obstruction of the
common duct, a longer prodromal phase of abdominal
pain, weight loss, anemia and cachexia before the ap-
pearance of jaundice,3 a palpable mass, and x-ray
evidence of an enlarged head of the pancreas.
The diagnosis is rarely made before and never estab-
lished until a surgical exploration is performed. No
patient should be permitted to go more than a few
weeks with an obstructive jaundice without a laparotomy.
Treatment
Dr. M. G. Gillespie: Barring a surgical death, the
excellent prognosis following radical resection of car-
cinoma of the papilla of Vater has led to a wide variety
of techniques in an effort to circumvent the many dis-
asters evidenced throughout the literature on this sub-
ject. In a review17 of 124 collected cases there was a
30.6 per cent surgical mortality. In one review12 of
thirty-eight deaths, twelve died of hemorrhage, five of
peritonitis, three of duodenal fistula, two of shock, two
of pneumonia, and fourteen were not stated. Five factors
of poor success have been listed14 as (1) the insidious
onset of the disease, (2) the poor condition of the pa-
tients, (3) the relative inaccessibility of the lesions, (4)
the proximity of important structures which cannot be
sacrificed, and (5) technical difficulties. In spite of
these, radical resection has sustained life for a longer
period than conservative treatment and it offers the
only prospect there is of a cure. With the advent of
vitamin K, a more liberal use of blood transfusions,
1176
Minnesota Medicine
CLINICAL-PATHOLOGICAL CONFERENCE
chemotherapy and improvements in surgical techniques,
surgical mortalities have decreased considerably.
No single operative procedure is suited for all va-
rieties of tumors of the papilla.5 The mistake of per-
forming a radical resection for a benign papilloma fol-
lowed by surgical death11 is indeed unwarranted. In
such benign lesions and possibly selected tiny malignant
neoplasms, local resections with reimplantation of the
common bile and pancreatic ducts may be indicated.13
Most surgeons prefer a one- or two-stage radical resec-
tion.9>18'23’a4 If the pancreatic duct is tied off, disturb-
ances in carbohydrate and fat metabolism may devel-
ope.10>19>23 The feeding of lecithin, choline and pan-
creatic extract or lipocaic have been advised for both
preoperative and postoperative care.20
Because of the fibrous adhesions resulting from the
first procedure, we favor a one-stage radical resection
in those cases wdiere there are no demonstrable metastases
and in which the patient has been suitably prepared and
is a good operative risk.
Summary
The case of a thirty-nine-year-old woman with a
carcinoma of the papilla of Vater is presented as a
diagnostic study. Over a five-week period she suffered
with diarrhea, vomiting, colicky abdominal pain, a slowly
progressive, apparently fluctuating jaundice and pruri-
tus followed by loss of from 5 to 10 pounds of weight,
profound weakness, chills and fever. The laboratory
studies revealed no urobilinogen in the stools or urine,
and normal results in a series of liver function tests.
A radical (Whipple) resection of the malignancy has
almost certainly resulted in a cure.
A very brief review of the literature concerning the
frequency, etiology, pathology, clinical manifestations
and treatment of carcinoma of the papilla of Vater
is presented.
References
1. Baker, H. L., and Caldwell, D. W. : Lesions of the am-
pulla of Vater. Surgery, 21:523-531, (April) 1947.
2. Brunschwig, A. / One stage pancreatoduodenectomy. Surg.,
Gynec. & Obst., 85:161-164', (Aug.) 1947.
3. Cattell, R. B.: Pancreatoduodenal resection. New England
J. Med., 232:521-526, (May 10) 1945.
4. Christopher, F. : Adenoma of the ampulla of Vater. Surg.,
Gynec. & Obst., 56:202-204, (Feb.) 1933.
5. Cooper, W. A. : Carcinoma of the ampulla of Vater. Ann.
Surg., 106:1009-1034, (D,ec.) 1937.
6. Dardinski, V. J. : Inflammatory adenomatoid hyperplasia of
the major duodenal papilla in man. Am. J. Path., 7:519-
527, (Sept.) 1931.
7. Dardinski, V. J.: Diseases of the major duodenal papilla
in man. Med. Ann. Dist. Col., v. 353, (Dec.) 1936.
8. Gray, H. K., and Sharpe, W. S. : Carcinoma of the gall
bladder, extrahepatic bile ducts and the major duodenal
papilla. S. Clin. North America, 21:1117-1128, (Aug.) 1941.
9. Grove, L., and Rasmassen, E. A.: Benign papilloma of the
ampulla of Vater. Am. J. Surg., 64:141-143, (April) 1944.
10. Harvey, S. C., and Oughterson, A. W. : Surgery of car-
cinoma of pancreas and ampullary origin. Ann. Surg., 115:
1068-1090, (June) 1942.
11. Horsley, J. S.: Resection of the duodenum for tumor of
the ampulla of Vater. Ann. Surg., 113:802, (May) 1941.
12. Hunt, V. C. : Surgical management of carcinoma of the
ampulla of Vater and of the periampullary portion of the
duodenum. Ann. Surg., 114:570-602, (Oct.) 1941.
13. Hyde, L., and Young, E. L. : Carcinoma of ampulla of
Vater. New England J. Med., 223:96-99, (July 18) 1940.
14. Judd, E. S., and Hoerner, M. T. : Surgical treatment of
carcinoma of the head of the pancreas and of the ampulla
of Vater. Arch. Surg., 31:937-942, (Dec.) 1935.
15. Lieber, M. ; Steward, H., and Lund, H.: Carcinoma of the
peripapillary portion of the duodenum. Arch. Surg., 109 :
219-245, (Feb.) 1939.
16. Orr, T. G. : Resection of duodenum and head of pancreas
for carcinoma of the ampulla. Surg., Gynec. & Obst., 72:
240-243, (AugO 1941.
17. Outerbridge, G. W. : Carcinoma of the papilla of Vater.
Ann. Surg., 57:402-429, 1913.
18. Ransom, H. K. : Carcinoma of the pancreas, and extra-
hepatic bile ducts. Am. J. Surg., 40:264-281, (Apr.) 1938.
19. Rekers, P. E. ; Pack, G. T., and Rhoads, C. P. : Carcinoma
of ampulla of Vater, J.A.M.A., 122:1243-1245, (Aug. 28)
1943.
20. Schnedorf, J. G., and Orr, F. G. : Fifty-two proven cases
of carcinoma of the pancreas and the ampulla of Vater:
with special reference to fatty infiltration of the liver.
Ann. Surg., 114:603-611, (Oct.) 1941.
21. Sharpe, W, S., and Comfort, M. W. : Carcinoma of the
papilla of Vater: clinical features in forty cases. Am. J.
M. Sc., 202:238-245, (Aug.) 1941.
22. Sternfeld, E. : Carcinoma of papilla of Vater. Ohio State
M. J., 39:436-438, (May) 1943.
23. Trimble, I. R. ; Parsons, J. W., and Sherman, C. P. : A
one-stage operation for the cure of carcinoma of the am-
pulla of Vater and of the head of the pancreas. Surg.,
Gynec. and Obst., 73:711-722, (Nov.) 1941.
24. Whipple, A. O. : The rationale of radical surgery for
cancer of the pancreas and ampullary region. Ann. Surg.,
114:612, (Oct.) 1941.
AMEBIC ABSCESS OF THE LIVER
(Continued from Page 1166)
problem of great importance. The key to an early
diagnosis is constant awareness of the disease.
3. Emetine cardiotoxicity and a brief review
of the experimental and clinical literature is cited.
The fact that emetine cardiotoxicity may occur
with the usual therapeutic doses is stressed.
References
1. Albright, E. C., and Gordon, E. S.: Present status of the
problem of amebiasis. Arch. Int. Med., 79:253, 1947.
2. Boyd, L. J., and Scherf, D. : Electrocardiogram in acute
emetine intoxication. J. Pharmacol. & Exper. Therap., 71:
362, 1941.
3. Brown, P. W. : Results and dangers in the treatment of
amebiasis: a summary of fifteen years’ experience at the
Mayo clinic. J.A.M.A., 105:1319, 1935.
4. Chopra and Ghosh, B.: Indian Med. Gazette, 57:248, 1922;
abstracted. Rinehart, J. F., and Anderson, H. H. : Effect
of emetine on cardiac muscle. Arch. Path., 11:5.46, 1931.
5. Cotrell, J. D., and Hayward, G. W. : Effects of emetine on
heart. British Heart J., 7:168, 1945.
November. 1947
6. Dack, S., and Moloshok, R. E. : Cardiac manifestations of
toxic action of emetine ■•hydrochloride in amebic dysentery.
Arch. Int. Med., 79:228, 1947.
7. Hardgrove, M., and Smith, E. R. : Effects of emetine on
the electrocardiogram, Am. Heart J., 28:752, 1944.
8. Heilig, R., and Visveswar, S. K. : On the cardiac effects of
emetine. Indian Med. Gazette, 78:419, 1943.
9. Karl, M. M., and Sloan, F. R. : The management of ame-
biasis. Ann. Int. Med., 25:789, 1946.
10. Klatskin, G. : Amebiasis of the liver: classification, diagnosis,
and treatment. Ann. Int. Med., 25:601, 1946.
11. Klatskin, G. : Observations on amebiasis in American
troops stationed in India. Ann. Int. Med., 25:773, 1946.
12. Levy, R; L., and Rowntree, R. G. : On toxicity of various
commercial preparations of emetine hydrochloride. Arch.
Int. Med., 17:420, 1916.
13. Ochsner, A., and DeBakey, M.: Surgical amebiasis. In-
ternat. Clin. (New Series 5) 1:68, 1942.
14. Ochsner, A., and DeBakey, M. : Amebic hepatitis and
hepatic abscess. Surgery, 13:460, 1943.
15. Ochsner, A., and DeBakey, M. : Amebic hepatitis and he-
patic abscess. Surgery, 14:612, 1943.
16. Rinehart, J. F., and Anderson, H. H.: Effect of emetine
on cardiac muscle. Arch. Path., 11:546, 1931.
17. Sayid, I. A.: Auricular fibrillation after emetine injection.
Lancet, 229:556, 1935.
18. Sodeman, W. A., and Lewis, B. O.: Amebic hepatitis. J.-
A.M.A., 129:99 1945.
19. Sodeman, W. A., and Lewis, B. O. : Amebic hepatitis. Am.
J. Trop. Med., 25:35, 1945.
1177
History of Medicine In Minnesota
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester, Minnesota
(Continued from October issue)
Jay Le Roy Sackett, the only son and one of the three children of Dr. and
Mrs. Reuben N. Sackett, was born at St. Charles, Winona County, in the late
fifties. His father and mother were of the finest type of pioneer settlers of
southern Minnesota, in Olmsted, Fillmore and Winona Counties.
Reuben Nathaniel Sackett was born on December 8, 1825, in Chautauqua
County, New York, obtained his general education and medical training in his
native state and was admitted to practice in Syracuse. On August 11, 1854,
he was married to Julia A. Palmer and in May of 1855 the young couple
moved to southern Minnesota, to settle first in Olmsted County, in Quincy
Township; in this period he was known as Dr. Nathaniel R. Sackett. Subse-
quently Dr. and Mrs. Sackett lived in St. Charles, Winona County, where the
doctor had a medical and surgical practice, and later they were in Janesville,
Waseca County, and in Windom, Cottonwood County. At one period, pre-
sumably before moving into western Minnesota, Dr. Sackett practiced for a
time in Chatfield, Fillmore County. Of the two daughters of the family,
Zilpha Estell died in infancy; Nettie was married to A. G. Chapman, a lawyer,
of Lanesboro. Dr. Sackett was active in the Masonic order and as a charter
member helped to organize lodges at St. Charles, Janesville and Windom.
He and his wife for more than seventy years were members of the Methodist
Church. Mrs. Sackett died at the home of her daughter, in Lanesboro, on
November 21, 1914; Dr. Sackett died on December 20, 1920, in a hospital at
Rochester; both were buried at Lanesboro, where they often had visited Mr.
and Mrs. A. G. Chapman and where they were well known.
Jay Le Roy Sackett received his preliminary education in the schools of
St. Charles. Later he was a student at Hamline University, in Saint Paul, and
took his medical training at the Hahnemann Medical College of Chicago,
from which he was graduated in the late winter of 1887; soon afterward he
was licensed to practice in Minnesota, receiving certificate No. 1328 (H),
dated March 16, 1887.
Just at that time Dr. James M. Wheat, since 1856 a highly respected physi-
cian and surgeon in Lenora, Canton Township, Fillmore County, was mov-
ing permanently to California, and Dr. Sackett, young, “a fine looking man of
the brunet type, intelligent and quick,” succeeded to his practice. The village
of Lenora, in a prosperous community fourteen miles from Lanesboro, its
nearest railway point, and five and a half miles from Canton, once was ex-
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HISTORY OF MEDICINE IN MINNESOTA
pected to become a railway town but, like many another village in the county,
had been left on one side by the Southern Minnesota Railroad in 1870, so
that its fortunes had dwindled; even in 1887, however, it had 125 residents, a
school, a hotel, two churches and several stores, daily mail and tri-weekly
stages to Canton and Rush ford.
His promising career so well begun in Lenora was cut short after only two
years when Dr. Sackett contracted tuberculosis ; in the hope of benefiting
from change of climate he removed to San Antonio, Texas, but he did not
improve and died in San Antonio soon after his arrival there. His wife, who
had been Minnie Spencer, of St. Paul, survived him; there were no children.
After her husband’s death Mrs. Sackett returned to Saint Paul, where she
remained until, some time in 1898, she removed to Colorado.
A Dr. Schoolcraft, of Fillmore County, started for Devils Lake, North Da-
kota, on Monday, stated the National Republican of Preston on April 8 (Thurs-
day), 1886; in subsequent issues Mrs. Schoolcraft was mentioned several
times as “canvassing for a number of useful works.” Other mention of this
physician, if he was a medical practitioner, has not been noted.
Louis Dwight Shipman, the only child of Mr. and Mrs. Dwight Edson
Shipman, was born on April 11, 1875, at Morrisville, New York, where his
father, a native of Easton, New York, owned a clothing manufactory ; his
mother, Augusta Ann Wales, was born at Morrisville.
In 1890 Louis Shipman came with his parents to their new home in Min-
neapolis and there continued the education which he had begun in the schools
of Morrisville. After completing his high school instruction at the Lyndale
School and taking collegiate courses at the Minneapolis Academy, he entered
the LIniversity of Minnesota College of Homeopathic Medicine and Surgery,
from which he was graduated on June 26, 1896, with the degree of doctor
of medicine.
The scene of Dr. Shipman’s earliest medical practice was Fillmore County,
first in the village of Preston, from 1896 to 1898, and next in Canton, which
offered better financial opportunity. Young Dr. Robert L. Conkey, new in
his profession, had died in Canton in that year, and Dr. Robert A. Sturgeon,
in his seventies and for many years past an invalid, was not in active practice,
so that Dr. Henry H. Haskins, in his middle fifties and perhaps already plan-
ning his retirement (1902) from practice, was the only resident physician.
Here for the next four years Dr. Shipman served the community as a private
physician and surgeon and for a time as county physician. On April 10,
1901, he was married to Bertha McKinney, at Canton. Dr. and Mrs. Ship-
man had two children, Cleon Dwight and Gladys.
Successful though he was as a general practitioner, Dr. Shipman early deter-
mined to become a specialist and in 1902 he left Canton to take postgraduate
work at the Chicago Eye, Ear, Nose and Throat College and Hospital. On
completion of this course, early in 1903, he went to London, England, to study
and there he first was a clinical assistant at the London Central Throat, Nose
and Ear Hospital and later at the Royal Ophthalmic Hospital. At the end
of 1903 he became acting house surgeon of the London Throat Hospital;
it has been said that had he been the holder of a degree from an English
medical school, as was required by the hospital for members of its profes-
sional staff, he would have been appointed house surgeon ; as it was, his
November. 1947
1179
HISTORY OF MEDICINE IN MINNESOTA
position was the highest which up to that time had been held in the institu-
tion by an American.
In the spring of 1904 Dr. Shipman returned to Minneapolis, to open offices
in the Medical Block, 608 Nicollet Avenue, as a specialist in treatment for
diseases of the ear, nose and throat. His announcement card of April 1 in-
cluded the lines, “Finsen’s London Hospital Light, Ultra-Violet Rays and
Eclectical Treatment of Lupus, Tuberculosis, Growths and Diseases of the
Nose, Throat, Ear and Face.”* Well qualified professionally and personally,
and possessing in addition the ability to write with clarity and interest on
subjects medical and nonmedical, Dr. Shipman entered on a career in which
he soon received recognition, for in 1907 he was appointed a member of the
faculty of the Medical School of the University of Minnesota. He was never
to realize his new position ; in the week that the appointment was confirmed,
Dr. Shipman contracted diphtheria from a patient whom he was treating
for the disease and died within a few days, on February 5.
Distinguished in appearance, tall and slender, with blue eyes and wavy
dark brown hair, Dr. Shipman was genial, friendly and considerate in all his
relationships. The interest in community life which he had shown in Canton
he broadened in Minneapolis, transferring his membership in the Masonic
order to Lodge No. 19 in the city and becoming an active member of the
Linden Hills Congregational Church, instrumental in the organization and
functioning of its men’s club. Happiest when in his home, he was the kindest
of husbands and fathers and was a gracious and delightful host to many guests.
After Dr. Shipman’s death Mrs. Shipman with the two children, both of
whom were born in Minneapolis, remained in the city and in 1943 she
continued to reside there as did her daughter Gladys (Mrs. R. B.) Nelson,
and her son, Cleon Dwight Shipman, associated with the Graybar Electric
Company.
Reuben Farmer Spencer, who was born in December, 1834, at West Burke,
Vermont, received his early education and medical training in the East. In
1856, when he was twenty-two years old, he traveled west to Wisconsin, where
he taught school and practiced dentistry until, sometime in 1861, he first
entered Minnesota. In the next fifteen years, judging from different com-
ments, he changed locations various times; in 1865 he returned to Wisconsin
and then to Vermont, and in 1868 he came again into Minnesota, to remain
three years before traveling on into Dakota Territory, where he practiced
medicine for several years. Finally, in 1877, he settled permanently in Min-
nesota, in the village of Etna, on the Root River, in the southeastern corner
of Bloomfield Township, Fillmore County, eight miles from Spring Valley
and twenty miles from Preston.
In those years Etna (laid out in the early fifties as “Tiffton,” sometimes
seen “Tefton,” a name rejected by common consent) had a population of
fifty, daily mail and stage connections with Spring Valley and also with
Lime Springs, Iowa. The Root River furnished power for grist mills. Hope-
fully, as late as 1883, a business gazetteer announced that a good store was
needed in the village. In the early seventies Dr. J. J. Morey, recently of
Spring Valley, was practicing medicine in Etna; perhaps he still was there
when Dr. Spencer came.
For seventeen years, until his death in 1894 at the age of sixty years, Dr.
*Neils Ryberg Finsen, Danish physician (1860-1904).
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HISTORY OF MEDICINE IN MINNESOTA
Spencer carried on from Etna a general medical and surgical practice in a
large territory which extended as far north as Spring Valley; he was well
known and highly respected. In 1882 he served as justice of the peace in
Etna. On October 25, 1883, under the “Diploma Law” of that year he re-
ceived state certificate No. 185-3, which he filed in Fillmore County on
November 26, 1883.
Reuben F. Spencer was married in 1874 to Carrie M. Howey, of Wiscon-
sin. Of the two children of the marriage, one was living in 1943, Mrs. Edwin
Finch, of Vulcan, Province of Alberta, Canada, and in this year also Mrs.
Spencer, at the venerable age of eighty-eight years, had long been making
her home in Spring Valley.
Aaron Marshall Stephens was born in June, 1842, at Frankfort Springs,
Beaver Codnty, Pennsylvania, the son of J. Stephens and Elizabeth Marshall
Stephens, and a descendant of an English family who were colonists in Vir-
ginia in 1607. Little record exists of his early years except that he was left
an orphan when he was a child, that he taught school when he was a youth,
that he was interested in science and microscopy, and that he early became
a Methodist minister. In 1866 he first came to Minnesota to occupy the posi-
tion of professor of mathematics and natural science at Hamline University
(then in Red Wing, Goodhue County). In 1879 he received the degree of master
of arts from One Study University, in Ohio, and soon afterward, accom-
panied by his wife, he came to Chatfield, Fillmore County, to fill the pulpit of
the local Methodist Church.
After some years in Chatfield The Reverend Mr. Stephens, A.M. (he
always used these letters) left the church and temporarily left the village to
prepare for entering the profession of medicine. It is recalled in Chatfield
to the credit of this clergyman and his wife that, before Mr. Stephens was
able to enter medical school, they joined in surmounting the financial dif-
ficulties of the undertaking by assuming additional employment, he in extra-
clerical work in the railroad roundhouses that were a feature of Chatfield in
those years, and she as a saleswoman in a local store.
Dr. Stephens was forty-one years old when, early in 1883, he was graduated
from the Hahnemann Medical College and Hospital of Chicago and returned
to Chatfield in his capacity as physician and surgeon. The Chatfield Democrat,
on March 8, 1883, carried the following item : “Degree of Doctor of Medicine
and Surgery conferred on Rev. A. M. Stephens, A.M., on February 21,
1883, at the Grand Opera House, Chicago, by Hahnemann Medical College
and Hospital. We expect the doctor home in a few weeks.” And this
note was followed on April 21 by a second : “Dr. A. M. Stephens, A.M.,
returned last week from Hahnemann Medical College and Hospital of
Chicago, where he has been attending lectures the past year. Dr. Stephens
has spent several years in the careful and earnest pursuit of medical studies,
besides attending the full course of lectures and is already well qualified for
his profession. He will remain for the present with his family in Chatfield
and engage at once in the practice of medicine.” On April 19, 1884, Dr.
Stephens received his license, No. 875 (H), to practice medicine in the state,
and on April 25 filed it in Fillmore County. His office was in his residence,
“near the foundry.”
This physician is remembered in Chatfield as a quiet, kind and fatherly
man, large and rather portly, who had dark brown hair and a long full brown
November. 1947
1181
HISTORY OF MEDICINE IN MINNESOTA
beard, unflecked by gray. Respected as a clergyman in the community, on his
graduation from medical school he was well received as a physician by the
residents. Children delighted in going to his office, both because they were
fond of him and because he kept there in a cage some fascinating white rats
— the psychologic effect of which no doubt aided therapeutics as represented
by Dr. Stephens.
During his years as a general medical practitioner in Chatfield, Dr. Stephens
served for a time as the local health officer and as an examining surgeon on
the board of pensions of the district. He also maintained an active interest in
the Methodist Church, occasionally preaching in Chatfield and in other villages,
and worked for betterment of the schools; in 1889 he filled a vacancy on the
board of education, and in 1890 was elected for three years, a term which
ended with his resignation on June 28, 1892.
After eight years as a physician in Chatfield, Dr. Stephens moved, in the
summer of 1892, to the suburbs of the Twin Cities, making his home in Ham-
line and engaging in the practice of medicine with Dr. Sheridan G. Cobb of
Merriam Park. In 1895 he returned to his first Minnesota home, Red Wing,
and there for the next thirteen years he followed his profession.
Aaron Marshall Stephens was married in 1864, at Waterloo, Iowa, to Mary
Bishop, a schoolteacher, of English descent ; Mary Bishop, like her husband,
had early been left an orphan and little is known about her family. Dr. and
Mrs. Stephens had two children, Ray Bishop Stephens, who died in Chatfield
in 1890 at the age of eighteen years, and Alice M. Stephens, who became a
trained nurse.
Dr. Stephens died in Red Wing on September 21, 1913, after a year and
a half of illness which followed a stroke of apoplexy. He was survived by
his wife and his daughter. Some time after her husband’s death, Mrs. Stephens
moved from Red Wing to Chicago, where her daughter had been since 1910,
and there she lived out her long life, dying at the 01,d People’s Home on May
28, 1943, within two weeks of her ninetieth birthday. Miss Stephens, retired
from the profession of nursing, in 1943 was still residing in Chicago.
Robert Anderson Sturgeon was born at Belfast, Ireland, on June 7, 1824,
the son of John Sturgeon and Elizabeth Anderson Sturgeon, both of whom
were natives of Ireland. The five other children of the family were William,
John, George, Samuel and Elizabeth.
Robert Sturgeon received his education in Belfast : his academic schooling
at Dr. Bryce’s Academy, his training in pharmacy, medicine and surgery at
Queen’s College, and, after his graduation as a physician, in 1848, two years’
work at the Belfast Hospital, a postgraduate service of inestimable value.
From Belfast he went to England, purposing to sail for America in search of
an older brother who had emigrated some years previously, and from Liver-
pool he embarked as medical officer on the Silas Greenman, bound for New
York. After much search and inquiry he traced his brother to Montreal,
Canada, only to learn that he had died in that city, leaving a wife and several
children.
Liking the city, Dr. Sturgeon established himself in Montreal and practiced
medicine there for three years. After the death of his wife, Harriet Scriver,
a Canadian to whom he was married in Montreal, he left Canada for the
Middle West of the United States, where he settled first in Burr Oak, Win-
nesheik County, Iowa, about three miles south of the. state line between
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HISTORY OF MEDICINE IN MINNESOTA
Iowa and Minnesota. After two years in that community he was attracted
by the thriving village of Elliota, just inside Minnesota, in Canton Township,
Fillmore County, and removed to that place in 1855, as nearly as can be
determined.
Elliota, sixteen miles equidistant from Preston, Minnesota, and Decorah,
Iowa, although for many years now a phantom village, was one of the most
interesting of the early settlements. It was laid out in 1854, as stated earlier,
by Captain Julius W. Elliott, a native of Vermont, who came to Minnesota
Territory from Moline, Illinois, in 1853, bringing with him a company of
pioneers. The first buildings of the village were burned but soon were replaced
and by 1858 the settlement was an important mail station at the intersection
of several stage lines, one of which was M. O. Walker’s route from Dubuque
to St. Paul. In its palmiest days Elliota had three hotels, the Elliott, the Lewis
and the Crags, two stores, a stone school house, built at a cost of $900, a
drugshop (probably Dr. Sturgeon’s), a mechanic shop, and at that time, it was
stated, there was need of a grist mill and a sawmill. The only early physician
in Elliota other than Dr. Sturgeon of whom note has been found was Dr.
Thomas Little.
Dr. Sturgeon’s residence in Elliota was interrupted by his military service
during the Civil War; record has not been available, except that he was with
the Union Army in Missouri. In the year after the close of the War, on July
18, 1866, Robert Anderson Sturgeon was married to Jane Young, who was
the daughter of a farmer near Elliota and was a native of Dumfermline, Fife
County, Scotland. The six children of the marriage were Helen, Georgina,
Robert, Harriet, Florence and William. The family were members of the
Presbyterian Church.
In Elliota Dr. Sturgeon remained for many years, contributing largely to
the interest and welfare of the community and sharing its fortunes, which
inevitably declined after the railroad passed the village by; in 1882 the greater
part of the business of the place was transferred three miles northeast to
Boomer (later named “Canton”), also in Canton Township; Boomer was
founded in 1879 but was not incorporated as- the railway village of Canton
until 1887. The postmasters of Elliota, after Captain Elliott, were Mr. Dick-
son, Mr. Wilcox, Mr. Morrell and, finally, Dr. Sturgeon, who closed the office
and surrendered the key of the mail pouch in April, 1882. In that final year
Elliota had only fifty residents ; there were still functioning one hotel, three
flour and grist mills of four run of stone each, two churches and the school,
and there was to be for a time stage connection with Rushford, Minnesota,
and with Decorah and Cresco, Iowa.
In his drug store in Elliota Dr. Sturgeon maintained his offices and com-
pounded his own medicines. The story is told of one of his prescriptions,
which was given to a patient who had contracted a severe cold after breath-
ing in dust while handling rubbish : The advice was to inhale the steam from
a mixture of iodine, oil of tar and water; the patient followed instructions
and the congestion cleared up promptly. In 1881, preparatory to removal
to Boomer, Dr. Sturgeon was having his store and office building taken down
and reconstructed in the new village.
In 1882 Dr. Sturgeon settled with his family in Boomer, or Canton, where
for nineteen years he continued to win and hold the love and confidence of
the community for his gentleness and professional skill and his capability and
dependability as a citizen. Under the medical practice act of 1883 in Min-
November, 1947
1183
HISTORY OF MEDICINE IN MINNESOTA
nesota lie received certificate No. 1172, given on March 24, 1886, and filed in
Fillmore County on the following May 6.
The last twenty years of his life Dr. Sturgeon was a semi-invalid, as the
result of a stroke ; one arm was paralyzed and he walked with a cane, but
he nevertheless consulted with patients, managed his drug store and, from
1893 to 1897, served as postmaster for the village. In the latter year, when
his health was failing greatly, and subsequently, his daughter Georgina and
his sons Robert and William in turn took his place as postmaster. His position
in the esteem, respect and gratitude of the community was such that no one
even considered making application for the office of postmaster as long as a
member of the Sturgeon family was willing to fill it.
Dr. Sturgeon’s professional contemporaries in Canton were few. Dr.
Henry FI. Haskins was the chief and eldest, practicing in the village from
1878 to 1902. Dr. C. Wilbur Ray was in practice there in 1894 and 1895. Dr.
Robert L. Conkey, a native of Preston, in his brief medical career, was in
Canton only a year, in 1897 and 1898, before his untimely death. Dr. Louis
D. Shipman, beginning in 1898, spent four years in Canton, as noted, before
leaving to prepare for specialization in ear, nose and throat work.
That Dr. Sturgeon was a cultured gentleman of warm and vivid personality
and a physician of exceptional native ability and professional training is cer-
tain. Although not consciously humorous, he possessed a lively fancy and a
felicitous turn of phrase that distinguished him among the less articulate.
One of his friends and truest admirers, the late Dr. George Kessel, of Cresco,
Iowa, who was a boy when Dr. Sturgeon was in his prime, gave the writer a
verbal picture of a tall, well-built man who had black hair and wore a black
mustache and whose eyes, once seen, were never forgotten, of more than
medium size, so darkly blue as to look black under heavy overhanging black
eyebrows, and holding always a little twinkle that indicated that they were
friendly and kindly eyes. Dr. Sturgeon was a man of arresting personality,
dignity and almost military bearing; of polished diction and extensive knowl-
edge of the world’s great literature in Latin and in English ; Latin he used
freely, but he quoted most often from the Bible and from Shakespeare. “He
seemed so different from our neighbors roundabout us on the farm.”
In his earliest years in the county, in the immediate community of Elliota,
Dr. Sturgeon commonly rode on horseback to make his calls, carrying his
drugs and instruments in saddlebags. In those times Indians were objects
of fear to the settlers, and wild animals were a menace to the denizens of
barnyards and poultry runs, so that almost every family in rural neighbor-
hoods kept at least one competently savage dog to protect them and their pos-
sessions from marauders, two-legged or four-legged. The dog could not or
did not always discriminate and therefore Dr. Sturgeon, being a prudent man,
when arriving at a homestead would not dismount until the guard had been
called off and pacified. After he had given up horseback riding. Dr. Sturgeon
always employed a driver in going about his business in horse-drawn vehicles.
Dr. Kessel described the doctor on drives in winter, sitting erect in his cutter,
his head up, his highly colored long scarf wrapped around his shoulders and
crossed over his chest in a bright “X,” an accessory “that was attractive and
again made him look different from other people.” And further, “He was a
wonderful man, one of the pioneer characters, and a real character he was
. . . enough ... to make a book in himself.”
Robert Anderson Sturgeon died in Canton on January 8, 1901, from paral-
1184
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HISTORY OF MEDICINE IN MINNESOTA
ysis. Of his family group there was living in 1943 Georgina Sturgeon, of
Amboy, Minnesota, and William Sturgeon, of Santa Ana, California.
Jerome B. Tamblin, who was in Lanesboro, Fillmore County, in the early
eighties, came to Minnesota indirectly from New York. Arriving in Winona
in 1867, he established his residence at 159 Third Street and opened an office
in Ford’s New Brick Block on Second Street, announcing himself as doctor
of medicine, physician and surgeon, recently from New York, of twelve years’
experience as a practitioner, especially interested in the diseases of women
and children, and willing to answer calls in city and country. After two
years in Winona Dr. Tamblin moved to St. Charles where he operated a drug
store with Dr. H. H. Guthrie and carried on a medical practice that extended
throughout the countryside to Elba, Utica, and other villages.
Described as at all times an active participant in local politics, Dr. Tamblin
was also an energetic member of his profession, progressive and evidently in
good standing. In 1869, then in St. Charles, he became a charter member of
Winona County Medical Society, and in 1871 he was elected to membership
in the Minnesota State Medical Society. At the annual, meeting of the state
group that year he debated vigorously, opposing the resolution that a com-
mittee of three be appointed to obtain from the legislature an appropriation
to aid in publishing the transactions of the society (this resolution was passed),
and by proposing that the fee for examination for life insurance by members
of the society be fixed at not less than three dollars (this resolution was
placed on the table). At different times he served as a member of the Com-
mittee for Essays on Medical Subjects, the Committee on Medical Societies,
and the Committee on Epidemics, Climatology and Hygiene.
In 1882 Dr. Tamblin moved from St. Charles to Lanesboro; by 1885 he
was living in Lincoln, Nebraska.
Isaac Whittington Timmons (1883-1912), a member of the homeopathic
school of medicine and, after 1887, the possessor of an exemption certificate
under the Affidavit Law of the state, was for many years a practicing physi-
cian in southern Minnesota. Coming to Minnesota in 1870, he began his medi-
cal practice in Money Creek, Houston County, leaving after a few years to
settle in Winona, Winona' County. By 1877 he had returned to Houston Coun-
ty and was practicing medicine in the village of Houston. In 1881 he went for
a time to North La Crosse, Wisconsin, and not long afterward, learning that
there was an opening for a physician in Chatfield, Fillmore County, he estab-
lished himself in that place for a year and a half. A note in the Chatfield
Democrat of November 3, 1883, stated that he was using the office formerly
occupied by Dr. R. W. Twitched. By the early spring of 1884 he had returned
to Winona and there he followed his profession and joined actively in the
civic life of the community until his death in 1912. In notes on medical his-
tory in Houston County the writer included a detailed sketch of the life of
Dr. Timmons.
(To be continued in December issue )
November. 1947
1185
p* esident s Cettei
NATIONAL PHYSICIANS' COMMITTEE CALLS CONFERENCE
OF THE PROFESSIONS
Recently, it was my privilege to attend the National Conference of the Professions
held in Chicago and sponsored by the National Physicians’ Committee for the Extension
of Medical Service. This meeting was attended by 184 physicians and dentists, and every
state in the Union was represented. It was the consensus of all who were fortunate enough
tO' be among those present that this was an epoch-making meeting. Any doubt of the need
for the National Physicians’ Committee was dispelled during those two memorable days,
September 29 and 30, 1947.
During the course of the Conference, vitally important facts were revealed with the
utmost clarity. 1 was profoundly impressed with the vastness of achievement which is
possible through co-ordinated effort. Several startling revelations were disclosed. For
example, it was demonstrated beyond peradventure that the source of the relentless drive
for compulsory sickness insurance — socialized medicine — is the “Moscow-dominated Com-
munist Party of the United States.” Also, incontrovertible evidence was provided that
statistics compiled by Federal bureaus have been misused or misinterpreted by government
employes to create the impression that there is a great lack of adequate health care in this
country. And furthermore, it was shown that an inquiry into government records indicated
that millions of dollars of public funds have been spent illegally' in an effort to create a
demand on the part of the people for socialized medicine. I was deeply impressed by the
step-by-step method by which the monument of evidence was built. Indisputable facts
demonstrated that forces behind the relentless drive for socialized medicine are pressing
toward the achievement of their chosen objectives by the use of coercive and deceitful devices.
The Honorable Forest A. Harness* spoke at the evening session. He said : “The amazing
ramifications of the Federal propaganda in behalf of socialized medicine have astonished
me.” He stated too that all the Federally financed activity for socialized medicine originates
in the Bureau of Research and Statistics of the Social Security Board. “Our committee
investigators,” he said, “have found in that Bureau a veritable nerve center of socialized
medicine propaganda for the entire world. On the basis of evidence at band American
Communism holds this program as a cardinal point in its objectives . . . and ... in some
instances, known Communists and fellow travelers within the Federal agencies are at work
diligently with Federal funds in furtherance of the Moscow party line in this regard.”
All during the meeting, the authoritative guest speakers, selected by the National Physi-
cians’ Committee, produced facts which indicate that the propaganda of the protagonists of
socialized medicine has its source in the Communist party and in a small group of officials
of certain Federal agencies charged by Congress with the administration of social and
welfare laws. These speakers stated that the Communist party finances its efforts by col-
lecting dues equal to 6 per cent of the wages and salaries of its members and in addition has
levied an assessment on all members, equal to one week’s earnings. In some instances the
assessment was as much as $2,500. Also, it was brought out that bureaucrats in our national
government have been dispatched to Tokyo and Manila for the purpose of establishing
programs of compulsory sickness insurance in the Philippine Islands and Japan.
I came away from the meeting with a feeling of admiration and esteem for the National
Physicians’ Committee. This organization has grown in strength and effectiveness until
now it is undoubtedly the most important single agency which has for its objective the
preservation of our system of private medical practice. Probably, it is the greatest single
force in the nation directed toward preserving the entire freedom of enterprise system.
The following quotation which I have taken from an editorial which appeared in the
October, F)47, issue of the North Carolina Medical Journal, pays fitting tribute:
“It may be recalled that the National Physicians’ Committee has been the principal target
of abuse for the proponents of socialized medicine, and that over a nationwide radio broadcast
^Chairman of the subcommittee on Publicity and Propaganda of the House Committee on Expenditures
of Executive Departments.
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Minnesota Medicine
this organization was accused of having spent one million dollars for the publication and
distribution of one pamphlet. Doctor Edward Carey, appearing before the Murray Com-
mittee, refuted this accusation by showing that in six years the National Physicians’ Com-
mittee had spent only $905,359.23 on all its activities. It is a tribute to the National Physi-
cians’ Committee’s management that with this sum — paltry by comparison with the $75
million spent by Federal Government agencies in one year — a handful of men have been
able to withstand the onslaught of 45,000 employes engaged full or part time in propaganda
activities.”
If one should seek official approval of the. National Physicians’ Committee, it can be
found in the records of the American Medical Association and other medical organizations.
In June, 1947, the House of Delegates of the American Medical Association approved the
report of its Committee on Executive Session, a portion of which read : “Among those who
were familiar with the organization (N.P.C.), the general impression was that it was just
about the only thing that had stood between the medical profession and political control. We
recommend that the House of Delegates of the American Medical Association continue its
commendation of the accomplishments of the N.P.C. and resolve a vote of confidence in the
managing board of that organization.”
During the past twenty-five years there have been approximately 100 attempts to enact
compulsory sickness insurance laws in Congress and in the state legislatures. An effort was
made to enact the most vicious kind of compulsory health insurance legislation during the
1947 session of the Territorial Legislature of the Hawaiian Islands. That this move toward
socialized medicine in Hawaii had great national significance becomes clear when one
realizes that the territory stands upon the very threshold of statehood. The delegate from
Hawaii to- the House, of Delegates of the American Medical Association made this report at
the Centennial meeting: “The pattern-trend in Hawaii has been and continues to be of such
nationwide importance that the N.P.C., at the request of the Territorial Association, made
its full facilities available to us. All the services, which the N.P.C. gave us so^ generously —
literature, analyses of legislation, comparative data, statistics, personal services — were of
such tremendous importance in solving our problems that every professional and business-
man in Hawaii now fully realizes that this all-physician organization can truly be called
the ‘shock troops’ and the ‘winning battalion’ in the cause of both professional freedom
and the whole freedom of enterprise system when the big push is on. The N.P.C. has
earned and truly deserves the financial and moral support of every ethical physician for its
long and effective services to the professions.”
It has not been my purpose merely to pay tribute to a group of physicians who un-
selfishly have rendered such yeoman service to the citizens of their country, but in addition
I wish to use this story of accomplishment as a stimulus toward even greater achievement.
Whenever there has been a grave crisis, these courageous men of the National Physicians’
Committee have quickly and effectively moved against the evil forces which would wreck
the finest system of health care which the world has ever known. And now, after nearly
a decade of service, they face their most important tasks. They must clarify in the public
mind the true meaning of the bold and purposeful, the adroit and sinister moves that would
result in political control of the distribution of medical care. This can be accomplished only
by the highest unity of purpose and co-ordinated effort on the part of the professions. We
must recognize the sterling character and performance of our colleagues of the National
Physicians’ Committee. Only through maximal co-operation and generous support of this
great organization by all physicians can the integrity of the medical and dental professions
be preserved.
President, Minnesota State Medical Association
November. 1947
1187
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
SOCIALISM OR FREE ENTERPRISE?
TT 7E are intrigued by the American Heritage
’ 'Program and the Freedom Train, said to
have been conceived by Attorney General Clark.
Making such historic documents as the Declara-
tion of Independence, the Constitution of the
United States, and the Rill of Rights available
to the gaze of millions of citizens throughout the
forty-eight states cannot fail to have an important
educational value. And after all, an informed
public opinion determines the kind of laws our
representatives pass, and will determine whether
we adhere to the form of government which has
made our country what it is in freedom and
opportunity or whether we shall go all out for
Communism or Socialism.
We have had recent examples of how Commu-
nism and Socialism work. The Communists ad-
vocate the elimination of private property and
the employment of all citizens by the state, with
equal compensation for all types of work. The
members of th£ Communist party are, of course,
to hold the important offices. Human nature
being what it is, we see how differently Commu-
nism has worked out in Russia. How any patri-
otic American can consider Communism for a
moment is beyond comprehension.
Socialism advocates the wide nationalization of
industry by the government, and correspondingly
less private industry. England has gone far on
the socialistic path under its present labor gov-
ernment. The effect on England’s economy does
not recommend Socialism for its efficiency accord-
ing to American standards.
How far we as a nation want to go in the direc-
tion of Socialism is for the people to decide — not
the government nor elements in the government.
If the public realizes that with Socialism comes
regimentation, government regulation of wages
and prices, and loss of personal ' freedom, it will
make the people pause. If the public learns that
socialization of industry in other countries has
begun with the socialization of medical care, they
will pause before they adopt such legislation as
the Wagner-Murray-Dingell bill. Of course,
there is the necessity for the government to
undertake certain activities for the good of the
public. A certain amount of socialization of
medical care has been deemed necessary, as evi-
denced by the governmental care given the insane,
the tuberculous, the veterans, et cetera.
To anyone not entirely blind to present-day
trends, it must be evident that there is a strong
element in Federal government circles working
with enthusiasm of zealots for a socialistic form
of government in our country.
The Wagner-Murray-Dingell bill, providing
for complete socialization of medical care, repeat-
edly submitted to Congress in a little different
form each time, was backed by President Truman
on its last submission. And now comes the sug-
gestion that this bill be incorporated as a plank
in the Democratic platform. We can conceive
of no worse outcome than that such a radical
change in government should be subjected to
the heat of a political campaign rather than to
cool, considered deliberation of Congress.
No more should the Taft-Hartley hospital bill
be considered a Republican measure just because
a Republican congress passed it !
We have referred editorially to the Health
Workshops conceived and promulgated entirely
by government employes in the U. S. Public
Health Association and other Federal depart-
ments. This is a good example of the enthusiasm
in certain parts of the Federal government for
the complete socialization of medicine.
The government’s Health Mission to Tokyo is
another example of the fanaticism for Socialism
which exists in certain quarters in Washington.
The scheme of a Health Mission to Tokyo orig-
inated in the Division of Research and Statistics
in the Social Security Board in Washington.
Federal employes were deliberately sent from
Washington to Tokyo for the purpose of en-
gineering a request for a health mission. Is it
not significant that the personnel of the mission
sent was composed entirely of men long identified
as advocates of socialized medicine not only in
the United States but throughout the world?
1188
Minnesota Medicine
EDITORIAL
According to Representative Harness, chairman
of a Congressional subcommittee investigating
publicity and propaganda of the U. S. Govern-
ment, the real purpose of the Health Mission to
Tokyo was to lay the foundation for a system
of socialized medicine in Japan. If this is not
evidence of a fanaticism for world Socialism,
what is it? As Harness said, “I deem it inappro-
priate for Federal employes, at the expense of the
American taxpayer, to travel throughout the
world preparing or assisting in the preparation
of legislation to be adopted by foreign countries
when similar legislation, long pending, has not
been approved by the Congress of the United
States.”
It seems very evident that America stands to-
day at a crossroads. Public opinion must decide
whether we are going to continue our socialistic
trend, which includes unwarranted competition on
the part of the government with private industry,
and Federal subsidy of states for activities which
each state should sponsor itself, or whether we
are going to retrench in our socialistic activities.
The recent declaration of Indiana that henceforth
she will refuse Federal subsidy and support her
own projects without Federal assistance is en-
couraging and merits emulation by 'other states.
We are in favor of any activities, such as the
American Heritage Program and the Freedom
Train, whose purpose is to give the public a clear
understanding of the price we have paid for our
liberty and the price we shall all have to pay
in personal freedom if we substitute Communism
or even Socialism for our present economic sys-
tem. There should be no question of what choice
informed and freedom-loving Americans will
make.
TYPHOID IN MINNESOTA
T N the old days, typhoid fever proved a very
substantial source of revenue for the general
practitioner — enough patients with typhoid, and
Junior’s college expenses were assured. Today,
many recent medical graduates have never seen
a patient with typhoid fever.
In 1910, there were 3,892 cases of typhoid in
Minnesota, with 688 deaths. Starvation and ice
packs, or tubbing in ice water, formed the stand-
ard treatment. Such figures show the disgrace-
ful status of public sanitation in the state at that
period. With improvement in water and food
supply, by 1920 there were only 684 cases with
seventy-one deaths, and by 1930 only 217 cases
and twenty-five deaths. For the past ten years the
number of yearly cases has been less than 100
with fewer than ten deaths, and with a low of
twenty cases in 1945 and no deaths in 1944.
This brilliant reduction in morbidity and mor-
tality from typhoid fever is due to improvement
in water supply by the sanitary engineers, the
use of pasteurized milk, and the diligent follow-up
of sources of infection by the Section of Prevent-
able Diseases of the Minnesota Department of
Health as soon as a case is reported. Since 1913
the Health Department has identified a total of
469 typhoid carriers and, what seems quite re-
markable, it has at present 206 on the active car-
rier list.
It is not generally realized that carriers afford
the most common source of infection. Individ-
uals who have obtained their infections out of
the state are next in frequency, and since 1940
a number of cases have been traced to1 Mexico.
Five infections with paratyphoid A and thirty
with paratyphoid B have occurred among the
total of 521 cases reported in the past ten years-.
The remainder have been straight typhoid infec-
tions. Three of the individuals with paratyphoid
A and one of those with paratyphoid B contracted
the disease in Mexico.
This summer three members of a party of
eighteen tourists from Saint Paul contracted
typhoid fever in Mexico. Two were classified
as typhoid and one as paratyphoid A. One of the
typhoid patients had been vaccinated in 1946.
The other two patients had never been vaccinated.
Nineteen cases of typhoid have been reported so
far in 1947, eight persons having contracted the
disease from carriers, three in Mexico, and one
from elsewhere outside the state.
As far as Minnesota is concerned there have
been thirteen cases of typhoid contracted in Mex-
ico since 1940. If other states have had similar
experiences, and there is no reason to suppose
that most of them have not, attention should be
called not only to the desirability of a recent vac-
cination with triple typhoid vaccine for those
planning to visit Mexico but also to the fact that
great care should be taken to avoid contaminated
food and drink when visiting Mexico.
Note: The statistics cited were kindly furnished by the Min-
nesota State Board of Health.
November. 1947
1189
EDITORIAL
TOPICAL SULFA N. G.
* I 'HAT we were at first carried away by our
enthusiasm for sulfa drugs has now become
apparent. Sulfa drugs were poured into lapa-
rotomy and other wounds to prevent infection in
clean ones and to clean up infected ones, were
applied in salves to skin lesions or incorporated
in lozenges for sore throats, and were used in
various and sundry other ways.
One of the contributions made to civilian prac-
tice by war experience was the discovery that
sulfa drugs actually delay healing of wounds
and were actually ineffective for wound steriliza-
tion. As a result, the Council on Pharmacy and
Chemistry of the AMA has made the following
statement on the topical use of sulfa drugs in the
1947 edition of New and Non-Official Remedies:
“Experience gained in World War II seems to in-
dicate that the use of crystalline sulfonamides as topical
agents was not very successful in the management of
wound infection or in the treatment of infections of
the skin and mucous membranes. The routine use of
sulfonamides as topical applications in wounds, burns
and in superficial infections is, therefore, to be discour-
aged.”
The sulfonamides intended for topical therapy
will, therefore, be discontinued in this volume. It
may be noted that sulfonamides in hair tonics
and shaving creams are useless. They not only
render a false security but may cause the develop-
ment of a cutaneous sensitivity which will in the
future prevent the use of sulfonamides in serious
conditions for which these drugs are known to be
effective.
AMA DIRECTORY INFORMATION CARD
Preparations are being made to publish the new,
eighteenth edition of the American Medical Directory!
The last edition of the Directory was issued late in
1942.
About November 15, a directory card will be mailed
to every physician in the United States, its dependencies,
and Canada, requesting information to be used in com-
piling the new Directory. Physicians receiving an in-
formation card should fill it out and return it promptly
whether or not any change has occurred in any of the
points on which information is requested. It is urged
that physicians also fill out the right half of the
card, which information will be used exclusively for
statistical purposes. Even if a physician has sent in
similar information recently he should mail the card
promptly to insure the accurate listing of his name and
address.
The Directory is one of the most important contribu-
tions of the American Medical Association to the work
of the medical profession in the United States. In it,
as in no other published directory, one may find de-
pendable data concerning physicians, hospitals, medical
organizations and activities. It provides full information
on medical schools, specialization in the fields of medical
practice, memberships in special medical societies, tab-
ulation of medical journals and libraries.
Therefore, should any physician fail to receive one
of these Directory Information cards by December 1,
he should write at once to the Directory Department,
American Medical Association, requesting that a dupli-
cate card be mailed.
TUBERCULOSIS AND CHRISTMAS SEALS
Pioneer days when tuberculosis was “captain of the
men of death” and when people suffering with it came
“west” to Minnesota seeking health are recalled by the
1947 Christmas Seal. It pictures a team of oxen pull-
ing a sleigh of greens over the snow.
Christmas Seals
. . . Your Protection
Against Tuberculosis
An outstanding figure in the pioneer days of Minne-
sota’s fight against tuberculosis was Dr. H. Longstreet
Taylor, of Saint Paul, who died in 1932 after a life de-
voted to the work. Dr. Taylor received his medical
degree from the Medical College of Ohio in 1882, the
same year that Dr. Robert Koch discovered the tubercle
bacillus. His imagination fired by this accomplishment,
he said : “It is now possible to drive tuberculosis out of
the world.” To this task he set himself.
After studying two years with Koch in Germany and
two years more in Prague, he practiced medicine in
Cincinnati, Ohio, and Asheville, N. C. In 1893 he came
to Saint Paul and began his crusade.
Dr. Taylor founded the Minnesota Association for
Prevention and Relief of Tuberculosis, the state Christ-
mas Seal organization, now called the Minnesofa Public
Health Association. Known throughout the United
States as the “father of the sanatorium movement” and
as an outstanding authority on tuberculosis, in 1927
Dr. Taylor was elected president of the National Tuber-
culosis Association.
A good picture of the tuberculosis situation at the
turn of the century is given in the following abstract
from an article written by him in 1893 :
“This is an age when a great deal is being done on
all sides to help the unfortunate members of society.
. . . Too much praise cannot be given to those who,
having wealth, have turned it in part or as an entirety
into channels that would bring happiness to other hearth-
stones, even if, in all this flood of liberality and gen-
erous help, one large class of sufferers has been almost
entirely overlooked. While many are the recipients of
so much charity and attention for ills which they have
brought on themselves by their own follies and vices,
these unfortunates are suffering from a condition trans-
ferred to them from others by the neglect of the state
in not putting an end to it, and are themselves spread-
ing it unwittingly right and left, among rich and poor,
the high and the low, at such a rate that one individual
in seven falls a victim.
1190
Minnesota Medicine
EDITORIAL
“This acquired condition is one, too, which would
yield to scientific care and treatment if applied early,
but which, once past this borderland of safety, destroys
nearly every victim it fastens upon. It is indeed diffi-
cult to explain, with all the boasted advantages of the
nineteenth century, why such preventable misery should
be allowed to grow and flourish. This is all the more
surprising in a commercial age, an age that counts the
cost and reckons the interest, and finding a profitable
balance plunges into the most enormous undertakings
and carries them through successfully.
“Such an estimate shows that the state is an annual
loser of many millions over and above what it would
cost to eradicate this form of suffering and effectually
put an end to its future ravages. This plague, which
knows no geographical limits and respects no race or
condition of man, is tuberculosis, and the unfortunates
on whose behalf this plea is issued are the consumptive
poor, than whom none appeal to us more strongly for
sympathy and help, and although the world has, with
a few exceptions, remained deaf to their supplications,
yet every motive of charity and selfishness urges us on
to do our utmost for them. . . . No steps are being
taken by national, state, or municipal governments to
prevent the propagation, and very little to rescue the
victims of this disease, although science has been pro-
claiming with increasing emphasis each year of the past
decade that the possibility of prevention is beyond ques-
tion, and that many can be rescued whom the fell
destroyer has marked as his prey. In short, if the state
did its duty, consumption would be one of the rarest
diseases instead of the commonest. Such statements
must be sustained by facts, and facts can be produced
to prove every one of them.”
Progress made since the period pictured by Doctor
Taylor is indicated by the fact that the tuberculosis
death rate has been cut approximately 80 per cent.
Minnesota now has more than 2,000 beds for the care
of the tuberculous. Early and unsuspected cases are
being searched out in tuberculin testing and mass x-ray
surveys. That there is still much to do in the fight
against tuberculosis is shown by the facts being stressed
in the educational campaign accompanying the Christ-
mas Seal sale. They include the following :
Tuberculosis is still the first cause of death from dis-
ease between the ages of fifteen and thirty-five.
It kills 53,000 people in the United States annually —
one every 10 minutes. Last year, 596 Minnesotans were
victims.
Tuberculosis germs are passed from sick persons to
well persons by contact. Early discovery and isolation
of spreaders is' essential for tuberculosis control.
Sixty-seven per cent of the patients entering Minnesota
sanatoria are in the advanced stages of the disease.
Five hundred thousand American have the disease at
the present time and only one-half of them know it.
Tuberculosis is curable. Mass chest x-ray surveys find
unsuspected cases.
Tuberculosis can be eradicated if we put to full use
present-day knowledge and facilities.
The Christmas Seal sale is conducted by some 10,000
volunteer leaders under the direction of the Minnesota
Public Health Association, state unit of the National
Tuberculosis Association. Ninety-five per cent of the
funds raised remain in Minnesota for local and state-
wide programs, while 5 per cent goes to the National
Tuberculosis Association for its medical research and
general program of organization and education through-
out the nation.
EPIDEMIOLOGY AND RECENT
DEVELOPMENTS IN POLIOMYELITIS
(Continued from Page 1148)
precludes the possibility of any effective means of
avoiding possible infection. Based upon these
facts, the rules and regulations for the control
of communicable, diseases have brought about a
change in attitude towards the isolation of polio-
myelitis cases and contacts. Presently but few
states isolate patients and contacts.
The only significant statement which a person
can make as far as prophylaxis of poliomyelitis
is concerned is that up to this time nothing has
been found to be effective, and the only encour-
aging statement which can be made is that clinical
and research efforts are ever expanding in the
hope of finding some effective ways and means
through which preventive measures may be ex-
ercised.
References
1. Adair, John, and Snyder, L. T. : Evidence for an autosomal
recessive gene for susceptibility to paralytic poliomyelitis.
J. Heredity, 33:307, 1942.
2. Aycock, W. L. : Epidemiology of poliomyelitis. Harvard
School of Public Health Symposium, 1939.
3. Aycock, W. L. : Autarcesiology of poliomyelitis. West Vir-
ginia M. J., 30:481, (Nov.) 1934.
4. Aycock, W. L. : Nature of autarcesiologic susceptibility to
poliomyelitis. Am. J. Pub. Health, 27:575, (June) 1937.
5. Brown, G. C. ; Francis, T., Jr., and Pearson, H. E. : Rapid
development of carrier state and detection of poliomyelitis
virus in stool nineteen days before onset of paralytic disease.
J.A.M.A., 129:121, (Sept. 8) 1945.
6. Cunning, D. S. : Tonsillectomy and poliomyelitis. Ann. Otol.
Rhin. & Laryng., 55:583, (Sept.) 1946.
7. Flexner, S., and Lewis, F. A.: The transmission of polio-
myelitis to. monkeys. J.A.M.A., 53:2095, (Dec. 18) 1909.
8. Francis, T., Jr.; Krill, C. E.; Toomey, J. A., and Mack,
W. N. : Poliomyelitis following tonsillectomy in five members
of a family. J.A.M.A., 119:1392, 1942.
9. Holms, J. : Acute anterior poliomyelitis and vitamin B
deficiency. Med. J. Australia, 1:717, 1941.
10. Kemp, J. E., and Soule, M. H. : Effect of chlorination of
city water on virus of poliomyelitis. Proc. Soc. Exper. Biol.
& Med.. 44:431, (June) 1940.
11. Kramer, S. D.; Gilliam, A. G., and Molner, J. G. : Recovery
of poliomyelitis from the stools of healthy contacts in an
institutional outbreak. Pub. Health Rep., 54:1914, (Oct.
27) 1939.
12. Paul, T. R. ; Trask, J. D., and Culotta, C. S.: Poliomyelitis
virus in sewage. Science, 90:258, (Sept. 15) 1939.
13. Paul, J. R., and Trask, J. D. : Recent development in
epidemiology of poliomyelitis. Internat. Clin. 3:59, (Sept.)
1939. *
14. Paul, J. R. ; Trask, J. D., and Vignec, A. J. : New aspects
of clinical epidemiology of poliomyelitis. Tr. A. Am. Physi-
cians, 54:119, 1939.
15. Sabin, A. B.: Olfactory bulbs in human poliomyelitis. Am.
J. Dis. Child., 60:1313, 1940.
16. Toomey, J. A.: Spread of poliomyelitis virus from gastro-
intestinal tract. Proc. Soc. Exper. Biol. & Med., 31:680,
(March) 1934.
17. Toomey, J. A.: Absorption of poliomyelitis virus by possi-
bly deficiently medullated nerves. Am. J. Dis. Child., 60:
548, 1940.
18. Weaver. H. M. et al.: Acute anterior poliomyelitis during
pregnancy. Am. J. Obst. & Gynec., 47:495, (April) 1944.
19. Weaver, H. M.: Resistance of cotton rats to the virus of
poliomyelitis as affected by intake of vitamin B complex,
partial inanition and sex. Am. J. Dis. Child., 69:26, 1945.
November, 1947
1191
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
NORTH CENTRAL CONFERENCE MEETS
IN SAINT PAUL, NOVEMBER 23
On Sunday, November 23, doctors from Min-
nesota, Iowa, Nebraska, North and South Dakota
and Wisconsin will convene in Saint Paul for
their annual North Central Medical Conference.
A panel of speakers will present half-hour dis-
cussions on several medical economic problems
common to the North Central states. Ample op-
portunity will be provided for delegates to com-
ment from the floor. Program topics include
the physician’s role in the total medical care pic-
ture, the co-ops, veterans’ medical care, rural
health, public relations and medical society admin-
istration.
Sessions begin at 10 a.m. with the presidential
address by Dr. William J. Duncan of Webster,
South Dakota, Conference president. Other
speakers on the morning program are Drs. Floyd
L. Rogers, Lincoln, Nebraska, and Fred Ster-
nagel, West Des Moines, Iowa, and Mr. Thomas
A. Hendricks, Secretary of the Council on Medi-
cal Service of the American Medical Association.
Educator to Speak at Dinner
A fresh viewpoint on the old problem of ways
and means of improving rural health will be pre-
sented at the 12:30 p.m. dinner by Dr. John O.
Christianson who directs the school of Agricul-
ture of the University of Minnesota Farm Cam-
pus. In the afternoon Mr. L. S. Kleinschmidt of
the American Medical Association, who has de-
voted considerable study to the problem of health
co-operatives, will speak on whether the co-ops
have a place in the voluntary prepayment medical
care program. Following this, Dr. W. A.
Wright, Williston, North Dakota, will describe
that state’s plan for veterans’ medical care, and
Dr. W. D. Stovall, Madison, president of the
State Medical Society of Wisconsin, will outline
a plan for speeding up administrative processes of
state medical organizations. At 3:30 p.m. there
1192
will be an open forum at which time conference
delegates can bring up specific questions for dis-
cussion. Moderator will be Dr. Louis A. Buie,
Rochester, president of the Minnesota State Med-
ical Association.
The Conference will close with a brief address
by the 1948 president of the Conference, Dr. A.
W. Adson, Rochester.
STATE DIVISION REHABILITATES
590 HANDICAPPED PERSONS
An increase during the past year in the number
of handicapped civilians who have been rehabili-
tated has been noted by the Division of Vocational
Rehabilitation of the State Board for Vocational
Education. In its annual report just published,
the division claims 590 cases closed as rehabili-
tated, an increase of fifty-two over the previous
year.
The economic returns of the program are far
outweighed by the human benefits derived from
these services to the handicapped, the report says.
Whereas these 590 rehabilitated persons who have
now been able to earn a total of $958,932 and will
pay Federal and state taxes in the amount of
$97,327.91, the transformation of men and women
from dependency into self-sufficiency is a return
which cannot be measured in dollars and cents,
the report points out.
In addition to those cases actually closed there
were 267 other handicapped persons in gainful
employment who are now being followed up to
determine the suitability of their jobs before
closing their cases. This brings the total to 875
disabled persons placed in employment this year.
Earn Good Wages
Based on earning reports secured from these
rehabilitated persons, their average weekly wage
is $33.18, showing that these disabled persons are
not earning a bare subsistence wage. Many have
Minnesota Medicine
MEDICAL ECONOMICS
found it possible to increase their earnings ; and,
looking at the total picture, they are now collec-
tively earning 80 per cent more than they were
when they first began working.
The Division of Vocational Rehabilitation can
take credit for saving thousands of dollars of
public assistance funds which need not be spent
when these disabled are rehabilitated to the status
of self-supporting wage earners. Its records
show that for thirty-five persons a total of $405
a week was being doled out to them when they
were first referred to the division for help. Now
these same thirty-five are actually earning $959
a week by their own efforts.
It is estimated that of the 195 persons who had
no income at all at the time when their cases
were first investigated, all are now earning their
own way so as to have earned in six weeks what
they cost the division.
Over 6.000 Received Services
During the year the total number of disabled
cases on the rolls of the division was 6,362,
an increase over last year. In preparing dis-
abled persons for their jobs, here are some of the
items the division purchased last year : twelve
artificial limbs, twelve hearing aids, one pair of
glasses, 309 medical examinations, two repairs for
appliances and 229 items of training supplies.
During the year the division’s medical con-
sultant reviewed 1,153 medical reports to deter-
mine eligibility and completeness of information
so that adequate programs could be outlined by
the counselors. Medical examinations were pur-
chased for 298 new clients ; and in addition, 855
medical reports were secured from family physi-
cians, clinics, and hospitals which had records
available.
More and more the disabled youth in this state
are looking to the division to prepare them for
employment. Results are being obtained by co-
operation on the part of the division with school
people over the state initiating programs to
emphasize the abilities of the handicapped youth
and minimize their disabilities.
Disabled Need Understanding
The great need for understanding of the dis-
abled on the part of the general public was cited
in the division’s report. The disabled person
must be reached early in the period of disable-
ment, the report said, so that restoration services
can be started before he is unduly subjected to
the disintegrating effects of idleness. The longer
the period between disablement and the start of
restoration, the more difficult and costly the lat-
ter becomes. Therefore the report urges that
all organizations, public and private, should know
about these services in order to make prompt
referrals.
Services for the seriously disabled or the
“homebound” continued to expand during the
last year. Their total earnings also increased
greatly over the last year. The area served was
increased by opening an office in Virginia, serv-
ing seven towns on the Iron Range. This ex-
pansion was made possible by a grant from the
Minnesota Society for Crippled Children and
Adults.
Tuberculosis rehabilitation continued to receive
considerable attention. In addition many deaf
and hard of hearing received assistance under
the program.
CONFERENCE STUDIES NATIONAL
SCHOOL HEALTH PROGRAM
“Civilization marches forward on the feet of
healthy, well-instructed children!” That state-
ment was made in a speech by a Missouri super-
intendent of schools before a recent national gath-
ering of physicians, educators and public health
officials and it summarizes perfectly the present
goal of our nation’s schools.
The physician’s responsibility in the attainment
of such a goal was the subject of the conference,
which was called by the American Medical Asso-
ciation in an effort to stimulate action, in a spirit
of friendly co-operation, among all groups con-
cerned with the health of our school children.
Held at Highland Park, Illinois, October 16
through 18, the gathering was entitled “The Con-
ference on the Co-operation of the Physician in
the School Health and Physical Education Pro-
gram,” and the purpose was, in the main, two-
fold : The three-day meeting was devoted to a
thorough examination of what is being done at
present to provide for the health and well-being
of children in school and to suggesting ways of
implementing the rather broad, ideal, national
policy within the various states.
Co-operation Is Key
The inspiring talk by the gentleman from the
Ozarks, Mr. John Bracken, superintendent of
November. 1947
1193
MEDICAL ECONOMICS
schools in Clayton, Missouri, echoed the senti-
ments of all of the conference delegates when it
placed most emphasis on the need for co-operation
on the part of everyone concerned in the school
health problem — teachers, administrators, govern-
ment officials, doctors, nurses and parents.
As the health adviser, the physician, Mr. Brack-
en declared, is “part of the team that takes care
of children.” It was the beginning of a new,
brighter era in child health, he said, when the
physician entered the picture.
Other conference speakers expressed ideas
along the same line. In his address of welcome,
at the opening of the conference, Dr. George Lull,
secretary and general manager of the AMA, em-
phasized the vital need for the medical profes-
sion to work with all groups toward the attain-
ment of better health for all people. It was
agreed that the foundations of health are laid
in childhood and that the level of the health of
people generally cannot be raised effectively with-
out first improving the health of youngsters in
school.
Dr. Edward L. Bortz, AMA president, viewed
the meeting as one of the most significant ar-
ranged by the AMA in a long time. He ex-
pressed the hope that it would be the first of
a series of such conferences.
“The AMA welcomes constructive criticism,”
Dr. Bortz declared. “The medical profession is
blazing trails in the fight for better health ; and
through the medium of such conferences as this,
with the help of educators and all other groups
involved, we can do an even more effective job.”
Health Is Important Topic
Health is the number one topic for study in
schools, it was pointed out at the conference.
For youngsters in their formative years, it was
recommended that they be given: (1) full and
scientific health information, (2) thorough, peri-
odic health examinations, (3) instruction in the
basic facts of healthful living, and (4) a balanced
program of mental and physical education.
The need for modernizing the health and physi-
cal education program in the nation’s schools was
cited as particularly important. A new concept of
education has developed which recognizes a child
as a total personality, and it is important to have
a health and physical education program in step
with this idea.
Since the conference was called by physicians,
discussions centered around what physicians
themselves can do in the program. However, it
was emphasized that doctors are not proposing
a medical profession’s program for health in the
schools, they are merely offering their services
in a constructive and co-operative way.
It was not the intent of the meeting to pub-
lish as a result of its deliberations a volume of
new information on policies and programs to im-
prove school health. It was rather the hope
of the delegates to decide upon plans for putting
into practice the existing policies and to take
these plans back to the various states.
Groundwork Already Laid
Discussions were based on the results of pre-
vious discussions and the preliminary groundwork
laid by the National Conference for Co-operation
in Health Education and its National Committee
on School Health Policies. This group formu-
lated in 1945 a set of suggested school health
policies, which was admittedly very idealistic. It
also compiled an analysis of the functions of the
school administrator, the physician and the nurse
in the total school health program.
In putting these health policies into effect, the
delegates noted that it would be necessary to
have an exchange of information between the
various states, descriptions of programs in oper-
ation for purposes of comparison and evaluation.
The problem of how to evaluate the various
programs was also discussed. It was suggested
that the United States Office of Education or
the AMA Bureau of Health Education micht be
asked to collect information of this kind for dis-
tribution to communities requesting information
on how to proceed.
Children themselves should have a share in
evaluating these programs, it was pointed out.
Children should be encouraged to take a very
live interest in the school health program so as
to secure their understanding and co-operation.
Conference in Four Sections
For purposes of more detailed study of the
problems involved, the Conference was divided
into four work sections. The sections were en-
titled (1) School Health Services, (2) School
Health Programs and Studies, (3) The Physician
and Physical Education and (4) Pre-Service and
In-Service Education.
Experts in the field from the various organi-
1194
Minnesota Medicine
MEDICAL ECONOMICS
zations participating, that is, state departments of
education and health, state education associa-
tions and state medical associations, led the dis-
cussions in each section. The conference was
brought to a close with a general meeting at
which a report or summary of the discussions
carried on by each of the four was read.
A wide range of topics was covered — for ex-
ample, the problem of too many “excuses” from
physical education classes. It was found that
this problem has many contributing causes, all of
which must be remedied. First of all, there are
the parents and children who do not understand
the importance of physical education to the total
school program, nor do they have any under-
standing of the role of exercise in body develop-
ment. Many children dislike physical education
because it is not properly taught — the program
in their school is not an attractive one.
As regards the doctors who write excuses for
these youngsters, they Have never been informed
about the aims of the school system and conse-
quently they cannot understand its problems.
Role of the Medical Society
Throughout the discussions it was agreed that
the state medical associations and the component
medical societies can do much to foster co-
operation between doctors and educators. It was
suggested that joint meetings, perhaps one a
year, between the school board and the local medi-
cal society might be of real benefit.
At the state level, the medical profession can
work for the co-operation of the groups involved.
It was suggested that sections at the medical as-
sociation’s annual meeting could be devoted to a
study of the problem with nurses, educators and
government officials invited to participate. The
medical association can also appoint committees
or utilize existing committees for the study of
school health.
All were in agreement that what is needed is
the participation of all groups concerned. If a
school health council is formed, for example,
it should include representatives from the medical,
dental, nursing and allied health professions, as
well as teachers, school administrators, parents
and students themselves. Since the school health
program takes in everything that affects the well-
being of children in school, every person who is
connected with the school must be enlisted before
the program can be a sq^cess.
November. 1947
MINNESOTA STATE BOARD OF MEDICAL
EXAMINERS
230 Lowry Medical Arts Building
Saint Paul 2, Minnesota
Julian F. DuBois, M.D.. Secretary
Minneapolis Woman Sentenced to Four-year Term
for Criminal Abortion
Re State of Minnesota vs. Alida Toivonen
On October 7, 1947, Alida Toivonen, forty-nine years
of age, 416 21st Avenue No., Minneapolis, was sen-
tenced to a term of not to exceed four years at hard
labor in the Women’s Reformatory at Shakopee by the
Hon. E. A. Montgomery, Judge of the District Court of
Hennepin County. Mrs. Toivonen entered a plea of
guilty on that date to an information charging her
with the crime of abortion and also to a second in-
formation charging her with having a prior conviction
of a felony. Following a statement of the facts to the
Court by legal counsel for the Minnesota State Board
of Medical Examiners, Judge Montgomery stayed the
execution of sentence and placed the defendant on
probation for a period of four years.
Mrs. Toivonen was arrested on September 17, 1947,
by Minneapolis police officers following the admission
of an eighteen-year-old married Minneapolis woman to
Minneapolis General Hospital. The patient was suffer-
ing from an infection following an abortion. She named
the defendant as the person who performed the abortion
which took place in a room at a Minneapolis hotel.
The defendant at first denied the charge, but subsequently
admitted that she performed the abortion and was paid
$75.00 for her services. Mrs. Toivonen was convicted
for a similar offense on February 13, 1945, in the District
Court of Hennepin County, and at that time was sen-
tenced to a term of one year in the Minneapolis Work-
house. She served six months of the sentence and was
on probation for eighteen months. In the present case
the investigation disclosed that Mrs. Toivonen refused
to perform the abortion when first requested, but was
prevailed upon to do so by the employer of the man
responsible for the patient’s pregnancy. There was no
evidence of any other offense and under those circum-
stances the Court stayed the execution of sentence.
During the investigation Mrs. Toivonen stated that
she was born and raised in Yellow Medicine County,
Minnesota, and had worked at a small hospital in
Wisconsin as a practical nurse. She also claimed to have
taken a correspondence course in nursing. The de-
fendant has resided in Minneapolis for twenty-five
years. She holds no license to practice any form of
healing in the State of Minnesota.
Two Saint Paul Women Sentenced
for Criminal Abortion
Re State of Minnesota vs. Astmcfla Willner, also known
as Sue Willner
Re State of Minnesota vs. Helen A. Heck
On October 9, 1947, Asunda Willner, also known as
Sue Willner, thirty-five years of age, 343 W. Central
Avenue, Saint Paul, and Helen A. Heck, forty years
of age, 799 Iglehart Avenue, Saint Paul, were sentenced
by the Hon. Clayton Parks, Judge of the District Court
1195
MEDICAL ECONOMICS
of Ramsey County, Minnesota, to terms of not to exceed
four years each in the Women’s Reformatory at Shako-
pee. Both sentences were stayed and the defendants
ordered to serve sixty days in the Ramsey County Jail.
Each defendant is to be on probation for the balance
of the four-year term. Both defendants had entered
pleas of guilty on August 21, 1147, to an information
charging each with the crime of abortion. At that time,
Judge Parks referred the matter to the Probation Officer
of Ramsey County, for a pre-sentence investigation.
The defendants, together with one John L. Capra,
were arrested by Saint Paul police officers on a com-
plaint filed in the Municipal Court of Saint Paul on
August 13, 1947. The complaint charged the defend-
ants with having performed a criminal abortion on a
twenty-two-year-old unmarried Saint Paul girl. The
abortion was alleged to have been performed on or
about July 5, 1947, at the home of the defendant Heck.
The patient stated that she paid $350.00 to the defendant
Willner and was taken to the Heck home where she
was blindfolded and the abortion performed by some
person unknown to her. The defendants denied per-
forming the abortion and claimed that it was done by
“a Minneapolis doctor.” Each of the defendants denied
knowing the identity of the doctor. The defendant Heck
stated that the person performing the abortion had been
to her home previously, but that she knew him only
as “Doc.” The persons investigating the case place
no belief in this part of the defendant Heck’s story.
The case against the defendant Capra was dismissed on
motion of the County Attorney for the reason that the
evidence disclosed that his only connection with the
case was that he drove the patient from the Heck home
where he lived, to the patient’s own home.
The defendant Willner has a previous criminal record
having entered a plea of guilty on August 8, 1942, in
the District Court of Ramsey County to an information
charging her with the crime of practicing healing without
a basic science certificate. That charge, likewise, grew
out of an alleged criminal abortion. For that offense
the defendant Willner was given a suspended sentence
of one year in the Ramsey County Jail. Neither of the
defendants holds any license to practice any form of
healing in the State of Minnesota.
THE MAN ON THE STREET
Does industry pay a dollar in dividends for every
dollar of wages? A poll on the West Coast showed
that The Man on the Street believes that capital gets
more than half of what is left after all other costs are
paid, and labor less than half. In fact, 72 per cent of
the Men on the Street believe this.
Believing it, how do they feel ? They feel sore at
the American system. They think that it is unfair. And,
if true, it would be unfair. If I believed it, I would be
a Socialist or a Communist, too. I would say, “To
h with them. Take it out of their lousy profits.”
Men vote as they think. “As a man thinketh in
his heart, so is he.” If he thinks wrong, he will strike
wrong and vote wrong.
How the Man on the Street thinks is more important
to business than any other thing whatsoever. The
Man on the Street holds every business, from the corner
grocery to the giant factory, in the hollow of his hand.
The Man on the Street elects Governors, Congressmen,
Presidents. As he believes, so he elects.
Well, what is the fact about this matter? Not the
“bull,” but the truth.
After all other expenses are paid, we have, say, $100
for both labor and capital, wages and dividends. The
belief is that capital gets $50 or more, and labor gets
$50 or less. Most people think less. That makes them
bitter.
Now for the truth. I have gone to two sources, one
private, the other the United States Department of
Commerce. The private statistical organization is the
National Industrial Conference Board. For the year
1939 it reports that of this $100 employes got $84.70
and capital got $15.30. This is nearly $6 to employes
and $1 to capital. But bear in mind that nearly 60
per cent of all business companies did not make any
profits whatever for capital that year.
That was the figure for 1939. So I took the question
up with the Department of Commerce. In their Survey
of Current Business for January, 1946, they give the
division for all corporations for the year of 1944. It
shows that after taking out the taxes paid to govern-
ment “the ratio was almost seven to one.” That is $7
to employes and $1 to capital.
This is a far cry from fifty-fifty, or more than 50
per cent to capital and less than 50 per cent to em-
ployes. The truth is about $87.50 to employes and $12.50
to capital. Of course, the ratio varies in one industry
from another, but this is the U. S. Government average
for all corporate business.
Now is 6 to 1, or 7 to 1 a fair division? Here is
Mr. Investor. He puts in, on the average, $6,000 in
tools, buildings, et cetera, for every man employed.
If the business fails he loses his dough. He takes
that risk. If it succeeds he gets $1, while the man
who uses his machinery gets $6 or $7.
For reasons I haven’t room for here, I believe Mr.
Worker would shake hands with Mr. Investor on the
division and say, “Fair enough, let’s go to work.”
But Mr. Worker has to know the truth about the
split, the whole truth, nothing under the table, and
believe it. If he doesn’t know it and doesn’t believe it,
he is ready for the hammer and sickle instead of the
Stars and Stripes.
Whose business is it to get the truth to him ? It is
the business of honest labor leaders themselves — rather
than to whip up envy and hate with fake figures.
But it is primarily the business of businessmen. In
this, most of them have fallen down on the job. They
wait until there is a strike and then when feeling
runs warm they try at the eleventh hour, in big full-
page ads, to tell a little of the story.
The only thing that makes me an optimist about the
American system — and its chance to survive — is that it
is, in truth and fact, an incomparably better and fairer
system than the picture of it which a lot of dumb
businessmen allow to persist in the minds of the public.
But, by their indifference and inaction, they are tak-
ing an awful chance for their stockholders, workers and
the country’s heritage of free institutions. — S. B. Pet-
TENGILL, National Radio Commentator and Newspaper
Columnist. .
1196
Minnesota Medicine
Minnesota Academy of Medicine
Meeting of April 9, 1947
The regular monthly meeting of the Minnesota Acad-
emy of Medicine was held at the Town and Country
Club on Wednesday evening, April 9, 1947. Dinner was
served at 7 o’clock and the meeting was called to order
by the president, Dr. E. M. Hammes, at 8:10 p.m.
There were sixty-three members and four guests
present.
The secretary read a letter from Dr. Giffin expressing
his appreciation of his election to Honorary Membership.
The secretary also read a letter from Dr. Diehl sug-
gesting that Dr. J. C. McKinley’s name be transferred
from the University to the Honorary Membership list.
This was voted unanimously, the Executive Committee
having approved the transfer.
Upon ballot the following were elected as candidates
for membership in the Minneapolis group : Drs. E. D.
Anderson and Erling Platou. There were no vacancies
in the Saint Paul membership list.
The scientific program followed. Dr. Charles W.
Mayo, Rochester, read his Inaugural Thesis which was
illustrated with lantern slides.
THE SURGICAL TREATMENT OF CARCINOMA
OF THE RIGHT PART OF THE COLON
CHARLES W. MAYO, M.D.
Rochester, Minnesota
It is possible that the public gradually is becoming
alert to the various manifestations of malignant disease,
and therefore, in the presence of symptoms, is seeking
the aid of the physician earlier than in previous years,
but such is not known definitely to be true. It is hearten-
ing, nonetheless, to observe that between 1907 and 1938,
inclusive, the resectability rate of malignant lesions of
the colon in one large series which I studied was 67
per cent ; whereas in another series between 1940 and
1946, inclusive, which I studied, the resectability rate was
increased to 77 per cent.
A number of factors are responsible for the general
improvement thus implied. The physician, for one thing,
is becoming more and more impressed with the necessity
for suspicion and investigation of the colon when a pa-
tient complains of fatigability and weakness and when
anemia is found to be present. For another thing, the
physician is now quick to realize that any digestive dis-
turbance which is persistent and is associated with an
alteration in intestinal habit calls for roentgenologic
study of the colon.
It is still true, however, that earlier diagnosis is of
paramount importance in the successful surgical treat-
ment of malignant processes of the right portion of the
From the Division of Surgery, Mayo Clinic, Rochester,
Minnesota.
Inaugural thesis. <
November. 1947
colon. Improvement in the end results of such treatment
is based on the fact that surgical intervention must be
carried out before the malignant process has developed
to such an extent as to limit the value of resection.
In the present paper I wish to present what I belieyt
are significant data, gained from a recent review of
cases, concerning malignant lesions of the right part of
the colon. In addition, I shall describe a method of re-
section and of end-to-end ileotransverse colostomy, car-
ried out in one stage, which has proved to be of con-
siderable value.
Definitions of Structure Concerned
The term, “right portion of the colon,” probably is
ambiguous from the anatomic standpoint. Some writers
have said that the abdominal portion of the colon is
composed of two main parts, the right and the left,
which would imply that the line of demarcation is in the
middle of the transverse colon. When statistical mate-
rial pertaining to the colon is under consideration, it is
important to know exactly what a speaker or writer
means when he concerns himself with this structure. In
the present paper, as in past considerations of the right
portion of the colon, I shall include the cecum, ascending
colon and hepatic flexure only.
Diagnostic Aids and Differential Points
Despite the advances in diagnostic procedures of re-
cent years, it is still uncommon, in the presence of early
lesions, to discover definite signs or symptoms to di-
rect the physician’s attention to the right part of the
colon. It is still true, unfortunately, that when the diag-
nosis is made early, it generally is done so accidentally.
A majority of patients (about 67 per cent) will have ex-
perienced symptoms for six months to more than a year
before a correct diagnosis is made.
Many malignant lesions in this portion of the colon
ulcerate as they progress. Some have a large surface
area, a fact which explains the oozing of blood and the
development of secondary anemia so often encountered
and too frequently mistakenly treated as primary anemia.
Another diagnosis sometimes made for patients who
really have a malignant lesion of this part of the colon
is “acute” or “subacute appendicitis.” In one study it
became apparent that 15 per cent of the patients con-
cerned had undergone appendectomy within the period in
which symptoms caused by the malignant lesion had been
present. This actually is an important consideration.
When it is linked to the fact that only about 2 per cent
of carcinomas of the right part of the colon develop
among persons less than thirty years old, then it becomes
clear that any incision for appendectomy should be ade-
quate to permit surgical exploration of the right part of
the colon.
Clear-cut symptoms of obstruction are not prominent.
A marked degree of obstruction is rare because of the
1197
MINNESOTA ACADEMY OF MEDICINE
fluid nature of the intestinal contents on the right side
and because constricting or napkin-ring lesions are un-
usual in this portion of the colon. Even so, a mass can
be palpated in about 75 per cent of the cases.
If the lesion is to be detected before surgical opera-
tion, roentgenologic examination is essential. It should
be done by one who understands roentgenoscopy. Dou-
ble contrast roentgenography should be employed ; in
such a procedure the second roentgenogram is made with
the colon inflated with air, after the barium bas been
expelled. Once it bas been demonstrated that a malignant
lesion is present, the situation becomes an emergency.
Hence, no time should be lost in preparing the patient
for surgical intervention unless operation is otherwise
contraindicated. Time is of prime importance in the
treatment of all malignant processes.
In view of present-day knowledge, the problem of
diagnosis might be summarized by the statement that if
digestive disturbances have been present, or a change in
intestinal habit bas persisted, in a patient wbo is more
than thirty years old, and if the stomach, duodenum and
gall bladder have been ruled out as seats of the disturb-
ance, then investigation of the right part of the colon
certainly is indicated.
Preparation of the Patient
The preparation of most patients for operations on
the colon requires about four days. Secondary anemia,
if it is present, may have to be corrected. The group to
which the patient’s blood belongs and the Rh factor
should be determined, because blood should be trans-
fused in all cases, during or immediately after operation,
when resection is performed.
As a rule, one of the sulfonamide drugs is employed
in the preparation of the colon for operation. I consider
sulfathalidine to be the drug of choice at present for the
preparation of patients for resection of the right por-
tion of the colon. This drug is administered by mouth
in a dose of 1.5 gm. every four hours, until the patient
has received 36 gm. Paregoric should be adminis-
tered in doses of 8 c.c. at 2, 6 and ID o’clock of the
afternoon and evening before operation, in order to put
the bowel at rest.
Surgical Procedures in General
It is a commonplace observation, but one which is
still true, that the anesthestic agent of choice is the one
with which the anesthetist is most familiar.
Surgical techniques. — Resection of the right portion of
the colon can be carried out by a number of methods ;
any one of the methods encompasses still more differ-
ences of detail in performance. Again, every surgeon
entertains certain preferences or antipathies toward va-
rious types of technique, suture material and suturing
procedures, and surgical instruments. Hence, I believe
it will be useful for me to consider the surgical trends,
and to present only one surgical procedure which has
been of value to me, namely, primary resection and end-
to-end ileotransverse colostomy.
A number of years ago a colleague and I reviewed
all the cases in which resection of the right portion of the
colon for malignant lesions had been performed at the
Mayo Clinic from 1907 to 1938, inclusive.1 The series
comprised 885 cases. I have just completed, with the
assistance of the Division of Biometry and Medical Sta-
tistics, another review of cases in which resection was
performed at the clinic from 1940 through 1946. Re-
sults of the latter study indicate that the following
changes have evolved.
First, as I mentioned earlier herein, the resectability
rate bas increased from 67 to 77 per cent, so far as the
Mayo Clinic series are concerned.
Second, primary resection and ileotransverse colostomy
carried out in one stage have superseded tw'o-stage and
multiple-stage operations. In the past six years, 73 per
cent of operations for the condition in question have
been one-stage procedures.
Third, in 38 per cent of the one-stage operations, the
particular procedures used have been primary resection
and end-to-end ileotransverse colostomy.
Fourth, in 1946, resection of the right portion of the
colon was carried out for malignant lesions in ninety
cases, with no deaths in the hospital. In only three of
these ninety cases was the operation done in two stages,
and extraperitoneal resection was not performed.
Fifth, although a comparison of mortality rates be-
tween the period from 1907 to 1938 and the period from
4940 to 1945 is not a fair one, it is interpolated herein
merely to emphasize the progress that has been made.
From 1907 to 1938 the mortality rate associated with
one-stage procedures was 22 per cent ; for two-stage
procedures it was 29 per cent. From 1940 to 1946 one-
stage procedures were performed with a mortality rate
of 3 per cent, and two-stage procedures were carried out
with a mortality rate of 6 per cent.
Primary Resection and End-to-End Ileotransverse
Colostomy
To the time of this report, on my surgical service,
one-stage resection and end-to-end ileotransverse colos-
tomy have been accomplished fifty-four times, with one
death. The two procedures at present constitute my
operation of choice for malignant lesions of the right
part of the colon.
1 make a longitudinal incision at the outer border of
the right rectus abdominis muscle through the rectus
sheath. The rectus abdominis muscle is retracted me-
dially and the posterior fascia and the peritoneum are
incised.
After exploration for jmetastasis or other complicat-
ing factors has been completed, the right portion of the
colon, beginning with the cecum, is mobilized. A wide
segment of the mesentery of the colon is resected and
the vessels are ligated deep.
The points for transection of the transverse colon and
the ileum are selected with special consideration of the
blood supply and the distance of these points from the
lesion. 1 transect the ileum at an angle in order to in-
sure a good blood supply to the cut edge and an adequate
lumen to fit the colon. I have not yet encountered a case
in which the ileum, cut in this manner, could not be made
to fit the transected end of the transverse colon. I cut
the colon and the ileum with the cold scalpel. I do not
use cautery because I believe that the heat involved de-
vitalizes the tissue.
1198
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
I do not, moreover, employ crushing clamps at the
site of anastomosis. I establish an open type of anasto-
mosis in which rubber-covered clamps are utilized to
minimize soiling. Whatever questionable loss may be
caused by some degree of soiling is more than compen-
sated for by the accuracy with which sutures can be
placed when the open method of anastomosis is used.
An outer row of running cotton suture is placed half
way around the serosa. The mucosa is closed with a
running catgut suture. The remaining half of the se-
rosal coat is closed with interrupted cotton sutures. Only
two rows of suture material are used because it is felt
that more would interfere unnecessarily with healing.
The mesentery of the ileum and the mesentery of the
transverse colon are brought together and closed in or-
der to keep the small bowel from slipping through this
opening. The raw surface on the right from which the
colon has been removed is peritonized after retroperito-
neal drainage has been established by the placing of two
Penrose drains in position and bringing them out
through a small incision in the right flank. Next, the re-
gion of the anastomosis is thoroughly swabbed with an
antiseptic agent (phemerol) ; before the incision is closed
5 gm. of sulfonamide powder is sprinkled on the area
intraperitoneally.
It is advisable, after the abdominal incision has been
closed and before the patient has recovered conscious-
ness, to dilate the anus manually enough to paralyze the
sphincters temporarily, so that gas cannot be retained.
This procedure, I feel, is a very important part of the
operation.
Except in one or two instances, it has not been neces-
sary to employ a Miller- Abbott tube preoperatively.
Thus far I have not found it necessary to use this tube
postoperatively for any of the patients on my service.
Patients are permitted to walk early. Most of them
are dismissed from the hospital in less than two weeks.
Outlook for the Patient
What the outcome will be for the patient operated on
for malignant lesions of the right portion of the colon
is an interesting problem in itself. The surgeon’s objec-
tive is, of course, to maintain a good result over the
years after operation, so that the patient will be as-
sured of a happy and productive existence.
A number of factors determine the outcome after
the operation in question. The pathologic grade of the
lesion, the mural penetration of the malignant cells, the
extent of metastasis to adjacent and distant points, and,
of course, the age of the individual patient, all are im-
portant factors.
Some definite data are at hand, however. That is, if
the patients in the present series are divided into two
groups — those who did not have nodal involvement and
those who did have nodal involvement, regardless of
other factors — the certain five-year survival rates appear
to be valid. Sixty-four per cent of those patients who
did not have involvement of lymph nodes lived five years
or longer; 47 per cent of those who did have such in-
volvement lived five years or longer. A recent study of
malignant lesions of the rectum for which one-stage
combined abdominoperineal resection was performed re-
vealed that, when involvement of lymph nodes was not
present, 74 per cent of the patients lived five years or
longer, but that when involvement of lymph nodes was
present, 38 per cent of the patients lived five years or
longer.
Conclusions
One-stage resection of the right portion of the colon
can be performed with a lower mortality rate and lower
morbidity rate than can multiple-stage procedures.
With certain rare exceptions, one-stage resection can
be carried out in any case in which it is possible to do
a multiple-stage procedure.
One-stage resection of the right portion of the colon,
with end-to-end ileotransverse colostomy, constitutes an
operation that has given very valuable results.
Reference
1. Mayo, C. W., and Lovelace, W. R., II: Malignant le»
sions of the cecum and ascending colon. Tr. West. S. A.,
(1939) 49:378-425, 1940; (Abstr.) Surg., Gynec. & Obst.,
72:698-70 6, (April) 1941.
Discussion
Dr. O. H. Wangensteen, University of Minnesota:
Dr. Mayo’s discussion of the management of lesions of
the right colon was most interesting and instructive.
The results of the period prior to 1938 from his own
clinic, and those achieved since that time, are repre-
sentative of the improvement in surgery that is occur-
ring everywhere. The surgery of the gastrointestinal
canal has been static for a generation ; it is reassuring,
indeed, to note that through the agency of some im-
provement here and some there with the problem of in-
testinal anastomosis how much better the mortality score
is. The primary anastomosis, which Dr. Mayo employs
with such satisfactory results in the management of
lesions of the right colon, antedated the exteriorization
operation for dealing with colic cancers. As a matter of
fact, now that surgery is ready for the primary anasto-
mosis, I feel it is time to exteriorize the exteriorization
operation throughout the colon. For several years now,
my associates and I at the University Hospitals routine-
ly have performed primary anastomoses for all colic
lesions, in the absence of acute obstruction, without the
aid of complemental external decompressive vents, save
the indwelling duodenal tube.
It is difficult to assay all the items that have contrib-
uted to betterment of the surgeon’s mortality record in
dealing with cancer of the colon. Certainly elimination
of the element of speed has been important, and the prin-
cipal occurrence that has made it possible to operate
without speed is improved anesthesia. It is no longer
necessary to rush through an operation to get the patient
off the table alive. Much surgery of the past genera-
tion had to be done that way. If there are any surgical
adherents to that “get in quick and out quicker’’ policy
still around, no matter how pleased they may be with
their own achievement, they will be startled, indeed, to
learn how their own accomplishment may be improved
upon by elimination of the element of hurry.
Better preoperative preparation and improved post-
operative care, too, have played important roles in the
reduction of surgical mortality. Moreover, today, opera-
November. 1947
1199
MINNESOTA ACADEMY OF MEDICINE
tions, because of these improvements, can be extended to
borderline surgical risks as well as older patients, with
risks that are not far out of line from the standard
surgical risk.
Dr. Mayo employs the open anastomosis. I will not
quarrel with anyone whose total hospital mortality is
only slightly more than 3 per cent for a large series of
cases. The main thing is to get as satisfactory imme-
diate and as good late results as can be achieved. We
can all agree on this. My associates and I use the closed
anastomosis exclusively from the stomach to the rectum.
Moreover, the best results we have achieved with resec-
tion of the colon occurred in the two-year interval from
1941 to 1943. During this pre-antibiotic era, as far as
intestinal antisepsis is concerned, we did sixty-one con-
secutive colic resections from the cecum to and includ-
ing the rectosigmoid with one hospital death — a mortal-
ity of 1.6 per cent. We have not duplicated that per-
formance since. In the series of colic resections done in
the next two-year interval, we had three unavoidable
deaths — a streak of bad luck that would mar any op-
erative record. But any surgeon who is operating upon
patients for malignancy in the upper age bracket must
be prepared to lose patients now and then through the
agency of coronary or cerebral thrombosis. In other
words, having no unavoidable deaths in that first series
of sixty-one cases, we did use up a lot of “surgical luck.’’
My feeling is that the most important item in the
procedure is a nice, closed anastomosis made without
spillage. Moreover, my associates and I are now mak-
ing such anastomoses with a single row of sutures, thus
assuring ourselves of large, patulous, functional stomas.
I think it goes without saying, if one is committed to
open anastomoses, he is dependent upon antibiotics to
suppress growth of intestinal bacteria to lessen the haz-
ard of peritoneal contamination. Drs. Ravdin and Zintel
of Philadelphia recently have reported a comparative
study of the efficacy of succinylsulphathiazole and
streptomycin in controlling B. coli in the feces. The>
gave each drug for a period of eight days prior to op-
eration. Streptomycin was given in 0.25 gram doses
every four hours. B. coli counts in the range of 400,000
per gram of feces was usual after succinylsulphathia-
zole; after streptomycin had been administered by mouth
for eight days, B. coli counts fell to about 400 organ-
isms per gram of feces. It would appear, therefore, that
streptomycin is about 1,000 times as effective as suc-
cinylsulphathiazole in reducing the B. coli count in the
feces.
There is another phase of Dr. Mayo’s presentation that
was very interesting — the diagnosis of cancer of the
colon. As you will remember, Dr. Mayo dwelt at length
upon the circumstance that the stage of development of
the cancer had much to do with the ultimate fate of the
patient after recovery from operation. If we were to
look at the problem of diagnosis of internal cancer from
a realistic point of view, it must be conceded that early
recognition of gastric or colic cancer is unusual. Even
rectal cancer in reach of the examiner's finger is not
diagnosed early ! In other words, internal cancer is a
silent disease. If is my feeling that, if we are to make
a greater impact upon this problem, we should be set-
ting up cancer detection clinics where patients may re-
port periodically for examination even in the absence of
symptoms. Cancer is a frequent disease. One out of
every five women past forty and one out of every six
men past fifty will die of cancer. It is just a question
of wfho will have it, in what organ and when. The public
W'ould like to have from us a cancer preventive or a
cancer cure. These are not available nor does there ap-
pear to be any likelihood that they soon will be. What
we need most now to help us with the detection of can-
cer is a biologic test. That also is not available. The
best substitute until a more universally applicable and
helpful diagnostic agent is found, would appear to be
to urge the erection and strategic placement of cancer
detection clinics. The w'orth of such clinics in the ear-
lier detection of cancer, I believe, can readily be assayed
in a few pilot plants. Surgery has made great strides in
the management of cancer. Our lament, however, is
that, so many patients come so late. Employing only the
knowledge we now have concerning the diagnosis of
cancer, recognizing at the same time that cancer is es-
sentially a silent disease, just as great strides in the
management of cancer can be made in the next decade
through diagnosis, if we will only implement that knowl-
edge to the best of our ability. The public looks to us
for helpful guidance. Here is an opportunity to lend
real impetus to the management of the cancer problem in
our own generation. The surgery of today makes it pos-
sible for patients having cancer to undergo serious and
difficult operations at low risks. If such patients are to
be offered better chances of permanent cure, earlier diag-
nosis is our only hope.
Dr. James Johnson, Minneapolis: I certainly want
to commend Dr. Mayo for the careful and exhaustive
way in which he has handled this particular subject. It
is interesting to see the mortality rate improvement over
a period of years. This, as has been pointed out, is no
doubt due not so much to the improvement in surgical
technique as to other measures such as the developments
in anesthesia, decompression of the obstructed intestine,
and the control of infections.
Only on two occasions, and they were before the in-
troduction of intestinal decompression, have I employed
the two-stage operation. It is very unsatisfactory in this
locality because of the great loss of fluid. Its purpose
was chiefly to relieve the obstruction. Since this can
now be eliminated by intestinal decompression, and the
general condition of the patient controlled by transfu-
sions and like measures, I see no occasion to do any-
thing but a one-stage operation. I do not believe it mat-
ters much whether an end-to-end, an end-to-side, or side-
to-side anastomosis is done. Personally, I have for
many years used an end-to-end or end-to-side anastomo-
sis by means of a Murphy button. I suppose, my early
training has led me to employ this method.
I would like to ask Dr. Mayo one question. During the
years I have operated upon two inflammatory lesions of
the cecum that I mistook for cancer. They in all re-
spects resembled cancer so I had to play safe and resect
them. I know of no certain way to differentiate them
1200
Minnesota Medicine
MINNESOTA ACADEMY OF MEDICINE
from cancer. I would like to know what Dr. Mayo’s
experience has been with these lesions.
Dr. A. W. Ide, Saint Paul: I have enjoyed hearing
Dr. Mayo’s paper and the discussion. The subject of
surgery of the colon has interested me for a long time.
The results described by Dr. Mayo are certainly grati-
fying.
I am particularly impressed with the great improve-
ment that has been made in recent years in anesthetics.
This, no doubt, is in a considerable measure responsible
for improved results. I am reminded of a remark made
by our old friend, the late Arnold Schwyzer, shortly be-
fore his death. He said that if he could have had mod-
ern anesthetics during his active surgical life he would
have been a much younger man.
Dr. Robert Earl, Saint Paul : I have nothing special
to add. I want to thank Dr. Mayo for his thesis. I
have done a number of these cases with side-to-side
anastomosis. I started with that method, have found it
very satisfactory, so have been following that technique
since.
Dr. Mayo (in closing) : I have appreciated the dis-
cussions. I can only say that I came back from service
in the army and found that the mortality rate in colon
surgery was lower by quite a bit than it was when I
went away. I don’t know where to give the , credit,
whether it was because I had been away, the surgery was
being done better, or it was due to antibiotics. I still
don’t know.
Every surgeon has his pet method and his pet way
of doing things. I do not want to appear to be discredit-
ing any other method ; it is simply that I have adopted
this particular procedure and have had good results, and
I thought they were w'orth bringing to your attention.
One point that I wish to mention here is that there are
many factors, aside from the surgical procedure, which
are helpful in bringing about a good result, and among
them are the expertness with which the anesthetic is
given and the administration of transfusions. Regarding
the latter, if one thinks that a patient does not need a
transfusion, I believe that it is well to give one anyway ;
if one thinks that one is indicated, I think it is well to
give two or three. The use of oxygen postoperatively
also has been a contributing factor in a smooth con-
valescence.
As far as granulomas are concerned, I appreciate that
situation. I have a patient on whom I operated in 1938.
He returned to the clinic in 1946 and I found he had
multiple abscesses. I drained the abscesses and later
resected about three feet of bowel. These cases certain-
ly present a problem. It seems to me that one seldom
is able to find out what the etiology is. I would much
rather resect a right colon for malignancy than for
granuloma.
There is one group of cases in which I believe there
is a chance of error from the standpoint of the nature
of primary lesions. That is in cases in which palliative
ileocolostomy is performed for lesions of the right
portion of the colon. We have found that in a percent-
age of these cases the patients have lived three or five
years, or longer, after the surgical procedure which, it
was thought, had been performed for a malignant lesion.
This is a group in which I am interested at present.
The meeting adjourned.
A. E. Cardle, M.D., Secretary
HEALTH DEPARTMENT SEVENTY-FIVE YEARS OLD
This year the Minnesota Department of Health cele-
brates its seventy-fifth anniversary. The Minnesota
State Board of Health was created March 4, 1872, with
Dr. Charles N. Hewitt of Red Wing as its executive
secretary.
Although Minnesota is comparatively young in state-
hood, it has one of the oldest health departments in
the nation. Only Massachusetts, California, the District
of Columbia, and Virginia were ahead of Minnesota in
establishing boards of health. The District of Colum-
bia is of course not a state, and Virginia’s health de-
partment was set up less than a month before Minne-
sota’s, so it may be said that Minnesota ties for third
place in the creation of a state department of health.
First home', of the Minnesota Department of Health
Keystone Building, Red Wing
The state has another remarkable record in the fact
that during its seventy-five years of existence, it has
had only four health officers, Dr. Hewitt, Dr. Henry
M. Bracken, Dr. Charles E. Smith, and Dr. A. J.
Chesley, the present executive officer. Dr. Chesley has
been state health officer since 1921, a period of more
than a quarter of a century, and has spent his entire
professional life in the health department.
To celebrate the 75th anniversary of the State Depart-
ment of Health and to honor many of its old board
and staff members, the Minnesota Public Health Con-
ference held a banquet at the Radisson Hotel in Minne-
apolis at 6:30 on the evening of Friday, November 14.
November. 1947
1201
MINNESOTA STATE MEDICAL ASSOCIATION
House of Delegates
Summary of Proceedings
Duluth Session — June 29-30, 1947
In accordance with action by the Council of
the Minnesota State Medical Association taken
in 1944, publication of the proceedings of the
House of Delegates is limited to summary.
First Meeting, Sunday, June 29, 1947
Ballroom, Hotel Duluth
Duluth, Minnesota
The Ninety-fourth Annual Session of the House of
Delegates of the Minnesota State Medical Association
convened in the Ballroom of the Hotel Duluth, Duluth,
Minnesota, at 2 p. m., Dr. W. A. Coventry, Duluth,
Speaker of the House of Delegates, presiding.
Dr. Coventry called the meeting to order and asked
for a report from the Credentials Committee. Dr. A.
G. Liedloff, Mankato, reported that a quorum was
present. After approval of the minutes of the pre-
vious session of the House, Dr. Coventry noted the
presence of a distinguished visitor, Dr: George F.
Lull, Secretary and General Manager of the American
Medical Association.
Dr. Lull addressed the assembly briefly, saying that
he was on his way back from a meeting of the Ca-
nadian Medical Association, where he had noted that
the problems facing organized medicine in Canada
are much the same as those facing doctors in the
United States. He also reported on the expanding
activities of the American Medical Association and
mentioned plans for developing regional meetings of
the Council on Medical Service and the Council on
Industrial Health.
Dr. Coventry then called upon Dr. F. J. Elias,
Duluth, for the report of the Chairman of the Council.
Report of the Council
Dr. Elias : The first meeting of the Council in
connection with the Annual Session was held at 2 p.m.,
Saturday, June 28, 1947, for the transaction of routine
business. The Council approved the minutes of the
previous meetings. Financial reports were submitted
and accepted.
The following applications for affiliate membership
accepted and approved : A. E. Booth, Minne-
apolis; J. H. Haines, Stillwater; H. L. Zlatovski,
Duluth; A. H. Brown, Pipestone; J. S. Kilbride,
Worthington ; Allen Sather, Fosston ; and C. M.
Gambill, Rochester. Affiliate membership also approved
for fifteen medical officers, former members' of Hen-
nepin County Medical Society and now taking post-
graduate professional training. Life membership was
granted to the following: C. P. Aling, W. H. Aurand,
I. F. Hendrickson, M. f. Jensen, T. C. Litzenberg,
A. E. MacDonald, H. W. Noth, O. A. Olson, J. R.
Peterson, G. H. Thomas, and J. A. Prim, Minne-
apolis; G. A. Dahl, Mankato; C. L. Scofield, Ben-
son ; Charles Bolsta, Ortonville ; and W. F. C. Heise
and C. P. Robbins, Winona. Associate membership
was granted to K. G. Wakim, Rochester.
Resignation of Richard M. Hewitt as Chairman of
the Editorial Committee was accepted with regret and
C. M. Gambill of Rochester was suggested to replace
him.
The Council went on record as approving the Sick-
ness Benefit Plan under the Railroad Unemployment
Insurance Act. It was recommended that the Chair-
man later give a report to the House of Delegates on
the plan which goes into effect July 1, 1947.
Mr. A. R. Hustad, Twin City Manager of the
Northwestern National Life Insurance Company, pre-
sented a proposal for group life insurance for active
members of the Minnesota State Medical Association.
It was decided that representatives of the company
should appear before the House of Delegates to ex-
plain the plan.
A merger of the Watonwan County Medical Society
with the Redwood-Brown County Medical Society was
approved. Thomas E. Broadie, Saint Paul, was ap-
pointed to the advisory board for registration of hos-
pital superintendents.
The second meeting of the Council took place at
6:30 p. m. Saturday, June 28, with the first order of
business the consideration of a panel of ten psychia-
trists, from which five might be selected to serve as
an advisory committee to the Minnesota Mental Health
Unit in the Division of Social Welfare. The fol-
lowing names were recommended : F. J. Braceland
and M. C. Petersen, Rochester ; S. A. Challman, A.
G. Dumas and D. W. Hastings, Minneapolis; W. P.
Gardner and E. M. Hammes, St. Paul ; G. H. Free-
man, St. Peter ; W. L. Patterson, Fergus Falls ; and
L. R. Gowan, Duluth. A request from the Director
of Social Welfare for approval of the organization
of outpatient clinics in the seven state mental hos-
pitals was granted.
The name of Albert Fritsche, New Ulm, was pre-
sented in answer to a request from the Practical
Nurses’ Association that the Council recommend a
physician to serve on its advisory board.
P. F. Eckman, Duluth, and B. C. Ford, Marshall,
were recommended as candidates for appointment as a
physician representative on the State Board of Ex-
aminers of Nurses, provided for under the act for
the licensure of practical nurses. One will be chosen
from these two.
Acting on a letter from the American Medical
Association, the Council suggested that Dr. Louis A.
Buie, President of the Minnesota State Medical As-
sociation and member of the National Committee on
Physical Fitness, represent the Association at a con-
ference on the co-operation of physicians in the school
health and physical education program to be held
October 16-18 in Chicago and that a member of the
State Office staff also attend.
After considering a request from a sub-committee
of the Committee on Tuberculosis that the Council
approve a proposed bill for the commitment of per-
sons suspected of being in the infectious stage of
tuberculosis, it was generally agreed that the law
as stated needed strengthening and that the matter
should be placed on the Fall Council agenda, at which
time a member of the Committee should be invited
to explain the law in detail.
1202
Minnesota Medicine
SUMMARY OF PROCEEDINGS— HOUSE OF DELEGAIES
The Council approved decisions of the Committee
on Ophthalmology with regard to the establishment
of a fee schedule so as to be eligible for federal
funds under the program of the Division of Social
Welfare services for the blind.-
Action taken by the Board of Directors of the
Hennepin County Medical Society with regard to the
establishment of a Cancer Detection Center at the
University of Minnesota was reviewed. It was de-
cided that Dr. Wells and the Cancer Committee be
invited to appear before the Council on Tuesday
morning to explain the program further.
The third session of the Council was held at 8
a. m. Sunday, June 29, at Hotel Duluth, called for the
purpose of discussing the rural health program. Dr.
Paul C. Leek, Austin, Chairman of the Committee
on Rural Medical Service, presented a proposal orig-
inating from the Second Annual Conference . on
Rural Health, sponsored by the American Medical
Association, for the organization of local health
councils throughout the state on a county, trade area
or councilor district basis.
Permission was granted to Dr. Leek and his Com-
mittee to hold two experimental meetings with allied
health professions to determine what methods should
be used to interest the lay public in an educational
program. One meeting was suggested for the south-
ern part of the state and another for the northern
part of the state. Dr. Leek was asked to report back
to the Council at a future meeting. The councilors
expressed willingness to meet with members of the
Committee on Rural Health and assist in the plan-
ning of these experimental meetings. After, the re-
sults of the two meetings have been determined, the
organization of local health councils throughout the
state could be considered, with an invitation to par-
ticipate extended to all interested lay groups.
* * *
Dr. Elias next summarized the program for sick-
ness benefits for railroad employees under terms of
the Railroad Unemployment Insurance Act, as it was
presented to the Council by members of the Railroad
Retirement Board. (An explanation of the program
will be found in the August, 1947, issue of Minne-
sota Medicine, page 883.)
Speaker Coventry next called upon Dr. R. L. J.
Kennedy, Rochester, for the report of the Finance
Committee.
Report of Finance Committee
Dr. Kennedy : Due entirely to the extremely wise
judgment exercised by the preceding Finance Com-
mittee, the financial status of the Minnesota State
Medical Association has weathered the increase in
costs of mate ials and services and the marked de-
terioration in the investment market with a slight net
increase in its worth. This is extremely gratifying,
and more so when you recall that the Association
undertook additional financial obligations to carry its
members through the war period as well as other
projects that necessitated financial support. Too
much cannot be said for the wisdom and good judg-
ment exercised by the administrative officers in main-
taining the sound economic position of the Association.
The investment portfolio of the Association has con-
tinued to receive close scrutiny by auditors and ad-
visors in finance and the latest evaluation by them on
the position of the Association is favorable. The sys-
tem of checks and balances exercised by the House
of Delegates and the Council has continued to prove
effective.
With the return to active practice of many of our
colleagues, continued steady progress in the affairs of
the Association can be expected.
November. 1947
Two major undertakings financed by the Association
were first, the organization of the prepayment medical
service plan, and of the Veterans Medical Service Divi-
sion The functions of the organization committees
have been completed, as have the details pertaining to
personnel and administrative offices. The work of the
Veterans Medical Service Division has been inaugurated
and the method of repayment of funds borrowed from
the Association has been worked out.
Experience of the past year has emphasized the need
for retaining strong reserve positions in order that the
successive projects undertaken by the Association which
demand financial support will not be jeopardized and,
on the other hand, the assumption of responsibilities
in connection with the furtherance of such projects will
not weaken the financial structure of the Association.
While this may be considered a favorable report in
that it indicates that the Association has been able to
maintain its own even keel, it would be evidence of
extreme shortsightedness were it presented without
reference to present financial trends. Continuation of
the present high market for help and materials will
undoubtedly have an adverse effect upon the finances
of the Association. If, in addition to this, a marked or
even a moderate recession develops, the financial condi-
tion may well be crippled. The Finance Committee
has been cognizant of the trends of affairs and has been
working with its advisers in an effort to fortify itself
against unfavorable developments. Every member
should be cognizant of these facts and should hold
himself ready to support the Finance Committee and
other duly elected officers and to protect them from
conditions beyond their control.
* * *
In connection with a matter referred to in the Chair-
man of the Council’s report, the Delegates next heard a
report from Mr. Arthur Hustad of the Northwestern
National Life Insurance Company in which he outlined
the plan for providing life insurance to active members
of the Minnesota State Medical Association on a group
basis.
Following Mr. Hustad’s report, it was moved and
seconded that Speaker Coventry appoint a committee
of three physicians to work out details of the Life
Insurance Program with the Council and the Executive
Secretary and that the Council be empowered to enact
the program. Motion carried.
It was requested that the Chairman of the Council
re-read the portion of his report dealing with the reso-
lution passed by the Hennepin County Medical Society
on the University Cancer Detection Center, and while
waiting for the resolution to be brought in, the Dele-
gates heard a brief report on the Centennial Session
of the American Medical Association, held in Atlantic
City, by Dr. F. J. Savage, St. Paul, a delegate to the
Session, supplemented by Dr. Coventry, also a delegate.
Dr. Elias then read the letter from the Executive
Secretary of the Hennepin County Medical Society to
Dr. A. E. Cardie, Councilor of the Sixth District, out-
lining action taken by the Society with regard to the
Cancer Detection Center. A general discussion of the
Cancer Detection Center took place. A resolution con-
cerning the approval of activities affecting the practice
of medicine, as applied to the Cancer Detection Centei,
was made and referred to the Resolutions Committee.
It was then moved that the report of the Chairman
of the Council be approved. Seconded and carried.
1203
SUMMARY OF PROCEKDINGS— HOUSE OF DELEGATES
Reports of Reference Committee
The next order of business was the reports of the
various reference committees. The Speaker called first
upon Dr. H. M. Carryer, Rochester, Chairman of the
Reference Committee on Medical Education Reports.
Medical Education Reports
Dr. Carryer: On Sunday, June 29, 1947, there was
a meeting of the Reference Committee of the House of
Delegates on Medical Education Reports. At this time
a number of committee reports were considered and
the contents recommended for approval. These reports
have been sent to each of you for study prior to this
meeting. Those considered were :
Committee on Cancer — A. H. Wells, M.D., Duluth,
Chairman
Committee on Conservation of Hearing — L. R. Boies,
M.D., Minneapolis, Chairman
Committee on First Aid and Red Cross — J. S. Lundy,
M.D., Rochester, Chairman
Heart Committee — F. J. Hirschboeck, M.D., Duluth,
Chairman
Committee on Hospitals and Medical Education — H.
S. Diehl, M.D., Minneapolis, Chairman
Committee on Public Health Nursing — M. McC.
Fischer, Duluth, Chairman
Committee on Syphilis and Social Diseases — P. A.
O’Leary, M.D., Rochester, Chairman
Committee on Tuberculosis — J. A. Myers, M.D., Min-
neapolis, Chairman
Committee on Vaccination and Immunization — E. J.
Huenekens, M.D., Minneapolis, Chairman
Since the report of the Heart Committee was sum-
marized and sent to you there has been an additional
note concerning the report. A Committee consisting
of Drs. C. N. Hensel, Saint Paul, M. J. Shapiro, Min-
neapolis, and F. J. Hirschboeck, Duluth, met with an
executive committee of the American Public Health
Association on June 25, 1947. A motion by that execu-
tive committee was passed indicating approval of a
Minnesota Heart Association.
The report of Dr. Diehl covering the activities of
the University of Minnesota Medical School is particu-
larly called to the attention of every delegate for care-
ful study in an effort to clear up much of the mis-
understanding.
* * *
The Delegates approved the report of the Reference
Committee on Medical Education Reports, after which
Dr. C. G. Sheppard, Hutchinson, Vice Speaker, took
over the Speaker’s chair and called for the report of
Dr. J. F. Briggs, Chairman of the Reference Commit-
tee on Miscellaneous Scientific Reports.
Miscellaneous Scientific Reports
Dr Briggs : The Reference Committee on Miscella-
neous Scientific Reports met Sunday, June 29, 1947,
and considered the following reports :
Committee on Anesthesiology — R. C. Adams, M.D.,
Rochester, Chairman
Committee on Child Health — G. B. Logan, M.D.,
Rochester, Chairman
Committee on Diabetes — J. R. Meade, M.D., St. Paul,
Chairman
Committee on Fractures — V. P. Hauser, M.D., St.
Paul, Chairman
Committee on General Practice — R. H. Creighton,
M.D., Minneapolis, Chairman
Historical Committee — M. C. Piper, M.D., Rochester,
Chairman
Committee on Industrial Health — A. E. Wilcox, M.D.,
Minneapolis, Chairman
Committee on Interprofessional Relations — W. P.
Gardner, M.D., St. Paul, Chairman
Committee on Maternal Health — J. J. Swendson,
M.D., St. Paul, Chairman
Committee on Medical Testimony — E. M. Hammes,
M.D., St. Paul, Chairman
Committee on Military Affairs — R. B. Hullsiek, M.D.,
Minneapolis, Chairman
Committee on Nervous and Mental Diseases — W. P.
Gardner, M.D., St. Paul, Chairman
Committee on Ophthalmology — T. R. Fritsche, M.D.,
New Ulm, Chairman
Committee on Public Health Education — S. H. Bax-
ter, M.D., Minneapolis, Chairman
Radio Committee — R. M. Burns, M.D., St. Paul,
Chairman
Your Reference Committee wishes to commend the
Committee on Medical Testimony for the excellent work
it is doing. Your Committee also noted the activities
that have been carried on by the Committee on Public
Health Education and wishes to make reference to the
Subject-of-the-Month Packets which it feels is an out-
standing activity carried on through the State Associa-
tion offices. The Committee also feels that the radio
programs of the State Association, with Dr. William
A. O’Brien as spokesman, are an excellent medium for
dissemination of medical and health education to the
public.
The Report of the Reference Committee on Miscel-
laneous Scientific Reports was accepted by the Delegates.
Dr. Sheppard called upon Dr. Monte C. Piper, Chair-
man of the Reference Committee on Officers and Coun-
cil Reports.
Officers' and Councilors' Reports
Dr. Piper : Your Committee considered the reports
of the Officers and Councilors very carefully and found
them to be very complete. 1 will take up each report
separately and make a few comments.
As regards the report of the Secretary and Executive
Secretary, your Committee was very much impressed
with the work that has been done in the State Office
during the past year and we noted the comprehensive-
ness of the report submitted. We recognize that the
State Office has been most efficient in attending to the
countless details incident to the development of the As-
sociation as a service organization. You will notice
in their report they say they have held 68 meetings
of committees during the year. That does not include
the nine Council sessions nor the special meeting of the
House of Delegates in December.
We wish to call special attention to the second para-
graph of the Secretary’s and Executive Secretary’s re-
port which enumerates briefly the major activities car-
ried on by the State Office during the year. Particular-
ly impressive is the part plaved by our Association in
the investigation of the Faribault institution since we
feel that such matters are properly the responsibility of
the medical profession. We should like to see such
investigations extended to other state institutions. We,
therefore, heartily recommend the acceptance of this
report.
Next to be considered is the report of the Treasurer,
Dr. W. H. Condit. In recommending the adoption of
this report, we believe the House of Delegates should
extend to Dr. Condit our thanks and appreciation for
his long service as Treasurer and for his efficient man-
agement of this office.
The report submitted by the Chairman of the Council
was most comprehensive and thorough and -we recom-
mend that it be read carefully by every member of the
House of Delegates, since it will acquaint them with the
1204
Minnesota Medicine
SUMMARY OF PROCEEDINGS— HOUSE OF DELEGATES
multitude of activities in which our Association figures.
. . . We recommend that the report be adopted by the
Delegates.
The reports of the Councilors were each carefully
considered also. We are of the opinion that many of
the problems cited are local in nature and should be
' handled by the individual districts. We would ask
special attention be given to Paragraph Three of Dr.
R. L. J. Kennedy’s report for the First District, re-
garding the availability of graduate students to supply
the need for general practitioners.
In Dr. L. Sogge’s report, attention is called to the
Cancer Institutes and the fine work done in this field.
We note also that there is no report from the Third
District by reason of the vacancy created by the death
of Dr. C. M. Johnson of Dawson. We believe that we
express the wish of the House of Delegates in voicing
our deep regret over the loss of Dr. Johnson as a
valued friend and faithful servant of the Association.
Dr. A. E. Sohmer’s report from the Fourth District
is very comprehensive and indicates a great amount of
activity has been going on in that locality. We note
particularly the fact that in the Fourth District several
of the societies within the district have held meetings
jointly during the year, with apparent mutual benefit.
The report of the Fifth District by Dr. E. M. Ham-
mes is brief and to the point, indicating strongly the
good will and spirit of co-operation in that district.
As for the Sixth District, Dr. Cardie mentions par-
ticularly the mobile x-ray project and the blood bank,
which have been so successful.
Dr. W. W. Will’s report of the Seventh District and
Dr. Burnap’s report of the Eighth District are also
indicative of the increasing participation by members
in Association affairs. We take cognizance with regret
of the fact that Dr. W. L. Burnap is requesting that
he be retired at the conclusion of his term in 1948.
An interesting fact worthy of mention from Dr. F. J.
Elias’ report of the Ninth District is that this district
has incurred no loss of membership either through cas-
ualty or transfer during the year.
sfc
The Delegates voted their approval of Dr. Piper’s
report.
Dr J. R. Manley, Duluth, was called upon next for
his report as Chairman of the Reference Committee
on Medical Economics Reports.
Medical Economics Reports
Dr. Manley : The Reference Committee reviewed
the report of the Committee on Medical Economics. Dr.
George Earl, Chairman, submitted a comprehensive re-
port covering his work in Minnesota Medicine and the
work of his sub-committee which will be taken up in
detail later. His remarks regarding the co-operative
health movement in this state are pertinent and should
be studied carefully. The Committee approved his re-
port.
The Committee next reviewed the report of the Edit-
ing and Publishing Committee of which Dr. E. M.
Hammes is Chairman. This is an excellent report and
the Reference Committee calls your attention to the
financial showing in this report since it indicates that
Minnesota Medicine is maintaining a very high stand-
ard.
The Medical Advisory Committee, with Dr. W. H.
Hengstler, Chairman, submitted a short report, stating
there had been two malpractice cases in which they had
given advice. The Committee on Medical Ethics, Dr.
R. H. Mussey, Chairman, reported no breeches of
medical ethics during the past year.
Next came the report of the Committee on Medical
Service, headed by Dr. A. W. Adson. This is the
committee which originated the prepayment plan that
we have been working on now for more than a year.
November. 1947
This report, however, does not take that up in detail
since it is covered in a report to come up for dis-
cussion later. The report mentions the National Health
Bill and the Hill-Burton Hospital Construction Act,
both of great importance to us. The latter should be
kept in mind in the development of medical service,
particularly in the rural areas. This Committee is to
be congratulated for its maintenance of close contact
with national medical affairs.
Your Reference Committee reviewed the report of
the Committee on Public Policy, of which Dr. L.
Sogge is Chairman. This is one of the most important
committees of the Association, and its report merits the
special attention of the Delegates.
To our Committee came the report of Dr. T. H.
Sweetser, Chairman of the Committee on State Health
Relations. This .report deals with state institutions and
particularly with the hospitals for the insane. You
have read, no doubt, in another report that there has
been a bill passed in the legislature to appropriate more
money to pay doctors who are in charge of these hos-
pitals reasonable salaries so that the standard of care
for the mentally ill can be raised.
Our Committee reviewed the report of the Committee
on University Relations, of which Dr. E. J. Simons is
Chairman. This is a complete report dealing with the
question of whether there has been overemphasis on
specialization in our University Medical School. The
contention that the University is trying to develop only
specialists is well refuted. I move the adoption of these
reports as submitted.
^
The motion was seconded and carried.
Dr. Sheppard asked for the report of Dr. M. J.
Anderson, Rochester, Chairman of the Reference Com-
mittee on Miscellaneous Medical Economics Reports.
The following reports were accepted without comment :
Faribault Investigating Committee — T. H. Sweetser,
M.D., Minneapolis, Chairman
Commitee on Licensure of Practical Nurses — W. H.
Valentine, M.D., Tracy, Chairman
Committee on Rural Medical Service — P. C. Leek,
M.D., Austin, Chairman
Minnesota Advisory Committee on Nursing — W. L.
Burnap, M.D., Fergus Falls, Chairman
Speakers’ Bureau — F. J. Heck, M.D., Rochester,
Chairman
Insurance Liaison Committee — A. W. Adson, M.D.,
Rochester, and B'. J. Branton, M.D., Willmar, Co-
Chairmen
In connection with the Report of the Operating Com-
mittee for Veterans Medical Service, considered by the
Reference Committee on Miscellaneous Medical Eco-
nomics Reports, Dr. Sheppard called up Dr. Ralph
H. Creighton, Minneapolis, for a supplementary verbal
report. Following Dr. Creighton’s remarks, Mr. Ray
Davison, Director of the Veterans Medical Service Di-
vision, was called upon to report on some of the
administrative details of the program.
Delegates heard next reports on the Minnesota Plan
for Prepayment Medical Care, Dr. Olof I. Sohlberg,
Saint Paul, President of Minnesota Medical Service, re-
porting on the progress made by that corporation,
and Dr. A. W. Adson, Rochester, Chairman of the
Insurance Liaison Committee, reporting on the work
of the physician-insurance underwriter committees to-
wards setting up a program utilizing the services of
reliable insurance concerns in the state. After full
1205
SUMMARY OF PROCEEDINGS— HOUSE OF DELEGATES
discussion by the Delegates, the report of the Reference
Committee on Miscellaneous Medical Economics Re-
ports was accepted.
Dr. Coventry, having resumed the Speaker’s chair,
called for new business. Dr. T. W. Weum, Minne-
apolis, presented a resolution concerning the need for a
state committee to investigate the various types of
health and accident policies issued to members of the
Minnesota State Medical Association. Following a
reading of the resolution, it was referred to the Coun-
cil.
A resolution, offered by the Hennepin County dele-
gates and relating to Rh typing by the State Depart-
ment of Health laboratories, was read and referred to
the Resolutions Committee.
A resolution calling for the appointment by the
Council or the President of a committee to study
traffic problems in the state was read and referred to
the Council.
The House of Delegates was then recessed until
8 p.m.
Second Meeting, Sunday, June 29, 1947
Ballroom, Hotel Duluth
Duluth, Minnesota
The second session of the House of Delegates was
convened at 8 p,m. with the first item of business a
report on activities of the Division of Social Welfare
by its director, Mr. Jarle Leirfallom. Mr. Leirfallom
was introduced by Dr. Edwin J. Simons, Chief of the
Medical Unit of the Division.
Mr. Leirfallom reported that crippled children’s serv-
ices had been greatly expanded during the year. Ortho-
pedic clinics had been held in various areas of the
state and two counties, Anoka and Washington, had
been added to the rheumatic fever project. Through
family physicians, the Division had given follow-up
care to children stricken with poliomyelitis and two
special physiologists had been employed.
All of these developments, Mr. Leirfallom said, had
the approval of the local medical societies and of the
Council of the Minnesota State Medical Association.
With regard to medical care of indigents, Mr. Leir-
fallom noted the increase in cost of welfare programs.
Factors which he included as contributing to the in-
crease were the upward revision of the topical code
and price schedule; the raising of the old age assist-
ance maximum from $40.00 to $50.00; the no-maximum
program ; and the higher costs of hospitalization, drugs,
etc.
Consideration had been given, Mr. Leirfallom said,
to the practice of requiring prior authorization of elec-
tive surgery.
Mr. Leirfallom also discussed briefly state tubercu-
losis services and the mental health program. In con-
cluding his report, he expressed his appreciation of the
fine co-operation received from the members of the
medical profession, both individually and collectively.
Dr. W. L. Burnap, Fergus Falls, Chairman of a
special committee appointed by the Governor, the Min-
nesota Medichl Advisory Committee on Nursing, then
1206
gave a report on the shortage of nurses which is being-
experienced generally over the state. Dr. Burnap
pointed out that this Committee can be of great serv-
ice as a liaison between the Nursing Board and the
hospitals wishing to establish schools for practical
nurses, or school training registered nurses. A general
discussion followed Dr. Burnap’s report, at the con-
clusion of which Dr. Julian F. Dubois, Sauk Centre,
presented his report as Secretary of the Minnesota
State Board of Medical Examiners.
Speaker Coventry then called upon Dr. Viktor O.
Wilson, Chief of the Section on Special Services of the
State Department of Health, for a report on the Min-
nesota Hospital Survey, the Minnesota Child Health
Survey and a recent project proposed for the Health
Department, that of studying the situation with regard
to nitrate poisoning of certain infants receiving formu-
lae prepared with water from contaminated wells.
Dr. Richard B. Hullsiek, Chief Medical Officer of
the Veterans Administration Regional Office, addressed
the Delegates briefly on the need for medical society co-
operation to insure the successful operation of the
Veterans Medical Care Program, supplementing pre-
vious reports by Dr. Creighton and Mr. Davison.
Dr. Monte C. Piper, Rochester, presented the annual
Necrology Report. The list of names of members and
former members who had passed on during the year
numbered 63, with 11 members having reached the age
of 80 years or more and 26 having reached at least
70. Following the reading of the names the Delegates
rose and observed a moment of silence.
The meeting was recessed until 1 :15 p.m. Monday.
Third Meeting, Monday, June 30, 1947
Ballroom, Hotel Duluth
Duluth, Minnesota
The final session of the House of Delegates was
convened at 1 :15 p.m., Monday, June 30, with Dr.
Coventry presiding. The Credentials Committee report-
ed that a quorum was present and the Delegates pro-
ceeded to the report of the Resolutions Committee,
presented by Dr. E. E. Scott, Saint Paul, Chairman.
The first resolution presented and approved was one
extending the thanks of the House of Delegates to the
officers and members of the St. Louis County Medical
Society; the St. Louis County Woman’s Auxiliary
and its Committee on Local Arrangements ; the man-
agement of Hotel Duluth and other Duluth hotels;
radio stations WEBC and KDAL; the Duluth Herald
and News-Tribune and the Minneapolis Morning Trib-
une.
A second resolution was adopted citing the nineteenth
anniversary of Dr. William A. O'Brien as radio spokes-
man for the Minnesota State Medical Association and
thanking Dr. O’Brien and radio stations WCCO,
KUOM, KROC and KFAM.
A third resolution was passed dealing with the in-
clusion by the State Board of Health of Rh typing
among its laboratory services.
The House of Delegates resolved to extend the thanks
Minnesota Medicine
SUMMARY OF PROCEEDINGS— HOUSE OF DELEGATES
of the Minnesota State Medical Association to all
members of the Committee on Organization for Min-
nesota Medical Service for their loyal and self-sacrific-
ing service in laying the foundations for Minnesota
Medical Service, Incorporated.
The next order of business was the report of the
Chairman of the Council, Dr. Elias. In accordance with
the Licensing Laws and Standards for Hospitals and
Related Institutions, Dr. Elias reported that Drs. B.
O. Mork, Jr., Worthington, and T. J. Catlin, Buffalo,
had been recommended for appointment to the Hospital
Licensing Board.
The Council also had recommended that Drs. E. W.
Hansen, Minneapolis, and F. J. Savage, Saint Paul,
succeed themselves as delegates to the American Medi-
cal Association, and that Drs. George Earl, Saint Paul,
and W. W. Will, Bertha, succeed themselves as alter-
nates.
With regard to the request received from the Hen-
nepin County Medical Society for action on a proposed
cancer detection center at the University of Minnesota,
the Council voted that this be held in abeyance until
the Council had opportunity to meet with the Cancer
Committee.
Dr. Elias read the following resolution, earlier re-
ferred to :
Whereas the increasing death toll resulting from au-
tomobile accidents is a matter of grave concern to all
citizens, particularly the medical profession, and
Whereas this serious situation has been officially
recognized by the President of the United States, gov-
ernors, mayors, law enforcement officials, safety organi-
zations and other groups, and
Whereas the medical profession in Minnesota feels
that it is incumbent on its members to assume leader-
ship in the responsibility for promoting action designed
to reduce this unnecessary loss of life and injury to our
citizens, and
Whereas only by concerted action of all groups
can any appreciable progress be expected in meeting this
urgent problem, now.
(Here Dr. Elias inserted the revision suggested by
the Council.)
Therefore be it resolved that the House of Delegates
of the Minnesota State Medical Association authorize
the Council to appoint three representatives of the
Association to sit with the Minnesota Safety Council,
present the profession’s views and suggestions and to
co-operate with the Safety Council’s efforts to reduce
traffic accidents.
The adoption of the resolution as revised by the
Council was moved, seconded and carried.
It was moved and seconded that a Liaison Commit-
tee from the Council be appointed to confer with the
Governor concerning appointments to the State Board
of Health. Motion carried.
Dr. Elias then read a resolution submitted to the
Council at its morning session :
Whereas the widespread publicity given to the use
of BCG in controlling tuberculosis in humans is lead-
ing to a feeling of security in the public mind, and
Whereas no well controlled study has been made
over an adequate period of time to prove that infec-
tion with BCG produces dependable immunity against
tuberculosis, and
Whereas there is need for further study of special
groups under carefully controlled conditions with suf-
ficient time to make the experiment worth while before
its use is publicly advocated, and
Whereas in the State of Minnesota highly satis-
factory results are being obtained by proved methods,
as shown by the marked reduction in mortality, mor-
bidity and infection attack rates, every effort possible
should be exerted to protect these results, and
Whereas to be infected with BCG sensitizes the tis-
sues and thus nullifies the value of the tuberculin test
which has been used so effectively therefore be it
Resolved, that the Minnesota State Medical Associa-
tion now meeting in its Ninety-fourl^ Session go on
record as opposing the use of BCG in the State of
Minnesota except on special groups under carefully
supervised and controlled study, and only after having
proper consideration by the State Medical Association.
Dr. Elias said that at the Council meeting approval
of that body had been given to this resolution; and
after some discussion, the Delegates also voted approv-
al.
After being introduced to the Delegates by Dr.
Louis A. Buie, Rochester, Mr. Charles H. Crownhart,
Madison, Wisconsin, Secretary of the State Medical
Society of Wisconsin, addressed the House briefly.
Following Mr. Crownhart’s talk, Dr. Sheppard, Vice
Speaker, took over for the annual election of officers.
The following officers were unanimously elected by the
Delegates :
President-elect: Archibald E. Cardie, Minneapolis
First Vice President: J. R. Manley, Duluth
Second Vice President : G. Irving Badeaux, Brainerd
Secretary: Benjamin B. Souster, Saint Paul (re-elected)
Treasurer : W. H. Condit, Minneapolis (re-elected)
Speaker of the House : C. G. Sheppard, Hutchinson
Vice Speaker: H. M. Carryer, Rochester
Councilor, First District: R. L. J. Kennedy, Rochester
(re-elected)
Councilor, Second District: L. L. Sogge, Windom (re-
elected)
Councilor, Third District (to replace C. M. Johnson,
Dawson, deceased) : L. G. Smith, Montevideo
Councilor, Sixth District (to fill the unexpired term
of Dr. Cardie) : O. J. Campbell, Minneapolis
Councilor, Ninth District: Frank J. Elias, Duluth (re-
elected)
Delegates to the American Medical Association : E. W.
Hansen, Minneapolis (re-elected), and F. J. Savage,
Saint Paul (re-elected)
Alternates: W. W. Will, Bertha (re-elected) and George
Earl, Saint Paul (re-elected)
It was then moved, seconded and carried that the in-
vitation of the Hennepin County Medical Society to
hold the 1948 Convention in Minneapolis be accepted.
At 2:45 p.m. the Ninety-fourth Annual Meeting of
the House of Delegates was adjourned.
November. 1947
1207
WOMAN’S AUXILIARY
SPECIAL FEATURES
At the annual banquet of the Minnesota State Medical
Association, held in the Ballroom of Hotel Duluth,
Tuesday evening, July 1, special recognition was given
to several Minnesota physicians.
Admitted to the Fifty Club, in recognition of their
fifty years of loyal and devoted service in the medical
profession, were the following twenty-two doctors :
J. F. Corbett, George B. Hamlin, A. J. H. Hammond
and G. D. Head, Minneapolis; Robert Earl, L. A. Nel-
son and W. R. Ramsey, Saint Paul ; A. H. Brown,
Pipestone; M. A. Burns, Milan; J. E. Crewe, Roches-
ter ; S. A. Drake, Lanesboro ; H. P. Dredge, Sandstone ;
J. F. Gendron, Grand Rapids ; Roland Gilmore, Bemid-
ji; J. H. Haines, Stillwater; G. H. Mesker, Cambridge;
W. L. Palmer, Albert Lea; George F. Reinecke, New
Ulm ; George J. Schottler, Dexter ; J. A. Thabes, Sr.,
Brainerd ; Morrill E. Withrow, International Falls; and
W. E. Wray, Campbell.
The Southern Minnesota Medical Association Medal,
awarded each year to the individual physician presenting
the most outstanding scientific exhibit at the annual
meeting, was awarded this year to Dr. A. H. Wells,
St. Luke’s Hospital, Duluth, for his exhibit on path-
ologic anatomy. Honorable mention was accorded to
another Duluth physician, W. V. Knoll, St. Mary’s
Hospital, for his “watch-glass” display of specimens
and Kodachrome transparencies. Judges were A. E.
Cardie, Minneapolis; R. P. Buckley, Duluth; and R.
N. Barr, Saint Paul.
Presentation of Distinguished Service Medal
to Dr. A. W. Adson
In appreciation of his many years of service to the
profession and to the Association, Dr. Alfred W.
Adson, former president of the Minnesota State Medi-
cal Association and present delegate to the American
Medical Association, was awarded the 1947 Distin-
guished Service Medal and Citation. Presentation was
made by Dr. Frank J. Elias, Chairman of the Council.
Dr. Elias : I deem it a great privilege, as Chairman
of the Council of the Minnesota State Medical Associa-
tion, to honor one of our most active and distinguished
members this evening. I say distinguished because he
has served our Association long and well — as a former
president, as committee chairman and as a delegate to
the American Medical Association.
A prominent neurosurgeon, he is a professor in the
Mayo Foundation graduate school of the University of
Minnesota and chief of the section on neurosurgery of
the Mayo Clinic. He is a fellow in the American
College of Surgeons, as well as a member of several
other societies related to his profession. These include
the American Neurological Association, the American
Surgical Association, the Association of Military Sur-
geons, the Association on Research in Nervous and
Mental Diseases, the Central Neuropsychiatric Associa-
tion, the International Neurological Association, the
Western Surgical Association and the Society of Neuro-
logical Surgeons, of which he is a past president.
His contributions to the advancement of scientific
medicine have been noteworthy, and he has an equally
fine record with regard to his efforts in behalf of or-
ganized medicine. His active participation on councils
of the American Medical Association, particularly his
tireless efforts in promoting the extension of medical
services, not only in Minnesota but in the nation, are
deserving of commendation and encouragement.
And so, at this time, for his devoted and illustrious
service to medicine, the Council of the Minnesota State
Medical Association awards its 1947 distinguished serv-
ice medal to Dr. Alfred W. Adson of Rochester. It
is an honor and a great pleasure to confer upon him at
this time this citation and this medal of which he is so
richly deserving.
WOMAN’S AUXILIARY
Renville County
The regular dinner meeting of the Renville County
Medical Society and Auxiliary was held at Olivia on
October 21, after which each group held separate meet-
ings. Mrs. A. A. Passer, regional advisor for the 4th
Councillor District, was present and suggested that
membership, sale of Hygcia and the Bulletin be par-
ticularly stressed this year and that each member “talk
county nurse.” As an added appeal to students to par-
ticipate in the Christmas Seal Essay Contest, the Auxil-
iary voted to give prizes of $5, $3, and $2 to the three
best essays in the county.
Stearns-Benton
Nine communities were represented when the Stearns-
Benton Auxiliary met on October 23 at the home of
Mrs. H. B. Clark, St. Cloud, with Mrs. J. Buscher as-
sisting. The Auxiliary went on record as favoring ap-
pointment of a public health nurse for both counties.
Members will assist with the mobile x-ray tuberculosis
unit. Chairmen were named for Hygeia and Postwar
Planning Committees. At each meeting articles are re-
ceived for the layette which the Auxiliary is again
sponsoring for needy mothers. Cancer dressings will
be one of the major projects of the Auxiliary this com-
ing year, and women of the communities are invited to
come and help with this urgent and worth-while activ-
ity.
Mrs. Buscher gave a report of the Atlantic City meet-
ing. New members were added, making the membership
this year thirty-seven. An interesting talk on “hosteling
in Europe” was given by Miss Patricia Butler, recently
returned from the Continent.
West Central
West Central Auxiliary mourns the passing of Mrs.
Charles Bolsta of Ortonville who has a long record of
activity in the Auxiliary.
120S
Minnesota Medicine
to the correction of simple constipation
involves the reeducation of the
normal bowel reflexes.
Metamucil embraces the "smoothage"
principle in constipation management.
METAMUCIL
is the highly refined mucilloid of Plantago
ovata (50%), a seed of the psyllium group,
combined with dextrose (50%) as
a dispersing agent.
Metamucil is the registered trademark of
G. D. Searle & Co., Chicago 80, Illinois.
SEARLE
Research in the Service of Medicine
November. 1947
1209
REPORTS AND ANNOUNCEMENTS
r
The Diagnostic >
Family is Growing
A new member has been added to the
ever-growing Ames Diagnostic Family.
The name of the latest arrival is —
Hematest. v
Here are the 3 members of the group
to date:
1. Hematest
Tablet method for rapid detection of oc-
cult blood in feces, urine and other body
fluids. Bottles of 60 tablets supplied with
filter paper.
2. Albutest
( Formerly Albumintest)
Tablet, no heating method for quick quali-
tative detection of albumin. Bottles of
36 and 100.
3. Clinitest
Tablet, no heating method of detection of
urine-sugar.
Laboratory Outfit (No. 2108).
Plastic Pocket-size Set (No. 2106).
Clinitest Reagent Tablets (No. 2101) 12x
100’s for laboratory and hospital use.
All products are ideally adapted to use by
physicians, public health workers and in
large laboratory operations.
Complete information upon request.
Distributed through regular drug
and medical supply channels only.
AMES COMPANY, Inc.
ELKHART, INDIANA
Reports and Announcements
INTERNATIONAL COLLEGE OF SURGEONS
At the twelfth assembly and convocation of the
Linked States Chapter, International College of Sur-
geons, held in Chicago on October 3, the following
Minnesota physicians were among the 810 surgeons in-
ducted into the College :
Fellows: Dr. 'Reinhold Milton Ericson, and Dr. Gerald
M. Koepcke, Minneapolis.
Associates: Dr. Philemon C. Roy, Saint Paul ; Dr.
Kenneth H. Abbott, Rochester; Dr. Philip E. Gordon,
Dr. John Korchik, and Dr. Daniel B. Mark, all of
Minneapolis.
Affiliates: Dr. Gilbert P. Wenzel, Dr. Merchislawr M.
Sarnecki, and Dr. Emil J. Fogelberg, Saint Paul ; Dr.
Lawrence J. Happe, Minneapolis, and Dr. James K.
Keeley, Rochester.
Matriculates: Dr. Samuel Leonard, Minneapolis and
Dr. Selmer Milo Loken, Saint Paul.
GEORGE CHASE CHRISTIAN LECTURE
One of the nation’s outstanding leaders in the war
on cancer, Dr. C. P. Rhoads, New York City, delivered
the University of Minnesota’s annual George Chase
Christian cancer lecture in the Museum of Natural
History auditorium on the evening of October 20.
The subject of Dr. Rhoads’ address was “Clinical
Investigation of Neoplastic Disease.”
In addition to his duties as director of the Memorial
Hospital Center for Cancer and Allied Diseases and
the Sloan-Kettering Institute for Cancer Research, in
New York, Dr. Rhoads is also chairman of the Com-
mittee on Growth of the National Research Council
and is responsible for the distribution of a large
share of the research funds raised by the American
Cancer Society.
At a medical school seminar held earlier in the day
on October 20, Dr. Rhoads spoke on “Butter Yellow
Carcinogenesis and Cancer Biology.”
MINNESOTA SOCIETY OF CLINICAL PATHOLOGISTS
A two-day meeting was held in Rochester on Sep-
tember 27 and 28 by the Minnesota Society of Clinical
Pathologists.
After a morning of visiting the pathological labora-
tories of the Mayo Clinic and St. Mary’s and Colonial
Hospitals, the society members spent the afternoon of
the first day at a seminar in hematology held in the
Mayo Foundation House. On the morning of the
second day a program was conducted in St. Mary’s
Hospital by staff members of the Mayo Clinic. In
charge of the program wTere Dr. P. G. Sayre and Dr.
G. G. Stilwell of Rochester. President of the society is
Dr. A. H. Baggenstoss, Rochester.
1210
Minnesota Medicine
REPORTS AND ANNOUNCEMENTS
ST. LOUIS COUNTY SOCIETY
A joint banquet meeting was held October 9 in
Hibbing by the members of the St. Louis County
Medical Society and its auxiliary.
Principal speaker at the meeting was Dr. O. I. Sohl-
berg, Saint Paul, president of the Minnesota Medical
Service, who spoke on prepaid medical care versus
socialized medicine.
Under the direction of Dr. E. L. Tuohy, society
members from Duluth conducted a clinical-pathological
conference for the scientific program, participated in
by Dr. F. G. Chermak, International Falls, and Dr.
Randall Derifield and Dr. Carl N. Harris, Hibbing.
At the meeting tribute was paid to the late Dr. C. W.
More of Eveleth.
Dr. Robert Murray, Hibbing, secretary of the society,
was in charge of arrangements for the meeting.
WABASHA COUNTY SOCIETY
The seventy-ninth annual meeting of the Wabasha
County Medical Society was held in Wabasha on
October 9.
At a business session in the afternoon, the society
members drafted an appeal to the State Public Health
Service to send into the locality as soon as possible
one of the mobile x-ray units for a chest x-ray sur-
vey. The members also adopted a resolution of ap-
preciation of the efforts of the Lake City Graphic in
pointing out editorially in recent years some of the
dangers of socialized medicine.
New officers elected at the meeting were Dr. R. N.
Bowers, Lake City, president; Dr. T. G. Wellman, Lake
City, vice president, and Dr. W. F. Wilson, Lake City,
secretary-treasurer. It was decided to hold the next
annual meeting at Lake City.
Guest speakers at a dinner preceding the evening
scientific session were Dr. A. J. Chesley, secretary and
executive officer of the State Board of Health, and Dr.
P. T. Watson, director of the Division of Local Health
Services.
The program for the evening scientific session in-
cluded the following:
President’s Address— “Some Experiences with Vitamin
K” — Dr. B. A. Flesche, Lake City.
“Minnesota Medical Service Incorporated” — Dr. E. C.
Bayley, Lake City.
“Ether by the Semi-Open Drop Method - — Dr. Albert
Faulconer, Rochester.
“Report on a Meeting of the Anesthesiology Com-
mittee of the State Medical Association”— Dr. W. P'.
Gjerde, Lake City.
Preventive medicine requires the co-operation of the
patient, and this in turn predicates the existence of a
personal and confidential relationship between the phy-
sician, who serves as health advisor, and the family.
Medicine in the Changing Order, Rep. N. Y. Acad.
Med. Comm., The Commonwealth Fund, 1947.
Surgical Principle
Accomplished
Medically
7)
rainage in the
presence of infection or conges-
tion is a sound surgical principle.
In chronic inflammatory conditions
of the bile passages without stones,
drainage is accomplished by increasing
the production and flow of free-flowing,
low viscosity bile, employing Decholin
for its hydrocholeretic action.
Decholin (dehydrocholic acid) stim-
ulates the production of thin bile by
the liver cells, with a resultant cleans-
ing action on the entire biliary tract.
DzcfaMn
Decholin is supplied in boxes of 25, ji£3
100, 500 and 1000 3H gr. tablets.
AMES COMPANY, Ine.
ELKHART, INDIANA
November. 1947
1211
Of General Interest
♦
After practicing in Brainerd for ten years, Dr. George
J. Halladay recently commenced a three-year fellow-
ship in otolaryngology at the University of Minnesota.
* * *
Appointed as a fellow in the Mayo Foundation, Dr.
L. A. Badheim has moved to Rochester from Tyler,
where he had been conducting his medical practice.
* * *
A medical practitioner in Glencoe since 1935, Dr. H. C.
Goss recently joined the staff of the Glencoe Clinic,
where he is now associated with Dr. A. Neumaier and
Dr. C. W. Truesdale.
* * *
Word has been received that Donald A. Dukelow,
health director of the Community Chest in Minneapolis,
has been elected secretary of the Education Section of
the American Public Health Association.
* * *
Included in the Minnesota physicians who attended
the meeting of the United States Chapter of the In-
ternational College of Surgeons, held in Chicago early in
October, were Dr. Thomas A. Lowe and Dr. R. B.
Tregilgas, South Saint Paul; Dr. O. J. Hagen, Moor-
head, and Dr. Homer H. Hedemark, Ortonville.
In charge of the Chippewa Hospital at Cass Lake for
the past three years, Dr. Philip A. Klieger recently left
for Sacramento, California, to become state director of
the Department of Health.
* * *
Early in October Dr. L. A. Brunsting, Rochester,
attended the triennial medical alumni reunion of the
University of Michigan at Ann Arbor, where he pre-
sented a paper entitled “The Antihistamine Drugs.”
* * *
Dr. M. W. Comfort, Rochester, was in Charlottes-
ville, Virginia, October 3, where he addressed the stu-
dents and faculty of the medical school of the Uni-
versity of Virginia on the subject, “Pancreatitis.”
* * *
At a meeting of the American Academy of Neuro-
surgeons in Colorado Springs, Colorado, early in October,
Dr. H. M. Keith, Rochester, presented a paper entitled
“Tumors of the Brain in Children.”
* * *
Experiences in China with the UNRRA were narrated
by Dr. Selma Mueller, Duluth, who spoke at a meet-
ing of the St. Luke’s Nurses Alumnae Association held
October 6 in St. Luke’s Hospital, Duluth.
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1212
Minnesota Medicine
OF GENERAL INTEREST
Dr. J. Richard Aurelius and Dr. Thomas B. Merner
have opened offices for association in the practice of
diagnostic roentgenology at 1355 Lowry Medical Arts
Building, Saint Paul.
* * *
On October 1, Dr. William C. Dodds left Park Rapids,
where he had been associated with Dr. D. M. Houston
for several months, to accept a partnership with Dr.
A. R. Ellingson of Detroit Lakes.
* * *
One of the speakers at the eighth regional Minnesota
Welfare Conference held October 15 at the state train-
ing school in Red Wing, was Dr. Maurice M. Walch,
assistant professor of neuropsychiatry i n the Mayo
Foundation.
* * *
In Lisbon, Portugal, early in October, Dr. Charles
W. Mayo, Rochester, participated in the program of the
Second International Course on Emergencies by pre-
senting several papers and giving several motion picture
demonstrations.
* * *
At the meeting of the International College of Sur-
geons held in Chicago early in October, Dr. W. C. Mac-
Carty, Rochester, presented a paper entitled “Early
Diagnosis of Abdominal Neoplasms” and took part in a
panel discussion on “Cancer of the Breast.”
* * *
“Aerosol Therapy in Bronchiectasis” was the title
of a paper presented by Dr. A. M. Olsen, Rochester,
at a meeting of the Potomac Chapter of the American
College of Chest Physicians in Washington, D. C.,
October 5.
* * *
When residents of Blue Mounds township met at
District 95 on September 30 to discuss a proposed
addition to the Minnewaska Hospital, Dr. A. F. Giesen
of Starbuck was present as the principal speaker to
explain and clarify problems in regard to the matter.
* * *
Dr. R. O. Johnston, formerly of Nashwauk, has been
engaged by the Board of School District 27 as physician
for the district. Before returning to live near his for-
mer Nashwauk home, Dr. Johnston practiced for fifteen
years in New Jersey and spent four years in the Army.
* * *
Honorary fellowship in the International College of
Surgeons was awarded to Dr. Henry W. Meyerding,
Rochester, at the annual meeting of the organization in
Chicago, October 3. Dr. Meyerding is a member of
the orthopedic surgery staff of the Mayo Clinic and
professor of surgery in the Mayo Foundation.
* * *
The prepaid medical care plan sponsored by Minne-
sota Medical Service, Inc., was explained by Dr. W. A.
Coventry, Duluth, in a talk given at a meeting held
September 30 in the Duluth Central YMCA. The din-
ner meeting was arranged by the Council of Social
Agencies’ Health and Plospital Committee, of which
Dr. Mario Fischer is chairman.
"Chronic Cardiac Disease
rarely develops in the presence
of good body mechanics"*
Goldthwait, et al,* found that even when the
disease had developed, the correction of faul-
ty mechanics helped greatly "in reducing the
peripheral load, in lessening cardiac strain,
and in increasing the patient’s usefulness.”
We invite the physician’s investigation of
Spencer Individual Designing as adjunct to
corrective treatment of body mechanics. A
Spencer automatically induces better posture,
thereby favorably influencing neuromusculo-
skeletal performance.
Each Spencer is specifically designed, cut, and
made for each individual patient — based on
a description of the patient’s body and pos-
ture and detailed measurements. That is why
Spencer Individual Designing is therapeuti-
cally more effective.
For information about Spencer Supports, tele-
phone your local "Spencer corsetiere” or
"Spencer Support Shop”, or send coupon
below.
*Goldthwait, J. E., Brown, L. Y., Swaim, L. T., and
Kuhns, J. G., Body Mechanics in Health and Disease,
103-105, J. B. Lippincott Co., Philadelphia, 1937.
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OF GENERAL INTEREST
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Two papers were presented by Dr. E. E. Gambill,
Rochester, at a meeting of the Panhandle District
Medical Society in Lubbock, Texas, October 14. The
subjects of his papers were “The Investigation and
Treatment of Patients with Jaundice” and “The Recog-
nition and Treatment of Patients with Peptic Ulcer.”
* * *
Among the physicians attending the thirty-third meet-
ing of the Rock Island Lines’ Surgical Association in
Des Moines, Iowa, October 2 and 3, were Dr. J. A.
Sanford, Farmington, and Dr. D. E. Morehead, Owa-
tonna, both members of the railroad’s medical-surgical
staff.
* * *
Announcement has been made that Dr. Adelaide Mc-
Fayden Johnson has been appointed clinical associate
professor in psychiatry and neurology at the University
of Minnesota. Dr. Johnson is the wife of Dr. Victor
Johnson, new director of the Mayo Foundation for
Medical Education and Research.
* * *
On the staff of the Mayo Foundation since 1929,
Dr. ,Oren L. Kirklin has moved from Rochester to In-
dianapolis, Indiana, to enter private medical practice.
A graduate of Indiana University in 1928, Dr. Kirklin
entered the Mayo Foundation as a fellow in 1929 and
was appointed an associate in medicine in 1934.
* * *
Hospital and medical librarians from five states heard
Dr. William A. O’Brien, director of postgraduate
medical education at the University of Minnesota, dis-
cuss “Guideposts for Hospital and Medical Librarians”
when they met with the Regional Library Conference in
Minneapolis on October 6.
* * *
At a meeting in Eveleth on September 23, the mem-
bers of the Range Medical Association heard Dr. John
McKelvey, chief of the Department of Obstetrics and
Gynecology at the University of Minnesota, speak on
modern principles of treatment for preventing obstetric
deaths.
* * *
A new addition to the Bratrud Clinic in Thief River
Falls is Dr. Edward A. Johnson, a graduate of the
University of Minnesota Medical School in 1944, who
recently completed a period of service in the Navy.
Dr. Johnson will be associated with Dr. R. M. Watson
of the clinic staff, specializing in obstetrics and gyne-
cology.
5|C
After jumping his way to victory in September, Dr.
L. A. Steffens of Red Wing was named state “mail”
checkers champion in the annual tournament conducted
by the Minnesota State Checker Association. Champion
at the LTniversity of Minnesota in 1919, Dr. Steffens en-
tered the tournament this year for the first time and
won in a field of twenty entrants.
* * *
Dr. H. M. St. Cyr, a graduate of the University of
Minnesota who recently completed an internship at
St. Luke’s Hospital, Duluth, was married on Sep-
MmUMUUMIIIIIIIIIIIIIII
1214
Minnesota Medicine
OF GENERAL INTEREST
tember 23 to Miss Margaret Christenson, formerly of
Aitkin, in Trinity Lutheran Church in Duluth. Dr.
St. Cyr has been called to active duty in the Army
medical corps and will be stationed in Germany, where
his wife plans to join him.
* * *
At the thirtieth annual meeting of the American
Dietetic Association in Philadelphia on October 16,
Dr. Ancel Keys, director of the University of Minne-
sota’s laboratory of physiological hygiene, spoke on
“Nutrition in Relation to the Genesis and Course of De-
generative Diseases.” The day before the meeting Dr.
Keys conferred with military officials in Washington
on medical research projects.
5{C ^ ijc
Gibbon will again have its own resident physician
after July 1, 1948, when Dr. John Glaeser, Chaska,
completes his tour of duty in the army and moves to
Gibbon to open his medical practice. Dr. Glaeser, a
graduate of the University of Minnesota, recently pur-
chased the residence and practice of Dr. P. C. Benton,
formerly of Gibbon. At present, arrangements are be-
ing made to secure a temporary resident physician
until Dr. Glaeser is released from the army.
5fC 5fC
ing the Milwaukee Railroad from Saint Paul to Mon-
tana. In 1908 he moved to Northfield, where he has
practiced medicine for the last thirty-nine years.
* # *
The September meeting of the medical staff of St.
Luke’s Hospital, Duluth, featured Dr. Walter G. Mad-
dock, professor of surgery, Northwestern University,
who spoke on “Parenteral Fluids for the Seriously 111
Medical or Surgical Patient.” Guest speaker at the
October meeting of the staff was Dr. Miland Knapp,
head of the Department of Physical Medicine, Univer-
sity of Minnesota, who discussed “Rationale of Treat-
ment of the Muscular After Effects of Poliomyelitis.”
* * *
Formerly of Minneapolis, Dr. Norton Rogin has
joined Dr. J. A. Sanford in Farmington in the practice
of medicine. Dr. Rogin has also taken over the Lake-
ville office of Dr. Paul Wagner, who recently moved to
Oregon. A graduate of the LIniversity of Minnesota
Medical School, Dr. Rogin interned at Queens General
Hospital in New York, then served for twenty-five
months in the Army. Before going to Farmington, he
was a resident physician at Abbott Hospital in Minne-
apolis.
* * *
On September 25, Dr. 1. F. Seeley began his fortieth
year of .service as a physician in Northfield.
After graduating in 1903 from the University of Iowa,
Dr. Seeley practiced in several other communities for
short periods of time, then spent two years as physician
to a construction company when the company was build-
Approximately 100 members of the Ramsey County
Medical Society attended a meeting held September 23
in Saint Paul to celebrate the fiftieth anniversary of
the founding of the society library. Guest speaker for
the event was Dr. John F. Fulton, Sterling professor of
physiology at Yale University, who spoke on “Early
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1215
OF GENERAL INTEREST
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hosi home a*uSt office
Years of Andreas Vesalius.” Other speakers included
Miss Perrie Jones, librarian of the Saint Paul Library,
and Dr. Wallace H. Cole, chairman of the Library
Committee.
* * *
After twelve years as chairman of the Blue Earth
County Public Health Association, Dr. A. G. Liedloff,
Mankato, has retired from office. In his honor a
dinner was given on October 9 by association mem-
bers, attended by representatives of the association ex-
ecutive board, county commissioners and public health
nurses.
To replace Dr. Liedloff, Dr. A. F. Kemp, Mankato
city health officer, has been appointed chairman of the
association. Dr. Liedloff still retains his position as
district health officer.
* * *
In Atlantic City on October 6, Dr. J. Arthur Myers,
University of Minnesota Medical School, stated at the
seventh annual meeting of the American Public Health
Association that early detection and not vaccination is
the answer to the problem of tuberculosis. He said that
BCG and other proposed vaccines would “serve only as a
smoke screen for the tubercle bacillus in Minnesota.”
He also told the group that in sizable areas in Minne-
sota tuberculosis had been eradicated at the school-age
level but that total eradication would be “several decades
away.”
* * *
Brownsville, Texas, was the destination of Dr. H. A.
Miller when he left Fairmont on September 29 after
closing his medical practice there. Dr. Miller had pur-
chased a building in Brownsville and planned to open
a clinic with the assistance of his two sons, Dr. Harry
E. Miller and Dr. John B. Miller. Dr. Harry E. Miller
has been taking postgraduate work in surgery in Detroit
for the past six years, while Dr. John B. Miller, an
obstetrician, is at present in military service stationed
in Hawaii. The two sons will join Dr. H. A. Miller
in Brownsville, Texas, early in 1948.
* * *
Of the 26,826 persons x-rayed in Blue Earth County
and North Mankato in a recent survey, 144 showed
definite signs of tuberculosis, it has been announced
by Dr. Hilbert Mark, director of the Tuberculosis
Division of the State Board of Health. Seventy-nine
other persons are suspected of having tuberculosis,
while diagnosis has been deferred in more than 60 other
individuals. About half of the cases of tuberculosis
discovered during the survey required medical or
sanatorium care. The x-ray campaign also revealed 360
persons with enlarged hearts.
:jc % %
In Chicago on September 30, Dr. Stanley F. Maxeiner,
clinical associate professor of surgery at the University
of Minnesota, told the International Congress of Sur-
geons that soft but tough gum-rubber tubing, wrapped
tightly around a severely injured leg, will practically
amputate the extremity without shock, pain or danger.
“If the rubber tubing is allowed to remain for a
week or ten days, it will completely sever the extrem-
ity down to the bone almost painlessly and without any
shock or deleterious general effect,” Dr. Maxeiner said.
“At a later date, when the patient’s condition will per-
mit, the bone may be severed and a hazardous operation
converted into a practically harmless one.”
* * *
Chinese medical practice was described by Dr. L. H.
Klefstadt, of the More Hospital, Eveleth, in a talk
given at the October 1 meeting of the Rotary Club in
Virginia.
“In general, there has been little change in the practice
of medicine in China in the last twenty centuries, al-
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though the better hospitals have excellent obstetricians
and good surgeons,” Dr. Klefstadt told the group.
He said the old Chinese medical men still dry the in-
nards of tigers, grind the tails and teeth, and prescribe
use of the powder to the afflicted.
Dr. Klefstadt served in the Navy from 1943 to 1946,
spending much of that time in the Phillipines, Korea and
China.
* * *
Officially retiring on October 1 as director of the
Mayo Foundation for Medical Education and Research,
Dr. Donald C. Balfour ended ten years of service in
that position. He now is director emeritus and pro-
fessor of surgery emeritus of the Foundation. He
continues to be senior consultant in surgery at the Mayo
Clinic.
First entering the Mayo Clinic as an assistant in
pathology, Dr. Balfour became a clinical assistant in
1908, junior surgeon in 1909, and head of a section in
the division of surgery in 1912. He became associate
director of the Mayo Foundation in 1935 and succeeded
Dr. Louis B. Wilson as director in 1937.
Succeeding Dr. Balfour is Dr. Victor Johnson, former
secretary of the Council on Medical Education and
Hospitals for the AMA, who joined the Foundation
April 1 as associate director.
* * *
Some figures on the number of medical school grad-
uates seeking advanced training were quoted by Dr.
Victor Johnson, Rochester, in a statement made as he
assumed directorship of the Mayo Foundation on
October 1.
“Before the war about 5,200 men were in graduate
medical training schools,” he said. “Today there are
about 12,000 men studying at that level of medical
training.”
In regard to Mayo Foundation facilities, Dr. John-
son stated : “We have many more applicants here than
we can handle at present. This is true partly because
of our commitments to fellows whose training was in-
terrupted by the war, and who were told they could come
back here and complete their work when they were dis-
charged from the service. Right now we have 552
fellows enrolled here for study. Before the war the
maximum was 360, in 1941.”
* *
“Multiple Births of Man” was the topic discussed
by Dr. George W. Corner, director of the Carnegie
Laboratory of Embryology, Baltimore, Maryland, when
he spoke at the University of Minnesota’s Museum of
Natural History on October 16. The lecture was spon-
sored by the Minnesota Human Genetics League and the
Dight Institute for the Promotion of Human Genetics.
Author of many books, Dr. Corner has been on the
faculty of the University of California, Johns Hopkins
Medical School, and the University of Rochester, as
well as a special lecturer at the Royal College of Sur-
geons, London, and at Princeton and Yale Universities.
On October 17 Dr. Corner spoke on “The Nature
and Causes of Prenatal Mortality and Congenital De-
fects” at a meeting principally for medical students.
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Recreational and occupational therapy.
Psychiatrists in Charge
L. R. Gowan, M.D. L. E. Schneider, M.D.
November. 1947
1217
OF GENERAL INTEREST
More than 200 alumni of the Mayo Foundation met in
Rochester October 8, 9 and 10 for the twenty-fourth
annual meeting of the Mayo Foundation Alumni As-
sociation. The meeting was the first since 1941 when
seventy-five alumni gathered to hear scientific lectures
by their colleagues and to renew friendships of fellow-
ship days.
Speakers at the scientific sessions of the three-day
meeting included Doctors R. B. Wilson, W. F. Kvale,
E. J. Kepler, R. G. Sprague, E. H. Rynearson, F. R.
Keating, L. E. Prickman, P. A. O’Leary, D. R. Nichols,
C. H. Slocumb, F. J. Heck and E. D. Bayrd, all mem-
bers of the present Mayo Clinic staff.
“Our Medical Heritage and Its Promise” was the
title of the second Judd- Plummer memorial lecture de-
livered on the evening of October 8 by Dr. Raymond B.
Allen, former fellow of the Mayo Foundation, now
president of the Plniversity of Washington.
President of the association. Dr. W. H. Long, now
of Fargo, North Dakota, delivered his presidential ad-
dress at the opening of the fourth scientific session on
October 9.
ELECTROLYSIS ASSOCIATES
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Betty Rue, R.N. Amy H. Gustafson, R.N.
Graduates of Abbott Hospital School of Nursing,
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During the three-day meeting the Foundation alumni
attended surgical clinics, medical rounds in the hos-
pitals, and demonstrations of current medical research.
* * *
At the meeting of the Minnesota Society of Internal
Medicine held October 20 in Saint Paul, Dr. Daniel
W. Wheeler, Duluth, was elected president, succeeding
Dr. Charles Watson, Rochester, as head of the organi-
zation. Also elected at the society’s annual meeting was
Dr. John A. Lepak, Saint Paul, as vice president, while
Dr. Alexander E. Brown, Rochester, was re-elected sec-
retary-treasurer. The next meeting of the group will
be held in Duluth in the spring of 1948.
* * *
Following his discharge from the army in June, Dr.
Robert J. Brotchner has opened an office at 244 Lowry
Medical Arts Building, Saint Paul, for the practice of
internal medicine. Dr. Brotchner was graduated from
the University of Minnesota Medical School in 1935,
spent two years at Minneapolis General Hospital as an
intern and medical resident, two years at Midway Hos-
pital, Saint Paul, and a year with Dr. E. T. Bell in
pathology at the University of Minnesota. He then
practiced for a short time at Minot, North Dakota,
before enlisting in the army in 1940.
* * *
Dr. Richard J. Plunkett has been appointed associate
editor of the Journal of the AMA. Dr. Plunkett, who
formerly was vice president and director of the Di-
vision of Health and Sanitation of the Institute of
Inter- American Affairs in Washington, D. C., received
his medical degree from Tufts Medical College in 1933
and his master’s degree in public health from Harvard
in 1939.
❖ 4= *
Physicians throughout the nation are being asked to
fu nish medical evidence to substantiate the claims of
railroad workers who may now draw cash sickness
benefits under the Railroad LInemployment Insurance
Act. The Railroad Retirement Board has pointed out
that unless an application is mailed not later than the
seventh day after the first day of sickness claimed, it
may not be received within the legal time limit for
filing applications. As a result, the employe may lose
one or more days’ benefits. Doctors are asked either to
return each completed statement of sickness to the
patient, or mail it promptly to the office of the Board
to which it is addressed.
* *
A four-day laymen’s course in tuberculosis control
opened October 28 at the University of Minnesota Cen-
ter for Continuation Study under auspices of the Uni-
versity and the Minnesota Public Health Association.
Approximately seventy registrants took the course,
which was planned for members of the Minnesota
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Minnesota Medicine
OF GENERAL INTEREST
Public Health Association interested in the control of
tuberculosis. Lectures were held at the Center with
demonstrations at Glen Lake Sanatorium and the Tu-
berculosis Control Division of the Minnesota Depart-
ment of Health on the University campus. Specialists
in various phases of tuberculosis treatment and control
comprised the faculty for the short course.
^ * *
Honoring the memory of the late Dr. Robert G.
Green, former head of the Department of Bacteriology
in the University of Minnesota Medical School, the
Minnesota Cancer Society has presented the University
with a $5,000 grant to support a cancer research fellow-
ship.
The grant was accepted by the Board of Regents of the
University at a meeting on the campus, November 1,
and was assigned to the Minnesota Cancer Society
research fund to support a fellowship in the division
of cancer biology. This research fellowship is held by
Dr. Robert A. Huseby, assistant professor of cancer
biology.
A check for $5,000 covering the memorial grant has
been presented to the University by Dr. William A.
O’Brien, president of the Minnesota Cancer Society,
and Mrs. S. E. Linsley, executive secretary.
Long an outstanding figure in cancer research work
at the University, Dr. Green died September 6, 1947.
HOSPITAL NEWS
Newly elected president of the medical staff of North-
western Hospital, Minneapolis, is Dr. J. C. Miller, who
succeeds Dr. L. Haines Fowler. Dr. Malcolm Hanson
has been elected vice president and Dr. R. S. Ylvisaker
re-elected secretary-treasurer. Named to the Executive
Committee are Dr. R. E. Hultkrans, Dr. William Sad-
ler, Dr. Harold S. Trueman and Dr. William R. Jones,
all of Minneapolis.
* * *
In October, Dr. Viktor O. Wilson, chief of the
Special Services Section in the State Department of
Health, announced that an administrative organization
would be set up by November 1 to direct a $24,000,000
hospital construction program in Minnesota during the
next five years. It was expected that applications for
construction funds would begin after January 1.
The Federal government, through the State Depart-
ment of Health, will grant approximately $8,000,000
for hospital construction in the state, while owners of
the individual hospitals will supply two-thirds of the
construction costs.
* * *
A new 140,000-volt x-ray therapy machine has been
installed at Wesley Hospital in Wadena to increase
the therapeutic service of the hospital. The apparatus
will be used under the supervision of Dr. S. Freifeld,
radiologist at Wesley Hospital and at five other hos-
pitals in the area.
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INSTRUMENTS • TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494 -----
November. 1947
1219
BOOK REVIEWS
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. 'Members, however, are urged to write reviews
of any or every recent book which may be of interest
to physicians.
Headache. Louis G. Moench, M.D. Assistant Clinical
Professor of Medicine, University of Utah
School of Medicine; internist, Salt Lake Clinic, Salt
Lake City. 207 pages. Illus. Price, cloth, $3.50.
Chicago: Year Book Publishers, 1947.
Pharmacology, Therapeutics and Prescription
Writing. For students and practitioners. Fifth
Edition. Walter Arthur Bastedo, Ph.D., Ph.M.
(Hon.), M.D., Sc.D (Hon.) F.A.C.P. Consult-
ing physician, St. I.uke’s Hospital, New York; St.
Vincent’s Hospital, Staten Island, and the Staten Is-
land Hospital; president U.S.P. Convention 1930-40,
member Revision Committee, U.S.P., etc., 840 pages.
Illus. Price, cloth, $8.50. Philadelphia: W. B. Saun-
ders Company, 1947.
Textbook of Clinical Neurology. With an In-
troduction to the History of Neurology. Sixth Edi-
tion. Israel S. Wechsler, M.D. Clinical Professor
of Neurology, Columbia University, New York; neu-
rologist, Mt. Sinai Hospital ; consulting neurologist,
Montefiore Hospital and Rockland State Hospital,
New York. 829 pages. Illus. Price, cloth, $8.50.
Philadelphia : W. B. Saunders Company, 1947.
Gifford’s Textbook of Ophthalmology. Fourth
Edition. Francis H. Adler, M.D. Professor
of Ophthalmology, University of Pennsylvania Medical
School. 512 pages. Illus. Price, cloth, $6.00. Phila-
delphia : W. B. Saunders Company, 1947.
The Oculorotary Muscles. Richard G. Scobee, B.A.,
M.D. Instructor in Ophthalmology, Washington
LTniversity School of Medicine, St. Louis, Missouri.
359 pages. Illus. Price, $8.00, cloth. St. Louis :
C. V. Mosby Co., 1947.
The Years After Fifty. Wingate M. Johnson, M.D.
Professor of Clinical Medicine and Chief of Private
Diagnostic Clinic, Bowman Gray School of Medicine
of Wake Forest College. Foreword by Morris Fish-
bein, M.D., editor of Journal of the American Medical
Association. 153 pages. Price, $2.00, cloth. New York:
Whittlesey House, McGraw-Hill Book Co., 1947.
OBSTETRICAL PRACTICE. Alfred C. Beck, M.D., Professor
of Obstetrics and Gynecology, Long Island College of Medicine,
Brooklyn, N. Y. 4th ed. 966 pages. Illus. Price $7.00.
Balitmore : Williams & Wilkins Co., 1947.
Dr. Beck in this the fourth edition of his textbook
of Obstetrical Practice, has enhanced the value of an
already excellent treatise by adding a chapter on anal-
gesia amnesia and anesthesia. It has been brought
thoroughly up to date, particularly in respect to chemo-
antibiotic therapy.
The drawings are clear and easily understood. In the
handling of controversial questions, he has adopted a
conservative attitude. His chapters on management of
pregnancy and toxicosis of pregnancy are noteworthy
and written in such a way as to create a lasting impres-
sion.
A really up-to-date book that will justify its selection
for a library.
James N. Dunn, M.D.
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Minnesota Medicine
BOOK REVIEWS
SYNOPSIS OF OBSTETRICS. Jennings C. Litzenberg,
M.D.,F.A.C.S., Professor Emeritus of Obstetrics and Gyne-
cology, University of Minnesota Medical School, Minneapolis.
3rd ed. 416 pages. Ulus. St. Louis: C. V. Mosby Company,
1947. Price $5.50.
The Synopsis of Obstetrics is a concise, orderly
resume of an ordinarily detailed and comprehensive
branch of medicine. The ability to be brief and yet
complete in his subject springs from Dr. Litzenberg’s
long and successful teaching career. This review of
obstetrics should prove of considerable help to the stu-
dent of the subject and tq the older practitioner, as
well, who for one reason or another has need for a
quick, comprehensive coverage of the field.
The obstetrical specialty is covered with marked
brevity. This should not be construed as a criticism
of the book, however, for, as the title suggests, it is
meant to be no more than a synopsis. For more com-
plete coverage of the various subjects, one should con-
sult the standard works on obstetrics or the current
literature. A useful addition to the book would have
been a bibliography at the end of each chapter to help
those students desiring to expand their knowledge of the
items skimmed over hurriedly in the text.
Several portions of the book have been rewritten or
additions have been made. The various laboratory
methods used in diagnosis of pregnancy are discussed.
The following subjects have been expanded: the relief
of pain in labor, diabetes in pregnancy, and puerperal
infections, their treatment with the sulfonamides and
antibiotics. A rather complete review of the relationship
of the Rh factor to obstetrics is included in this, the
latest edition of the Synopsis of Obstetrics.
A. F. H.
DISEASES OF CHILDREN’S EYES. James Hamilton Dog-
gart, M.A., M.D. (Cantab), F.R.C.S. (Eng.), London, Eng-
land. 282 pages. Ulus. Price, $10.00. St. Louis: C. V. Mosby
Company, 1947.
The author of this book has covered quite completely
the subject from the embryology and anatomy to the
many conditions encountered in adults’ as well as in
children’s eyes. The individual style in this text is
direct, concise, and very understandable. There are
282 pages of text and 210 illustrations, thirty-two of
which are colored plates. These illustrations have been
freely borrowed from the best British ophthalmic works
and enhance the value of the book. The chapters are
well arranged and, following most chapters, is a short
bibliography of British references.
The text, as the author states, is his personal view
of the subject matter. In these times when texts are
padded volumes of every author’s views, it is refreshing
to find one with the temerity to write his own ideas
in his own fashion and let the reader accept it as the
frank expression of the author’s opinion. While ex-
ceptions will be taken by many, as for example the
chapters on treatment, no two would agree anyway.
As the reader will have to admit, the author has
crammed more ophthalmological information into 282
pages in concise readable form than has been done any
other modern treatise on the subject.
John C. Brown, M.D.
Classified Advertising
FOR SALE — Complete x-ray equipment, also all Victor
electrical treatment equipment. Very reasonable. Time
to pay, if required. Address E-36, care Minnesota
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FOR SALE — Wisconsin Lake Cottage, furnished, an
ideal retreat 80 miles from Twin Cities. Excellent
sand beach, good roads. Dr. R. G. Arveson, Frederic,
Wisconsin.
YOUNG PHYSICIAN desires association with prac-
titioner or group in Minnesota. Particularly interested
in Obstetrics and Pediatrics. Address E-43, care
Minnesota Medicine.
WANTED' — Chemist for special blood work in doctor’s
office. State education, training, experience and salary,
also references. Address E-44, care Minnesota
Medicine.
FOR SALE — At price of equipment, long-established
practice of deceased physician in eastern Minnesota.
No other doctor in community. Address E-45, care
Minnesota Medicine.
FOR SALE — Physician’s practice and up-to-date office
equipment, for immediate disposal. Two-year lease
on downtown office suite. Address Mrs. F. L. Gilles,
2521 Thomas Avenue South, Minneapolis 5, Minnesota.
Telephone KEnwood 0401.
FOR SALE — 24 x 18 American sterilizer in good con-
dition. Will make good terms. Warren Hospital,
Warren, Minnesota.
FOR SALE — Office equipment of deceased physician,
including surgical instruments, medical books, micro-
' scope, cystoscope, et cetera. Will sell individual items
or as a unit. Address Mrs. E. I. Gendron, Grand
Rapids, Minnesota.
WANTED — Resident physicians for state mental hos-
pital. Address Superintendent, State Hospital for the
Insane, Jamestown, North Dakota.
WANTED — Well-established small clinic in North Da-
kota wants recent graduate to do general practice.
Possibility of early partnership to right man. Address
E-46, care Minnesota Medicine.
LOCATION FOR PHYSICIAN— At Isanti, Minnesota,
40 miles north of Minneapolis on Highway No. 65.
Large territory, good farming community. Exceptional
opportunity for right man. Complete, new medical
equipment available. Telephone 21-J, or write S. G.
Johnson, D.D.S., Isanti, Minnesota.
FOR RJLNT- Desirable office space for physician. Lo-
cated above drug store in heavily populated Midway
district. No other physician in vicinity. Apply
Charles Davis, 1336 Grand Avenue, Saint Paul 5,
Minnesota. Telephone EMerson 9531.
November. 1947
1221
is a proud profession
. . . and rightfully so. For next to the doctor in service rendered stands
the present-day nurse. Into her hands is entrusted the care of the sick,
and often the success of the doctor’s work depends directly upon her skill.
GLENWOOD HILLS HOSPITAL— through its
School of Nursing — is anxious to cooperate with you
in your effort to increase the number of nurses in your
community. A student from your locality will result
in increased nursing assistance to you in the near
future.
Your help is greatly needed in recruiting candidates
for this profession. A one-year course in psychiatric
nursing is currently being offered to eligible appli-
cants. Tuition is free. Regular classes begin in Jan-
uary, June and September.
TEACHING STAFF
Margaret Chase, R.N., B.S Director
Josephine Westerdahl, R.N., B.S Assistant Director
Julius Johnson, M.D Case Study
Robert Meller, M.D Psychiatry
C. O. Erickson, M.D Psychiatry
Donald Reader, M.D Neurology
N. J. Berkwitz, M.D Psychiatry, Neurology
Grace, Johnson, O.T.R
Occupational & Recreational Therapy
Marian Tucker, B.S., M.T. (ascp) Bacteriology
Louise Neilon, B.A Psychology
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SCHOOL OF PSYCHIATRIC NURSING
Candidates for the January class should make reservations at once.
School and health records must be reviewed prior to acceptance.
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Miss Margaret Chase, R.N. B.S.
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3501 Golden Valley Road : Route Seven : Minneapolis, Minn.
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Minnesota Medicine
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SHOULD VITAMIN D BE
GIVEN ONLY TO INFANTS?
ITAMIN D has been so successful in preventing rickets during in-
fancy that there has been little emphasis on continuing its use after
the second year.
But now a careful histologic study has been made which reveals
a startlingly high incidence of rickets in children 2 to 14 years old.
Follis, Jackson, Eliot, and Park* report that postmortem examina-
tion of 230 children of this age group showed the total prevalence
of rickets to be 46.5 % .
Rachitic changes were present as late as the fourteenth year, and
the incidence was higher among children dying from acute disease
than in those dying of chronic disease.
The authors conclude, “We doubt if slight degrees of rickets,
such as we found in many of our children, interfere with health
and development, but our studies as a whole afford reason to pro-
long administration of vitamin D to the age limit of our study, the
fourteenth year, and especially indicate the necessity to suspect and
to take the necessary measures to guard against rickets in sick
children.”
*R. H. Follis, D. Jackson, M. M. Eliot, and E. A. Park: Prevalence of rickets in children
between two and fourteen years of age. Am. J. Dis. Child. 66:1-11, July 1943.
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MEAD'S Oleum Percomorphum furnishes 60,000 vitamin A units and
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bottles of 50 and 250 capsules. Ethically marketed.
MEAD JOHNSON & COMPANY, Evansville 21, Ind., U.S.A.
1224
Minnesota Medicine
Every epileptic seizu.e takes its toll— psychically and somatically.
Mental deterioration, extreme emotional instability and physical
decline are generally the ultimate fate of the untreated.
DILANTIN SODIUM KAPSEALS, by effective anti-convulsant
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DILANTIN SODIUM KAPSEALS are one of a long line of Parke-Davis
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1226
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30
December, 1947
No. 12
Contents
The Fenestration Operation for Otosclerosis.
George E. Sliambaugh, Jr., M.D., Chicago,
Illinois 1249
Follow-up of Abnormal Pulmonary Findings
Observed in Mass Chest X-Ray Surveys.
Hilbert Mark, M.D., Minneapolis, Minne-
sota 1251
Acute Perforated Gastric and Duodenal Ulcer.
Donald C. MacKinnon, M.D., F.A.C.S., Minne-
apolis, Minnesota 1253
Streptomycin : Its Present Uses.
Donald R. Nichols, M.D., Rochester, Minnesota .. 1263
Cardiac Findings Due to Sternal Depression.
Allan E. Moe, M.D., Moorhead, Minnesota 1265
History of Medicine in Minnesota :
Notes on the History of Medicine in Fillmore
County Prior to 1900. ( Continued from Nozrem-
ber issue.)
Nora H. Guthtey, Rochester, Minnesota 1268
President’s Letter : 1274
Editorial :
Streptomycin and Tuberculosis 1276
Shortage of Nurses 1276
Minnesota Medical Service 1277
More CARE 1277
William A. O’Brien 1278
A Memorial to Doctor O’Brien 1278
Editorial Department :
William A. O’Brien — A Tribute 1279
Comparative Costs of Medical Care 1280
Medical Economics :
Prepayment Medical Care Termed “Jig-Saw
Puzzle” 1281
Mower County to Organize State’s First Health
Council 1283
Minnesota State Board of Medical Examiners. .. 1283
Minneapolis Surgical Society :
Meeting of May 1, 1947 1284
Alimentary Diverticula.
Horace G. Scott, M.D., F.A.C.S., Minneapolis,
Minnesota 1284
Constrictive Fibrino-Pleurisy.
N. K. Jensen, M.D., Minneapolis, Minnesota. .. 1293
In Memoriam 1302
Reports and Announcements 1308
Woman’s Auxiliary 1311
Of General Interest 1312
Index to Volume 30 1325
Contents of Minnesota Medicine copyrighted by Minnesota State Medical Association, 1947.
Entered at the Post Office in Minneapolis as second class mail matter. Accepted for mailing at the special rate of postage provided
for in Section 1103, Act of October 3, 1917, authorized July 13, 1918.
December, 1947
1227
MINNESOTA MEDICINE
Official Journal of the Minnesota State Medical Association
Published by the Association under the direction of its Editing and Publishing Committee
Office of Minnesota State Medical Association,
493 Lowry Medical Arts Bldg., Saint Paul 2, Minnesota.
EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, Saint Paul
Philip F. Donohue, Saint Paul
H. W. Meyerding, Rochester
H. A. Roust, Montevideo
B. O. Mork, Jr., Worthington
A. H. Wells, Duluth
O. W. Rowe, Duluth
T. A. Peppard, Minneapolis
Henry L. Ulrich, Minneapolis
C. L. Oppegaard, Crookston
EDITORIAL STAFF
Carl B. Drake, Saint Paul, Editor
George Earl, Saint Paul, Associate Editor
Henry L. Ulrich, Minneapolis, Associate Editor
BUSINESS MANAGER
J. R. Bruce
Annual Subscription — -$3.00. Single Copies — $0.40. Foreign and Canadian Subscriptions — $3.50.
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company order.
Display advertising rates on request.
Address all communications concerning the journal to Minnesota Medicine, 2642 University
Avenue, Saint Paul 4, Minnesota. Telephone Nestor 2641.
ST. CROIXDALE ON LAKE ST. CROIX
PRESCOTT, WISCONSIN
MAIN BUILDING— ONE OF THE 8 UNITS IN “COTTAGE PLAN”
A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous and Mental Disorders
Located on beautiful Lake St. Croix, eighteen miles from the Twin Cities, it has the advantages of both
City and Country. Every facility for treatment provided, including recreational activities and occupational
therapy under trained personnel. Close personal supervision given patients, and modern methods of
therapy employed. Inspection and cooperation by reputable physicians invited. Rates very reasonable.
Illustrated folder on request.
NEUROPSYCHIATRISTS
PRESCOTT OFFICE
Prescott, Wis.
Howard J. Laney, M.D.
Tel. 39 and Res. 76
Hewitt B. Hannah, M.D.
Joel C. Hultkrans, M.D.
Howard J. Laney, M.D.
511 Medical Arts Building
Minneapolis. Minnesota
Tel. MAin 1357
SUPERINTENDENT
Dorothy M. Most, R.N.
Prescott, Wisconsin
Tel. 69
1228
Minnesota Medicine
Fully guaranteed against defects of
material and workmanship. Deal-
erships being established. Order
direct for prompt delivery.
$995
Size 2"x2"
Plus Tax of 30c
TERADO COMPANY
Manufacturers of Precision Equipment
1068 RAYMOND AVE. • ST. PAUL 8, MINNESOTA
KAR-SHAVE CONVERTS 6 volt:
D.C. (car or boat battery) to 1 1C
volts at 15 watts. Neat and compact, onl\
2 x2"x3j/2" in size. Habitually carried ir
the glove compartment in the dash. Idea!
for use also in the boat, trailer, or in the
car while at the lake cottage where line
current is not available. Kar-Shave is buill
to last a lifetime. It makes any razor work
better.
JCa/L-Shcwje,
makes it
to be
Clean-Shaved
on every call
and occasion,
day and night
A Revelation in Convenience & Time Economy
Kar-Shave is new! It is
Here! It fills a long-felt
need. Wonder is it wasn’t
developed a long time
ago. Physicians and Sur-
geons especially find it
the only answer to a daily
problem. Immediate de-
liveries are being made.
THINK back in your own experience, of the occasions when
Kar-Shave would have been “worth its weight in gold” . . .
Regular calls, full waiting rooms, and emergencies leave no time to
maintain personal appearance, especially to shave. No time at the
office, no time to wait in a shop, no time to rush home. Kar-Shave
is the only answer. On the way to a patient, to a meeting, or a din-
ner, drive up to and stop at the curb. Plug Kar-Shave into the cigar
lighter on the dash of your car. Plug your razor into Kar-Shave.
In a few moments the job is done, neat, smooth, clean.
December, 1947
1229
Immediate and substantial improvement in the great majority of cases— that is the en-
couraging prospect offered by Tridione to thousands of children suffering from petit
trial. Tridione has achieved an outstanding clinical record in this field. In one study,
for example, Tridione was given to 166 patients suffering from petit trial (pyknoepi-
lepsy), myoclonic jerks or akinetic seizures.1 This group had received only mediocre
benefits from the use of other medicaments. With Tridione 83% were definitely im-
proved. Thirty-one percent became free of seizures; 32% had less than one-fourth
of the previous number; 20% improved to a lesser extent; 13% were unchanged;
and only 4% became worse. Furthermore, in some cases the seizures did not return
when Tridione was withdrawn. • Clinical investigations have also shown that
Tridione is beneficial in certain psychomotor cases when combined with other
antiepileptic therapy.2 You may obtain Tridione in 0.3-Gm. capsules and
in pleasant-tasting aqueous solution containing 0.15 Cm. per fluidrachm.
Wish literature?. I ustdropa line to Abbott Laboratories, North Chicago, 111.
1. Lennox, W. G. (1947), Tridione in the Treatment
of Epilepsy, J. Amer. Med. Assn., 134:138, May
10. 2. Dejong, R. N. (1946), Further Observations
on the Use of Tridione in the Control of Psycho-
iwutor Attacks, Am. J. Psychiat., 103:162, Sept.
rfi • ®
Tridione
(Trimethadione, Abbott)
1230
Minnesota Medicine
Formulae—
a modern
infant food
i
Formulac Infant Food is a concentrated milk in liquid form, for-
tified with all vitamins known to be necessary to adequate infant
nutrition. No supplementary vitamin administration is required.
By incorporating the vitamins into the milk itself, the risk of
human error or oversight is reduced. Formulac contains sufficient
B complex, Vitamin C in stabilized form, Vitamin D (800 U.S.P.
units), copper, manganese and easily assimilated ferric lactate —
rendering it a flexible formula basis both for normal and difficult
feeding cases. The only carbohydrate in Formulac is the natural
lactose found in cow’s milk. No carbohydrate has been added.
Formulac, a product of National Dairy research, has been
tested clinically, and proved satisfactory. It is promoted to the
medical profession alone. Formulac is on sale at grocery and drug
stores nationally.
Distributed by KRAFT FOODS COMPANY
NATIONAL DAIRY PRODUCTS COMPANY, INC.
NEW YORK, N.Y.
• For further information about
FORMULAC, and for professional
samples, mail a card to National
Dairy Products Company, Inc., 230
Park Avenue, New York 17, N. Y.
December, 1947
1231
Swift’s Strained Meats
specially prepared-
fine enough for tube-feeding
All nutritional statements made in this ad-
vertisement are accepted hy the Council on
Foods and Nutrition of the American Med-
ical Association.
Swift’s Diced Meats
For patients on a soft, high-protein,
low-residue diet who can eat meat in
a form less fine than Strained, Swift’s
Diced Meats offer an excellent, appe-
tizing source of proteins, B vitamins
and minerals. Swift’s Diced Meats are
tender, juicy cubes of meat — offer a
variety of: beef, lamb, pork, veal,
liver and heart, five ounces per tin.
Here’s protein-rich meat that patients on soft, smooth
diets can eat and enjoy! Swift’s specially prepared Strained
Meats provide an excellent base for a high-protein, low-
residue diet — in a form that is chemically and physically
non-irritating. There are six different, highly palatable
meats: beef, lamb, pork, veal, liver and heart. These
wholesome meats are readily accepted by most patients,
even when normal appetite is impaired.
Swift'S Strained Meats were developed originally for
feeding to young infants. The individual particles of
meat are fine enough to pass through the nipple of a
nursing bottle — may easily be used in tube-feeding.
Swift's Strained Meats are prepared with expert care from
selected, lean U. S. Government Inspected Meats, care-
fully trimmed to reduce fat content to a minimum, and
cooked to retain a maximum of the valuable meat nu-
trients— biologically complete proteins, B vitamins and
minerals. Swift's Strained Meats are convenient to use —
come ready to heat and serve. Each vacuum-sealed tin
contains three and one-half ounces of strained meat.
If you wish samples of Swift’s Strained
and Swift’s Diced Meats together with
complete information, write: Swift &
Company, Dept. B.F., Chicago 9, III.
fteres
rm
o/i soft, s/nooi
1232
Minnesota Medicine
UKI9UVJL IN PROPYLENE GLYCOL
MILK DIFFUSIBLE VITAMIN D PREPARATION
ODORLESS • TASTELESS • ECONOMICAL
from the third week of life
to adolescence ...
The simplicity and conven-
ience of using milk diffusible
Drisdol in Propylene Glycol facil-
itate patient cooperation from
early infancy to adolescence.
An average daily dose of
2 drops in milk for infants and
from 4 to 6 drops for children
provides effective low-cost
vitamin D protection throughout
the critical years of growth and
development.
Available in bottles of 5, 10
and50cc. with special dropper de-
livering 250 U.S.P. units per drop.
WINTHROP STEARNS
DRISDOL, trademark reg.
U. S. Pat. Off. & Canada,
brand of crystalline vitamin Dz
(calciferol) from ergosterol
INC.
New York 13, N. Y. Windsor, Ont.
The businesses formerly conducted by Winthrop Chemical Company, Inc.
and Frederick Stearns & Company are now owned by Winthrop-Stearns Inc.
1947
1233
"What are the
MAGIC WORDS?”
No magic words, no magic wand can improve a cigarette.
Something more tangible is needed.
PHILIP Morris superiority is due to a different method
of manufacture, which produces a cigarette proved * definitely
less irritating to the smoker’s nose and throat.
Perhaps you prefer to make your own test. Many doctors
do. There is no better way to prove to your own satisfac-
tion the superiority of PHILIP MORRIS.
* Laryngoscope, Feb. 1935, Vol. XLV . No. 2. 149134
Laryngoscope. Jan. 193 7, Vol. XLVII, No. I, 58-60
Philip morris
Philip morris 8c co., ltd., Inc.
119 Fifth Avenue, N. Y.
TO PHYSICIANS WHO SMOKE A PIPE: We suggest an unusually fine new blend— COUNTRY DOCTOR
PIPE MIXTURE. Made by the same process as used in the manufacture of Philip Morris Cigarettes.
1234
Minnesota Medicine
Oral Effectiveness
and High Potency
ADD.. .a “plus
An increasing number of investigators are commenting on the general "sense of well-being”
which is usually experienced by menopausal patients following "Premarin” administration. This
is a "plus” in therapy which is most gratifying to the woman crossing the threshold of the climacteric.
"Premarin" is supplied as follows:
Tablets of 2.5 mg bottles of 20 and 100
Tablets of 1.25 mg bottles of 20, 100 and 1000
Tablets of 0.625 mg bottles of 100 and 1000
Liquid, containing 0.625 mg. in each 4 cc. (1 teaspoonful) . . . bottles of 120 cc.
While sodium estrone sulfate is the principal estrogen in "Premarin/' other equine estrogens
. . . estradiol, equilin, equilenin, hippulin . . . are also present in varying small amounts, probably as
water-soluble sulfates. The water solubility of conjugated estrogens lequine) permits rapid
absorption from the gastrointestinal tract.
CONJUGATED ESTROGENS
(equine)
AYE R ST, McKENNa & HARRISON Limited
22 EAST 40TH STREET, NEW YORK 16, N. Y.
123
“Premarin”
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1236
Minnesota Medicine
Leading home economists have called
Rexair, "The greatest advance in home
cleaning methods in more than thirty
years."
There is a reason for this enthusiasm.
That reason is Rexair's entirely new
cleaning principle.
To begin with, Rexair uses neither a
bag nor a filter. Bags and filters depend
for their operation on porousness. They
must be porous to let the air escape;
and when air escapes, small particles
of dust escape with it. You take dust
from the floor and actually blow it
into the air you breathe.
Bags and filters also clog up, and then
cleaning efficiency drops.
Rexair completely does away with
bags, filters, screens, or anything else
that depends on porousness for its
operation. Instead Rexair — and only
Rexair — uses a bath of pure water to
catch and hold dust and dirt.
The complete story of Rexair,
told in colorful pictures and
text. Shows how Rexair per-
forms all home cleaning tasks
and gives vitalizing freshness
to the air you breathe.
REXAIR DIVISION, MARTIN-PARRY CORP..
Box 964, Toledo, Ohio, Dept. L-12
Send me copies of your free booklet, "Rexair—
The Modern Home Appliance Designed to Hospital
Standards," for my own use and for my patients.
SEND FOR THIS FREE BOOK
Wet dust cannot fly. A water bath
cannot clog up. Learn more about
Rexair today!
NAME
ADDRESS
December, 1947
1237
WHEN SAFE MEDICAL CARE
depends oh gie^U^aitan...
Every office and clinic needs a certain
type of sterilizer to meet a particular sterili-
zation problem. You will find the answer in
the complete line of Castle Sterilizers. We
will be glad to discuss your requirements
with you . . . and help you select the most
scientifically correct for the required service.
C407
Syringe
Sterilizer
CAST - IN - BRONZE
smooth tinned inte-
rior, with chrome ex-
terior. 7 Yu" long x 3" wide, large enough
for 50 cc. syringes and small instruments.
Boils in 5 minutes. Automatic low water cut-
off.
Castle "95'
Smart, functional design. Baked porce-
lain top with extra working area, recessed
sterilizer (16"x6"4") with chrome finish,
CAST IN BRONZE leakproof boiler,
footlift with oil check, double “Full-Auto-
matic” control, roomy storage cabinet.
(Illustration shows No. 95G with glass
door.)
C416 Standard Instrument
Sterilizer
CAST IN BRONZE leakproof boiler, double;
“Full-Automatic” control. Smooth tinned interior,
16"x6"x4", chrome exterior. Tray lifts with cover.
Draw-off faucet. Heat resistant Bakelite feet and
handle.
V— —
Send for your copy of our Castle Sterilizer Catalog MM-1247
Distributed by
PHYSICIANS AND HOSPITALS SUPPLY CO., Inc.
MINNEAPOLIS MINNESOTA
1238
Minnesota Medicine
THE SMITH-DORSEY CO
Lincoln, Nebraska
BRANCHES AT LOS ANGELES A
December, 1947
TRADEMARK REO. U.5. PAT. OFT.
URGinni JELLV
• Immobilizes sperm in the
fastest time recognized
under the Brown and Gam-
ble measurement technique;
• Does not liquefy at body
temperature nor separate on
standing . . . not unduly
lubricating;
# Maintains an occlusive film
over the cervix uteri for as
long as 10 hours after coitus
as confirmed by direct-color
photography;
# Nonirritating and nontoxic,
therefore suitable for con-
tinuous use.
For the optimum protection which can be furnished by a
vaginal jelly — "RAMSES"* Vaginal Jelly can be specified
with the confidence that no better product is available.
Active ingredients: Dodecaethyleneglycol Monolaurate 5%;
Boric Acid 1%; Alcohol 5%.
JULIUS SCHMID, INC., 423 W. 55th St., New York 19, N. Y.
1240
Minnesota Medicine
which attends the shrinkage of swollen turbi-
nates, the re-establishment of the patency of
the upper respiratory airway and the opening
of blocked ostia of accessory nasal sinuses with
the resulting promotion of drainage.”"'
Neo - Syn ephri n e
B X A N P Of X H £ X £ X H X / X £
HYDROCHLORIDE
FOR LOCAL VASOCONSTRICTION
PROVIDES rapid, enduring nasal decongestion with minimal compensatory vaso-
dilatation . . . relative freedom from systemic side effects or local irritation . . . mildly
acid pH, approximating the normal acidity of nasal mucous membranes.
INDICATED for prompt, prolonged relief of the nasal symptoms of acute coryza,
allergic and vasomotor rhinitis, acute and chronic sinusitis, etc.
ADMINISTERED by dropper, spray or tampon, using V4 per cent solution in most
cases, 1 per cent when a stronger solution is required, Vz per cent jelly for through-
the-day convenience.
SUPPLIED as 54 per cent and 1 per cent in isotonic saline solutions, XA per cent in
isotonic solution of three chlorides (Ringer's) with aromatics, bottles of 1 fl. oz.; Vz
per cent in water-soluble jelly, applicator tubes of Vs oz.
Trial Supply Upon Request
The businesses formerly conducted by Winthrop
Chemical Company, Inc. and Frederick Stearns &
Company are now owned by Winthrop-Stearns Inc.
♦ Goodman, L., and Gilman, A.: The Pharmacological Basis of Therapeutics, New York, The Macmillan Company, 1941, p. 433.
Neo-Synephrine, Trade-Mark Reg. U. S. Pat. Off.
December, 1947
1241
"SIMPLICITY
WITH
ACCURACY”
IS ASSURED
WITH
Immediate Delivery!
JONES WATERLESS MOTOR BASAL METABOLAR
»->- # Operative simplicity# accuracy checked
by protractor
^))) y % Alcohol checked to 99% accuracy
# Motor blower for easy breathing
))))) y # Economical — 7 cents per test
0 Automatic slide rule calculator, no com-
putation or mathematical errors
$>» V # Protractor eliminates technical errors
Write for free descriptive booklet
C F. ANDERSON CO., Inc.
Surgical and Hospital Equipment
901 MARQUETTE AVENUE MINNEAPOLIS 2. MINN.
ONLY JONES
HAS THESE
EXCLUSIVE
FEATURES
1242
Minnesota Medicine
Yes! And experience is the best teacher in smoking , too!
ft. J. Reynolds Tobacco Co.
Winston-Salem, N. C.
t/ian any ot/ier cigarette
Three nationally known independent research organizations asked
113,597 doctors — in every branch of medicine — to name the ciga-
rette they smoked. More doctors named Camel than any other brand.
DURING the wartime cigarette
shortage, people smoked— and
compared — many different brands
. . . any brand they could get. That’s
when so many people learned the
big differences in cigarette quality.
And, out of that experience, more
and more smokers found that
Camels suit them best. As a result,
more people are smoking
Camels than ever before!
Try Camels! Let your “T-Zone”—
your taste and throat— tell you why,
with millions who have tried and
compared, Camels are the “choice
of experience.”
siccorc/tng to a Afatiomv/cfe suroey.
More Doctors
smoke Camels
December, 1947
1243
Medicine and Dentistry, before Harvey
(1578-1657), knew little about organic func-
tion. But, after discovery of valves in the veins
by Fabricus, his teacher at Padua, Harvey was
ready for his great work.
He saw blood spurt from a snake’s artery
nicked above a ligature. When he nicked its
main artery below a ligature, he saw no spurt
of blood; and its heart swelled to bursting.
He found only 4 pounds of blood in a sheep’s
body, but its heart was pumping out 3.5
pounds in an hour. It must return to the
heart! It must make a circuit! Now a doctor
could really understand the spread of infection
and the function of major organs, and per-
form more intelligent surgery.
A doctor’s responsibility was growing as
fast as his knowledge. By 1553, he was liable
for negligence, even without breach of con-
tract. Tort law was on the way, with its
newer doctrines of the doctor’s liability.
★ ★ ★
Doctors Today avoid loss of reputation,
time and money by securing the Medical
Protective policy’s complete protection, pre-
ventive counsel and confidential service.
Professional Protection exclusively. . .since 1899
MINNEAPOLIS Office: Stanley J. Werner, Representative, 816 Medical Arts Building, Telephone Atlantic 5724
1244
Minnesota Medicine
When confusing abdominal symptoms and signs create a
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PRIODAX
PRIODAX is rarely eliminated prematurely from the
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PRIODAX Tablets, beta-(4-hydroxy-3,5-diiodophenyl)-alpha-phenyl-
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Trade-Mark PRIODAX— Reg. U. S. Pat. Off.
In Canada, Sphering Corporation Limited, Montreal
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1246
Minnesota Medicine
/
“See Your Doctor”
A Continuing educational campaign
should know i*oul
Some things you
about yOW
;hou\d know so
things you
,i.u' '-c 1
ta&>i 1 "" '
,u\W»r U"
,»l M'"'"'
in behalf of the medical profession
208 full-page advertisements have appeared to date.
All stressing the importance of prompt and proper medical
care. All urging the public to "See Your Doctor.”
reaching 23 million people regularly
Alert people. The readers of LIFE
and other important national
magazines. People of action and
influence in every community.
DETROIT 32, MICHIGAN
December, 1947
1247
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1248
Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 30 December, 1947 No. 12
THE FENESTRATION OPERATION FOR OTOSCLEROSIS
GEORGE E. SHAMBAUGH, JR.. M.D.
Chicago, Illinois
\T INE years ago a new operation was de-
^ scribed for restoring hearing in certain
cases of progressive deafness. From a small be-
gining beset with difficulties, the fenestration op-
eration has become one of the major advances in
surgery of recent years.
The principle of the fenestration operation is
simple. Otosclerosis, the most important cause
for progressive deafness in early and middle adult
life, blocks the conduction of sound to the inner
ear by a formation of spongy bone in the oval
window. The fenestration operation removes the
block by making a new window into the laby-
rinth and connecting it with the tympanic mem-
brane by a plastic skin flap.
The principle of the fenestration operation was
thought of many years ago, but the early at-
tempts to restore hearing in otosclerosis failed,
for the new window always closed by new bone
formation following operation. The first success-
ful operation was by a French otologist some
twenty years ago, whose complicated several-stage
procedure was simplified nine years ago by Lem-
pert in the one-stage fenestration operation.
As with the earlier operations, bony closure of
the new window was the chief obstacle to the
fenestration operation. At first 50 per cent or
more of the fenestrae closed within a few months
after operation. This difficulty has been over-
come largely from knowledge gained by animal
experiments.
The six factors that were found to influence
Read at the annual meeting of the Minnesota State Medical
Association, Duluth, Minnesota, June 30, 1947.
December, 1947
new bone formation at the fenestra may be ap-
plicable to other operations on bone, and are,
therefore, of general interest.
First, we observed in our animal experiments
that particles of bone dust, even microscopic in
size, exert a powerful stimulus to osteogenesis,
new bone forming rapidly around such particles.
The first requisite in making a fenestra that will
remain open is to make a clean window entirely
free from any particles of bone dust.
Second, we found that the middle layer of bone
of the labyrinthine capsule, called the enchondral
layer because it comes from the fetal cartilage, is
much less active in forming new bone than the
outer periosteal layer or the innermost layer of
endosteal bone. The second requisite in preventing
closure is to expose the inert enchondral layer as
far as possible around the new window.
Third, we demonstrated that stratified squa-
mous epithelium lying close to bone inhibits oste-
ogenesis. Therefore, the fenestra should be cov-
ered with the thinnest possible skin flap closely
applied to the margins of the fenestra.
Fourth, we proved that trauma to the endos-
teum that lines the labyrinth stimulates osteo-
genesis. In making the fenestra great care must
be taken not to scrape or strip the endosteum
within the labyrinth.
Fifth, we discovered that bone polished with a
hard gold burnishing burr rarely shows osteo-
genesis from the polished surface.
Sixth, we confirmed the known fact that fibrosis
tends to be followed by osteogenesis in bone in-
juries. Accordingly fibrosis must be kept to a
1249
FENESTRATION OPERATION FOR OTOSCLEROSIS— SHAMBAUGH
minimum by controlling hemorrhage, preventing
infection and minimizing inflammatory reaction
due to tissue trauma.
The application of these six factors demonstrat-
ed by our animal experiments to the fenestration
operation has resulted in reducing bony closures
to less than 3 per cent of operations followed for
more than two years.
This does not mean that nearly every patient
operated upon experiences a good result, for
there are still problems to be overcome. But it
does mean that once the patient experiences a
good hearing improvement he may expect to keep
it permanently, with the technique that is now
being used.
The risks of the fenestration operation have
proved to be slight, despite the proximity to the
facial nerve, to the dura of the middle and pos-
terior cranial fossa, and to the sigmoid portion of
the lateral sinus. In more than 1,600 operations
over a nine-year period we have had no deaths
and no serious complication. Temporary paraly-
sis of the facial nerve is the most frequent com-
plication. Dizziness lasting a few weeks, and in
some cases persisting in a mild form for as long
as two years, is the most annoying symptom fol-
lowing operation.
The careful selection of cases for the operation
is very important, for the outcome will depend
as much upon the selection of cases as upon the
correct surgical technique properly carried out.
The fenestration operation is first of all an
elective operation, and the patient must be in
good health.
The tympanic membranes must be intact and
within normal limits.
Above all, the cochlear nerve function must be
good for the speech frequencies as measured by
the bone-conduction hearing tests. Making a new
window cannot improve the hearing if the hear-
ing nerve does not respond.
According to the bone-conduction hearing tests
we classify each patient and give him an ap-
proximate prognosis with regard to his chances
of regaining practical hearing.
The ideal “Class A” candidate for the fenes-
tration has normal hearing by bone conduction
for all three of the speech tones of 512, 1,024
and 2,048 vibrations per second. Such a patient
has at least eight chances out of ten of regaining
permanent hearing sufficient to do without a hear-
ing aid.
The suitable but not ideal “Class B” case has
normal hearing for all but one of the speech fre-
quencies bv bone conduction. He has about five
or six chances out of ten of a permanent good
hearing result.
The borderline “Class C” case shows a bone
conduction curve below normal for two or three of
the speech frequencies. He has only about one
chance out of ten of a good hearing improvement,
and as a rule such patients are encouraged to use
a hearing aid rather than to be operated upon.
In conclusion, the fenestration operation offers
the victim of progressive deafness from oto-
sclerosis a chance to regain sufficient hearing to
do without a hearing aid. The prognosis in a
particular case depends upon the condition of the
auditory nerve as measured by the bone-conduc-
tion hearing tests for the speech frequencies.
If the operation is not successful, the hearing
in the operated ear may be improved too little to
be of value, or it may remain the same as be-
fore operation, or, in about one per cent of cases,
the hearing may be worse in the operated ear.
For this reason the poorer hearing ear is select-
ed for operation.
At the present time, with the technique that is
being used, the ideal candidate for the fenestra-
tion operation has eight chances out of ten of
regaining and keeping practical hearing.
FBI CHECKS STATE MEDICINE
One of the most startling misuses of public funds in
many years was disclosed last week by Congressman
Harness of Indiana who divulged that the FBI has com-
menced an investigation of Federal agencies illegally
propagandizing for socialized medicine.
The Bureau of Research and Statistics of the Social
Security Board was characterized by Harness as the
“nerve center of socialized medicine propaganda for the
entire world.” Harness declared that if the medical
profession “can be taken over by the Federal Govern-
ment and forged into a new and gigantic health bureauc-
racy, it would only be a question of time until Wash-
ington likewise moved into the field of education, re-
ligion, the press and radio.”
Bureaus are charged by law with responsibility for
administering legislation enacted by Congress, but the
spending of huge funds by government agencies to
“pressure” the enactment of legislation is a relatively
new and alarming development. Since the first of this
year various Federal agencies, according to Congress-
man Harness, have spent nearly 75 million dollars for
publicity and propaganda work. — California Feature
Service, October 6, 1947.
1250
Minnesota Medicine
FOLLOW-UP OF ABNORMAL PULMONARY FINDINGS OBSERVED
IN MASS CHEST X-RAY SURVEYS
HILBERT MARK. M.D., M.P.H.
Director, Division ol Tuberculosis, Minnesota Department of Health
Minneapolis, Minnesota
C URVEY FILMING is only a means of screen-
^ing the apparently healthy population into two
groups: (1) those persons with essentially neg-
ative chests and (2) those in whom the project
x-rays give an impression of some abnormality.
Further examinations of the individuals in
group 2 and adequate clinical evaluations are re-
quired to sort out those in need of medical super-
vision. All examinees who require such evalua-
tion are referred back to their preferred physi-
cian. Although every pulmonary shadow is not
tuberculosis, yet tuberculosis should be ruled in
or out as soon as possible. Primary tumors of the
lung and other non-tuberculous pulmonary dis-
eases may simulate tuberculosis. It is possible to
diagnose early bronchiogenic tumors, benign or
malignant, by adequate follow-up of localized em-
physemas which appear as a result of partial ob-
struction of a bronchus. This could lead to an
earlier surgical attack on this type of tumor. Of
course, there are other causes of localized disten-
tion of the lung.
The prompt clinical attention of the first physi-
cian to see the patient after the survey report of a
possible pathological condition is a serious respon-
sibility. In many of these cases the determination
of a correct diagnosis may require varied diagnos-
tic tests.
It can be said, therefore, that the clinical evalu-
ation should determine the following:
1. Definite diagnosis and whether the disease
is communicable
2. Extent of the disease and whether it is acute
or chronic
3. Prognosis and determination of therapeutic
procedure
4. If tuberculosis, disposition of the patient
and whether his condition requires hospital
or sanatorium care or whether he may con-
tinue under local medical supervision.
Since tuberculosis should be ruled in or out
without undue delay, a complete clinical study
should include the following:
1. History. — -As the abnormality found will
vary from very recent to very old, the degree and
variety of symptoms present will also vary widely
from no apparent to marked symptoms. Past his-
tory should be checked for tuberculosis exposure,
hemoptysis, extended colds and coughs, malaise,
et cetera.
Occupational history may be exceedingly im-
portant in the differential diagnosis. The results
of previous tuberculin tests and roentgen examin-
ations should be obtained in detail and verified.
2. Physical Examination.- — A complete phys-
ical examination should be made, and although a
chest x-ray has been obtained, the examination of
the chest should not be omitted. Temperaure re-
cordings at different times of day and sedimenta-
tion rates should be obtained. Special attention
should be given to the determination of the pres-
ence or absence of increased temperature, fatigue,
or loss of weight.
3. Tuberculin Tests. — To be of value, this test
must be given correctly with potent material and
then interpreted correctly. It is then an extreme-
ly valuable test in establishing the diagnosis of the
case. Usually, the single test with 0.1 cc. of a
1 :1000 dilution of old tuberculin (0.1 mgm) will
suffice. A negative test on several trials will rule
out tuberculosis except under the following con-
ditions :
(a) fulminating cases when the ability to react
to the antigen is lost
(b) overwhelming miliary infections
(c) recent cases when the infection has not
been present long enough to produce the
allergic phenomenon
(d) following some infectious diseases such as
measles when the allergic respone is tem-
porarily lost.
4. Sputum Tests — It is exceedingly impor-
tant that a thorough search be made for tubercle
bacilli. The presence of proved tubercle bacilli
establishes the diagnosis. When sputum is pres-
ent the initial examination can be by direct smear,
but if no bacilli are found on direct smear, cul-
tural studies should be made.
December, 1947
1251
FOLLOW-UP OF ABNORMAL PULMONARY FINDINGS— MARK
TABLE I. GUIDE FOR DISPOSITION OF PERSONS DIAGNOSED AS TUBERCULOUS*
Group
Tubercle
Bacilli
Cavity
on
X-Ray
Film
Changes
on
X-Ray
Film
Tuberculin
Test
(1:1000 O.T.)
Intracutaneous
Principal
Symptoms:
Temperature,
Fatigue, or
Weight Loss
Disposition of Case
Sanatorium
Care
Sanatorium
Observation
If Beds Are
Available
Clinic or
Private Phys.
Local Medical
Supervision
+ Present
S Suspect
0 Absent
-f- Reactor
0 Non-Reactor
+ Any one or
all Present
0 All Absent
i.
Sputum
Culture
Negative
and
Gastric
Culture
Negative
0 or +
0
0 or +
X
2.
0
+
0
X
3.
0
+
+
X
4.
S or +
+
0 or +
X
5.
No Sputum
and
Gastric Culture
Positive
0
+
0
X
6
s
+
0
X
7.
Sputum Culture
Negative
and
Gastric Culture
Positive
s
+
+
X
8.
+
+
0 or +
X
9.
Sputum, Smear
or Culture
Positive
0 or +
0 or +
0 or +
X
*Suggested modification of guide proposed by Hilleboe & Holm published in December 6, 1946, issue of Public Health Reports.
In the absence of expectoration, a gastric lavage
of the fasting stomach is indicated in order to ob-
tain the required specimen.
The work of a number of bacteriologists has
shown that the gastric acid or enzymes or both
have a deleterious effect on the tubercle bacilli. A
twenty-four-hour delay markedly reduces the
chance of recovery of viable tubercle bacilli. Both
sputum and gastric specimens should be mailed to
an accredited official or private laboratory with-
out delay.
If there are beds available in the sanatorium, it
is better to have the patient admitted to the insti-
tution so that the gastric lavage can be done early
in the morning before the patient has had an op-
portunity to move about or to drink. The speci-
men obtained can then also be handled promptly
and cultures inoculated while the tubercle bacilli,
if present, are still viable.
5. Serial and Special X-Ray Studies. — If pos-
sible, previous chest films should be obtained and
used in review. These examinations may be in-
dicated to determine the extent and position of the
lesion. Changes or lack of changes of the pulmo-
nary lesions will aid in determining whether the
disease is acute or chronic and whether the lesion
is stable, retrogressive, or progressive.
If the diagnosis is tuberculosis, the next consid-
eration is the disposition of the patient. To de-
termine this the physician should consider the sta-
tus of the disease, the presence or absence of tu-
bercle bacilli, the extent and character of the pul-
monary lesion as revealed by the roentgeno-
grams, and the presence or absence of cavities.
It is hoped that the clinicians will submit spu-
tum or gastric specimens periodically to the
Health Department Laboratories on all patients
remaining home under medical supervision.
Contacts of positive sputum cases should be
given the Mantoux test. If there is no reaction,
the test should be repeated in two months and
again in four months. If no reaction, further fol-
low-up is not required. If the contact reacts, he
should be x-rayed at the time of the Mantoux re-
action, and rerayed in six months. If the x-ray
examinations are negative, reray yearly unless
the contacts are children, then reray at the age
of twelve, and annually thereafter.
Summary
1. The necessity for a complete clinical evalu-
ation by the private physician is discussed. Rec-
ommendations are made of the points to consider
in making such an evaluation.
2. A modification of the Guide for Disposition
of Persons with Lesions Diagnosed as Tubercu-
losis as outlined by Hilleboe and Holm is pre-
sented.
1252
Minnesota Medicine
ACUTE PERFORATED GASTRIC AND DUODENAL ULCER
An Eighteen-Year Survey
DONALD C. MacKINNON, M.D., F.A.C.S.
Minneapolis, Minnesota
HP HE general interest in acute perforated gas-
trie and duodenal ulcer is indicated by the
tremendous number of recorded observations, and
the excellent reviews of this subject reported in the
literature. Most of the publications disclose an
obvious dissatisfaction with the high mortality
rate in this acute abdominal catastrophy. Fur-
thermore, there is a unified effort to correct the
deplorably high mortality by outlining treatment
along certain definite and well-established prin-
ciples.
During the first three decades of the twentieth
century, the mortality in perforated ulcers de-
creased considerably, according to DeBakey,6
whereas, during the fourth decade, it diminished
only 2.4 per cent with an operative mortality dur-
ing that period of 23.4 per cent. The operative
mortality figures of Sallick28 (10.8 per cent in
seventy-four cases), Berson3 (15.2 per cent in
151 cases), and Black and Blackford4 (11.8 per
cent in ninety-three cases) are more favorable.
According to DeBakey,6 the lowest mortality rates
have been reported in the smaller series of cases.
With refinements in surgical technique, anes-
thesia, chemotherapy and preoperative and post-
operative care, more encouraging results should
be recorded in the future. However, there has
been very little published during the last few
years in support of this contention, except in the
smaller series of cases. Graham12’13 reported
fifty-one cases with one death, but when his series
was extended to 111 cases, the operative mor-
tality rate was 6.3 per cent. From the United
States Navy, Fyons and Sinclair23 reported one
death in twenty-two Seabees. The recent figures
of Baritell2 (1.1 per cent operative mortality in
eighty-eight cases) were unique. Whether these
figures can be approached in the larger series,
where the mortality risk is increased by including
more individuals who are likely to develop car-
diac, renal, and pulmonary complications, is prob-
lematic. Only by repeated analyses and reviews
of this subject can lowered mortality rates be
From the Minneapolis General Hospital and the Department of
Surgery, University of Minnesota Medical School, Minneapolis,
Minnesota.
Presented before the Minneapolis Surgical Society, April 3,
1947.
December, 1947
revealed and improved methods of procedure be
developed.
During the past six years, the members of the
surgical staff of the Minneapolis General Hospital
have been impressed with an apparent decrease in
the mortality from acute perforated gastric and
duodenal ulcers operated upon in that hospital.
In order to prove this impression, the present
study was undertaken. Furthermore, a more
complete interpretation of our changes in therapy
and an opportunity to compare the statistical as-
pects of our series with other collected series
would then be possible.
Source of Material
This study includes all the cases of acute per-
forated gastric and duodenal ulcers in which
operation was performed at the Minneapolis Gen-
eral Hospital during an eighteen-year period from
1929 to 1946, inclusive. This represents a series
of 176 cases. These patients were indigent, in
a poor physical, economic, and social status, quite
unlike patients in private practice. The emer-
gency operations were performed in thirty-seven
instances by ten visiting staff surgeons. One hun-
dred thirty-nine patients were operated upon by
thirty-four senior resident surgeons during their
final six-month training period of the three-year
fellowship in general surgery. The operations
performed by the visiting staff were done, for the
most part, during the first three years of the
series before postgraduate training was well es-
tablished in this hospital.
Only the acute perforated gastric and duodenal
ulcers treated surgically were included. Pene-
trating ulcers and elderly moribund individuals
who' were admitted to the medical service with a
diagnosis of coronary thrombosis, or other incor-
rect diagnoses, showing perforated ulcers at
necropsy, were excluded. Three patients treated
conservatively were excluded. Two of these died
and the diagnosis was verified at necropsy. One
recovered and was operated on for a second per-
foration three years later. One young woman
was excluded whose appendix was removed and
the overlooked perforated duodenal ulcer was dis-
covered at necropsy.
1253
ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
TABLE I. MORTALITY FOR THE SERIES AND
ACCORDING TO SIX-YEAR AND NINE-YEAR
PERIODS (176 cases)
Period
No.
Cases
No.
Deaths
Mortality
Per cent
1929-1946
176
38
21.6
1929-1934
49
12
24.5
1935-1940
63
21
33.3
1941-1946
64
5
7.8
1929-1937
82
24
29.3
1938-1946
94
14
14.9
TABLE II. MORTALITY ACCORDING TO THE
AGE IN OUR SERIES AND IN THE
COLLECTED SERIES6
Age
Decades
c
)ur Cases (1
76)
Collected
Cases
(4,147)
Mortality
Per cent
No.
Cases
No.
Deaths
Mortality
Per cent
10-19
2
0
0.0
14 3
20-29
26
1
3.8
12.2
30-39
40
3
7.5
18.9
40-49
46
10
21 .7
28.0
50-59
39
12
30 7
40.8
60-69
17
9
52.9
55 3
70-79
6
3
50.0
53.8
Table I shows the mortality rates for the en-
tire series : three consecutive periods of six years
or two consecutive periods of nine years. The
operative mortality rate of 21.6 per cent approx-
imates- the figure of 23.4 per cent in the col-
lected series of 15,340 cases reported by De-
Bakey.6 The higher mortality rate in the second
six-year period is due to a greater number of poor
risk patients operated upon during that period. A
more marked reduction in the mortality rate is
found in the last six years, of our series (7.8
per cent in sixty-four cases), than in the last
nine years of the series (14.9 per cent in ninety-
four cases). Factors contributing to this reduc-
tion will be discussed later in this report. At
present, it is of interest to correlate various fac-
tors of the disease with the death rate in order
to determine their importance in the immediate
prognosis.
Age
Age has long been recognized as being an im-
portant prognostic factor. In this series the range
was from fifteen to seventy-six years. The aver-
age age of the entire series was 44.3 years. The
average age of the survivors was 41.8 years and
of those who died 53.5 years. The patients of
the entire series were in a significantly older age
TABLE III. MORTALITY ACCORDING TO
SEASONS (176 cases)
Season
No.
Cases
No.
Deaths
Mortality
Per cent
Winter
47
10
21.3
Spring
55
15
27.3
Summer
33
4
12.1
Autumn
41
9
21.9
group, 35 per cent being fifty years or older.
According to six-year periods, the number of
patients over fifty years of age was 22.4 per cent
for the first period, 38.1 per cent for the second
period and 39.1 per cent for the third period.
These figures show that from the standpoint of
age, the greatest number of poor risk patients
were in the last six-year period when our mor-
tality was the lowest, making our figure of 7.8
per cent statistically significant. Table II shows
a correlation between the mortality incidence
and age according to decades in our cases and the
collected series.6 There is a definite increase in
the mortality with each succeeding decade. These
figures do not differ markedly from those already
reported by Graves,14 Judine,18 and DeBakey.6
Their exceedingly high mortality incidence of 33.3
to 50 per cent in individuals over fifty years
clearly indicates the seriousness of the disease in
people of that age group.
Sex
In uncomplicated ulcer there is a ratio of six
males to one female. The incidence of perfora-
tion is much greater in the male, exceeding this
ratio by four or five times. In our series there
were 171 males and five females, a ratio of 34
to 1. There were no deaths among the females.
DeBakey6 reported a mortality rate of 43.9 per
cent in 474 females and 25.7 per cent in 2,152
males, indicating that the prognosis is not as
favorable in the female sex. Possibly this can
be explained by the fact that women are more
likely to develop gastric rather than duodenal
perforations, which, as will be shown later, usually
result in a higher mortality rate.
Seasonal Incidence
Ulcer activity is considered to be greatest dur-
ing the spring and autumn seasons. Table III
shows the higher incidence of perforation in the
spring and autumn, but also high during the win-
ter, with the lowest incidence during the summer
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ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
season. Ulfelder and Allen35 correlated the mor-
tality incidence with the season in which upper
respiratory infections were frequent and found
a close relationship. In late autumn, winter, and
early spring respiratory infections are frequent in
Minnesota. In our series the mortality incidence
was highest during these seasons and lowest dur-
ing the summer months.
Previous History
A correlation between mortality and the pres-
ence or absence of either a positive or a sugges-
tive history of ulcer did not disclose a signifi-
cant relationship in our series. There was a
rather high incidence of some type of ulcer dis-
tress as shown by the fact that 21.5 per cent of
our patients gave a positive history of ulcer for
a year or longer, 59.6 per cent gave a suggestive
history of ulcer for a few weeks to several years,
17 per cent gave no history of ulcer, and in three
cases the history of ulcer was unspecified. All
patients with a positive and suggestive history of
ulcer had carelessly and stupidly neglected ade-
quate medical therapy, in many instances having
resorted at irregular intervals to alkalies or food
for relief of their symptoms. Emphasis must
again be placed upon the fact that these patients
were indigent; most of them from the lower
social and economic levels of society. Some were
chronic alcoholics, others were transient and
homeless, so there should be little difficulty un-
derstanding that adequate medical management in
such individuals is often unsuccessful and occa-
sionally impracticable. Though perforation can
occur in the presence of an adequate medical
regimen, as observed in a few cases reported by
Eliason and Ebeling,8 it did not occur under sim-
ilar circumstances in any of our cases. There
were three patients with recurrent perforations in
our series. The original perforations were treated
elsewhere in two patients. In one patient, a sim-
ple closure was performed one year prior to the
second perforation. In the second patient, the
initial perforation was closed and a gastroenteros-
tomy was performed ; seven years later this pa-
tient had a perforated gastrojejunal ulcer. The
third case was- of interest because the patient had
a perforation three times at three-year intervals.
The first perforation was treated conservatively,
and the last two were duodenal perforations treat-
ed by simple closure. Subsequently, this patient
had a subtotal gastric resection.
TABLE IV. MORTALITY ACCORDING TO THE
PREOPERATIVE TIME INTERVAL IN OUR
SERIES AND IN THE COLLECTED SERIES6
Time Interval
Hours
c
)ur Cases (1
76)
Collected
Cases
(7,683)
Mortality
Per cent
No.
Cases
No.
Deaths
Mortality
Per cent
0-6
92
10
10.9
10.5
7-12
59
14
23.7
21.4
13-18
14
6
42.8
38.5
19-24
5
4
80.0
62.4
Over 24
5
4
80.0
61.5
Unspecified
1
0
0.0
0.0
Time of Perforation
In the literature, reference is made to the caus-
ative relationship of activity, trauma, and oc-
cupation, to perforation. Little attention has
been given to the time perforation occurs in re-
lation to ordinary mealtime. There is a general
conception that perforation often takes place
during or after a heavy meal. In our series it
was possible to determine the hour of perforation
in 172 cases. In 121 cases (70.3 per cent) per-
forations occurred between 9 a.m. and noon, 3
p.m. and 6 p.m., and 9 p.m. and 6 a.m., with
slightly more than 50 per cent occurring during
the latter period or night hours. This figure
might even be higher if one could assume that
some of the twenty-five patients whose perfora-
tions occurred during the dinner and supper hours
had not eaten. This analysis is only presumptive
evidence that perforation occurred more often
during the periods when highly acid gastric secre-
tions were less likely to be neutralized by food.
In our series, only four patients definitely had a
perforation while eating, six immediately after
eating, one after drinking coffee, two after drink-
ing beer, and two a few hours after a gastrointes-
tinal x-ray study.
Preoperative Time Interval
Another extremely important factor, contrib-
uting to the high mortality rate, is the lapse
of time between perforation and operation. The
rapid rise in mortality rate is clearly demonstrated
in Table IV where our figures are compared with
DeBakey’s6 collected series. The mortality dou-
bles, approximately, with the lapse of each suc-
ceeding six-hour interval up to twenty-four hours.
In our series the operation was performed dur-
ing the first twelve hours in 85.7 per cent of the
cases, indicating that there was little delay in
operating upon these patients. According to
December, 1947
1255
ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
six-year periods, the number of patients with
perforations over twelve hours old before opera-
tion was 14.2 per cent for the first period, 25.4
per cent for the second period, and 19.1 per cent
for the third period. The greatest number of
poor risk patients were in the second period when
our mortality was the highest. There were more
patients with perforations over twelve hours in
the last period when our mortality was the lowest,
than in the first period. Therefore, from the
standpoint of the preoperative time interval, a
relatively large number of poor risk patients were
operated upon during the last six years, making
our mortality rate of 7.8 per cent significant for
that period.
The preoperative time interval is uncontrollable
until the patient is within the jurisdiction of the
medical attendant, when it then becomes a fac-
tor directly under his control. This was shown
in one of our deaths which was attributed, in part,
to unnecessary delay. A thirty-three-year-old
man was admitted three hours after first noticing
symptoms of perforation but he was not operated
upon until six hours more had elapsed. It is
our policy to operate upon these patients imme-
diately after making the diagnosis, which usually
can be determined quickly and easily. Scoutter29
has shown that true shock is infrequent in these
cases. This was also true in our patients where
it was found rarely in a few late cases. There-
fore, a short period of preoperative preparation
ordinarily can be accomplished. We are also in
accord with Olson and Norgore,27 and Graham,12
who believe that a sufficient delay is justifiable
in the late case to correct the secondary manifes-
tations of perforation, such as shock, and fluid
and biochemical depletions.
Though there is a tendency for the perforation
to become sealed in late cases, this fact cannot
be determined definitely with any degree of ac-
curacy. Only three of our patients were treated
conservatively and only one recovered. These
three were seen late and were admitted in such
poor condition that they were inoperable, or in
sufficiently good condition to indicate that the per-
foration may have been sealed and recovery might
have been taken place. Baritell2 treated five
patients conservatively who were seen late when
their signs and symptoms were subsiding, with
recovery in all cases. He emphasizes careful
evaluation, constant observation, and surgical in-
tervention only when there were signs indicating
a relapse. Ulfelder and Allen35 agree with Wan-
gensteen37 that nonoperative therapy should be
considered in the older age group seen twelve
hours after onset and showing signs of localiza-
tion. Sherman32 reported a 50 per cent mortality
in fifty patients not submitted to operation ; this
group was not analyzed so the high mortality was
equivocal. Visick36 reported two deaths in
fourteen unselected patients treated conservative-
ly. Taylor34 bases surgical intervention on the
degree of leakage that takes place, recommending
conservative management in the early perforations
and operation in the late cases. He reported four
deaths in twenty-eight patients treated conserva-
tively. Unquestionably, patients admitted to the
hospital after the optimum time for operation
has passed, and who are in poor physical condition,
constitute a real problem in therapy and surgical
judgment, as shown by two of our patients who
died of profound shock during and immediately
after the operation. We now believe that in the
late case the patient should have a reasonable
chance to survive the operation before operation
is undertaken.
Pneumoperitoneum
The scope of this report does not include a
detailed study of the symptoms and signs which
are characteristic and helpful in making the diag-
nosis of perforated ulcer. Roentgen-ray evidence
of free air under the diaphragm in the upright
position, or between the liver and the chest wall
in the left lateral decubitus position is practically
pathognomonic of a perforated viscus.
Due to improved x-ray technique, the accuracy
of this procedure has improved noticeably during
the last ten years of our survey. Pneumoperi-
toneum is not present in all cases, especially when
the perforation is small, of short duration, or when
the air bubble becomes pocketed by adhesions in
a subhepatic position. The injection of air
through an indwelling catheter in the stomach to
increase the accuracy of this diagnostic aid was
not practiced. Intraperitoneal free air was ob-
served in the usual locations by roentgen-ray ex-
amination in only 55.6 per cent of our patients.
It was not demonstrated in one-fourth of the
cases, and in the remaining patients an x-ray was
not taken or was unsatisfactory. The literature
contains numerous reports in which pneumoperi-
toneum was demonstrated in from 50 per cent,
as shown by McCabe and Mersheimer,25 to 95
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ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
per cent of the cases, as reported by Shallow.30 In
the absence of pneumoperitoneum, an elevated
serum amylase, as shown by Elman,9 is helpful
in distinguishing acute pancreatitis. Serum
amylase determinations were done shortly after
admission to the hospital in only eight of our
patients, and in two cases they were abnormally
high. Needle aspiration of the peritoneal cavity
was done occasionally. The diagnostic value of
this procedure has been reported by Steinberg.33
If a small amount of methylene blue given orally
can be retrieved by peritoneal aspiration, a per-
foration is present. Recently, this procedure has
been used in the cases showing no air under the
diaphragm. When these procedures are positive,
they are valuable diagnostic aids. When they are
negative, they may cause further confusion and
unnecessary delay in which valuable time is lost
prior to surgical intervention. The diagnosis is
not difficult in most cases and must be interpreted
in the light of the characteristic history and phys-
ical findings.
Leukocyte Count
The average initial leukocyte count performed
on admission to the hospital was 14,250. The
range was from 3,200 to 29,800. In some in-
stances there was no leukocytosis. Among the
deaths there were seven cases with an initial
leukopenia of counts below 6,350. In perfora-
tion of less than twelve hours’ duration, the aver-
age initial leukocyte count in 118 patients who
survived was 14,550, and in sixteen deaths was
11,950. When perforation had been present more
than twelve hours the leukocyte count was not
of prognostic value — for the average count in
those who survived was 14,600 and in those who
died 14,050. Berson3 reports a mortality of 52.4
per cent in patients with a leukocyte count under
10,000. From these figures a normal leukocyte
count or an initial leukopenia may indicate a grave
prognosis.
Anesthesia
There is a controversy regarding the anesthetic
of choice in operating for perforated gastric and
duodenal ulcer. Sallick28 and McCreery26 found
a lower mortality in those operated upon under
general anesthesia, while Fallis,10 Shawan,31 and
Judine18 found mortality rates from two to four
times as great under general as under spinal anes-
thesia. Baritell,2 in his spectacular series of
TABLE V. MORTALITY ACCORDING TO
ANESTHESIA (176 CASES)
Anesthetic
No.
Cases
No.
Deaths
Mortality
Per cent
Ether
9
1
n.i
Ethylene ether
65
16
24.6
Cyclopropane ether
32
6
18.8
Pentothal induction, cvclo-
propane ether
5
0
0.0
Pentothal induction, cyclopro-
pane or nitrous oxide oxygen,
curare
27
2
7.4
Total general anesthetics
138
25
18.1
Spinal
22
7
31.8
Spinal, Ethylene ether
7
2
28.6
Total spinal analgesia
29
9
31.0
Local
2
1
50.0
Local, Ethylene ether
3
3
100.0
Local, Pentothal
4
0
0.0
Total local analgesia
9
4
44.4
eighty-eight cases with a 1.1 per cent mortality
rate, used spinal anesthesia routinely. In a series
of 1,776 collected cases, DeBakey6 reported a
mortality under general anesthesia of 29.9 per
cent, under spinal anesthesia of 17 per cent, and
under local anesthesia of 52.8 per cent. The
higher mortality rate in the local anesthetic group
can be explained by the fact that local was the
anesthetic of choice in the late and originally
poor risk patients.
Table V shows a large variety of general, spinal,
and local anesthetics, and combinations of anes-
thetics used in our patients. They actually ran
the gamut of anesthetic agents from the days of
drop ether. This is a startling example of the
changing trends in anesthesia and of the new
discoveries constantly being made to find the
most satisfactory and safest anesthetic or combi-
nation of anesthetic agents for abdominal opera-
tions. In our series the mortality incidence for
the general anesthetic group was 18.1 per cent,
spinal analgesia group 31 per cent, and local
analgesia group 44.4 per cent. Supplementary
anesthesia was frequently used in the spinal and
local groups. Local analgesia was used in the
poor risk patients. In this hospital spinal anal-
gesia has been used frequently in lower abdominal
operations, although it has never been popular
in upper abdominal operations as shown by the
relatively few times it was employed in our cases.
The newer general anesthetic agents have defi-
nitely contributed to our lower mortality rate dur-
ing the last six-year period. A combination of
these agents recommended by Knight,20 with the
administration of pentothal induction, cyclopro-
pane or 70 per cent nitrous oxide and oxygen,
and the injection of curare intravenously, pro-
December, 1947
1257
ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
TABLE VI. MORTALITY ACCORDING TO THE
LOCATION OF THE PERFORATION IN OUR
SERIES AND THE COLLECTED SERIES6
Location
c
)ur Cases (1
76)
Collected
Cases
(4,825)
Mortality
Per cent
No.
Cases
No.
Deaths
Mortality
Per cent
Gastric
64
12
18.7
33.3
Duodenal
103
23
22.3
21.1
Pyloric
8
2
25.0
22.2
Gastrojejunal
1
1
100.0
—
duces a pleasant induction, adequate anesthesia
with a high concentration of oxygen, excellent re-
laxation, and a short recovery period which are
all the desirable features of perfect anesthesia.
Incision
A right rectus muscle-splitting incision was
used in 65.9 per cent of our cases. Other inci-
sions employed were the left rectus, midline, sub-
costal, and transverse. Wound infection and evis-
ceration are frequent complications following op-
erations for perforated ulcer, ranging from 25.6
to 37 per cent of the cases reported by DeBakey
and Odom,7 Meade,24 and Kelly.19 Wound infec-
tion, minor degrees of separation, and evisceration
occurred in 18.7 per cent of our patients. There
were five cases of extensive wound disruption and
evisceration.
Adequate exposure for closure of a perforation
can be accomplished through a small vertical or
transverse incision. Amendola1 used a small, ob-
lique subcostal approach for suture of his perfora-
tions. Hartzell and Sorock16 recommended a
short, transverse incision and lateral retraction of
the rectus muscle for simple closure of acute per-
foration. During the past four years our wound
complications have been reduced to a minimum
and no eviscerations have occurred following a
small transverse incision used in twenty-six cases
in which the diagnosis was certain. The incision
was made 2 or 3 inches above and to the right of
the umbilicus, transversely, through all layers of
the abdominal wall. When more exposure was re-
quired, the incision was extended to the right
or left. Therefore, our incision was usually one-
half the length of the transverse upper abdominal
incision described by Lynn and Hull.22 A sul-
fonamide was frequently applied to the wound
prior to opening the peritoneum, and the edges
of the wound were carefully protected with ab-
dominal packs. The wounds were closed with
fine, interrupted, non-absorbable sutures. By
using this type of incision and wound closure,
complications were reduced, and the patients were
ambulatory within a few days.
Site of Perforation
The site of perforation is a significant factor
in the prognosis. Some observers found a higher
mortality rate in duodenal ulcers. However, the
majority of authors report a higher death rate
in gastric perforations, explained on the theory
that they are likely to occur in older individuals,
and produce greater spillage and contamination of
the peritoneal cavity. In 4,825 cases collected by
DeBakey,6 the mortality incidence was 33.3 per
cent in gastric perforations, 21.1 per cent in duo-
denal perforations, and 22.2 per cent in pyloric
perforations. As shown in Table VI, there was a
slightly higher mortality rate in our duodenal per-
forations. Also contrary to the rule, there were
no deaths in our five female patients, and four
of their perforations were in the duodenum.
There was one perforation at the site of an old
gastrojejunal anastomosis which resulted in a
fatality.
Unquestionably, in our series, there were sev-
eral errors made in correctly locating the site of
perforation at the time of operation, especially in
the prepyloric ulcers. This was established in
some patients by biopsies taken from the edges of
what appeared to be gastric perforations but which
proved to be inflamed duodenal mucosa. Like-
wise, in some cases in the gastric group, gastroin-
testinal x-ray studies taken before the patient was
discharged from the hospital revealed a duodenal
niche or deformity and a normal stomach. The
error can be explained in most instances, by the
obliteration of the normal landmarks around the
pylorus in the presence of large ulcerations with
widespread inflammation, induration, and edema.
Graham13 included only the duodenal perfora-
tions in his most recent report, excluding the gas-
tric cases on the basis that malignant degeneration
was of common occurrence. Malignant degen-
eration was not found in our gastric perforations.
However, it must be admitted that biopsies were
not taken in all of our cases, and immediate post-
operative x-ray studies were also incomplete. A
more careful immediate examination and follow-
up study must be made to determine the incidence
of malignancy in this group of patients.
There were no multiple perforations discov-
1258
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ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
TABLE VII. MORTALITY ACCORDING TO THE
SIZE OF THE PERFORATION (176 CASES)
Size
mm.
No.
Cases
No.
Deaths
Mortality
Per cent
1-5
92
16
17.4
6-10
26
6
23.1
Over 10
9
5
55.5
Unspecified
49
11
if* . . '
ered at operation. However, in our deaths, mul-
tiple ulcerations were found at necropsy in two*
gastric ulcers, four duodenal ulcers, and one duo-
denal ulcer with concurrent gastric ulceration.
The second ulcer in the duodenum usually was
found on the posterior wall opposite the anterior
wall ulcer, the so-called “kissing ulcer.” The
second ulcer was not perforated and, therefore,
not a contributory cause of death in any of these
cases. The possibility of a second perforation,
though rather infrequent, must always be kept in
mind.
Size of Perforation
Statistical data correlating the death rate with
the size of the perforation are noticeably lacking
in the literature. 'If the amount of spillage into
the peritoneal cavity, which is an accepted etio-
logical factor in many deaths, is directly propor-
tional to the length of time the perforation has
been present, there should also be a similar rela-
tionship between the amount of peritoneal soil-
ing and the size of the opening. Accurate meas-
urement of our perforations was not made. Nev-
ertheless, in the majority of operative reports
there was an estimated measurement or a com-
parative description of size noted. As shown in
Table VII there was a definitely higher rate of
mortality in the larger perforations. Therefore,
this factor is important and bears a significant re-
lationship to the prognosis.
Bacteriology
Davison, Aries, and Pilot5 have shown that the
peritoneal culture is usually sterile during the first
six hours following perforation and the convales-
cence in these patients is good. When the peri-
toneal fluid contains organisms, the prognosis
should be guarded. In our patients only forty-
three cultures were taken. Two were unsatisfac-
tory. Prior to twelve hours, thirty-four cultures
were taken. In the patients who survived, fifteen
showed no growth, thirteen were positive, and
the six cultures taken on the patients who died
TABLE VIII. MORTALITY ACCORDING TO THE
TYPE OF OPERATIVE PROCEDURE IN OUR
SERIES AND IN THE COLLECTED;.; SERIES6
c
)ur Cases (1
76)
Collected
Cases
(11,284)
Mortality
Per cent
Operative
Procedure
No.
Cases
No.
Deaths
Mortality
Per cent
Simple closure
160
33
22.6
25.9
Closure and
gastro-
enterostomy
10
3
30.0
20.4
Excision and
closure or
pyloroplasty
6
2
33.3
15.9
Subtotal
gastrectomy
0
0
0.0
13.4
were all positive. After twelve hours there were
only eight cultures taken. All were positive.
Four patients survived and four died. Of
the twenty-seven patients with positive cultures,
ten (39.3 per cent) died. A variety of mixed and
single growths of pathogenic and nonpathogenic
organisms were found. The more common or-
ganisms were the diphtheroids, yeast, staphylococ-
cus, and hemolytic and nonhemolytic streptococ-
cus. The streptococcus was found more often in
the patients who died.
Operative Procedure
During the past few years, the surgical pro-
cedures of pyloroplasty and gastroenterostomy
have become relatively obsolete. Most surgeons
with wide experience in this country agree that
in this abdominal emergency a quick, simple clos-
ure of the perforation is the procedure of choice.
Lahey21 aptly stated that the life of the patient
should be saved and no attempt made to cure the
ulcer. Though there are numerous authors, in-
cluding DeBakey6 (Table VIII), who have re-
ported a lower mortality following radical pro-
cedures, including partial gastrectomy, it should
be understood that simple closure was admittedly
performed in the poor risk patients. The late
results of simple closure have been good in 65
to 90 per cent of the cases followed by Johnston,17
Gutherie and Sharer,15 and Williams,38 indicating
more extensive procedures are unnecessary. In
DeBakey’s collected series6 of 1,525 cases, the fol-
low-up results were good or fair in 65 per cent
of the cases.
As shown in Table VIII, the mortality in our
series is considerably lower for simple closure
December, 1947
1259
ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
than for closure plus gastroenterostomy, or ex-
cision plus closure according to the Heincke-
Mikulicz pyloroplasty. The latter procedures
were done in only sixteen cases during the earlier
years of the survey. Simple closure has been a
routine procedure for several years in our insti-
tution. The ulcer was usually closed with two
or three rows of sutures, incorporating an omental
tab in the outer row. In some of the large in-
durated ulcers, this type of closure was accom-
plished with difficulty. A modification of the pro-
cedure of Gatch and Owen,11 of approximating
the anterior wall of the stomach to the duodenum
over the perforation with interrupted silk sutures,
was performed in a few cases. The method
described by Graham,12 of suturing a free omental
graft over the opening, was done in two cases
with success. A variety of suture material was
used in our closures. In seventy-six cases in
which absorbable suture material was used, the
mortality incidence was 31.5 per cent. In sev-
enty-seven cases in which non-absorbable sutures
were used throughout, or chromic through the
ulcer and non-absorbable sutures in the outer
layers, the mortality incidence appears to be sig-
nificantly lower, 7.8 per cent. However, sucb
correlations have questionable statistical value
since there are several factors having an impor-
tant relationship to the death rate. A sulfonamide
was frequently, but not routinely, implanted lo-
cally in the peritoneal cavity around the site of
perforation. The value of this procedure has
not been definitely determined. On two occa-
sions, 100,000 units of diluted penicillin were
used locally in the peritoneal cavity.
Drainage
Years ago drains were used frequently follow-
ing operation for perforation. They were com-
monly placed either below the liver, in the pelvis,
in the upper right lateral gutter, or in the sub-
cutaneous space of the wound to prevent com-
plications and abscess formation. Later, a period
followed in which drainage was advocated only
when there was rather marked peritoneal soiling.
Though many surgeons continue to employ drain-
age, there seems to be an equal number of
authors, as shown by DeBakey,6 who believe
drainage is contraindicated. At the present time
there is an increasing tendency not to drain.
Since fibrinous adhesions begin to form around
the drains within the first twenty-four hours, it
becomes apparent that drainage of the peritoneal
cavity is impossible except for a very limited area
directly around the drain.
Since 1935 drains have been rarely used in our
cases. The incidence of wound closure without
drainage was 46.5 per cent in our series. We
believe that drainage is indicated only when a lo-
calized abscess is present. Much reliance is
placed on thorough cleansing of the peritoneal
cavity by adequate removal of free fluid and food
particles. In many cases the peritoneal cavity
in the region of the ulcer was washed with a
liter or more of warm saline and removed by
suction.
The problem of drainage is not of sufficient
importance to make a statistical correlation sig-
nificant between mortality and drainage, and such
comparisons seem worthless. In our series the
mortality rate was 34.6 per cent in the patients
with intraperitoneal drainage, and 9.7 per cent
in cases closed without drainage. The incidence
of wound complications, such as infection, sep-
aration, and evisceration, was 12.8 per cent in the
patients without drainage and 18.2 per cent in
those who were drained.
Postoperative Management
An analysis of cases over an eighteen-year
period naturally brings to light many new methods
of postoperative care. Ever since 1932 we have
employed constant gastric siphonage until peristal-
sis returns, which is usually on the third or fourth
postoperative day. Adequate fluid and chemical
balance were maintained ; plasma and whole blood
were administered when indicated. At present,
fluids are routinely started at the beginning of
the operation, if not before. Occasionally oxy-
gen was required. Patients were hyperventilated
for two or three days and encouraged to cough
up tracheo-bronchial secretions. Vitamin B com-
plex and ascorbic acid were administered on the
assumption that a vitamin deficiency exists occa-
sionally in the ulcer patient. With the discovery
of sulfonamides, the various drugs were fre-
quently, but not routinely, used in either one of
three ways : in the peritoneal cavity, in the wound,
and/or postoperatively. Since penicillin has been
available, we have used it routinely ; consequently
the use of sulfonamides has diminished. By
making a small transverse incision, tightly closed
with a fine, interrupted silk technique in all layers
of the wound, early ambulation was possible.
1260
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ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
TABLE IX. POSTOPERATIVE COMPLICATIONS
(176 cases)
Complication
No.
Per pent
Bronchopneumonia
34
19.5
Wound infection, slight separation
28
15.9
Atelectasis
17
9.6
Paralytic ileus
8
4.5
Wound disruption, evisceration
5
2.9
Pleural effusion
4
2.2
T hrombophlebitis
2
1 . 1
Delirium tremens
2
1.1
Empyema
1
.5
Subdiaphragmatic abscess
1
.5
Intestinal obstruction
1
.5
Gastric fistula
1
.5
Others*
3
1 .7
*Include needle in thigh, otitis media and mastoiditis, and abscess
right flank.
These are the postoperative measures which have
reduced our complications and mortality during
the past six years. When discharged from the
hospital, the patients were referred to the out-
patient clinic for further observation and man-
agement. A follow-up study of this series is
contemplated as a problem for a subsequent re-
port.
Postoperative Complications
Peritonitis is not classified as a complication
because it is present in some degree, either chem-
ical or bacterial, in all cases of perforated ulcer.
Bronchopneumonia, with clinical symptoms and
signs, together with roentgenological evidence,
was the most frequent postoperative complication,
occurring in thirty-four cases (19.5 per cent),
as shown in Table IX. In twenty-six of those
cases death occurred from bronchopneumonia as
the chief, or as an important contributory cause
of death, as shown in Table X. Wound infection
with minor degrees of wound separation was the
next most frequent complication. Various de-
grees of atelectasis, as demonstrated clinically and
roentgenologically, was the third most common
complication, occurring in seventeen cases (9.6
per cent). However, atelectasis was an asso-
ciated cause of death in only one case. A few
cases of massive collapse were saved by broncho-
scopic aspiration. Paralytic ileus was marked in
eight cases and an associated cause of death in
six. Pleural effusion and empyema were present
in a few cases. Among the five patients who
eviscerated there were two deaths. The eviscera-
tion was not the sole cause of death in those
cases but a secondary complication of broncho-
Dfxember, 1947
TABLE X. CAUSES OF DEATH
(38 cases)
Causes of Death
No.
Necropsy Diagnosis (15 Cases)
Bronchopneumonia
13
Generalized peritonitis
11
Cardiac disease*
4
Paralytic ileus
3
Subdiaphragmatic abscess
3
Subhepatic abscess
1
Pelvic abscess
1
Clinical Diagnosis (23 Cases)
Generalized peritonitis
19
Bronchopneumonia
13
Localized peritonitis
3
Paralytic ileus
3
Pleural effusion
3
Profound shock
2
Wound evisceration
2
Cardiac disease
2
Atelectasis
1
Septicemia
1
Delirium tremens
1
Possible pulmonary embolism
1
*Include coronary sclerosis, rheumatic endocarditis (old valve
defect), syphilitic aortitis, and mural thrombosis.
pneumonia or peritonitis with paralytic ileus and
abdominal distention. Only one subdiaphragmatic
abscess was recognized postoperatively and treat-
ed successfully. Other rare complications were
intestinal obstruction, thrombophlebitis, gastric
fistula, and delirium tremens. Our incidence of
pulmonary complications including bronchopneu-
monia atelectasis, pleural effusion and empyema
was 31.8 per cent. DeBakey’s6 incidence of
pulmonary complications was 32.8 per cent in 772
collected complications.
Causes of Death
Necropsy was done in fifteen of the thirty-eight
deaths. Causes of death frequently overlapped.
For example, some patients died of either gener-
alized peritonitis or bronchopneumonia, while
others died with enough peritonitis and broncho-
pneumonia or some other associated condition,
such as an intraperitoneal abscess, making it im-
possible to determine accurately, from the record,
the chief cause of death. As shown in Table X,
bronchopneumonia and generalized peritonitis
were the most common causes of death. Pleural
effusion, empyema, paralytic ileus, localized
peritonitis were less commonly found. The two
deaths from profound shock include a patient who
died on the operating table and another who died
a few minutes after the operation. A few patients
with overlooked localized abscesses might have
been salvaged. DeBakey6 also reported perito-
nitis and pulmonary disease as the most frequent
causes of death in his collected cases.
1261
ACUTE PERFORATED GASTRIC AND DUODENAL ULCER— MacKINNON
Conclusion
In general, our series is similar to other re-
ported series. During the past six years our
mortality rate has been reduced to 7.8 per cent
in sixty-four consecutive cases. We attribute this
reduction to factors within our control, such as
early operation, improvements in anesthesia, re-
finements in surgical technique, and better pre-
operative and postoperative management acquired
through more complete knowledge of the fluid,
chemical, protein, and vitamin requirements of
the surgical patient. The use of chemotherapeu-
tic drugs, especially penicillin, postoperatively
appears to be a very important recent advance
in reducing our complications and mortality.
Summary
One hundred seventy-six cases of acute gastric
or duodenal perforations with operations during
an eighteen-year period are presented. Mortality
rates are discussed for the series and by periods.
Correlations are made between the mortality and
factors known to have a significant relation to
the prognosis, such as age, preoperative time inter-
val, anesthetic, site of perforation, size of perfora-
tion, operative procedure, and postoperative man-
agement. Other factors such as sex, seasonal
incidence, time of perforation, pneumoperito-
neum, leukocyte count, incision, drainage, com-
plications, and causes of death are discussed.
References
1. Amendola, F. H.: A simplified approach for the suture
of acute perforation of peptic ulcer. Surg., Gynec. & Obst.,
64:76-77, (Jan.) 1937.
2. Baritell, A. L. : Perforated gastroduodenal ulcer. Surgery,
21:24-34, (Jan.) 1947.
3. Berson, H. L. : Acute perforated peptic ulcers: an eighteen
year survey. Am. J. Surg., 57:385-394, (May) 1942.
4. Black, B. M., ana Blackford, R. E. : Perforated peptic
ulcer; review of ninety-six cases. S. Clin. North America,
25:918-928, (Aug.) 1945.
5. Davison, M.; Aries, L. J., apd Pilot, I: A bacteriological
study of the peritoneal fluid in perforated peptic ulcers.
Surg., Gynec. & Obst., 68:1017-1020, (June) 1939.
6. DeBakey, M. : Acute perforated gastroduodenal ulceration;
a statistical analysis and review of the literature. Surgery,
8:1028-1076, (Dec.) 1940.
7. DeBakey, M., and Odom, C. B.: Significant factors in the
rognosis and mortality of perforated peptic ulcer. South,
urgeon, 9:425-436, (June) 1940.
8. Eliason, E. L., and Ebeling, W. W. : Catastrophies of peptic
ulcer. Am. J. Surg., 24:63-82, (April) 1934.
9. Elman, R. : Surgical aspects of acute pancreatitis with
special reference to its frequency as revealed by the serum
amylase test. J.A.M.A., 118:1265-1268, (April 11) 1942.
10. Fallis, L. S.: Perforated peptic ulcer; an analysis of 100
cases. Am. J. Surg., 41:427-436, (Sept.) 1938.
11. Gatch, W. D., and Owen, J. E. : The technique of closing
perforated ulcers of the duodenum. Ann. Surg., 105:750-757,
(May) 1937.
12. ' Graham, R. R. : The treatment of perforated duodenal ulcers.
Surg., Gynec. & Obst., 64:235-238, (Feb.) 1937.
13. Graham, R. R., and Tovee, Major E. B. : The treatment of
perforated duodenal ulcers. Surgery, 17:704-712, (May)
1945. "
14. Graves, A. M. : Perforated peptic ulcer. Internat. S. Di-
gest., 16:259-267, (Nov.) 1933.
15. Gutherie, D., and Sharer, R. F. : Permanence of cure
following ruptured duodenal ulcer. J.A.M.A., 107:1018-
1023, (Sept. 26) 1936.
16. Hartzell, J. B., and Sorock, M. L. : Acute perforated peptic
ulcer; simple closure through a short transverse incision.
Surg., Gynec. & 6lbst., 69:669-670 (Nov.) 1939.
17. Johnston, L. B. : Acute perforation of gastric and duodenal
ulcers. Internat. Clin., Ser. 36, 2:145-156, (June) 1926.
18. Judine, S. : Etude sur les Ulceres gastriques et duodenaux
perfores. J. Internat. de chir., 4:219-338, (May and June)
1939.
19. Kelly, M. W. : Acute perforated peptic ulcers. Surgery,
6:5^4-534, (Oct.) 1939.
20. Knight, R. T. : Combined use of sodium pentothal, into-
costrin (curare), nitrous oxide. Canad. M. A. J., 55:356-
360, (Oct.) 1946.
21. Laliey, F. H. : Peptic ulcer. Pennsylvania M. J., 41:79-87,
(Nov.) 1937.
22. Lynn, F. S. and Hull, H. C. : The elective transverse
abdominal incision. Ann. Surg., 104:233-243, (Aug.) 1936.
23. Lyons, S. C., and Sinclair, L. G. : Perforated peptic ulcers
in naval personnel. South, M. J., 39:575-581, (July) 1946.
24. Mead, R. H., Jr. : A study of the healing of abdominal
operative wounds following closure of perforated ulcers of the
stomach and duodenum. Surgery, 14:526-530, (Oct.) 1943.
25. McCabe, E. J., and Mersheimer, W. L. : Acute gastroduo-
denal perforations; review of Metropolitan Hospital series,
1930-1941. Am. J. Surg., 62:39-49, (Oct.) 1943.
26. McCreery, 1. A.: Perforated gastric and duodenal ulcer.
Ann. Surg.. 107:350-358, (March) 1939.
27. Olson, H. B,, and Norgore, M.: Perforated gastroduodenal
ulcers; a study of 166 cases. Ann. Surg., 124:479-491,
(Sept.) 1946.
28. Sallick, M. A. : Late results in acute perforated peptic
ulcer treated bv simple closure. Ann. Surg., 104:853-863,
(Nov.) 1936.
29. Scoutter, L. : Shock in perforated peptic ulcer. Surgery,
10:233-241, (Aug.) 1941.
30. Shallow, T. A. : The surgical treatment of peptic ulcer.
T. M. Soc. New Jersey, 38:576-580, (Nov.) 1941.
31. Shawan, H. K. : Acute perforated ulcer. Am. J. Surg.,
40:70-72, (April) 1938.
32. Sherman, L. F. : Acute gastroduodenal perforation. Bull.
Surg. Staff Seminars Minneapolis Veterans Hosp., 1:36-47,
(Sept. 17) 1946.
33. Steinberg B. : Peritoneal exudate; a guide for the diag-
nosis and prognosis of peritoneal conditions. J.A.M.A.,
116:572-578, (Feb. 15) 1941.
34. Taylor II.: Perforated peptic ulcer treated without opera-
tion. Lancet, 2:441-444, (Sept. 28) 1946.
35. Ulfelder, Captain H., and Allen, A. W. : Acute perfora-
tion of ulcer's of the stomach and duodenum. New England
J. Med., 227:780-784, (Nov. 21) 1942.
36. Visick, A. H.: Conservative treatment of acute perforated
peptic ulcer. Brit. M. J., 2:941-944, (Dec. 21) 1946.
37. Wangensteen, O. H.: Non-operative treatment of localized
perforations of the duodenum. Minnesota Med., 18:477-480,
(July) 1935.
38. Williams, A. C.: Perforated peptic ulcer; a follow-up study
of 100 cases. New England T. Med., 230:785-790, (June
29) 1944.
Discussion
Dr. Clarence E. Dennis : It is probable that Dr.
MacKinnon’s review reflects the more recent experience
of most hospitals of the type of Minneapolis General.
As he points out, the general improvements that have
been widely adopted in anesthesia, preparation of the
patient, surgical technique, and postoperative manage-
ment have resulted in a marked drop in mortality rates
in the past few years. The advent of penicillin has
played no small part in this development.
This general change in type of management nullifies
in part some arguments that one would like to draw from
Dr. MacKinnon’s figures. He found a 35 per cent mor-
tality rate in those patients in whom the abdomen was
drained and a 10 per cent mortality when drainage was
omitted. The significance of these figures is open to
doubt by the fact it is the recent cases only, by and
large, which have been closed tightly. The same con-
siderations apply to the use of nonabsorbable suture
in the closure of the gastric or duodenal defect, a
relatively recent development ; in this group the mor-
tality was one-fourth that of the older catgut closed
group.
Even though one could challenge the argument that
this showed silk intestinal closure to be safer than cat-
gut, we are inclined to favor the use of silk through-
out in view of the rather conclusive demonstration by
Shambough and Dunphy ( Surgery , 1937) that contam-
inated wounds heal more cleanly when closed by silk
than by catgut.
A major share in the improvement in results comes
from the quality of anesthesia now available to us. The
exact type of anesthetic is much less important than the
training which Dr. Knight and his group have provided
(Continued on Page 1267)
1262
Minnesota Medicine
STREPTOMYCIN: ITS PRESENT USES
DONALD R. NICHOLS. M.D.
Rochester, Minnesota
npHE effectiveness of streptomycin in control-
ling certain infections which are resistant to
other chemotherapeutic agents is now well es-
tablished. Most authors agree that the use of
streptomycin is justified in the treatment of all
serious or potentially serious infections caused
by organisms which are known to be sensitive to
this antibiotic agent. Streptomycin has been found
to be definitely superior to other available thera-
peutic agents in the treatment of certain diseases.
These diseases include tularemia, meningitis
caused by Hemophilus influenzae, bacteriemia
caused by susceptible organisms, uncomplicated
infections of the urinary tract caused by certain
organisms, pneumonia caused by Klebsiella pneu-
moniae or Hemophilus influenzae, and some forms
of tuberculosis. Streptomycin appears to be of
value in the treatment of certain other infections
but further clinical research will be necessary be-
fore a final estimate of the value of streptomycin
in the treatment of these infections can be made.
The effectiveness of streptomycin in most cases
of tularemia has been amply demonstrated.3,9’10
The morbidity and mortality from this disease
have been significantly decreased.
Meningitis caused by Hemophilus influenzae
usually responds well to treatment with streptomy-
cin.1’9’10 In cases in which the patients are seri-
ously ill, the use of sulfadiazine and rabbit anti-
serum also should be considered. Meningitis
caused by other organisms which are sensitive to
streptomycin may respond to treatment with this
antibiotic agent. Penicillin often is necessary to
eradicate secondary invaders.
Bacteriemia caused by certain Gram-negative
and Gram-positive organisms responds well to
treatment with streptomycin if the organisms are
sensitive to this antibiotic agent.9’10 Streptomycin
is often effective in the treatment of bacteriemia
caused by organisms which are resistant to peni-
cillin. The literature contains reports of a few
cases of bacterial endocarditis in which adminis-
tration of streptomycin produced a cure.8’12
Infections of the urinary tract caused by cer-
From the Division of Medicine, Mayo Clinic, Rochester, Min-
nesota.
• Read at the annual meeting of the Minnesota State Medical
Association, Duluth, Minnesota, July 1, 1947.
tain susceptible Gram-negative organisms respond
well to treatment with streptomycin but the results
of' the routine treatment of urinary infections with
streptomycin have been disappointing.9’10 The best
results appear to have been obtained in cases in
which the infection was caused by Proteus am-
moniae or Aerobacter aerogenes. Poor results
usually are obtained when a foreign body or ob-
struction is present in the urinary tract. It should
be remembered that streptomycin is most effective
in an alkaline urine. Sodium bicarbonate or other
alkalies should be administered when indicated.
Encouraging results have been obtained in the
treatment of some types of pulmonary disease
with streptomycin.2’5 Pneumonia, particularly that
caused by Klebsiella pneumoniae or Hemophilus
influenzae, may respond to treatment with strep-
tomycin. Empyema caused by sensitive organisms
occasionally responds well.
Accumulating evidence indicates that strepto-
mycin has a limited suppressive action on infec-
tions caused by Mycobacterium tuberculosis.6 In
many cases of predominantly exudative tuber-
culosis of the lungs, the immediate results have
been satisfactory. Tuberculous lesions of the
larynx and tracheobronchial tree usually have
healed under treatment with streptomycin. Chronic
draining sinus tracts may close within a few weeks
after the administration of streptomycin is started.
However, mortality rates remain high in cases of
tuberculous meningitis and miliary tuberculosis
in spite of treatment with streptomycin. In renal
tuberculosis, actual healing has been observed
only rarely. The place of streptomycin in the
treatment of tuberculosis has not been fully deter-
mined. It appears, however, that this will be a
useful adjunct when combined with standard
methods of treatment.
Results obtained with streptomycin in the treat-
ment of other types of infections have been vari-
able. A suppressive effect has been noted5’10 in
some cases of acute brucellosis but there has been
a recurrence of symptoms in most of the cases.
No effect has been obtained in the treatment of
chronic brucellosis. The results obtained to date
in the treatment of typhoid fever have been dis-
appointing. Laboratory studies suggest that
December, 1947
1263
STREPTOMYCIN : ITS PRESENT USES— NICHOLS
whooping cough may respond to treatment with
streptomycin.4
Streptomycin is an effective agent when ad-
ministered to certain types of surgical patients.
Recent studies have indicated that streptomycin,
when administered by the oral route, is the most
effective agent available for reducing the number
of bacterial organisms in the feces.13 It has been
used successfully in the preparation of patients
prior to operations on the colon. When admin-
istered by intramuscular injection or by nebuliza-
tion, it is a helpful adjunct in the preparation of
patients prior to pulmonary resection.11 In certain
instances streptomycin appears indicated in the
treatment of traumatic or operative wounds.7
There is evidence to suggest that streptomycin
is of value in the treatment of experimental peri-
tonitis13 but clinical experience is as yet too limited
to warrant any definite statements regarding the
effectiveness of this agent in the treatment of
clinical peritonitis.
The ability of some strains and species of or-
ganisms to develop a resistance to streptomycin
rapidly in vitro has been demonstrated repeat-
edly.10 Clinically, a similar development of resist-
ance appears to take place. The ability of bac-
teria to develop a resistance to streptomycin is,
of course, of great clinical importance. It appears
essential that the bacteria be eradicated completely
in the shortest possible time if satisfactory clinical
results are to be obtained. This means the admin-
istration of adequate doses of streptomycin from
the onset of treatment and the use of all other
measures which will aid in eradicating the in-
fecting organism rapidly.
Some toxic reactions have been encountered
from the use of streptomycin. Disturbances in
equilibrium and hearing may occur if treatment
with streptomycin is prolonged. Dermatitis is
encountered in some cases. Because of these toxic
manifestations, care must be used in the admin-
istration of this antibiotic agent, and the indis-
criminate use of streptomycin is to be condemned.
Summary
Streptomycin appears to be definitely superior
to other available chemotherapeutic agents in the
treatment of certain diseases. These diseases in-
clude tularemia, meningitis caused by Hemophilus
influenzae, bacteriemia caused by susceptible or-
ganisms, uncomplicated infections of the urinary
tract caused by certain organisms, pneumonia
caused by Klebsiella pneumoniae or Hemophilus
influenzae, and some forms of tuberculosis. Strep-
tomycin appears to be of value in the treatment of
certain other infections but further clinical re-
search will be necessary before a final estimate
of the value of this agent in the treatment of these
infections can be made. Streptomycin is an efifec-
tive agent when used in the preparation of patients
for operations on the colon and prior to pulmonary
resection. Certain toxic manifestations are occa-
sionally encountered when streptomycin is ad-
ministered to patients.
References
1. Alexander, Hattie E., and Leidy, Grace: The present status
of treatment for influenzal meningitis. Am. J. Med., 2:457-
466, (May) 1947.
2. Durant, T. M.; Sokalchuk, A. J.; Norris, C. M., and Brown,
C. L. : Streptomycin therapy in Hemophilus influenzae pul-
monary infections. J.A.M.A., 131:194-196, (May 18) 1946.
3. Eoshay, Lee: Treatment of tularemia with streptomycin. Am.
J. Med., 2:467-473, (May) 1947.
4. Hegarty, C. P. ; Thiele, Elizabeth, and Verwey, W. F. : The
in vitro and in vivo activity of streptomycin against Hemoph-
ilus pertussis. J. Bact., 50:651-654, (Dec.) 1945.
5. Herrell, W. E., and Nichols, D. R. : The clinical use of
streptomycin: a study of forty-five cases. Proc. Staff Meet.,
Mayo Clin., 20:449-462, (Nov. 28) 1945.
6. Hinshaw, H. C.; Pyle, Marjorie M., and Feldman, W. H.:
Streptomycin in tuberculosis. Am. J. Med., 2:429-435, (May)
1947.
7. Howes, E. L. : Topical use of streptomycin in wounds. Am.
J. Med., 2:449-456, (May) 1947.
8. Hunter, T. H.: Use of streptomycin in the treatment of
bacterial endocarditis. Am. J. Med., 2:436-442, (May) 1947.
9. Keefer, C. S. : Blake, F. G. ; Lockwood, J. S.; Long, P. H. ;
Marshall, E. K., Jr., and Wood, W. B., Jr.: Streptomycin
in the treatment of infections; a report of one thousand cases.
J.A.M.A., 132:4-11, (Sept. 7) and 132:70-77, (Sept. 14) 1946.
10. Nichols, D. R., and Herrell, W. E. : Streptomycin: its clini-
cal uses and limitations. J.A.M.A., 132:200-205, (Sept. 28)
1946.
11. Olsen. A. M.: Streptomycin aerosol in treatment of chronic
bronchiectasis; preliminary report. Proc. Staff Meet., Mayo
Clin., 21:53-54, (Feb. 6) 1946.
12. Priest, W. S., and McGee, C. J.: Streptomycin in the treat-
ment of subacute bacterial endocarditis; report of three cases.
J.A.M.A., 132:124-126, (Sept. 21) 1946.
13. Zintel, H. A.: Streptomycin in peritonitis. Am. J. Med., 2:
443-448, (May) 1947.
Think of the benefit from a campaign to stop the
spray of infected mouth and nose droplets ! Not only
would the spread of the disease be slowed, hut the sea-
sonal surge of diseases like the common cold, influenza,
measles, whooping cough and pneumonia would diminish.
It would be possible to go to a movie without having a
germ-laden spray hurled at one from behind and conse-
quently having to suffer from the other fellow’s respira-
tory infection. Under these conditions, dodging the
tubercle bacillus, in and out of the hospital, would be
possible for all of us. — Ezra Bridge, M.D., NTA Bulle-
tin, June, 1947.
1264
Minnesota Medicine
CARDIAC FINDINGS DUE TO STERNAL DEPRESSION
Report of Two Cases
ALLAN E. MOE. M.D.
Moorhead, Minnesota
A N apical systolic murmur is often the domi-
■*- nating sign on which the diagnosis of organic
heart disease is based. Rarely, it may be the only
finding indicative of organic involvement. In-
correct evaluation of this murmur is frequently
responsible for the erroneous diagnosis of heart
disease. This is particularly serious in young in-
dividuals, usually resulting in unnecessary limi-
tation of physical activities, and its implications
lead many of them to a psychoneurotic state.
Sternal depression is a deformity commonly
encountered in the average medical practice. It
was found, according to Lang, in 3 to 5 per cent
of children in the first year of school.5 The
pathogenesis of this condition is not clear. Some
of the possibilities mentioned are : delayed and
abnormally slow growth of the sternum ; purely
mechanical intra-uterine deformity caused by
pressure of the chin, heel, or knee; trauma dur-
ing the second half of pregnancy ; fetal rickets ;
fetal mediastinitis ; disturbances of the central
nervous system ; persistence of a physiologic de-
pression in the anterior chest wall during the sec-
ond month of fetal life.3 Bromer1 observed sternal
deformities in rachitic children in the late stage
of complete healing, and states that these de-
formities often remain throughout life.
When a sufficient degree of sternal depression
exists, the heart is shifted to the left.3’4’6 In cases
where the heart is fixed in the normal position
the sternal depression indents the heart.6 Other
findings noted in different cases are : basilar,
apical, and pulmonary systolic murmurs ; redu-
plication of the first and second heart sounds ;
accentuation of the second pulmonic sound.2’3’4’7.
Fig. 4
The electrocardiographic findings are not char-
acteristic. Evans2 points out that apparent en-
largement of the cardiac shadow in the anterior-
posterior roentgenogram of the chest is not con-
firmed in the oblique views, where the heart
shadow is normal in size or sometimes seems
small. In a comprehensive review of a series of
sixteen cases of sternal depression, he notes that
the apex beat was displaced outward and a systolic
Fig. 1 Fig. 2 Fig. 3
December, 1947
1265
CARDIAC FINDINGS DUE TO STERNAL DEPRESSION— MOE
Fig. 5 Fig. 6 Fig. 7
Fig. 8
murmur present in every case. In five of these
cases rheumatic heart disease had been wrongly
diagnosed. It can easily be seen how this com-
bination of signs would lend itself to the er-
roneous diagnosis of heart disease.
The following two cases were thought worthy
of presentation to emphasize this aspect of the
problem.
Case Reports
Case 1. — A white girl, eighteen years of age, con-
sulted me because of a “heart condition" discovered
during a physical examination for college entrance. She
had been advised to exclude all strenuous activity, and
was not allowed to take gymnastic classes. She had no
complaints and had always enjoyed good health. On
questioning, she felt that she became slightly more
dyspneic than her friends on strenuous exertion. There
was no rheumatic or rachitic history. Family history was
noncontributory.
On physical examination her height was 5 feet 5
inches, weight 125 pounds. She appeared in excellent
health. A moderate degree of , sternal depression was
apparent (Fig. 1). A soft systolic murmur was heard
over the pulmonic area and at the apex. There was a
slight reduplication of the first sound at the apex.
The pulmonic second sound was markedly accentuated.
Pulse was 80 per minute and rhythm was regular. Blood
pressure was 118 mm. of mercury systolic and 86 di-
astolic. After exercise the apical . systolic murmur was
accentuated, loudest during inspiration, returning to its
original intensity within 10 seconds, as soon as the heart
rate slowed somewhat. The heart size seemed within
normal limits. The remainder of the physical examina-
tion was negative.
Routine laboratory studies, including urinalysis, com-
plete blood counts and hemoglobin determination, blood
sedimentation rate and Kahn flocculation test, were
all interpreted as normal. In the anterior-posterior
roentgenogram of the chest a slight shift of the entire
heart to the left was noted (Fig. 2). The lateral view
shows the sternal indentation with a heart shadow of
normal size (Fig. 3). Fluo'oscopic study revealed the
heart to be within normal limits as to size and contour.
The electrocardiogram was not abnormal (Fig. 4).
Case 2. — A sixteen-year-old boy in good health con-
sulted me for a physical examination. He had no com-
plaints. His past health had been excellent; however,
he had been said to have had rickets during infancy.
Family history was non-contributory.
On physical examination his height was 5 feet 11
inches, weight 140 pounds. A mild degree of pyorrhea
1266
Minnesota Medicine
CARDIAC FINDINGS DUE TO STERNAL DEPRESSION— MOE
was present. Moderate depression of the sternum was
evident (Fig. 5). At rest a soft rubbing apical systolic
murmur was heard during inspiration. The pulmonic
second sound was moderately accentuated. Blood pres-
sure was 130 mm. of mercury systolic and 76 diastolic.
Pulse was 96 per minute and rhythm was regular. The
heart size seemed within normal limits. The remainder
of the physical examination was negative.
Routine laboratory studies, including urinalysis, hemo-
globin determination, white blood count, blood sedimen-
tation rate, and Kahn flocculation test, were all inter-
preted as normal. Roentgenographic study, including
anterior-posterior (Fig. 6) and lateral films (Fig. 7)
of the chest, with fluoroscopic study, revealed the sternal
depression, with no alteration in the position of the heart.
The heart size and contour were within normal limits.
The electrocardiogram revealed no abnormal findings
(Fig. 8).
Comment
Sternal depression is encountered frequently
enough so that a clear understanding of possible
abnormal cardiac findings due to this deformity is
important. The erroneous diagnosis of organic
heart disease in a young individual may needlessly
deprive that person of a normal life, and build up
psychoneurotic patterns which may endure. In
sternal depression, apparent enlargement of the
heart plus abnormally accentuated heart sounds
and murmurs furnish the necessary criteria for a
diagnosis of heart disease based upon a cursory
examination. Thorough study, with roentgeno-
grams of the anterior-posterior and lateral views
of the chest, with fluoroscopic study, will eliminate
erroneous diagnoses of heart disease in this type
of case.
Summary
Two cases in which depression of the sternum
produced abnormal cardiac findings are reported.
There was no evidence of organic heart disease
in either case. Attention is called to the abnormal
cardiac findings possible on the basis of this de-
formity, and the importance of careful evaluation
in order to avoid the erroneous diagnosis of or-
ganic heart disease, particularly in the young in-
dividual. ,
References
1. Bromer, R. S. : The chest in rachitic children: a roentgen-
ologic study. J.A.M.A., 96:509, (Feb. 14) 1931.
2. Evans, Wm. : The heart in sternal depression. Brit. Heart
J„ 8:162, (July) 1946.
3. Grieshaber, H.: Heart in patients with funnel chest. Helvet.
med. acta, 4:462, (August) 1937.
4. Hutcheson, J. M. : The cardiac complications of funnel
breast. South. Med. & Surg., 101:266, (June) 1939.
5. Lang, K. : quoted by Wm. Evans.2
6. Pohl, R. : Funnel breast and heart form. Wien. klin.
Wchnschr., 41:1439, (Oct. 11) 1928.
7. Smith, K. S. : The heart in thoracic deformity. Middlesex
Hosp. J., 30:43, (March) 19.30.
ACUTE PERFORATED GASTRIC AND DUODENAL ULCER
( Continued from Page 1262)
for our personnel. It is a pleasure to compliment Dr.
MacKinnon on the excellent review which his study has
provided.
Dr. Stanley R. Maxeiner: Ninety consecutive cases
of perforated peptic ulcer were treated surgically at the
Minneapolis Veterans Hospital with a mortality of 5.5
per cent, and sixty-two cases treated consecutively with
but one death. Some of these patients were seen from
twenty-four to thirty hours after perforation and still
recovered. I might also add that we had no regular
anesthetist and that anesthesia consisted of spinal and
local done by the surgeon. I personally served, in the
capacity of consultant, and the greater part of the sur-
gery was done by Doctors Sedgley, Culligan, Westphal
and Mandell.
Dr. E. A. Regnier: I enjoyed hearing Doctor MacKin-
non’s paper immensely and I want to congratulate him
on his presentation. The tables he presented afford a
great deal of information. I was impressed by his
conclusions that the type of incision and the type of
closure of these wounds are important factors in mor-
bidity and mortality. I definitely subscribe to the trans-
verse incision or some modification of such incision for
the repair of perforated ulcers.
Dr. MacKinnon (in closing) : One should not in-
clude untreated cases having an incorrect diagnosis of
December, 1947
perforation with the cases in which the diagnosis has
been made and conservative management instituted. Our
records reveal several deaths due to gastric and duodenal
perforations in patients who were not operated upon or
treated conservatively. In these cases the correct diag-
nosis was unknown until necropsy had been performed.
Several of these perforations, with incorrect diagnoses,
occurred in moribund and elderly people over seventy
years of 'age. Due to their moribund condition, or the
difficulty in obtaining an adequate history, or the pres-
ence of minimal abdominal findings, an incorrect diag-
nosis of coronary disease was frequently made. Appar-
ently, acute perforations are difficult to. detect in old
people, but the possibility of this condition being pres-
ent should be kept in mind.
From our analysis, the most important and constant
factors having a relationship to the mortality are age
and the interval between perforation and operation. Per-
forations present for longer than twelve hours, or per-
forations in people over fifty years of age, have a mor-
tality rate higher than the general average. This rate
increases in direct proportion to age and the lapse of
time up to twenty-four hours. Since the physician has
no control over age and only a partial control of the
preoperative time interval, extremely low mortality fig-
ures for the larger series of cases seem unlikely in the
future. Nevertheless, one must strive for a lowered mor-
tality rate through the proper employment of the in-
fluential factors under his control.
1267
History of Medicine In Minnesota
NOTES ON THE HISTORY OF MEDICINE IN FILLMORE COUNTY
PRIOR TO 1900
By NORA H. GUTHREY
Mayo Clinic
Rochester. Minnesota
(Continued from November issue)
H. Thomas, a general practitioner of the eclectic school, was in Chatfield
from about 1865 through 1881, according to a business gazetteer, and al-
though entries in such directories are not always indices to terms of residence,
since their insertion presumably depended on the inclination of the subjects,
the fact that Dr. Thomas’ registration was continuous from 1865 through 1881
may reasonably be taken to mean that he left Chatfield in the year 1880 or 1881.
The venerable Timothy Halloran, in his history of Chatfield, in dis-
cussing physicians mentioned that “Dr. Thomas also practiced here for many
years and moved to Saint Paul, where he died.” In 1942 an eminent citizen
of Chatfield recalled Dr. Thomas as a man of middle age who was in Chatfield
ten or fifteen years, “about in line in professional abilitv with the rest of
them.” Another resident of Chatfield, one of the few to remember him, said
that Dr. Thomas “was genteel and polished. His wife’s maiden name was
P>erdon. She was the widow Terwilliger, living with her two children in
Chatfield, when Dr. Thomas fell in love with her and married her.” And
still another early citizen, in 1943 in his nineties, described Dr. Thomas as
one of dignified presence, meticulous grooming and fine clothes who habitually
wore a tall silk hat and carried a cane. On one occasion, however, dignity and
sartorial splendor were forgotten. It seems that on a day when the wooden
sidewalk in front of Briley’s Store was being torn up for replacement, sundry
of the unoccupied citizens of the town were at hand, looking in hope of
coins among the debris that had accumulated under the boards. A clerk in the
store (the old gentleman of this reminiscence), happening to have a fiye
dollar gold piece in his pocket, palmed the coin, ostensibly joined the search,
and suddenly with a shout announced this imposing find. To his great de-
light, among the group of searchers which now rapidly increased, was Dr.
Thomas, on his hands and knees, fine clothes, silk hat, cane and all.
In September, 1870, when Dr. O. A. Case, of Preston, was appointed
deputy coroner of Fillmore County, he moved to Chatfield, where he entered
partnership with Dr. Thomas, “who is well known in this county as a skillful
practitioner.” And it was in the office of Drs. Thomas and Case that a meeting
of the Fillmore County Eclectic Medical Society, of which Dr. Case was
president, was called for October 3, 1870, “all brethren of the profession in
good standing” being invited to attend.
Tt is wmrthy of note, in view of scanty data and some necessarily unverified
statements, that a Dr. Harold Thomas, residing in 1883 in Hubbard, Ilub-
1268
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
bard County, was licensed on examination under the “Diploma Law” of
1883, receiving state exemption certificate No. 598-1 (R), given on December
31, 1883.
It is believed worthy of note also that, as mentioned earlier in this series,
there came to Minnesota in 1864 one “Hammond, Thos.,” physician and sur-
geon, native of Adams County, Pennsylvania, who settled in section 31 (in
which a part of the village of Chatfield lies), Elmira Township, Olmsted Coun-
ty. This man was listed, post office Chatfield, in an illustrated atlas of Min-
nesota of 1874 as one of the book’s patrons. Considering the complete lack
of information otherwise concerning a Dr. Hammond and the fact that Dr.
H. Thomas supposedly came to Chatfield in 1864 or 1865, it is suggested
that through a clerical error the name appeared “Hammond, Thos.” instead
of “Thomas, Hammond” (or, possibly, “Harold”).
Edward R. Thompson was born in 1853 at Chicago, Illinois, one of a family
of five boys. His father, Richard Iver Thompson, was a native of Bergen,
Norway; his mother was an American woman, a native of Chicago. In their
adult years the five Thompson brothers all were residents of Minnesota : Enos,
a lawyer, and William, who had an abstract office, were in Preston ; Clarence,
a manufacturer, and Cilius, a lawyer, settled in Minneapolis.
Edward Thompson, on completion of his preliminary schooling, was a stu-
dent at the Upper Iowa University, at Fayette, for two years and thereafter
completed his academic work and took a course in pharmacy at the University
of Minnesota. It is probable that immediately on completion of his work
at the university he entered the Minnesota College Hospital, which was or-
ganized in East Minneapolis in the summer of 1881, for he was graduated
from that school of medicine in 1882. On November 10, 1883, after the pas-
sage of the “Diploma Law” in Minnesota Dr. Thompson received certificate
No. 275 (R). He was then practicing medicine in Minneapolis and the inference
is that he remained in Minneapolis until moving to Harmony, Fillmore Coun-
ty, in 1893. Dr. Lewis K. Onsgard, a native of Spring Grove, Houston County,
had just moved to the village of Houston after five years as a physician in
Harmony and the village was temporarily without a resident physician. Here
Dr. Thompson remained in general practice for fifteen years, a well-qualified
physician who is recalled as progressive in his methods and in his use of
superior equipment that was advanced for the time. He was a member of
the Methodist Church and of fraternal orders, among them the Independent
Order of Odd Fellows and the Modern Woodmen of America. In 1908 Dr.
Thompson left Harmony to settle in the village of Peterson, a few miles from
Rushford, where he spent the remainder of his life.
Edward R. Thompson was married to Harriet Lockwood, a schoolteacher,
of Eau Claire, Wisconsin. One child was born of the marriage, Lulu, who
became Mrs. E. R. Pitt, of Eau Claire, and Dr. and Mrs. Thompson adopted
one daughter, Mae, Mrs. R. L. Hanson, of St. Paul. When Dr. Thompson
died of pneumonia in 1918, in a La Crosse Hospital, he was survived by
Mrs. Pitt and Mrs. Hanson and one brother, Clarence Thompson.
French W. Thornhill, son of Samuel Payne Thornhill, M.D., was born in
Coshocton County, Ohio, on- July 18, 1843.
Dr. Samuel Payne Thornhill, in any record of physicians in Minnesota and
in any mention of his physician son, should receive consideration. Born in
Rockingham County, Virginia, on March 21, 1821, Samuel P. Thornhill was
December, 1947
1269
HISTORY OF MEDICINE IN MINNESOTA
left an orphan when he was a small child. For a few years he lived with rela-
tives but early was thrown on his own resources for support and education;
and the fact that he became an able physician bespeaks the caliber of his
native ability. He studied medicine under a preceptor in West Carlisle,
Coshocton County, Ohio ; began medical practice there and married in the
community. His sons, French W. Thornhill and Ampstead S. Thornhill and
a third child were born in the county, presumably in West Carlisle, in the
forties. While the children were young, Dr. Thornhill moved with his family
to Wisconsin, settling first in Horicon ; his wife had died, and in Horicon he
married again. Of the second marriage there were two children. After a
year or two he moved to Janesville, in 1848, where he was in partnership
with Dr. Treat, who later practiced successfully in Chicago. In 1855 Dr.
Thornhill settled in Hudson, Wisconsin, for seven years. When the Civil War
broke out he was made regimental surgeon of the Eighth Wisconsin Volunteer
Regiment, the Eagle Regiment under Colonel Murphy, and in 1862 he became
brigade surgeon. In the winter of 1869-1870 Dr. Samuel P. Thornhill, accom-
panied by his son, French W. Thornhill, who had qualified as a physician,
arrived in Austin, Mower County, and there he practiced medicine ably for
the next ten years, the first three in partnership with Dr. French W. Thorn-
hill, the last seven alone. He died in Austin in March, 1879, from gastric
hemorrhage. At the time of his death he had for a period of years been making
his home with Mr. and Mrs. (Ellen M. Backus) Fairbanks. (Mrs. Fairbanks
studied medicine under Dr. T. Thornhill’s instruction and subsequently, in
1881, she was graduated from the Women’s Medical College of Chicago and
carried on a successful practice in Austin.) Dr. S. P. Thornhill was known in
Austin as an untiring, skillful physician, “second to none in his professional
attainments” and, “if he had faults, he also had virtues,” for he was a true
and generous friend and a kind father.
French W. Thornhill at the age of nineteen years entered the Union Army
during the Civil War and served as assistant surgeon in the Eighth Volun-
teer Wisconsin Regiment, in which his father was regimental surgeon. It
seems obvious that Dr. Samuel P. Thornhill had been and continued to be
his son’s preceptor. After the war French Thornhill became a student at the
Cincinnati Medical College, from which he was graduated in 1869. Soon
after his graduation he was married and when, in 1869, he joined his father
in moving to Minnesota, his young wife accompanied him. Minnie A. Smith
was born in Daggett Hollow, Tioga County, Pennsylvania, moved with her
family to Cambria, Columbia County, Wisconsin, when she was a young
girl, and at Cambria was married to French W. Thornhill. There were four
children of the marriage, two of whom died in infancy.
For a few years Dr. French W. Thornhill practiced medicine with his
father in Austin and for a part of the time managed a farm in sections 5 and
6 of Austin Township that the senior Dr. Thornhill had bought from John I.
Wheeler, who was going into Freeborn County. In 1872 with his family Dr.
French W. Thornhill settled permanently in Spring Valley, Fillmore County.
For many years his professional card appeared in the local newspaper, West-
ern Progress: “F. Thornhill, M.D., Physician and Surgeon. Over Bank,” and
until after the turn of the century he was listed in a reliable gazetteer as a
practicing physician of the village. In 1883, when the act to regulate medical
practice in Minnesota was passed, he received an exemption certificate on
the basis of his years of experience.
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HISTORY OF MEDICINE IN MINNESOTA
Dr. Thornhill followed his profession in Spring Valley and the surround-
ing community for forty years, combining his professional activities with farm-
ing and the raising of fine horses. He died at his home on February 4, 1912,
in his sixty-ninth year, survived by his wife, two sons and his brother, Amp-
stead P. Thornhill, of Racine, Mower County, since deceased. Minnie A.
Thornhill lived twenty-one years after her husband’s death and died in Spring
Valley on February 1, 1933, at the home of her son, Fred Thornhill. In 1943
the two sons, Fred and Frank Thornhill, both retired farmers, were living in
Spring Valley.
Augustus Howland Trow was born at Cummington, Massachusetts, on
October 22, 1822; he was graduated from the' Castleton Medical College
(sometimes known as the Academy of Medicine) at Castleton, Vermont, on
November 13, 1853; and in the summer of 1856, physician and surgeon, Bap-
tist minister and farmer, he came with his wife and four children into south-
ern Minnesota and settled in Chatfield, Fillmore County. Olive Almira Trow,
of equal age (October 17, 1822) with her husband, was a native of Stamford,
Vermont. The children were Ellen Acenith, born on July 27, 1843, and Henry
Nathaniel, born on July 24, 1849, both at Windsor, Massachusetts; William
Howland, native of Victory, New York, born on August 8, 1851 ; and Milton
Augustus, native of Montezuma, New York, on May 10, 1853.
A portion of Chatfield lies in the adjoining county of Olmsted on the north,
but in 1856, as now, the greater part of the business section of the village
was in Fillmore County. One of Dr. Trow’s earliest acts of which there is
record after his arrival in Chatfield was to conduct the first religious services
to be held in the village, reading his texts from his sheepskin-covered Bible,
and shortly afterward he preached in a neighboring community in Elmira
Township, Olmsted County. The little congregation of Elmira met in a
grove, for in the settlement less than two years old there was not yet a
church building and the pioneers as a rule attended services at Chatfield
(settled in 1853).
It was not long before Dr. Trow was well established in the practice of
medicine, in business, civic affairs and politics, and in farming. In the course
of a few years after his arrival he owned and farmed land in section 33,
Elmira Township, Olmsted County, and in section 4, Chatfield Township,
; Fillmore County, and in the early period he hauled his grain, as was cus-
tomary in the region, with horses or oxen to the mills and markets of Win-
ona, on the Mississippi River. In uncertain autumn and winter weather, over
rough and hilly roads, yuth thirty to forty bushels of grain to a load and
each trip taking three or four days, those were long and cruel hauls for both
men and beasts. It has been remembered that the route was dotted with
the bones of animals that had succumbed to the rigors of the work.
In the autumn of 1856, then with his headquarters on Fillmore Street, Dr.
Trow was one of the physicians of Chatfield who published professional
cards in the first issue of the Chatfield Republican. And in the summer of 1858
he advertised in the Chatfield Democrat, as follows :
DRUG STORE
Dr. Trow would respectfully say to the public that he has on hand a full
and well selected assortment of Drugs, Patent Medicine, Xc., which he will
sell on the very lowest terms, for Cash — including Sloan’s Medicine, which
he will sell at the unprecedented low prices as follows :
Sloan’s Ointment 15 cts. per box
Condition Powders 20 and 4 per box
All other Medicines and Drugs in Proportion.
July 31, 1858. A. H. Trow, M.D.
December, 1947
1271
HISTORY OF MEDICINE IN MINNESOTA
And, seasonably, in the late autumn appeared this announcement :
CUTTERS! CUTTERS! Those who would like a sleigh ride, will do well
to call upon the subscriber, who has on hand and offers for sale, a stock
of splendid
CUTTERS
at the lowest market prices.
Chatfield, November 20, 1858. A. H. Trow
Although his professional and business cards were not published regularly
in the newspapers, his name was listed in various directories of the state
from 1865 to and including 1887.
Apparently a man of foresight and sense of professional obligation, in the
autumn of 1866 Dr. Trow joined a small group of physicians from various
parts of the county in founding the Fillmore County Medical Society and he
became the first treasurer of the organization. In one account, in the list of
charter members appears the name of M. A. Trow, obviously by mistake, as
related earlier, for Milton A. Trow, a son of Augustus H. Trow, although in
due time a physician, was in 1866 only thirteen years of age. Dr. A. H. Trow
became a member of the Minnesota State Medical Society not long after its
re-organization in 1869; his name (A. Trow) appears in the transactions of
1873 as a member of the Committee on Obstetrics. And in 1879 and 1880,
with nine other physicians, of Fillmore County, among whom was Dr. Refine
W. Twitchell, of Chatfield, Dr. Trow and his son, Dr. Milton A. Trow (grad-
uated in medicine in 1876), replied to circulars sent out from the State Board
of Health by Dr. Franklin Staples, of Winona, asking for reports on the
local incidence and control of diphtheria. Excerpts from the statements sent
in from Chatfield and published in the official report without the reporters’
names, were used in the narrative that preceded the present series of bio-
graphical notes. During these years Dr. Trow served locally in the interest
of public health and sanitation ; on April 14, 1880, he was appointed one of
the three members of the local board of health, the first such board to be
recorded in the community. After the “Diploma Law” of 1883 came into ef-
fect in Minnesota, Dr. Trow received state license No. 883 (R), given on
April 19, 1884.
There are anecdotes of Dr. Trow’s medical practice. A venerable citizen
of Chatfield who in 1943 was ninety-two years of age, recalled that when he
was fifteen he had lung fever and diphtheria and that Dr. Trow (“Old Doc
Trow”) was summoned. A few weeks previously the boy had had a severe
cough that kept him, and his family, awake at night, and for relief from which
his father had prescribed chewing black plug tobacco and swallowing the
juice — “Don’t be afraid if it makes you a little sick”- — with unfortunate re-
sults. Dr. Trow came and bled the patient, who was giving evidence of ex-
treme congestion, puncturing each arm three or four times, to produce bleeding
from about noon to night, and, be it said, watching the boy the entire time.
(Here was included a detailed description of the black blood and the patient’s
theory as to the circulation of the blood and the purpose of the bleeding.)
After the bleeding stopped, the doctor instructed the family to put wilted
cabbage leaves on the patient’s chest and keep them warm, and by morning,
the reminiscence ran, the poison was all out of the lungs, and the patient got
better— -but it took him a long time to get well after that.
And another resident of Chatfield, of the generation of the old doctor’s
sons, recalled his own father’s description of Dr. Trow’s technique of cu-
1272
Minnesota Medicine
HISTORY OF MEDICINE IN MINNESOTA
taneous vaccination against smallpox. The “old Doctor” carried around with
him a tin can full of scabs from smallpox pustules. In vaccinating a patient,
he first would scarify the skin, then search through the collection, in the tin
can for a suitable specimen and, when the choice had been made, would rub
the scab vigorously onto the prepared field. “If the patient did not die,”
said the narrator, “he was immune.” This method, however, as is well
known, was not peculiar to Dr. Trow.
Dr. Trow was not negligent of civic duty. In 1859-1860 he served a term on
the school board of Chatfield and at various times from 1859 to 1874 was a
trustee on the village council. In 1873 he and Dr. Refifie W. Twitchell, it
appears, were of the same opinion about taxation for improvements and de-
cided that it was best to let the village construct sidewalks as required and
assess individual property owners for payment; his assessment was $40.78
and Dr. Twitchell’s $10.14. In 1859 and in 1860 and again in 1872 Dr. Trow
served as representative from the district in the state legislature, at the same
time that another physician of Fillmore County, Dr. Thomas H. Everts, of
Rushford, was a senator. In a candidacy of 1868, however, he evidently was
defeated, on the Democratic ticket; of this campaign the Chatfield Democrat
had to say on October 17 that “the way he used his opponent in a debate
was cruelty to dumb animals.”
Among many items -in the local newspapers concerning Dr. Trow was an
account, “Surprise for Dr. A. H. Trow,” in the Democrat of February 3, 1883,
that seems worthy of inclusion : When some forty to fifty ladies and gentle-
men, the story ran, appeared at the Trow home, “Dr. Trow surrendered un-
conditionally.” The ladies of the party had brought with them “an abundance
of the good things that make up a rich collation,” but before the collation
was served, Milvin Bibbins, Esq. presented Dr. and Mrs. Trow “with two
comfortable rocking chairs as a token of regard from their friends.” Dr. Trow
“was almost overcome, but rapidly recovered from his second surprise* and
responded in well chosen and feeling words.” All the guests, it followed,
stayed until the witching hour of twelve under the hospitable roof of Dr.
A. H. Trow.
By the early eighties Dr. Trow, a true pioneer, had turned his thoughts to
the new Dakota Territory and had invested there in farm lands. Various ref-
erences to his interest in Dakota have been noted in the Chatfield newspapers
of the time. In August, 1883, for instance, he had returned from the territory,
driving one team 372 miles in six days, and on the last day driving eighty-
seven and a half miles and making thirteen stops ; “Flow is that for mus-
tangs?” he asked. A year later he again had just returned to Chatfield from
Dakota where he had been all summer superintending his farm. In the spring
of 1887 Dr. Trow and his son Dr. William H. Trow moved permanently
from Minnesota to Dakota. Both father and son registered on the territorial
roster of physicians on July 11, 1887, as from Carthage, Miner County,
Dakota Territory.
(To be continued in the January issue.)
President s fettel
HIDE NOT YOUR LIGHT UNDER A BUSHEL
When looked upon in the aggregate, the accomplishments of medicine appear rich and im-
posing. In the field of public relations, however, medicine has lagged. Without attempting to
offer full explanation of this situation, it may be said that, in our supposedly enlightened time,
obstacles to medical progress nevertheless are so formidable that physicians have done credit-
ably to progress at all. It is justifiable to believe that, as adverse pressure is diminished, ad-
vancement will become accelerated. I would like to devote a few moments here to further
examination of some of these thoughts.
There are in the medical profession men so imbued with the ideals of public service that
they volunteer for the task of mitigating those prejudices and obstructive notions, inimical to
the public health; which are held by some of our citizens and by some of the personnel of our
national governmental establishment. With the same high purpose of defending the people
against quackery in society and government, the American Medical Association, through its
House of Delegates, has recommended that effort be made by the medical profession to develop
a comprehensive public relations program. Accordingly, physicians of Minnesota would do
well to enlarge their public relations activities.
It has been said that one of the most fruitful sources of improved public relations is the
physician’s office. The truth of this statement cannot be denied ; but were we to rely on that
factor alone, the objective of the House of Delegates of the American Medical Association
could not be accomplished.
How, then, can we expand our public relations program? Our approach to the problem
must be realistic. We must recognize that publicity does not make up the major portion of
such a progfam but that many other factors must be considered. These should include our
relationship with other medical societies and other medical organizations, as well as with
the individual members of the Medical Association anti of the Woman’s Auxiliary. We must
strengthen our relationship with voluntary health agencies such as the Minnesota Heart Asso-
ciation, the American Cancer Society, the Minnesota Trudeau Society, and others. We must
establish mutual understanding and good will with governmental agencies, the state legisla-
ture, the state departments of health, welfare, public assistance, and education, and with
the governor’s office. We must continue to improve our relationships with the Blue Cross, the
Minnesota Medical Service ; with private insurance companies, and with groups professionally
allied with us, such as nurses, pharmacists, dentists and hospital administrators; with organ-
izations such as women’s clubs and men’s clubs and with that active liaison which unofficially
is known as the parent-teachers association; with farm and labor organizations and with news-
paper editors, radio officials, civic leaders, the clergy and educators. We must not consider
how well we are known by all these people but how favorably we are regarded by them.
We must establish methods whereby we can inform others of our activities and our prob-
lems and, at the same time, whereby we can learn as much as possible concerning their interests
and difficulties. At its last meeting, the House of Delegates of the Minnesota State Medical
Association instructed the Committee on Rural Medical Service to establish local health coun-
cils throughout the state. I attended the first meeting which was called in connection with this
program. It was held in Austin on November 11 and was planned and carried through by Dr.
Paul Leek, chairman of the Committee on Rural Medical Service. Among those who at-
tended this meeting were representatives of the farm bureau, labor, pharmacists, nurses, schools,
the American Red Cross, the League of Women Voters, mayors, county agents, and others,
and the enthusiasm manifested augurs well for the project. That is what I mean.
The work of the speakers bureau of the State Medical Association was discontinued during
the war. At this time, the demand for speakers exceeds greatly the facilities for meeting it.
This bureau should be re-established as soon as possible in order to satisfy the needs of a
citizenry which is becoming more health conscious. There is a great demand for information
on health and it is very important that the association increase the amount of literature for
general distribution.
1274
Minnesota Medicine
These and many other developments are necessary if we, hope to establish an efficient public
relations program. If we fail in this responsibility, not only shall ’we find ourselves unknown
among our neighbors, but the lack of understanding between us will be adverse to the interests
of both.
The committees of the State Medical Association and of its component societies are the
workshops in which plans of action are created. For many years these committees have
proved their value. However, they are composed of practicing physicians who, in order to
merit the trust imposed in them, must be concerned primarily with the welfare of their
patients. They are, as I said earlier, volunteers who magnanimously take of their own time
and energy and money in the interests of persons who often do not realize that the sacrifices
just mentioned are being made in their behalf. From what has just been said, it is evident that
these self-sacrificing physicians can be and should be only part-time workers. Therein, never-
theless, lies the most significant reason for failure in attainment of many of the objectives of
the American Medical Association. Consequently, employment of additional full-time per-
sonnel looms as one of the most important needs of the State Medical Association as it faces
the task of extending its public relations activities.
I would urge the House of Delegates and the Council to authorize the employment of one,
later .probably of more than one, full-time assistant in the office of the executive secretary.
This assistant should be given the responsibility of co-ordinating the activities which have
been mentioned herein and he should interpret them, for the public. He should implement the
public relations activities of the county medical societies and perform many important func-
tions as an understudy of the executive secretary.
Of course, the price of expansion of the public relations program presents a serious prob-
lem. Unfortunately, the need has become imperative at a time when the association is obliged
to use for current expenses funds which formerly have been used to supplement the reserve
fund. Owing to the unsettled economic state of the world, our reserve fund has shrunk. From
authoritative sources we learn that the dollar which was earned in 1940 is. worth only fifty cents
now, or even less. Industries have recognized this and have modified their financial structure
in order to continue in business. State medical associations similarly have found it necessary
to increase their annual membership dues in order to meet increased costs. Our annual dues
are among the lowest of all the states. In many state medical associations, each member
pays annual dues which are more than twice as much as each of us pays. Our out-of-state
colleagues have chosen to accept this added financial responsibility because they realize the
disastrous consequence to the public, and secondarily to themselves, which might attend their
failure to do so. The Minnesota State Medical Association, too, will discharge its responsibil-
ities creditably.
I say this with confidence because I know the aims and the character of my colleagues. Al-
though their outward lives are those of men of the world, their duties often resemble those
of the minister or the priest. They say little about it, but they recognize that their lives are
dedicated, first, to the service of others, as was the life of Him whose birthday we celebrate
in this final month of every year. It was He who, in the Sermon on the Mount, spoke the
words which often are paraphrased as they are given at the heading of this letter and which,
in full, according to Matthew* read as follows :
“Neither do men light a candle, and put it under a bushel, but on a candlestick; and
it giveth light unto all that are in the house.
“Let your light so shine before men, that they may see your good works and glorify v
your Father which is in heaven.”
*Matthew V; 15, 16
CL>& Lujs_-
President, Minnesota State Medical Association
December, 1947
1275
♦ Editorial ♦
Carl B. Drake, M.D., Editor; George Earl, M.D., Henry L. Ulrich, M.D., Associate Editors
STREPTOMYCIN AND TUBERCULOSIS
"PHYSICIANS are being asked about the value
of streptomycin in tuberculosis. Sufficient ex-
perience has been had in the use of this new-
antibiotic in the treatment of tuberculosis to en-
able the physician at least to advise an inquiring
patient.
A preliminary report by the Council on Phar-
macy and Chemistry* concerning the results from
543 patients treated in twenty-two different Army,
Navy and Veterans Hospitals appeared recently
and is a fine presentation of the experience with
the drug to date. We quote :
“Streptomycin is a useful adjunct in the treat-
ment of tuberculosis. Indeed, this is an under-
statement in the case of tuberculous meningitis,
miliary tuberculosis, tuberculous sinuses and
tuberculous ulcerations of the tracheobronchial
tree, for an occasional patient wdth meningitis
has survived, a high percentage of pulmonary
miliary lesions have cleared, and nearly all the
sinuses and ulcers have healed.”
Streptomycin, on the other hand, seems to have
little value in the treatment of tuberculosis of the
genitourinary tract or of bone or joint. It does
not cure the old fibrocavernous lesions of pul-
monary tuberculosis. It does, however, in con-
junction with bed rest, clear a considerable pro-
portion of exudative pulmonary disease.
As disadvantages to its use, aside from its
cost ($6.00 per gram) and scarcity, must be men-
tioned its toxicity (which is a very serious draw-
back) and the development of resistance on the
part of the tubercle bacilli during its use. The
most serious toxic effect is on the labyrinth ; this
may be permanent and may be disabling. The
development of resistance of the bacillus to strep-
tomycin in vitro probably means resistance in
vivo, and this probably means that, after a cer-
tain period of treatment, its administration is use-
less.
The conclusion is justified, therefore, that
*The effects of streptomycin in tuberculosis in man. T.A.M.A.,
135:634 643, (Nov. 8) 1947.
streptomycin should not be used in minimal pul-
monary tuberculous infection in which the pres-
ent methods of treatment are effective nor in the
presence of advanced pulmonary lesions. Neither
is it proven that it is indicated preparatory to
operation. One can also conclude that in spite of
the marvelous results obtained in certain cases,
streptomycin is not the answer in the search for an
antibiotic which will cure tuberculosis in all its
protean manifestations.
SHORTAGE OF NURSES
f | 'HE shortage of nurses which was present be-
fore the war has become even more acute since
the armistice. The causes are largely economic.
The high wages available for a young woman in
industries which require little or no training cause
her to hesitate to devote the three years to train-
ing necessary to become a trained nurse. Taking
advantage of the present level of high wages is
likely to be a short-sighted policy.
A trained nurse acquires a profession which,
like all professions, is something that cannot be
taken away. While a member of a profession
with a more or less stable income is at a dis-
advantage during periods of inflation, he or she
has the advantage during hard times. In making
this statement, we are not unmindful of the de-
pression years when there was little or no em-
ployment for certain professional people, includ-
ing nurses. Such periods, however, are fortunate-
ly comparatively brief, and the possession of pro-
fessional training is not lost during such periods.
Today, in Minnesota at least, the trained nurse
receives $9.00 a day, which for a five and a half
day week and not counting holidays averages
$185.00 a month. While a young woman in cer-
tain industries can obtain comparable compensa-
tion without much preliminary training, one
should consider whether such available work is
comparable with nursing in interest and impor-
tance.
In some states, the requirements for a regis-
1276
Minnesota Medicine
EDITORIAL
tered nurse have been lowered, and training
schools have been increased to meet the shortage.
This has not occurred in Minnesota, and we ap-
prove of maintaining the present standards re-
quired for registration so that the possession of
an R.N. degree may continue to mean the posses-
sion of high qualifications. Additional nurses can
better be provided by opening new schools or new
course.s for the training of practical nurses with
a year’s training.
A nation-wide effort is being made to increase
the enrollment in nurses’ training schools. The
American Nurses’ Association, American Hos-
pital Association and the American Medical As-
sociation have joined hands in an effort to remedy
the shortage. Individual physicians, members of
the Woman’s Auxiliary and the public at large
are urged to present to potential candidates the
advantage of entering the nursing profession.
MINNESOTA MEDICAL SERVICE
T N the September, 1947, issue of Minnesota
Medicine there appeared under “Medical Eco-
nomics” an article by Mr. Don C. Hawkins,
Chairman of the Liaison Committee of Insurance
Underwriters, describing a prepayment plan of
medical and surgical care.
When the question of prepayment medical in-
surance came up, two plans were studied, one to be
managed by the doctors themselves and the other
by commercial insurance companies, with the ap-
proval of the doctors as has been done in Wis-
consin. The latter was the plan described by Mr.
Don Hawkins in the September issue. The fol-
lowing is the doctor-backed nonprofit plan of
the Minnesota State Medical Association.
A group of eleven doctors were commissioned
by the State Medical Society to present a prepay-
ment plan which would work on the same
principle as the Blue Cross plan. This we have
done. We have had the experience of many
others to guide us and we hope we have avoided
their mistakes.
The plan of the doctors is a nonprofit corpora-
tion which came into being January 4, 1946, under
a special enabling act passed by the legislature in
1945. The object of it is “to make possible a
wider and more timely availability of medical
care, thereby advancing public health and the
science and art of medicine in Minnesota.”
Free choice of doctor is provided and the doc-
tor may refuse to serve if he so desires. Most
of the doctors in the state have signed up to co-
operate with this plan. It will take care of doc-
tors’ bills in full for unmarried individuals with
incomes of $1,500.00 or less, or $2,500.00 or less
if they have families. Above that payments may
be applied toward the doctor’s bill. No attempt is
made to set fees. The relation between the doctors
and the patient is entirely unchanged. This is
a means of helping people to pay their doctor bills
and that is all. It will pay for surgical services
and obstetrical services anywhere, and for medical
services in the hospital only.
Payment will be made according to the schedule
which is available to any doctor asking for it.
This, of course, is subject to revision as experi-
ence dictates. The present schedule we realize is
far from perfect. It was lifted “as is” from the
Massachusetts plan and was the one we con-
sidered best suited to our needs as a starter.
The estimated cost to the patient is $1.00 a
month for the individual and $2.25 a month for a
family. The method of enrollment is as with
the Blue Cross, in groups.
Again I wish to state that the patient may
choose any doctor of medicine.
We are using the Blue Cross to do the mecha-
nics of the job, selling, bookkeeping, billing, pay-
ing doctors, et cetera, but are an entirely separate
and distinct organization.
This is the doctors’ plan, the success or failure
depends upon them and their co-operation. Im-
provements, changes, et cetera, will take place
as experience warrants.
Preparations have been completed. We are now
enrolling a few large groups and on December 1,
we will begin to expand and accept all eligible
applicants.
No one profits from this plan but it will help
lower income people to pay for their medical and
surgical expenses. It will, in my opinion, give
people more for their money than any combina-
tion now offered to the general public.
OlAF I. SOHI.BERG, M.D.
MORE CARE
TN our May issue, we mentioned CARE (Co-
operative for American Remittances to Europe,
Inc.) editorially. Since then, much publicity has
December, 1947
1277
EDITORIAL
been given to this philanthropic quasi-govern-
mental organization, associated with some twenty-
seven relief agencies.
It is not so well known that this agency has
grown by leaps and bounds so that it is now
delivering 10,000 packages daily to the needy in
Europe and is prepared to increase the number to
50,000 a day. Also, instead of a limited choice in
the make-up of packages, fourteen different types
of packages are available, their contents ranging
from twenty-two pounds of “standard foods” and
special baby food packages to cotton, household
utensils, blankets and knitting wool.
It is not necessary for one to know some needy
family in Europe in order to take a small part in
relieving the widespread suffering in Europe. A
check for $10.00 sent to CARE, 50 Broad Street,
New York 4, New York, will assure the delivery
of a package to some needy family in the country
designated. Instead of giving a useless Christmas
Christmas present to some friend, in transmitting
the order for a CARE package, that friend’s name
can be sent in and a Donor Certificate will be sent
him or her, indicating that the CARE package
has been given in the name of that individual.
If each reader would try to interest ten other
people in this practical way of helping to meet
the tragic situation in Europe today, the services
of CARE would be greatly increased.
WILLIAM A. O'BRIEN
T N every field of human endeavor it happens
that from time to time one individual is out-
standing— head and shoulders above all others.
This was true of Dr. William A. O’Brien, known
as “O. B.” to many of his friends.
Instead of one, he had two specialties. The one
best known to the public was the education of the
laity in medical matters. For twenty years, he had
broadcast weekly over the radio under the spon-
sorship of the Minnesota State Medical Associa-
tion. He also broadcast for the Minnesota Hos-
pital Association and the Minnesota State Dental
Association. For many years his nationally syn-
dicated articles on health had appeared daily in
the newspapers. Elis was a remarkable facility
for putting information pertaining to medicine
and health in the simple language understandable
to the non-medical listener or reader. The field he
covered was a wide one and showed a wide range
1278
of medical knowledge. This specialty alone would
have been a full-time job for an ordinary mortal.
Dr. O’Brien’s main vocation was as an educator.
As director of the Center for Continuation Study
of the University of Minnesota since its organi-
zation, the success of this pioneer undertaking in
postgraduate instruction absorbed much of his
thought and energy. Its outstanding success was
due to Dr. O’Brien.
As though this were not enough, Dr. O’Brien
was professor of preventive medicine and health
education in the medical school. He was also ac-
tive in cancer and tuberculosis control, being a
member of the board of directors of the American
Cancer Society and chairman of the Hennepin
County Tuberculosis Association’s annual Christ-
mas Seal campaign for the past ten years.
Probably no member of our profession had
such a wide acquaintance among the physicians of
the state and he seems to have had a remarkable
faculty for remembering names and faces. Thou-
sands of citizens of Minnesota and bordering
states who had heard his genial voice and had
read his newspaper articles felt they had lost a
personal friend when news of his sudden depar-
ture was announced.
While it seems likely that Dr. O’Brien’s stren-
uous existence may have shortened his life, he
used his abilities to the utmost for the benefit of
medicine and mankind. The proposal of Dean
Harold Diehl to start a memorial fund to provide
for the inclusion in The Mayo Memorial Center
of new and more adequate quarters for the Center
of Continuation Study in memory of Dr. O’Brien
seems most timely and appropriate.
A MEMORIAL TO DR. O'BRIEN
HEN death claimed Dr. William A. O’-
Brien last month many thousands of people
felt a sense of great personal loss. In his individ-
ual contacts, in his classes, in his public lectures,
;in his radio talks, and in the many groups with
which he worked, Dr. O’Brien radiated friend-
ship, interest and wise counsel. It can be truly
said that the world is better for his having lived
in it.
Since Dr. O’Brien’s death many of these
friends have suggested that in appreciation of
what he meant to them they would like to contrib-
ute toward a memorial in his honor. In response
Minnesota Medicine
EDITORIAL
to these suggestions, Dr. Harold S. Diehl, Dean
of Medical Sciences at the University, appointed
a special committee, under the chairmanship of
Mr. Ray M. Amberg, Superintendent of the Uni-
versity Hospitals, to consider an appropriate me-
morial. This committee proposes that adequate
facilities be provided in the new medical center
for the continuation study programs in medical
and health fields which Dr. O’Brien developed.
These programs were Dr. O’Brien’s primary in-
terest because they contribute so directly to better
health and better medical care ; they reach down
into every home and community in the state.
This memorial will perpetuate the memory of
Dr. O’Brien, and insure continuation of the work
in which he pioneered.
Contributions toward this memorial may be
sent to the University of Minnesota for the Wil-
liam A. O’Brien Memorial Fund. The names of
contributors will be made a matter of record and
sent to the family.
WILLIAM A. O'BRIEN
A Tribute
When Dr. O’Brien signed off on his radio program the
morning of November IS, no one could have suspected
that his life’s work of public education had been finished.
For years his voice had entered classrooms throughout
this State and had also been listened to attentively by
thousands who welcomed this opportunity of attending
school in their homes and learning from him the message
of good health. Through his radio programs, through
his newspaper articles, his countless addresses, and his
personal contacts, he had become one of the best-known
and best-loved citizens of this State. Barely nine hours
after this last broadcast Dr. William A. O’Brien lay
physically dead but his spirit and influence continue to
live as powerful and moving as was the personality
which they reflected.
It is probable that most people in Minnesota never
saw Dr. O’Brien though many of them knew him by
his pictures. It is equally certain that he had never seen
most of them. But no one could listen to him week after
week without coming to know him, for it> was his per-
sonality as well as his voice that entered the classroom
and the home. They came to know him as a person of
great human warmth, who radiate a sense of well-being
and good cheer. They recognized him as a genial friend
who inspired confidence in all who came within his
sphere. They felt that here was an inspired teacher who
had a profound affection for all mankind ana was anx-
ious to carry his message of health to all his friends.
And it was as one friend to another that he met
the public over the air, through his speeches and his per-
sonal contacts. While he may not have known most of
his public by sight, there were many whom he did know
in person, many more whom he knew through friends
and relatives, and all of them he knew as a group. In
these radio or public addresses, as in his University
classroom, he loved to think that he was talking to his
friends or to the sons or daughters of those whom he
knew well or whom he had met as he travelled around
Minnesota. Dr. O’Brien was a man of vast acquaint-
ances. Few have been privileged to know personally so
many people throughout the State and few have ever
cherished these friendships as deeply as did he. Apart
from his family they were his most prized possession.
He also knew human nature, and had a singularly broad
understanding of young and old alike and a capacity to
project himself into their situation and understand their
needs and uncertainties. It was from this basis of un-
derstanding and love of mankind that Dr. O’Brien talked
or wrote his way into the hearts and lives of millions
throughout the nation.
Dr. O’Brien talked and wrote simply, naturally and
directly, in keeping with his character. He did not re-
sort to oratorical or rhetorical devices, to tricks of de-
livery or teaching. He had a message to deliver, a mes-
sage that came from the heart, one that he was most
anxious to have heard because it was designed for
friends whom he wanted to help. The public recognized
the reliability of this message for it was a reflection of
the integrity of his character. It was something more
than a mere message of medical facts. He was teaching
facts, to be sure, but he was most interested in these as
part of the normal development for life and the tasks
and responsibilities that citizenship imposes on the in-
dividual. He was most eager that everyone should learn
to assume his share of the burden of protecting the
health and well-being of the community.
To the medical profession of the Northwest and of
Minnesota in particular, Dr. O’Brien was a symbol of
continuing professional development. He had a singular
capacity for sympathetic understanding of the profes-
sional and educational needs of the practitioner. This
was coupled with an impelling urge to help his fellow
physicians in their quest for that further knowledge
needed to keep them abreast .of the rapid current changes
in medical practice. He was not satisfied with a career
devoted solely to public education for health but took
unto himself the added burden of helping his medical
friends to appreciate the benefits of postgraduate study
and to obtain that instruction required to satisfy their
needs. This he did, not out of a detached interest in
the scope and techniques of postgraduate medical edu-
cation, but as a personal friend of the physician imbued
with an overwhelming desire to put his talents to work
to improve the profession to which he was so proud to
belong.
Dr. O’Brien was also a man of great courage. Few
realized the last few months that they were listening to
one who was not well, who knew' that he w;as staring
death in the face. He knew it probably better than did
anyone else. Yet in this realization he deviated in no
Decemtei!, 1947
1279
EDITORIAL
respect from his normal warmth of personality, his de-
votion to his work, his firm desire to help to a more
healthful living. So strong was this devotion to the
task which he had set himself that lie continued his
teaching, his talking to various groups long after the
time had come when for his own good he should have
rested. Courageously and unchanged, he walked in the
shadow of death, a kindred soul who could sing with the
poet :
Fear death? to feel the fog in my throat,
The mist in my face,
When the snows begin, and the blasts denote
I am nearing the place,
The power of the night, the press of the storm,
The post of the foe ;
Where he stands, the Arch Fear in a visible form.
Yet the strong man must go:
For the journey is done and the summit atained.
And the harriers fall.
Though a battle’s to fight ere the guerdon be gained,
The reward of it all.
I was ever a fighter, so — one fight more,
The best and the last !
I would hate that death bandaged my eyes, and forbore
And bade me creep past.
No! let me taste the whole of it, fare like my peers
The heroes of old,
Bear the brunt, in a minute pay glad life's arrears
• Of pain, darkness and cold.
For sudden the worst turns the best to the brave,
The black minute’s at end,
And the elements’ rage, the fiend-voices that rave,
Shall dwindle, shall blend,
Shall change, shall become first a peace out of pain,
Then a light, then thy breast,
O thou soul of my soul ! I shall clasp thee again.
And with God be the rest !
Today the voice of Dr. O’Brien is stdled. We shall
not be privileged to hear it further. We shall miss it.
But though the voice is stilled, his spirit remains and
pervades the classrooms and homes where he taught.
The memory of his life and the warmth of his person-
ality will linger in the minds and hearts of all who knew
him, whether directly or through these indirect radio,
newspaper or lecture contacts. Those of us who knew
him best and worked side by side with him know that
we, like the reading and listening public, have lost a true
friend. Like them we have had a great privilege in be-
ing associated with him. Few persons have touched the
lives of so many of their fellow beings, and of few can
it be so truly said that they left the world a better place
from the fact that they lived in it. As his friends pick
up the torch and prepare to carry on the work which he
would wish to have continued without interruption, they
pause humbly and reverently to pay tribute to his mem-
ory and to say simply as he wrould have had it, “Well
done, Dr. O’Brien.”
Gayi.ord W. Anderson, M.D.
Director, School of Public Health
November 19, 1947
1280
COMPARATIVE COSTS OF MEDICAL CARE
Expenditures for medical care in comparison with
such items as alcoholic beverages, recreation, tobacco,
personal care and jewelry, using the figures published
by the U. S. Department of Commerce published in
July, 1947, has been made by Dr. Frank G. Dickinson,
Director of the Bureau of Medical Economic Research
of the American Medical Association, and he pre-
sents some interesting findings. The cost of oper-
ating veterans hospitals and governmental tubercu-
losis sanatoriums are not included in the government’s
figures. The items for physicians’ services include the
gross receipts of physicians in private practice exclu-
sive of payments from life insurance companies, fees
from businesses and the like. It is admitted that the
reduction in the number of physicians and dentists in
private practice, due to the war, affects the figures
somewhat.
The total expenditures for all the items selected
(medical care, alcoholic beverages, recreation, tobacco,
personal care and jewrelry) increased from 11.8 billions
in the basic period (the average for the years 1933-
1939) to 29.4 billions in 1946. The cost of medical care
alone increased from 2.6 billions to 5.6 billions during
the same period. In 1945, the amount paid for physicians’
services alone was 1.3 billions compared with 0.8 bil-
lion in the basic period. The figure for 1946 is not
available.
The totals spent in 1946 compared with the basic
period increased from 3.2 to 8.8 billions for alcoholic
beverages; from 3.1 to 7.9 billions for recreation; from
1.6 to 3.4 billions for tobacco; from 0.9 to 2.3 billions
for personal care and from 0.3 to 1.4 billions for jewelry.
The total amount spent for medical care from this
basic period (the average for 1933-39) to 1946 went up
211 per cent; alcoholic beverages 277 per cent; recrea-
tion 253 per cent ; tobacco 210 per cent ; personal care
253 per cent and jewelry 408 per cent. The total spent
on physicians’ services increased only 163 per cent from
the basic period to 1945.
The personal income of the American people not in-
cluding amounts received by the armed forces increased
from 68.7 billions in the basic period to 149.1 billions in
1945. The percentage of these totals paid for physicians’
services decreased from 1.2 per cent to 0.9 per cent dur-
ing this period. The percentage total income paid to
hospitals during this same period also decreased from
0.2 per cent to 0.5 per cent. The total cost of medical
care similarily showed a reduction from 3.8 per cent to
3.3 per cent of total income.
How is the cost of medical care divided? It is in-
teresting to note that in 1945, the physician received
30.8 per cent; the hospitals 16.8 per cent; drugs and
sundries 21.2 per cent; dentists 13.4 per cent and all
other medical care 17.8 per cent of the total.
To quote: “Medical care is expensive; it is becoming
more expensive ; yet, as a percentage of national income
in a period of frenzied prosperity, it is a shrinking item.
Medical care is expensive, but patients are getting more
for their money in terms of longer life.”
Minnesota Medicine
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
PREPAYMENT MEDICAL CARE
TERMED "JIG-SAW PUZZLE"
A jig-saw puzzle, in need of being fitted to-
gether— that is the way the present prepayment
medical care picture was sketched for delegates
to the annual North Central Medical conference,
held in Saint Paul, Ffovember 23.
Finding the proper place for health co-operatives
in the prepayment picture was one of the several
economic questions facing doctors in the north
central states discussed at the conference which
was attended by about 75 officers and committee
chairmen of the medical associations of Minne-
sota, Iowa, Nebraska, North and South Dakota
and Wisconsin.
Speaking on the health co-ops was Mr. L. S.
Kleinschmidt who has been studying the rural
aspects of prepayment medical care programs and
particularly the health co-operative movement for
the American Medical Association since 1945.
Speaking from his thirty-two years’ experience
in dealing with the developing of organizations for
meeting special rural problems, which began with
his employment in 1919 as one of the first county
agents in Missouri, Mr. Kleinschmidt gave the
doctors some of the background of the co-operative
or so-called consumer-sponsored movements.
Health Co-Ops Not New
“The health co-operative movement is not new,’
Mr. Kleinschmidt said. “It dates back ninety-six
years to the ‘French Mutual Benevolent Society of
San Francisco,’ organized in California in Decem-
ber, 1851. The AM A has been particularly in-
terested in health co-ops for the last decade.”
Mr. Kleinschmidt stressed the importance of
the medical profession’s making certain that the
highest possible level of medical care standards
are maintained in all prepayment medical care
proposals, including the co-ops. Back in 1941,
he said, the AMA announced that it was not op-
posed to the use of the principle of insurance
purely as a means of meeting the cost of medical
care when there is no interference with the quality
of service. The AMA has since been working to
set up standards to be used by co-operative or
consumer-controlled health plans when providing
medical services.
About two-thirds of all consumer-sponsored
medical care plans have been developed within
the last nine years, Mr. Kleinschmidt said. How-
ever, he pointed out, medical society plans have
an actual enrollment six times as large as the
probable enrollment of consumer-sponsored plans.
Doctors Ideal Community Leaders
Doctors as community leaders was the subject
discussed by Mr. Thomas A. Hendricks, secretary
of the AMA Council on Medical Service. Pointing
out the tremendous possibilities physicians have
as molders of public opinion, Mr. Hendricks de-
clared :
“Endowed with a formal education and back-
ground beyond that available to any other group
in the community and experienced in daily inti-
mate contacts with their fellow men as are no
other individuals, the members of the medical
profession are expected to have a conception of
affairs, an analytical power, an outspoken, in-
dependent viewpoint that gives warmth, expres-
sion, humor, philosophy and ‘color’ to their com-
munities.
“The physician more than any other person
should have a decisive influence on the life, the
thinking and the daily habits of the people.”
Mr. Hendricks warned that the American medi-
cal profession jeopardizes its position of authority
and its possibilities for leadership in the preserva-
tion of the American ideals of freedom if it al-
lows its members to become what he termed “in-
tellectually colorless.” The American medical pro-
fession, he declared, must never backslide from
the fearlessness and courage of its men “who
told their world what they thought and their
world listened and molded its action accordingly.”
December. 1947
1281
MEDICAL ECONOMICS
Vets Home-Town Care Expanding
Home-town medical care for veterans is due
to expand in the future, according to Dr. W. A.
Wright, Williston, N. D., who reported to the
doctors on a recent national conference on vet-
erans’ medical care held in Chicago.
Dr. Wright, chairman of the North Dakota
State Medical Association’s economic committee,
predicted that the administration of the veterans’
medical care program will improve as it continues
in operation.
Dr. Paul R. Hawley, medical director of the
Veterans Administration in Washington, ex-
pressed general satisfaction with the Home-Town
Care program at the Chicago Conference, Dr.
Wright said; and he indicated that the VA ap-
parently intends to use the services of private
physicians even more in the next few years.
The future course of home-town care for
veterans will depend on whether the doctors them-
selves, through their local medical societies, de-
termine to co-operate to the fullest in the present
program and whether they can enlist the support
of veterans’ organizations and lawmakers to keep
veterans’ medical care on a sound, workable basis.
Improve Agency Relations
Better relations with the public through better
co-operation with public agencies providing medi-
cal care was recommended for medical societies
by Dr. F. L. Rogers of Lincoln, Nebraska, chair-
man of the planning committee of the medical
association in that state.
National, state, county and local agencies, during
recent years, Dr. Rogers said, have been request-
ing an ever-increasing amount of medical service
for such groups as the aged, the blind, the handi-
capped, dependent children, veterans and indi-
gents ; and with this there is a growing demand for
some sort of uniform plan or policy to apply to
all such requests for doctors’ services.
Dr. Rogers described the Nebraska physicians’
solution — a carefully worked out system of closer
co-operation between the medical profession and
these agencies wherein doctors endeavor to in-
terpret medical problems to agency administrators
and to understand, in turn, the problems of the
various agencies.
Speaking on the administration of state medical
organizations, Dr. W. D. Stovall, president of
the Wisconsin State Medical Society, called at-
tention to the present trend toward organization
in which the individual has apparently been for-
gotten.
Must Act as Individuals
“We have allowed ourselves to be sucked into
a whirlpool of organization,” Dr. Stovall de-
clared. “We must give more consideration to the
individual ... all our plans are simply words —
action takes place around the individual.”
Dr. Stovall’s remarks were in accord with other
conference talks calling for leadership by physi-
cians at the community level. Setting up local
health councils, extending medical service and in-
creasing co-operation with public agencies — all
are worthy objectives, he said; they are accom-
plished best through effective local leadership.
Local leadership is the key to good medical prac-
tice and good government, Dr. Stovall main-
tained.
Dr. Stovall also suggested certain steps that
could be taken by a State Medical organization
wishing to revise its methods of operation. He
recommended that the society first appoint a com-
mittee to thoroughly analyze and evaluate the
present setup before attemping to revamp it.
Discuss Local Health Councils
A plan for establishing local health councils
was discussed by Dr. Fred Sternagel, a member
of the Iowa Interprofessional Association. Dr.
Sternagel described the plan in Iowa which is
closely allied with the work of a health council
and in which the Interprofessional Association co-
operates with the state health department to carry
health education to the people by conducting local
forums on health topics.
Working through public-spirited citizens and
organizations in the individual communities — such
as the local Parent-Teacher Association— speak-
ers are provided to go out and talk, in language
that lay audiences can understand, on topics that
the local organization has itself selected.
Professor John O. Christianson, superintendent
of the University of Minnesota school of agri-
culture, who spoke at the conference dinner, en-
couraged the doctors to continue to increase their
efforts in behalf of better rural health by taking
advantage of the awakening of farm people to
the need for improved living conditions.
For his presidential message, Dr. William Dun-
can of South Dakota reviewed the situation with
regard to the present need for more general prac-
titioners and an accompanying demand for more
service from specialists. According to Dr. Dun-
1282
Minnesota Medicine
MEDICAL ECONOMICS
can, the problem is a combination erf maldistribu-
tion of the available medical men ; not enough em-
phasis on the ideals of service inherent in the
practice of medicine ; and a tendency to over-rate
the advantages of specialization.
Dr. Gavin Named President-Elect
At the business session of the conference, Dr.
S. E. Gavin of Fond du Lac, Wisconsin, was
named president-elect, to serve as head of the con-
ference in 1949. Mr. R. R. Rosell, Minnesota’s
executive secretary, was re-elected to the secre-
tary-treasurership.
Dr. A. W. Adson, in his remarks as incoming
president of the North Central Medical Con-
ference, concluded that physicians have a duty to
shape public opinion within their own communi-
ties and their own states. They likewise, he said,
have a responsibility to utilize every possible and
workable means to extend medical care to all the
people.
Reflecting the entire spirit of the 1947 confer-
ence, the Resolutions Committee, of which Dr.
Roy W. Fouts of Omaha, Nebraska, was chair-
man, submitted the following recommendation
which was unanimously adopted by the confer-
ence :
Whereas the principal purpose of these meetings is
to stimulate thinking and to develop ideas in connection
with the changing concepts with reference to medical
needs as they affect both the public and the medical pro-
fession, and
Whereas prudence would seem to indicate that it is
wise to confine our activities to the educational phase
of these questions rather than to engage in policy-
making by becoming a resoluting organization, there-
fore, be it
Resolved that the delegates and officers of the various
state medical organizations represented in this confer-
ence and their delegates to the American Medical As-
sociation, that are in attendance at this meeting, be re-
quested to carry back to their respective societies the
ideas proposed in our discussions to the end that these
ideas may be properly presented to the appropriate com-
mittees and councils of both state and national organiza-
tions.
MOWER COUNTY TO ORGANIZE
STATE'S FIRST HEALTH COUNCIL
Steps to organize a local health council, the
first in Minnesota, were taken at a meeting No-
vember 1 1 held at Austin. The meeting, to which
were invited representatives of organizations and
agencies interested in rural health, was called by
Dr. Paul C. Leek of Austin, chairman of the Com-
mittee on Rural Medical Service of the Minnesota
State Medical Association.
About twenty-five organizations (including
some of the surrounding towns and villages) were
represented. The meeting was conducted purely
to acquaint those present with the purposes be-
hind health councils, the possibilities for better-
ment of health services in the community and to
determine whether the professional groups, gov-
ernment officials and the citizens generally would
be interested in such a project and would support
it.
The lceenst possible enthusiasm was displayed
by everyone present at the meeting. Assisting
Dr. Leek in outlining the possibilities of a health
council were Mr. J. S. Jones, secretary of the
Minnesota Farm Bureau Federation, Dr. Robert
N. Barr of the State Flealth Department, and
Dr. Louis A. Buie, president of the Minnesota
State Medical Association.
MINNESOTA STATE BOARD OF MEDICAL
EXAMINERS
230 Lowry Medical Arts Building
Saint Paul, Minnesota
Julian F. DuBois, M.D., Secretary
Mountain Lake Pharmacist Sentenced to Prison Term
ol Eighteen Months for Criminal Abortion
Re: State of Minnesota vs. Jacob S. Balzer
On November 11, 1947, Jacob S. Balzer, fifty-four
years of age, a registered pharmacist of Mountain Lake,
Minnesota, entered a plea of guilty in the District Court
of Cottonwood County to an information charging him
with the crime of abortion. Following a statement of
the facts to the Court, Balzer was sentenced to a term
of not to exceed eighteen months in the State Prison
at Stillwater, by the Hon. Charles A. Flinn, Judge of the
District Court. In sentencing the defendant, Judge Flinn
pointed out that Balzer, as a layman, was jeopardizing
the life of each person upon whom he attempted to per-
form an abortion.
Balzer was arrested on October 18, 1947, following
an investigation made by the Minnesota State Board of
Medical Examiners, County Attorney Milton F. Juhnke
and Sheriff N. J. Bell, both of Cottonwood County.
This investigation disclosed that Balzer had performed
a criminal abortion on an eighteen-year-old Mountain
Lake girl on October IS, 1947. The abortion was per-
formed by injecting an abortifacient paste manufactured
by the defendant. The paste consisted, of a soft soap
base together with iodine, potassium iodide, alcohol and
water. Balzer was to receive $100 for his services but
the fee was not paid. The patient became critically ill
and was hospitalized at Mountain Lake. Following his
arrest, Balzer gave a statement in which he admitted
having performed approximately fifteen criminal abor-
tions over a period of the past several years.
Balzer was born at Mountain Lake, Minnesota, in
1893, and graduated from the University of Minnesota
in 1916, from the School of Pharmacy. He also stated
that he took a massage course at the Chicago College
of Chiropractic. Balzer holds no license to practice mas-
sage in the State of Minnesota. The Minnesota State
Board of Medical Examiners wishes to acknowledge
the very splendid co-operation that it received in this
case from County Attorney Milton F. Juhnke and
Sheriff N. J. Bell of Windom, Minnesota.
December, 1947
1283
Minneapolis Surgical Society
Meeting of May 1. 1947
Dr. Thomas J. Kinsella, Presiding
ALIMENTARY DIVERTICULA
Single-Stage Cervical, Thoracic and Abdominal
Diverticulectomy
HORACE G. SCOTT, M.D., F.A.C.S.
Minneapolis, Minnesota
My interest in the subject of diverticula of the ali-
mentary tract was aroused during the past fifteen months,
as I had the opportunity to see and operate upon four
patients with such lesions. Each of these patients had
a rather unusual lesion either from the standpoint of
size, location, preoperative or postoperative course.
These four patients happened to be quite representative
of diverticula of the alimentary tract in general, as one
was located in the hypopharynx, one in the lower thora-
cic esophagus, one in the third portion of the duodenum,
and one was a Meckel’s diverticulum containing gastric
mucosa with acute ulceration and hemorrhage. In each
instance a single-stage operative procedure was em-
ployed for the removal of the diverticulum, in spite of
the fact that in the first three cases the lesions were
quite large for their respective locations. In each of
the first two cases the base of attachment to the
esophagus measured 4 centimeters in diameter. The
duodenal lesion had a base which measured 3 centimeters
in diameter. All four patients recovered and are in ex-
cellent health and free from symptoms at the present
time.
In addition to these four patients, I had the privilege
of seeing ten other patients with diverticula in the upper
alimentary tract and eleven additional ones with lesions
in the colon, during the past three years. In view of the
fact that most of the colon cases were asymptomatic
and had only incidental findings in the course of eighty-
eight x-ray studies of the colon, I shall exclude these
cases from this paper except to mention them and com-
ment briefly on their surgical significance. This paper,
therefore, concerns fourteen diverticula of the upper
alimentary tract seen in thirteen different patients, four
of whom came to operation (Table I).
Of the fourteen diverticula, two occurred in the upper
esophagus, one in the lower esophagus, one in the cardia
of the stomach, one in the first portion of the duodenum,
five in the second portion of the duodenum, and three in
the third portion of the duodenum, with the Meckel’s
diverticulum in the terminal ileum. Four of the thirteen
patients were males and nine were females. This fact is
of interest because in most reported series the males
predominate two to one, whereas in this series the ra-
tio was reversed. Their ages ranged from twenty-tw'o
to sixty-nine years. Their average age was fifty-two
years. Of the nine duodenal lesions, three were as-
Tnaugairal thesis.
sociated with active duodenal ulcers, one with a healed
ulcer, one with a large hiatus hernia of the diaphragm
and a sixth with metastatic melanoma of the liver. Six,
or tw'o-thirds, of the duodenal diverticula were therefore
associated with other lesions of the gastrointestinal tract.
I shall briefly review7 the literature relative to the
history of these lesions, their embryology and surgical
significance, and shall try to cover the highlights of the
past and the pertinent papers of the last five years. In
order to present the literature in a logical sequence, I
shall divide the gastrointestinal tract, from the pharynx
to the rectum, into seven parts. The first part is repre-
sented by the pharynx and cervical esophagus ; the sec-
ond, the thoracic esophagus; the third, the stomach; the
fourth, the duodenum; the fifth, the small bowel; the
sixth, the Meckel’s diverticulum, and the seventh, the
colon.
Pharyngo-Esophageal Diverticula
The history of diverticula of the cervical esophagus
dates back to 1767, when a case of pharyngoesophageal
diverticulum was observed by Ludlow. Strickly speak-
ing, these lesions are not true esophageal lesions in that
they arise from the lower portion of the pharynx close
to the junction with the upper end of the esophagus —
wherefore the name pharyngoesophageal diverticula.
Harrington has shown that these lesions arise chiefly
from three places. First, they arise on the left or right
side of the posterior hypopharynx between the inferior
constrictor and cricopharyngeal muscles. Secondly,
they may arise in the midline between these muscle
bundles, or they may arise immediately beneath the
cricopharyngeal muscle above the circular fibres of the
esophagus. He believes that there may be congenital
malformations in the attachment of these muscles and
that with advancing years a herniation may develop as
the result of constant and increasing pressure on this
congenitally weak region. To support his theory, he
stated that in his series of 140 cases the average age
of these patients was fifty-seven years. Jackson, the
Philadelphia endoscopist, has frequently noted a spasm
in the cricopharyngeal muscle while passing an eso-
phagoscope and believes that this too may be a factor
in causing increased pressure in the hypopharynx. He
likes to dilate this muscle to prevent recurrences. Mc-
Quillan thinks that in addition to these factors there
may be a neuromuscular dysfunction and associated
cardiospasm at the lower end of the esophagus and that
there may also be a constitutional basis, as diverticula
of the esophagus, duodenum and colon are often found
in the same individual.
Although this lesion was first described 180 years ago,
the first surgical attempt to extirpate one of these
pouches was not tried until 60 years ago. At that time,
1284
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
TABLE I. ALIMENTARY DIVERTICULA
Case
Age
Sex
Location of Lesion
Symptoms
Other Pathology
1.
64
M
Esophagus-U pper
Choking, regurgitation
None
2
57
F
Esophagus-Upper
Dysphagia, neck enlargement
None
3.
56
F
Esophagus-Lower
Dysphagia, regurgitation
Cardiospasm
4.
22
M
Stomach-Oardia
Halitosis, pain
Meckel’s diverticulum
5.
28
M
Duodenum — First part
Epigastric pain
Active duodenal ulcer
6.
48
F
Duodenum — Second part
Epigastric pain
Active duodenal ulcer
7.
63
M
Duodenum — Second part
Pain and soreness
Active duodenal ulcer
8.
69
F
Duodenum — Second part
Epigastric pain
Hiatus hernia
9.
65
F
Duodenum — Second part
Epigastric pain
Melanoma
10.
58
F
Duodenum — Second part
Epigastric pain
None
11.
54
F
Duodenum — Third part
Pain and nausea
None
12.
32
F
Duodenum — Third part
Pain and soreness
Healed duodenal ulcer
13.
66
F
Duodenum — Third part
Epigastric pain
None
14.
22
M
Meckel’s diverticulum
Bowel hemorrhage
Gastric ‘tic’
Nicoladoni produced a servical fistula by diverticulot-
omy. The first successful operation was performed
forty-five years ago by Von Bergmann. Since this time
the operation has been performed successfully by many
surgeons throughout the world. However, the early
reports contained many fatalities from mediastinitis and
a high morbidity rate because of cervical fistulas. These
complications led to the two-stage operation, which has
been employed until fairly recently. The two-stage
procedure reduced the mortality greatly, but led not in-
frequently to constriction of the esophagus, necessitating
postoperative dilatations.
In 1941 Stanley Maxeiner presented a single-stage
operation, used successfully in three cases, where the
danger of leakage was obviated by leaving a clamp on
the stump until it sloughed away spontaneously about
five days later. More recently the introduction of the
sulfa drugs and penicillin has definitely reduced the
hazard of the single-stage operation to the near zero
mark. Harrington reported 115 single-stage operations
in 1945 with no mortality. Only five of his cases re-
quired postoperative dilatation and only five developed
a temporary fistula. He has abandoned the routine use
of the indwelling catheter. After the experience which
I had in one of the cases I am about to present, I shall
do likewise, because I feel that the failure of this tube
to remove gastric contents led in this case to the pa-
tient’s aspiration of bile vomitus which almost resulted
in her death the night of the operation.
Case Reports
The first two cases in my series are of this pharyngo-
esophageal type. Case 1 is a typical average sized
lesion. Up to the present time, this lesion has not been
removed, although removal is definitely indicated.
Case 1. — Mr. H. C., aged sixty-four, had been troubled
for several years with paroxysms of coughing associated
with regurgitation of undigested food which he had
eaten the night before. He stated that he had brought
up whole grapes and capsules of medicine the morning
after taking them. On hearing his story, my clinical
impression was that he had an esophageal diverticulum,
On November 16, 1944, his pharynx and esophagus were
x-rayed, and a typical esophageal diverticulum of mod-
erate size was found. The pouch contained food from
the day before. This lesion was rechecked by x-ray
again in June, 1946, and the pouch was found to be
about 10 per cent larger than when first examined. To
date the lesion has not been removed.
December, 1947
Case 2 represents a very large diverticulum in this
same area. In fact, the lesion was so large that it com-
pletely filled the entire cervical mediastinum. In Har-
rington’s series of 140 cases, he reports fifteen cases of
Fig. 1. Case 2. (a) Posterior-anterior x-ray view of the upper
esophagus with 200 c.c. of barium in the pouch. Note fluid level
and gas bubble overlying barium. (b) Oblique view of same
patient preoperatively.
this large variety. The rest of his series were similar to
Case 1 of this series. Two hundred and forty cubic
centimeters of barium were needed to fill the pouch in
the upright position before the barium would trickle
over into the esophagus and down into the stomach.
X-rays taken with this amount of barium in the pouch
reveal an air pocket over the barium equal in size to
about 50 per cent of the filled diverticulum. Therefore,
the completely filled diverticulum was capable of holding
about 360 c.c. or more of fluid material. When it was
filled, the patient’s neck protruded like a patient with
a moderately large colloid goiter.
Case 2. — Mrs. M.D., aged fifty-seven, was first seen by
me on January 12, 1946. At that time she sought medical
aid for what she thought was a goiter. Her chief com-
plaint when seen was difficulty in swallowing. She stated
that she could bring up liquids as well as solids two to
three hours after eating. She had noted a gradual en-
largement in her neck during the past ten years. About
four years ago she began having choking spells when
she swallowed solid food. This condition had grown
progressively worse during the past year.
X-rays of her esophagus were taken and she was
found to have a very large pharyngoesophageal divertic-
ulum coming off the right side of the esophagus at the
level of the cricoid cartilage (Fig. 1, a and b).
1285
MINNEAPOLIS SURGICAL SOCIETY
She was admitted to the hospital on January 21, 1946,
for blood typing and intravenous fluids. Two days later
the operation was performed. Under sodium pentothal,
cyclopropane endotracheal anesthesia, a collar type of
incision was made about 4 centimeters above the clav-
icles. The platysma muscles together with the skin
flaps were reflected upward to the level of the superior
border of the thyroid cartilage and downward for several
centimeters. The carotid sheath with its contained ves-
sels, together with the sternomastoid muscle on the right
side were retracted laterally and the space between these
structures and the lateral border of the right lobe of
the thyroid was deepened down to the sac which pro-
jected laterally from the esophagus into this space. The
sac was rather easily separated from the surrounding
structures. It proved to be a very large sac, measuring
approximately 10 centimeters in length and varying from
4 to 5 centimeters in diameter; the base coming, off the
esophagus also measured 4 centimeters in length. It was
invested by an outer fascial structure which probably
represented the deep layer of the cervical fascia. This
fascial structure was opened into and the sac was isolated
near its base.
Dr. Kenneth Phelps then passed an esophagoscope
down to the sac and fed a No. 18 long catheter into the
distal esophagus. Several attempts were made before the
distal esophagus could be identified and the tube inserted
into it. A few muscle bundles were found and separated
from either side of the sac; the base was then clamped
and cut between the forceps. After excising the sac
and treating the edges of the mucosa with tincture of
merthiolate, a continuous chromic catgut dulox suture
was used to close the base. A second row of continuous
catgut was placed over this first row and then about
fifteen interrupted mattress sutures of silk were used
to reinforce these sutures. Following this, two rows of
running chromic catgut sutures were placed in the
muscle bundles surrounding the esophagus to further
reinforce the suture line. After completing the closure
of the esophageal defect, about 2 grams of microform
sulfathiazole were placed in the wound. A small Penrose
drain was placed down to the point from which the
sac was removed and the flaps were reapproximated
using interrupted chromic catgut sutures in the platysma
muscles and skin clips in the skin. The drain was
brought out through the incision about 3 centimeters to
the right of the midline. The patient left the operating
room in good condition with a rubber suction tube ex-
tending down the esophagus about half way to the
stomach. Later an attempt was made to insert the tube
into the stomach, but a spasm of the cardia prevented
inserting it into the stomach without exerting undue
force on the suture line. The tube was left in the
esophagus and connected to a suction bottle.
About 7 o’clock p.m. on the day of operation, the pa-
tient had an emesis which was followed at once by
marked respiratory difficulty. The patient became cya-
notic and comatose. Her pulse became very rapid, respira-
tions labored and her blood pressure rose to 190 systolic.
An intern, not knowing she had vomited and thinking
that she had an obstruction from a hemorrhage around
the trachea, opened the wound. However, as no hemor-
rhage was found, she was taken immediately to the op-
erating room where an intratracheal tube was introduced
and a large amount of bile-stained fluid was aspirated
from her bronchi and trachea. Her color soon returned
to normal, following which her pulse rate and blood
pressure also became normal. The wound was resutured
and the intraesophageal tube was then inserted into the
stomach. The patient was returned to her room.
The intratracheal tube was also left in the trachea dur-
ing the night and bile-stained fluid was aspirated fre-
quently from this tube through a catheter connected to an
electric suction pump. The following morning the intra-
tracheal tube was removed. As a result of the aspiration
of bile into the bronchi, the patient developed one small
patch of atelectasis at the base of the right lobe. On
the second postoperative day, she developed evidence of
a wound infection probably due to the emergency open-
ing of the wound. A few days later, a stab wound was
made just above the sternal notch and some seropurulent
fluid evacuated. She was given penicillin, 20,000 units,
every three hours, but did not respond well to it. She
was given one deep x-ray treatment to the neck. When
she was discharged from the hospital, on the fifteenth
postoperative day, she still had some drainage from the
wound. However, she was eating well and within a week
the wound had stopped draining. An esophagram on
February third revealed a normal outline. It was almost
impossible to find the site from which the diverticulum
had been removed.
When the diverticulum was examined in the laboratory,
microscopically, it measured 7 centimeters in length and
6 centimeters in diameter. It had a fibrous wall 1 to 3
millimeters thick and a white smooth lining. There were
several pieces of cooked meat 1 to 2 centimeters in
diameter in the sac, in spite of the fact that the patient
had been on a liquid diet for four days before the opera-
tion. Microscopically, the diverticulum had a wall of
smooth muscle and a little fibrous tissue with a moderate
number of lymphocytes in it. It was lined by a thick
layer of stratified squamous epithelium.
During the past year, the patient has been examined by
fluoroscopy and x-ray at regular three-month intervals.
A small fleck of barium is seen to cling to the wall of
the esophagus at the site from which the former diver-
ticulum was removed. The scar in the neck is almost in-
visible in spite of the postoperative infection, owing no
doubt to the fact that a “collar” type of incision was
employed instead of the customary incision parallel to
the border of the sternomastoid muscle.
She has gained weight and has felt much better since
the operation. She no longer has any difficulty in swal-
lowing either liquids or solids.
Thoracic Esophageal Diverticula
Case 3 in this series is a large pulsion diverticulum of
the lower esophagus, which arose from the anterior sur-
face of the esophagus probably initially as a traction
diverticulum and later became a pulsion diverticulum
because of an associated spasm at the lower end of the
esophagus. When first seen two years earlier by an-
other doctor, the diverticulum was mistaken for a simple
aclasia of the esophagus. This is not an uncommon oc-
curance especially when only an anterior-posterior view
of the esophagus is made. However, a good oblique or
lateral view of the barium-filled esophagus should reveal
the true nature of this lesion. Most of the diverticula
of the lower third of the esophagus are of this type.
However, the most common lesion of the thoracic
esophagus is the small traction type, located in the middle
or upper third of the esophagus behind the bifurcation of
the trachea. Here inflammatory peribronchial and me-
diastinal nodes frequently lead to extension of the proc-
ess to the adjacent esophagus with resultant scar tissue
contracture leading to small out-pouchings of the
esophagus. Unless these lesions are associated with an
aclasia they rarely attain size sufficient to produce symp-
toms.
This is not true, however, of the less common pulsion
type seen just above the diaphragm. To date, few op-
erative reports concerning removal of these lesions can
be found in the literature. Most of the lesions in the past
have been treated by dilatation of the cardiac sphincter.
Hurst in 1925, Jackson and Jackson in 1933 and Nissen
in 1934 have all obtained relief of symptoms in similar
cases by dilatation of the cardia. The patient included
in this report, likewise, was relieved by dilatation for
1286
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
about twenty months after this was done in 1944. She
then had a return of her former symptoms.
Based' on experimental work, Cosset in 1903 and Lo-
theissen in 1908 suggested transdiaphragmatic anastomo-
sis of these lesions with the stomach. According to Her-
grovsky in 1912, this was actually done by Lotheissen.
In 1931, Lotheissen briefly referred to his case and re-
ported that esophagogastrostomies supposedly for di-
verticulum had been carried out by Sauerbruch and
Henschen. However, the first extirpation of one of these
diverticula was apparently carried out successfully by
Clairmont in 1924, using the abdominal transdiaphrag-
matic route. He displaced the sac and adjacent esophagus
into the peritoneal cavity and then removed the pouch.
Von Hacker and Lotheissen in 1926 noted the success-
ful removal of a sac from the lower esophagus by Willy
Meyer. In 1927, Sauerbruch reported three successful
cases, one by the transpleural route, the other two
through the anterior and posterior mediastinum. One
additional case each was reported by Quartero in 1931
and Barrett in 1933, making a total of seven successful
cases, five by the transpleural route. Turner attempted
to avoid the dangers of opening the esophagus by in-
verting a small pouch. Recently, this same procedure has
been employed by Ferguson and Cameron in handling
lesions of the duodenum. In 1937, Lahey sutured the sac
in an inverted manner. This same method had been em-
ployed by Bortone in lesions of the hypopharynx to
avoid the dangers of infection.
In 1945, Lahey reported successful transpleural re-
moval of a pulsion diverticulum and stated that he now
had treated a total of six such cases with no mortality.
In five of these cases the sac was not removed. He
employed the method of fixing the apex of the sac up-
ward along the paravertebral bodies. Recently Janes and
Harrington have each reported the removal of four
diverticula of the thoracic esophagus by the transpleural
route. To date, fourteen transpleural extirpations of the
sac have been reported in the literature, in addition to
one transabdominal removal, several treated by trans-
diaphragmatic anastomosis to the stomach, and six
apical fixations of the sac in an upward direction. The
following case represents another successful trans-
pleural extirpation of a large pouch of the lower
esophagus.
Case 3. — Mrs. E. C., aged fifty-six, gave a history of
bouts of intermittent vomiting since 1913. For the past
twelve to fifteen years, she has had difficulty in swal-
lowing and has had a feeling that foods stuck back of
the lower sternum and that she had to wash them down
with water or else vomit. Two years ago, a diagnosis
of aclasia was made and her cardiac sphincter was
dilated. She was relieved for some time, but during the
two months preceding the operation, her former symp-
toms returned and she regurgitated liquids whenever she
bent over to pick something up from the floor.
On August 26, 1946, she was admitted to the hospital.
X-rays were taken which revealed a rather large diver-
ticulum coming off from the anterior part of the distal
fourth of the esophagus about 4 centimeters above the
dome of the diaphragm, just back of the heart (Fig.
2, a and b).
An indwelling gastric tube was inserted through the
nose five days prior to operation and Varco feedings with
added vitamins were started. The patient was operated
December, 1947
on, September 3, under endotrachial cyclopropane, so-
dium pentothal and curare anesthesia. The ninth rib
was removed on the left side in the usual manner. The
chest was opened through the bed from which the ninth,
rib was removed. The ribs were then spread, exposing
Fig. 2. Case 3. (a) Posterior-anterior x-ray view of large
diverticulum of lower esophagus. Note x-ray resemblance to an
aclasia of the esophagus, (b) Lateral x-ray view of same patient
shows location of diverticulum just above the dome of the dia-
phragm.
the left lower lobe of the lung. Adhesions were found
between the diaphragm and the base of the lower lobe.
These were cut carefully and all bleeding points were
ligated as they were encountered with 000 chromic
catgut sutures. The pulmonary ligament to the left
lower lobe was then cut up to the point where the
bronchial veins were seen coming from the hilum of
the lung. The lung was then pushed upward exposing
the heart and the thoracic aorta. The esophagus between
these two structures above the dome of the diaphragm
was seen to be broader and fuller than no.mal at this
point. The reflection of the pleura over the esophagus
was then split vertically and separated gradually by
blunt dissection from this portion of the esophagus and
the diverticulum. Gradually the entire diverticulum
was exposed and pulled upward into the wound until
its base, which measured about 4 centimeters in diame-
ter, was visualized clearly. Two Carmault clamps were
then placed across the base and the diverticulum was
removed by cutting between these Clamps.
The mucosa was phenolized and then inverted with an
over and over running dulox suture. A second row of
running suture was applied over the first row and then
reinforced with about fifteen mattress sutures of fine
silk. Several interrupted sutures were placed in the
pleural covering of the esophagus to reapproximate these
leaves loosely. Then a drain was placed down to the
base of the esophageal incision in the form of a soft
rubber catheter and this was brought out through the
posterior end of the incision. The chest was closed in
the usual manner, using through and through sutures of
00 chromic catgut. In order to facilitate the closure,
four heavy silk sutures were placed around the ribs
to approximate them. These were removed after the
muscle closure had been effected. The skin was closed
with a running lock silk suture. The patient left the
operating room in good condition. After she had re-
turned to her room, the end of the chest catheter was
placed in a bottle of sterile saline. About 200 c.c. of
serosanguineous fluid drained into the bottle during the
first twenty- four hours. Three days later this tube was
removed from the chest.
The pathologist reported the diverticulum to be 5 by 4
centimeters with an opening 2 centimeters in diameter.
It had a fibrous wall 3 millimeters thick and was lined
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MINNEAPOLIS SURGICAL SOCIETY
by white epithelium similar to that of the esophagus.
Microscopically, the diverticulum was lined by stratified
squamous epithelium and had a wall composed of
bundles of smooth muscle and fibrous tissue. One cluster
of mucous glands was noted in the submucosa.
Following the operation, nasal suction was continued
for five days. Varco feedings, through the tube, were
started on the second postoperative day and continued
until the tube was removed five days later. On the
ninth postoperative day she was placed on a soft diet.
On the tenth day x-rays were taken which revealed a
straight esophagus with only slight narrowing at the site
of the resection. The chest contained only a small
amount of fluid in the left costophrenic angle.
She has been rerayed following the operation at three-
month intervals, and to date the esophagus appears es-
sentially normal. The patient feels very well, has gained
weight and has none of her former symptoms.
Gastric Diverticula
Case 4 in this series is that of a gastric diverticulum
involving the cardia of the stomach. These lesions are
found less often than are diverticula in any other part
of the gastrointestinal tract. Rivers, Stevens and Kirk-
lin found only twenty-five lesions in 91,532 routine x-ray
studies at the Mayo Clinic since 1926. Four specimens
were found at that institution in 3,662 postmortem ex-
aminations, and ten lesions were discovered in 11,234
exploratory operations on the stomach. Thus the in-
cidence varies from one in 1,000 to about one in 4,000
cases. Forty-three per cent of their lesions were located
in the cardia, 43 per cent in the pylorus and 14 per cent
in the fundus of the stomach.
Case 4. — Mr. R. D., aged twenty-two, came in to see
me on February 25, 1946. He complained of occa-
sional bouts of epigastric pain, failure to gain weight,
and halitosis for which he was unable to find relief.
A general examination was essentially negative and he
was advised to have gastrointestinal studies, which were
done March 4. The upper gastrointestinal tract was
normal except for a large diverticulum extending out-
ward from the cardiac portion of the stomach on the
lesser curvature just below the esophageal hiatus (Fig.
3). He was advised of the nature of his lesion and
told that it could be removed if he felt that his symp-
toms warranted it. He felt that they did, but before
be could be operated upon for this lesion he was seen
for a massive rectal hemorrhage and was operated upon
for a bleeding Meckel’s diverticulum. This report will
be given later in detail as Case 14.
Duodenal Diverticula
Next to the colon, the duodenum is the most common
site of diverticula. Several excellent articles have been
written on this subject, by Ferguson, and Cameron,
Lahey, Pearse, Edwards, and most recently Arthur Col-
lins of Duluth in the March, 1947, issue of Minnesota
Medicine. Beaver and Boland each have reported acute
perforations of duodenal diverticula. In view of the
many articles on this subject, I will make no attempt to
review the history, treatment and complications of these
lesions, but should like to confine my remarks to their
etiology.
Numerous theories have been proposed to explain the
high frequency of these lesions in the duodenum. None
seems adequate to me to explain all of these pouches and
therefore, I would like to suggest another explanation to
account for the diverticula of the third part of the
duodenum, in particular. I believe, like most authors,
that the infrequent lesions of the first part of the duo-
denum are probably secondary to ulcers which have
weakened the wall in this area. Secondly, I believe the
pouches of the second part of the duodenum form in the
weak areas produced by the entrance of the common
bile and pancreatic ducts and their accompanying blood
vessels. This is the general opinion held by most
authors. However, I have not found a good explanation
for the large mushroom type of pouches seen in the
third part of the duodenum. Those formed in this area,
cephalad to the point where the mesenteric vessels cross
the duodenum, I believe, arise as the result of increased
intraluminal pressure which reaches a maximum just
proximal to the point of this crossing. When a partial
obstruction of the duodenum exists at the mesenteric
crossing, a high intraluminal pressure develops just
proximal to this point as the result of peristaltic waves
passing down the duodenum. Just why some vessels
produce a partial obstruction I am not prepared to say.
A number of different factors may be responsible, such
as short mesentery, lumbar lordosis or heavy loops of
small bowel. The patient to be reported had a very
large duodenal loop cephalad to these vessels. It was
about 50 per cent larger than normal, indicating a
probable partial obstruction where the mesenteric ves-
sels cross the duodenum.
A summary of nine duodenal diverticula encountered
in my practice, including a detailed report of the op-
eration in this one case, follows:
Case 5. — Mr. V. J., aged twenty-three, came in on
September 19, 1944, with a history of recurrent epigas-
tric pain. X-rays and fluoroscopic examination made
after the barium meal showed a fairly large duodenal
ulcer and a small diverticulum in the first portion of
the duodenum. He was placed on an ulcer regimen and
made a good recovery. The x-rays revealed a small
stalk connecting the diverticulum with the floor of the
ulcer, revealing the etiology of this lesion to be a duo-
denal ulcer.
Case 6. — Mrs. H. J., aged fifty-three, had a history
of epigastric pain and tenderness in the epigastrium.
On November 29, 1944, films and fluoroscopic examina-
tion was done. These revealed a scar of a healed duo-
denal ulcer and a small diverticulum in the second por-
tion of the duodenum. This patient was placed on ulcer
treatment. She has had intermittent exacerbations of
her ulcer symptoms, but it is difficult to evaluate the role
that the diverticulum plays, if any, in the causation of
her symptoms.
Case 7. — Mr. A. H. D., aged sixty-three, complained
chiefly of “heart burn,” also some intolerance to fatty
foods. On April 27, 1946, he had upper gastrointestinal
studies done. These revealed a moderate amount of py-
lorospasm, an ulcer crater in the duodenal bulb and also
a diverticulum of the descending portion of the duo-
denum. He was placed on ulcer management and made
a good recovery.
Case 8. — Mrs. A. H., aged sixty-nine, had a history of
recurring pains in the left upper epigastrium immediately
after meals. She had noted these symptoms for the past
two years but they had become more frequent of late.
On December 29, 1945, she had gastrointestinal studies
done. These showed approximately the upper three-
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Fig. 3. Case 4. Oblique x-ray view
of stomach shows diverticulum high on
lesser curvature near entrance of
esophagus.
Fig. 4. Case 10. Oblique x-ray view
of stomach, cap and duodenum, shows
small diverticulum of second portion of
the duodenum.
Fig. 5. Case 11. Oblique x-ray view
of stomach, cap and duodenum, shows
moderate-sized diverticulum of third
portion of the duodenum.
quarters of the stomach to be herniated into the tho-
racic cavity, through the esophageal hiatus. There was an
associated diverticulum of the descending portion of the
duodenal loop. Surgical repair of the diaphragmatic
hernia was suggested, but the patient declined operation
because of her age.
Case 9. — Mrs. M. L., aged sixty-five, came in on Sep-
tember 24, 1945, for relief of her symptoms which con-
sisted of pains in the left upper abdomen radiating into
the rectum. This patient had had her left eye removed
<?ne month previous to this examination. A malignant
melanoma had been found. Upper gastrointestinal and
colon x-rays were done. These revealed a normal colon,
hypertrophic gastritis and a diverticulum of the second
portion of the duodenum. This patient has since died
from liver matastases from the primary malignant mela-
noma of the choroid plexus of the eye.
Case 10. — Mrs. I. N., aged fifty-nine, complained of
recurrent attacks of pain in the epigastrium which ra-
diated into the back. On October 16, 1946, a complete
gastrointestinal study was done and was negative except
for a small diverticulum of the second portion of the
duodenum (Fig. 4). A gall bladder study was likewise
negative. This patient’s symptoms are probably due to
the diverticulum, but have not been considered severe
enough to warrant operation.
Case 11. — Mrs. M. N., aged fifty-four, was first seen
by me on January 10, 1944. She gave a history of epi-
gastric pain radiating into her back, nausea and vomiting.
On January 14, 1944, gastrointestinal studies were done.
These showed no evidence of gastric or duodenal ulcer
or cancer. However, they did show a large diverticulum
of the third portion of the duodenum with retained
food (Fig. 5). A six-hour examination showed barium
still in the diverticulum. Since this study, she has had
another bout of severe pain, associated with nausea and
vomiting. This has been the sixth such episode in the
past ten years, with each episode she has been hospital-
ized and intravenous fluids have been given from one to
several days before the vomiting could be controlled.
Operation, I feel, is definitely indicated in this case,
but so far has not been carried out.
Fig. 6. Case 12. Anterior-posterior x-ray view of stomach, cap
and duodenum, shows mushroom type of diverticulum in the
third portion of the duodenum.
Case 12. — Mrs. R. E., aged thirty-two, was first seen
on January 31, 1947. She gave a history of intermittent
bouts of pain in the epigastrium which sometimes ra-
diated into her back, associated with nausea and some-
times vomiting. Certain foods seemed to aggravate this
condition. However, she always had a tender spot in the
right lower epigastrium. For the month previous to the
examination, she ran a fever from 99° to 100° F. every
afternoon.
She had been advised on previous occasions to have
gastrointestinal and gall-bladder x-rays, but had not done
so until February 5, 1947. This examination revealed a
deformed duodenal bulb due to an old healed ulcer.
She also had a large duodenal diverticulum measuring
approximately 5.5 centimeters in its greatest diameter
(Fig. 6). The roentgenologist reported that considerable
pain and tenderness were elicited when pressure was
exerted on the diverticulum but not over the duodenal
December, 1947
1289
MINNEAPOLIS SURGICAL SOCIETY
cap. The diverticulum was located at the junction of the
second and third portions of the duodenum on the lesser
curvature side. Within the diverticulum there were
some rarefactions which probably represented retained
food. After four hours, the diverticulum still retained
considerable barium. Chest and gall-bladder x-rays were
negative for abnormalities.
On March 8, 1947, under sodium pentothal, curare and
nitrous oxide anesthesia, a diverticulectomy was per-
formed. A high right rectus incision was made and the
rectus muscle was retracted laterally. The stomach and
duodenum were examined. The scar from the old duo-
denal ulcer was found hut no evidence of an active ulcer
could be made out. The duodenum was quite large
and redundant. The duodenal portion of the gastrocolic
omentum was opened, exposing the descending portion
of the duodenum ; the superior mesenteric vessels were
located and retracted medially.
The diverticulum was then seen on the mesenteric
border just lateral to the point at which the mesenteric
vessels crossed the duodenum. Several small blood ves-
sels between the pancreas and the duodenum were
clamped, cut and tied off. The diverticulum was
gradually pulled out from beneath the head of the pan-
creas under which it was hidden. The diverticulum had
a second small pouch projecting from the medial side
near the base. After freeing the muscular fibers which
constricted the neck, it was found to have a base mea-
suring about 3 centimeters in diameter. The base was
then clamped with two Carmault forceps and cut between
the clamps. The mucosa was phenolized and a running
dulox suture placed over the clamp to approximate the
edges. After removing the clamp, a second row of
dulox sutures was taken and this row was reinforced
with an interrupted row of silk sutures. The gastrocolic
omentum was then closed with a few interrupted su-
tures. The appendix was located and found to be quite
injected; it was amputated and the stump inverted with
a purse string suture.
Gastric suction was started following the operation.
1 he tube was left in place for three days and the pa-
tient was given the usual postoperative care, including
intravenous fluids and penicillin. On the fourth post-
operative day, she was able to take soft foods. She
made an uneventful convalescence and left the hospital
on the ninth postoperative day.
After the diverticulum was removed it measured 3.5
centimeters in length and 2.5 centimeters in width. It
was attached by a broad neck and had a thin wall lined
with mucosa. Microscopically, the diverticulum was
lined by small bowel type of mucosa, the outside of
which was a small amount of fibrous tissue and smooth
muscle.
The patient was re-examined by x-ray one month
following the operation and showed a normal continuity
of the duodenum and jejunum where the diverticulum
was removed. She has been able to eat all nonirritating
foods and has been completely free from pain and sore-
ness in the epigastrium. It is undoubtedly too soon to
know whether her symptoms have been relieved com-
pletely and permanently. The young woman, who hap-
pens to be a graduate nurse, states that she feels like a
different person already and seems confident that she is
cured of her troubles.
Case 13. — Mrs. M. L., aged sixty-six, first consulted
me on March 11, 1947. Her symptoms were chiefly epi-
gastric in character, but extremely vague in nature.
Abdominal findings were essentially negative. A gastro-
intestinal study on April 4, 1947, revealed a normal
esophagus, stomach and duodenum with a moderately
large diverticulum of the third portion of the duodenum
near the duodeno-jejunal junction. It is hard to know
how much her symptoms are attributal to the diverticu-
lum. Her case will be studied further before any definite
conclusions can be drawn relative to the role that this
lesion plays in her symptomatology.
Small Bowel Diverticula
Diverticula of the jejunum and ileum other than a
Meckel’s are rare. Only a few cases have been reported
in the literature. One such case was reported to this
society by Dr. Janies A. Johnson in December, 1944.
According to him, Kozium and Jennings, reporting in
1941, found only one hundred and eighty-seven cases
recorded in the literature. There are no cases in this
series of a small bowel lesion other thin the Meckel’s
diverticulum to be reported next.
Meckel's Diverticulum
The so-called Meckel’s diverticulum is probably the
only true congenital diverticulum found in the entire
alimentary tract. As is well known, it represents the
persistent ileal end of the omphalomesenteric or vitel-
line duct which in early fetal life connects the mid-gut
with the yolk sac. Normally the duct closes in the fifth
week of fetal life. It is found in about 2 per cent of
all people, with a ratio of about two males to one
female. It is usually found about one to three feet from
the ileocecal valve, although it may be found anywhere
from the duodenum to the cecum. About 25 per cent
of these lesions contain pancreatic tissue, gastric, jejunal
or duodenal mucosa.
The chief complications arise from intestinal ob-
struction, diverticulitis, perforation or hemorrhage. It
may become strangulated or form the head of an in-
tussusception. It has been known to contain foreign bod-
ies and neoplasms. Hemorrhage and intussusception
from these lesions are seen most often in infants. Ladd
and Gross report twenty-six cases of hemorrhage and
seventeen cases of intussusception in seventy-three pa-
tients operated upon by them. Strangulation and diver-
ticulitis are more often seen in adults, although hemor-
rhage is not uncommon in young adults between seven-
teen and twenty-two years. A bleeding Meckel’s lesion
should always be considered in painless massive hemor-
rhage from the rectum in this age group.
Case 14. — Mr. R. D., aged twenty-two, called me to his
home on the evening of March 18, 1946. He had been
having frequent hloody stools for the past forty-eight
hours and profound hemorrhage with the last two bowel
movements. The patient was almost completely ex-
sanguinated from blood loss. His blood pressure was
86/46. He was taken to the hospital by ambulance, where
he was given 3 pints of blood and 2 liters of 5 per cent
glucose in saline during the night. He was also given 8
milligrams of vitamin K and Coaglin (Ciba) intramus-
cularly. Oxygen was given by the BLB mask. He
was given another 3 pints of blood the following day.
By the end of that day, his hemoglobin was 53 per cent,
his bleeding time was 1 minute and 55 seconds and
clotting time 2 minutes. A proctoscopic examination was
not satisfactory owing to the large amount of blood in
the bowel. The lower rectum was essentially negative.
He continued to have bloody stools for the next two
days and more blood was given each day. During the
first ninety-six hours in the hospital, he had 9 pints of
blood, 94 milligrams of vitamin K, several ampules of
Coaglin (Ciba), and several pints of 5 per cent glucose
in saline. On March 23, he had an x-ray study of his
colon. This revealed -a very ragged outline to the colon
and terminal ileum which filled with barium for about
18 inches. This was interpreted as representing blood
in the colon and terminal ileum, otherwise the x-ray
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MINNEAPOLIS SURGICAL SOCIETY
findings were negative.- In view of the fact that he had
not been nauseated or vomited blood, we felt certain
that he was not bleeding from the gastric diverticulum ;
therefore, by indirect deduction a diagnosis of bleeding
Meckel’s diverticulum was made.
Fig. 7. {above) Case 14. Low-power photomicrograph shows
ulcer and gastric mucosa in fundus of Meckel’s diverticulum.
Fig. 8. {below) Case 14. High-power photomicrograph shows
bleeding ulcer in ectopic gastric mucosa of Meckel’s diverticulum.
About two o’clock p.m., March 23, 1946, under sodium
pentothal, cyclopropane and curare anesthesia, a right
rectus incision was made. The rectus muscle was re-
tracted laterally and the abdomen opened. The cecum
had a very long mesentery allowing it to be pulled well
outside the abdomen with ease. No lesion was found in
the cecum but there was much old blood within it, as
well as in the lower 6 or 8 inches of the terminal
ileum. A Meckel’s diverticulum was found about 2
feet from the ileocecal valve. It measured 2 by 2 by 4
centimeters. The distal 1 centimeter was firm and solid
in consistency. It had a mesentery of its own, contain-
ing moderate-sized blood vessels. The diverticulum was
amputated transversely to the long axis of the ileum.
Wangensteen bowel clamps were used for this pur-
pose. A running dulox suture was placed over the
clamp after first using phenol and alcohol on the cut
edges. Then the clamp was withdrawn and the suture
tightened, inverting the mucous membrane. The suture
was reinforced with a second layer of dulox catgut and
then the serosa was inverted with a row of mattress
silk suture. No blood was found proximal to the Mekel’s
December, 1947
diverticulum. The appendix was missing, as it had been
removed at a previous operation. The stomach was
examined because of the presence of the diverticulum
high in the cardia which had previously been disclosed
one month before. This diverticulum could be palpated
Fig. 9. Diverticulum of colon. Typical x-ray picture of mul-
tiple diverticula of colon.
and apparently had an extremely thin wall. The abdo-
men was then closed in layers in the usual manner.
At the conclusion of the operation, the Meckel’s le-
sion was opened and a small ulcer was noted in the fun-
dus. Blood was seen to come from a marginal vessel
on the circumference of its base. The outer surface of
the diverticulum was pale, smooth and shiny. It was
about 25 millimeters long and 16 millimeters wide. The
wall was about 2 millimeters thick and there was a
marked stenosis about 10 millimeters from the tip, after
which the lumen opened out again. The diverticulum
was lined with mucosa with transverse rugae. There
was a shallow ulcer 3 millimeters in diameter just to
the side of the constriction on the proximal side. Micro-
scopically, the upper three-fourths of the diverticulum
was lined with intestinal mucosa; the smooth area near
the tip and the extra pocket were lined by gastric
(fundic) mucosa. The ulcer was partially covered by a
single layer of epithelium (Figs. 7 and 8).
Following the operation, gastric suction through an
indwelling nasal tube was started for twenty-four hours.
He was given two more pints of blood and two liters
of 5 per cent glucose in saline. He then made an un-
eventful convalescence and left the hospital on the
eleventh postoperative day. A total of 4,825 cubic cen-
timeters, or roughly 11 pints, of blood were given in
order to restore the major part of that which was lost.
During the past year, he has remained entirely well
except for his one complaint of halitosis, which we feel
is due no doubt to fermentation of food in the diverticu-
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MINNEAPOLIS SURGICAL SOCIETY
lum in the cardia of his stomach. A transthoracic ap-
proach is planned for the removal of this lesion some-
time this coming year.
Diverticula of the Colon
Diverticula of the colon occur quite frequently in the
older age groups (Fig. 9). Most roentgenologists re-
port finding these lesions chiefly in the sigmoid colon
in about 12 to 16 per cent of all colon studies. The chief
significance of these lesions lies in the fact that about
15 per cent become inflamed. A smaller percentage
cause general peritonitis and obstruction due to peri-
diverticulitis. A few will develop internal or external
fistulae. Those causing obstruction may be difficult to
differentiate from neoplasms. The sigmoid colon being a
common site for both conditions, the two may be easily
confused. Not until the lesion has been resected may a
definite diagnosis be made at times. However, with the
use of penicillin and the sulfonamide drugs today, most
cases of diverticiditis will resolve on a restricted hland
diet combined with the use of large amounts of mineral
oil.
Conclusions
1. Single-stage resections of diverticula of the upper
and lower esophagus may be safely carried out today,
even with lesions having a large base of attachment.
2. Lesions of the duodenum not infrequently cause
sufficient symptoms to warrant their removal. Whenever
they are large enough to retain food or barium for more
than four hours, I think that they should be removed
because of the hazard of perforation, obstruction or
hemorrhage.
3. Diverticula of the third part of the duodenum are
thought to be caused by partial obstruction of the duode-
num resulting from pressure caused by the mesenteric
vessels crossing this part of the duodenum.
4. A ragged barium x-ray pattern in the colon and
terminal ileum is indicative of blood in these parts.
Whenever these findings are noted in the absence of
other demonstrable pathologic conditions in the colon, a
bleeding Meckel’s diverticulum should be considered.
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20. Harrington, Stewart W. : Pulsion diverticulum of the hypo-
pharynx at the pharyngoesophageal junction. Surgery, 18:66-
81, (July) 1945.
21. Harrington, Stewart W. : Reported four diverticula of the
thoracic esophagus successfully removed. In the discussion
to Dr. Robert Jane-s’ paper listed.
22. Heyrov^ky, H.: Casuistik und Therapie der idiopathischen
Dilatation der Spieserohe, Oesophago-gastroanastomose.
Arch. f. klin. Chir., 100:703-713, 1912-1913.
23. Hurst, A. F. : Two cases of diverticula from the lower end
of the esophagus. Guy’s Hospital Rep., 75:361-366, 1925.
24. Jackson, C., and Shallow, T. A.: Diverticulum of the
esophagus, pulsion and traction, malignant and congenital,
Ann. Surg., 83: 1, 1926.
25. Jackson, C., and Jackson, C. L. : Pulsion diverticulum of
the esophagus and hypopharynx. South. Surgeon, 2:255-
266, 1933.
26. Janes, Robert M.: Diverticula of the lower thoracic esopha-
gus. Ann. Surg., 124:637-652, (Oct.) 1946.
27. Johnson, James A.: Diverticula of the alimentary canal.
Minnesota Med., 24:386-392, (May) 1941.
28. Johnson, James A.: Diverticula of the jejunum. Minnesota
Med., 28:395-396, (May) 1945.
29. Jones, J. A. Seymour: Diverticulum, thoracic esophageal,
with case record. J. Laryng. & Otol., 60:121-125, (March)
1945.
30. Ladd, William E., and Gross, Robert E. : Abdominal Surgery
of Infancy and Children. Pp. 71-82. Philadelphia: W. B.
Saunders & Co., 1941.
31. Lahey, F. H.: The management of pulsion esophageal diver-
ticulum. J.A.M.A., 109:1,414-1,419, 1937.
32. Lahey, F. H. : Intrapleural pulsion diverticulum; report of a
case. Lahey Clinic Bull., 5:2-5, (July) 1945.
33. Lahey, F. H.: Surgery of the duodenum. New England J.
Med., 222:444-451, (March) 1940.
34. Lawson, A. O. : Duodenal diverticulosis. Am. J. Roentgenol.,
34:610-615.
35. Lotheissen, G. : Ein Vorschlag zur Operation tiefsitzender
Oesophagus divertikel. Zentralbl. f. Chir., 35 :811-815. 1908.
36. Lotheissen, G. : Diagnose und Behandling der Divertikel der
Speiserohe. Klin. Wchnschr., 10:73-76, 1931.
37. Ladlow, A.: Obstructed deglutition from a preternatural
dilatation of and bag formed in the pharynx. M. Soc.
Physicians, 3:85-101, 1762-1767.
38. Maxeiner, Stanley: The present surgical management of
esophageal diverticulum with presentation of a new method.
Minnesota Med., 24:91-96, (Feb.) 1941.
39. McQuillan, A. S. : Diverticulum of the esophagus operation.
Laryngoscope, 55:309-317, (June) 1945.
40. Meckel. J. F. : Manual of Anatomy. Pp. 286-287. Philadel-
phia: Carey and Lea, 1832.
41. Nicoladoni, K.: Ein Beitrag zur Operativen Behandlung
der Oesophagusdivertikel. Wien. Med. Wchnschr., 27 :605,
631, 654. 1877.
42. Nisser, R.: Behandlung der funktionellen und organischen
Verenderungen von Oesophagus und Kardia. Schweiz. Med.
Wchnschr., 15:1111-1113, 1934.
43. Noon, Z. B. : Peptogenic ulcer in Meckel’s diverticulum,
case. Arizona Med., 1:197-200, (July) 1944.
44. Owen, R. A. C. : Melana due to peptic ulceration of Meckel's
diverticulum. Brit. M. J., 1 :630-631, (May) 1945.
45. Paulson, D. L. : Diverticulum of the stomach, transthoracic
resection. J. Thoracic Surg., 13:518-522, (Dec.) 1944.
46. Pearse, Herman E.: Surgical management of duodenal
diverticula. Surgery, 15:705-712, (May) 1944.
47. Quatero, I’. B. V. : Un cas de diverticulte epiphrenique del
oesophage. Acta Oto-Laryng., 15:94-100, 1931.
48. Rivers, Andrew B., Stevens, G. Arnold, and Kirklin, B. R.:
Diverticula of the stomach. Surg., Gynec. & Obst., 60:106-
113, (Jan.) 1935.
49. Sauerbruch. F. : Oesophagusdivertikel. Zentralbl. f. Chir.,
54:1508-1509, 1927.
50. Smith, M. K. : Deep pulsion diverticula of esophagus. Ann.
Surg., 88:1,022-1,027, 1928.
51. Smith, Lester A.: Diverticula of the thoracic esophagus.
Am. J. Roentgenol., 19:27-35, (Jan.) 1928.
52. Tracey, M. L., and Adams, Ralph: Meckel’s diverticulum
demonstrated by roentgenogram case with hemorrhage. Lahey
Clinic Bull., 4:23-26, (July) 1944.
53. Turner, A. G., and Knight, G. C. : Surgery of the oesophagus.
Tr. M. Soc. London, 59:171-181, 1936.
54. Weeks, K. D. : Bleeding from ulceration of Meckel’s diver-
ticulum with report of two cases. North Carolina M.J.,
5:524-527, (Nov.) 1944.
55. Womack, Nathan A., and Siegert, R. B.: Surgical aspects of
lesions of Meckel’s diverticulum. Ann. Surg., 108:221-236,
(Aug.) 1938.
1292
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MINNEAPOLIS SURGICAL SOCIETY
Discussion
Kenneth A. Phelps, M.D. : Thank you very much
for asking me to discuss Dr. Scott’s excellent paper.
The only part of his paper I am at all qualified to dis-
cuss is diverticulum of the pharynx, which he refers to
as “pharyngo-esophageal.” Before long we will eliminate
one part of this term and refer to diverticula which
are anatomically pharyngeal as “pharyngeal” diverticula
and not “pharyngo-esophageal.”
I have had the opportunity of seeing about twenty-five
of these cases and have used the esophagoscope to help
the surgeon during the operation. It has been of great
interest to watch different surgeons handle the same
problem. The method of closing the stump of the sac
has varied from a careful suturing, layer by layer,
to no suturing whatever, merely a clamp being applied
and allowed to remain for several days until it sloughs
off. All have closed satisfactorily.
Operation should be advised even if the patient is
seen when the diverticulum is small and the symptoms
are insignificant. The sac always enlarges, and the
patient’s discomfort will increase, making operation a
necessity. As a general rule, the smaller the sac, the
easier the operation is, on both patient and surgeon.
In the few cases I have seen I have been surprised
at the number of complications, such as paralysis of
the recurrent laryngeal nerve, pneumothorax, post-
operative atelectasis, fistula, postoperative stenosis, recur-
rence of the sac, but no mediastinitis.
Dr. Scott’s handling of his patient who aspirated
vomitus on the night of the operation, deserves commen-
dation. He inserted a rubber intratracheal anesthetic
tube and through this passed aspirating catheters. He
was thus able to keep up more or less continuous bron-
chial aspiration for several hours, a thing that would
have been impossible had a bronchoscope been employed.
This technique could be recommended as a good method
of draining the bronchi in any case of postoperative
atelectasis.
I enjoyed Dr. Scott’s paper tremendously and I
appreciate your giving me this opportunity to discuss it.
CONSTRICTIVE FIBRINO-PLEURISY
N. K. JENSEN, M.D.
Minneapolis. Minnesota
The development of chemotherapy and antibotics over
the past ten years has brought about considerable con-
fusion in the management of empyema. Following the
studies of the Empyema Commission4 in the First World
War, the treatment of empyema became standardized.
This standardization was based on well-tested and ra-
tional concepts, the major consideration of which may
be summarized as follows:
1. Vital capacity is protected during the acute phase
of the pneumonic process by avoidance of open tho-
racotomy and reduction of the pleural effusion by needle
aspiration.
2. The pleural pocket is completely evacuated and
kept so by adequate dependent drainage as soon as the
lung has become firmly adherent to the chest wall about
the margins of the pocket.
3. The sealed-off uninvolved pleural space is strictly-
avoided upon draining the empyema pocket, for to
expose the uninvolved pleura frequently results in fur-
ther pulmonary collapse with a sucking chest wound
and a massive empyema from dissemination of the in-
fectious contents of the pleural pocket.
4. Re-expansion of the pulmonary tissue, collapsed
by the space-filling empyema, is left to the slow' process
of fibrous tissue contraction and obliteration of the space.
The object of this standardized management of em-
pyema is twofold : first, to reduce the mortality of
empyema and, second, to avoid the development of
chronic empyema. In the period from 1918 to the
introduction of the sulfonamides, empyema, as known
to the Empyema Commission, regularly occurred, and by
all odds its best management was that outlined by the
Commission.
With the introduction of the sulfonamides, and to an
even greater extent with the introduction of penicillin,
empyema has become less frequent and much less stand-
ardized in its manifestations and evolution. The most
confusing difference is that the fluid fails to become
purulent on schedule, and as a result treatment by
aspiration may be greatly prolonged. However, under
this management, despite the apparent sterilization of
the empyema pocket, absorption of the fluid often fails
to occur and in a distressing percentage of cases the
fluid loculates and organizes. Removal of the fluid
now is no longer possible by aspiration, and open drains
age is resorted to. Re-expansion of the lung frequently
fails to occur despite the open drainage and secondary
infection of the pocket follow's. This result is a chronic
empyema very incapacitating and difficult to cure.
Chronic empyema was not totally avoided in the period
prior to the introduction of the sulfonamides and peni-
cillin, but it probably occurred in a smaller percentage
of the cases than now. In any event, either with anti-
biotics or without, open drainage of a pleural effusion
which has been allowed to persist until it has clotted
and loculated, or until the pus has become too thick,
is followed by failure of the . lung to re-expand in a
fair percentage of cases.
Since the work of the Empyema Commission, a direct
attack on the empyema pocket to bring about re-expan-
sion of the lung, has generally been avoided. If re-
expansion did not spontaneously occur with prolonged
open drainage, the chest wall was deribbed and allowed
to fall into the pleural space, bringing about its oblitera-
tion.
These principles in the management of both acute and
chronic empyema were crystallized prior to the devel-
opment of anesthetic agents and techniques which allow
respiration to be easily maintained with wide thoracot-
omy, and before the discovery of effective antibiotics;
that is, they were developed to make surgical treatment
of empyema safe by avoiding open pneumothorax and
dissemination of infectious material at a time when
even the temporary occurrence of either was frequently
disastrous.
A further factor which has conditioned the manage-
ment of chronic empyema was the misconception com-
monly held that in instances when the lung failed to
re-expand, following open drainage, the failure of
expansion was due to thickening and contraction of
the visceral pleura.
Theoretically, a more radical mechanical removal of
the fluid and fibrin from the pleural space, allowing
December, 1947
1293
MINNEAPOLIS SURGICAL SOCIETY
immediate 'complete expansion of the lung, offers the
possibility of shortening the recovery time and pre-
serving respiratory function. Consequently many sur-
geons have attempted this procedure since the appear-
ance of a brief report by Fowler3 in 1893. He excised
the fibrous envelope of a chronic empyema cavity and
allowed the lung to re-expand. Delorme2 at about this
same time carried out excision of a localized tuberculous
empyema pocket with freeing of the underlying lung
and later extended his experiences. Both Fowler and
Delorme understood that in any empyema it is not
thickened pleura which makes up the wall of the em-
pyema cavity, but rather an organized layer of fibrin
which is gradually converted to dense fibrous tissue.
This layer only gradually fuses with the pleura. Un-
fortunately this concept was lost, and soon the erro-
neous idea that thickened pleura constituted the wall
of the empyema cavity came to have wide acceptance.
Lilienthal5 in 1915 was the first to treat acute empyema
by decortication, and he carried out the procedure much
as we do today except that he hesitated to separate the
lung from the mediastinal pleura, or thoracic wall. He
feared the dissemination of infection. Ware7 also re-
ported a series, in 1917, of acute empyemas treated by
decortication. Many others, from the time of Fowler
and Delorme to the beginning of World War I, reported
on the treatment of empyema by decortication, but due
to the constant hazards of anesthesia in open thoracot-
omy, the inability to prevent the dissemination of infec-
tion, and inadequate means of replacing blood loss, the
procedure never gained wide acceptance.
Initially, pulmonary decortication was revived in
World War II as a procedure to deal with sterile con-
strictive fibrino-pleurisy accompanying massive hemo-
thorax. The first such decortication was performed by
Thomas H. Burford1 in May of 1943. In the months
that followed, this surgeon and gradually many others,
working first in the Mediterranean theater and then
throughout the armed forces, became more aggressive.
By the last of 1943 frank empyemas resulting from
infected hemothoraces were being drained by rib-
resection, and subsequently, as the patient’s sepsis sub-
sided, decortication was carried out. The type of or-
ganism recovered from the pleural pocket was not an
influencing factor in electing decortication, but rather
the degree of pulmonary compression present. With the
introduction of penicillin early in 1944 for the treatment
of surgical infections, the preliminary rib-resection
drainage was largely abandoned and primary decorti-
cation of grossly purulent hemothoraces became routine.
I have chosen the title, Constrictive Fibrino-Pleurisy,
for this paper as I wish to emphasize that hemothorax
is not the only intrapleural pathological process which
results in compression of a lung and its imprisonment
by a dense shell of organized and fibrosed fibrin. Uni-
versally this process occurs sooner or later in the
development of every neglected empyema. Blood intro-
duced into the pleural cavity is irritating to the pleura,
and promptly there is laid down over the pleural sur-
faces a layer of fibrin. This undergoes organization
by the ingrowth of fibroblasts and capillaries. Exactly
the same thing happens in a bacterial pleurisy. The
1294
subpleural inflammatory process within the lung irritates
the pleura; a pleural effusion forms and fibrin is laid
down over the pleura. The effusion gradually becomes
more purulent; fibrin clots frequently form within the
effusion and organization of the fibrin deposit on the
pleura occurs. However the visceral pleura itself is not
thickened, if at all, until many weeks later. In 1893
Delorme removed, at autopsy, a leatherlike membrane
from the lung of a patient who had had tuberculous
pleurisy for six months. The underlying lung was
healthy and could be detached, its pleura still thin and
elastic. Paulson6 has recently reported successful decor-
tication of thoracic empyemas which have existed for
more than a year. These followed such various primary
pleural effusions as postpneumonic pleurisy, subphrenic
abscess, and hemothorax.
The following seven cases* are reported to illustrate
the similarity between the constrictive fibrino-pleurisy
produced by pyogenic infections of the pleura, tubercu-
lous infections of the pleura, and hemothorax. The
hemothorax cases are of further interest as they illustrate
some of the mechanism producing hemothorax in civilian
life, and demonstrate the various stages of constrictive
fibrino-pleurisy associated with hemothorax.
Case Reports
Case 1. — A nineteen-year-old boy accidentally shot by
a .22 caliber pistol at close range was admitted to St.
Mary’s Hospital two hours after the injury. The bullet
had passed through the soft tissues on the dorsum of
the right forearm and entered the thorax through the
sternum. It traversed the left upper lobe and left the
thorax through an interspace to lodge in the subscapular
area.
The patient had no pulmonary symptoms on admis-
sion, but both physical signs and roentgen examination
demonstrated a closed pneumothorax on the left of
moderate degree, and some fluid at the base almost cov-
ering the diaphragm which was elevated three inter-
spaces. There was no dyspnea. Color was good and
pain was limited to the right forearm.
The fluid in the left chest increased in the next
twenty-four hours, completely covering the diaphragm
and reaching up to the eighth rib posteriorly. There
was a slight shift of the mediastinum and no dyspnea.
A total of 750 c.c. of dark blood and 200 c.c. of air
were aspirated at this time. Full re-expansion of the
lung followed, with only a small amount of fluid remain-
ing in the costophrenic angles. Subsequently the residual
fluid absorbed and the roentgenogram studies revealed
a normal-appearing chest.
This case illustrates that prompt re-expansion of the
lung by complete aspiration of the irritating pleural fluid
prevents fibrino-pleurisy and subsequent constrictive
pleuritis.
Case 2. — Three weeks prior to admission to St. Mary’s
Hospital this eleven-year-old boy fell in the snow -and
was stabbed in the back by an unrecognized object.
Examination immediately after the injury revealed a
small puncture wound, and only some days later did
symptoms suggestive of a pleurisy develop, associated
with moderate dyspnea. A roentgenogram on admission
to the hospital revealed a massive pleir al effusion extend-
ing almost to the apex of the right pleural cavity with
*Three of the cases of hemothorax are from the Thoracic Sur-
gical Service of the United States Veterans Hospital, Minne-
apolis, Minnesota. Dr. Penn Harper performed these decorti-
cations under my supervision. The other five cases are from
the Minneapolis St. Mary’s Hospital service of my senior asso-
ciate, Dr. T. J. Kinsella, and were cared for jointly.
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
marked compression of the lung and a small pointed
foreign body, 3 cm. in length, occupying the costophrenic
angle (Fig. 1).
A diagnosis of hemothorax was made, and thoracot-
omy with evacuation of the hemothorax and decorti-
cation of the lung was carried out promptly. The post-
expansion over the next ten days. A roentgenogram
of the chest at this time showed complete collapse of
the left lung except for a small area of air-bearing
tissue above the clavicle. The entire left thorax was
filled with an empyema pocket reaching from above
the third rib posteriorly to the eleventh inferiorly.
Fig. 1. Case 2. Admission roentgenogram of
eleven-year-old boy three weeks after sustaining
small puncture wound in posterior sixth inter-
costal space. Foreign body seen in last inter-
space proved to be a sliver of window-pane
glass.
Fig. 2. Case 2. Roentgenogram two weeks
after decortication, at time of discharge from
hospital. Note fragment of glass has been re-
moved from pleural space.
operative course was entirely uneventful and two weeks
later the patient was discharged from the hospital with
complete re-expansion of the lung and good respiratory
motion on both sides (Fig. 2).
This very excellent result was possible because the
decortication was carried out early. The peel was only
about 5 to 8 mm. in thickness and came away from the
pleural surfaces easily and without bleeding. Diaphrag-
matic mobilization was accomplished completely, as
the peel could be removed from its entire surface. It
moved well postoperatively and has continued to do so.
The histologic condition of the peel removed in this
case is illustrated and discussed later in this paper.
Case 3. — A twenty-four-year-old man sustained closed
fractures of ribs 7, 8, and 9 on the left, and a severe
head injury in an auto accident. He was unconscious
for many hours and confused for several days. During
this time his thoracic injury received little attention
other than strapping which relieved his pain. Two weeks
later severe pleuritic pain developed on the left accom-
panied by chills and fever. Despite several aspirations
of the chest and vigorous systemic antibiotic therapy,
the septic course persisted for the following three weeks.
Marked weakness and weight loss resulted, and five
weeks after injury, the patient was transferred to the
Minneapolis Veterans Hospital.
Aspiration of the chest on admission to the Veterans
Hospital demonstrated frank pus containing hemolytic
streptococci. Dyspnea was marked at this time. A
diagnosis of empyema was made and the patient treated
vigorously by interpleural and parenteral penicillin with
frequent aspirations of the chest. The infection was con-
trolled but pulmonary re-expansion failed to occur, and
after eighteen days a trochar thoracotomy with estab-
lishment of closed drainage was resorted to. Frequent
pleural irrigations, with penicillin, and continuous neg-
ative pressure failed to bring about any pulmonary
December. 1947
Nine weeks after injury the patient was transferred
to the surgical service, and pulmonary decortication was
carried out. Exploration revealed a typical hemothorax
with thick peel over all the pleural surfaces. The peel
separated easily from the pulmonary surfaces but was
densely adherent to the parietal pleura. Care was taken
to free the diaphragm but no effort was made to remove
all the peel from the parietal surfaces. Bleeding was
troublesome. Complete pulmonary expansion was ob-
tained and the chest closed with three suction catheters
in place. These were removed in seventy-two hours.
Upon discharge from the hospital twelve days later, vital
capacity had returned to 2,700 c.c, .He was seen six
weeks later, and a roentgenogram at this time showed
only residual pleural thickening at the base.
This case is of interest in that the hemothorax was
unrecognized and misinterpreted as a massive empyema
for almost nine weeks of treatment in two different
hospitals. It also illustrates that a closed hemothorax
will become infected spontaneously and the infection
responds to intrapleural and parenteral penicillin, and
further that once constrictive fibrino-pleurisy has become
established, pulmonary re-expansion can only be gained
by decortication. The histologic picture of the peel re-
moved in this case is illustrated and discussed later in
this paper.
Caise 4. — A thirty-six-year-old man, an office worker,
developed a spontaneous pneumothorax which rapidly
became a hemo-pneumothorax of such magnitude that
he spent most of the first three weeks of his illness
in an oxygen tent. Aspiration of 1,000 c.c. of dark
wine-colored fluid on the twentieth day relieved the
dyspnea. During the next two weeks, five more aspira-
tions were carried out. He was admitted to the Vet-
erans Hospital six weeks after onset of his illness.
Roentgenograms on admission demonstrated a massive
pneumothorax. Five additional weeks of intrapleural
1295
MINNEAPOLIS SURGICAL SOCIETY
and parenteral penicillin with frequent aspirations of
the chest failed to re-expand the lung or control the
severe staphylococcic infection which developed during
this treatment. The first aspirations on admission were
sterile, but the subsequent cultures showed staphylococci
despite the penicillin.
admission, 500 c.c. of syrupy dark-red fluid was aspi-
rated which contained hemolytic staphylococcus aureus.
Figure 3 shows the massive hemothorax present on
admission. Decortication was carried out with complete
re-expansion of the lung. The peel separated readily
from the lung and with some difficulty from the dia-
Fig. 3. Case 5. Roentgenogram on admis-
sion to hospital forty-nine days after injury.
This shows the typical features of a massive
hemothorax before attempted pleural drainage
has created a pneumo-hemothorax. The only
air-bearing lung remaining is in the upper me-
dial portion of the pleural space. The remain-
der of the lung is completely collapsed in the
paravertebral gutter.
Fig. 4. Case S. Roentgenogram three months
after decortication. Lung is fully re-expanded,
pleural space obliterated, considerable pleural
thickening persists at the base. Peel was not
removed from parietal pleural, and is thickest
in this region.
Ten weeks after onset of the hemothorax, the patient
was transferred to the surgical service and a decortica-
tion carried out. A typical hemothorax, grossly infected,
was found. The peel separated easily from the visceral
pleura but was densly adherent to the parietal pleura,
from which it was removed only over the diaphragm.
Excellent re-expansion was obtained and the chest
closed with the usual three suction catheters.
Following decortication the patient’s sepsis promptly
subsided but six days later he again became febrile.
A small basal pleural pocket was identified and drained
by catheter. This patient's vital capacity just prior to
decortication was 1,900 c.c. Two months later it was
3,000 c.c.
This case illustrates several interesting features. He-
mothorax can occur without any trauma. Here, with the
development of the spontaneous pneumothorax, an ad-
hesion must have torn and subsequently bled. The true
nature of the condition was unrecognized even after
aspiration of a liter of “dark wine-colored fluid.’’ On
admission to the second hospital, the hemothorax, now
six weeks old, became infected despite intrapleural and
parenteral penicillin. Pulmonary re-expansion could
not be accomplished until decortication was carried out,
which in turn obliterated the pleural pocket and con-
trolled the infection. The histologic picture of the peel
will be discussed later.
Case 5. — A fifty-five-year-old male was admitted to
the Veterans Hospital six weeks after falling when he
tripped over a railroad tie. At the time of the fall on
June 20, he sustained several minor lacerations, includ-
ing one on the right anterior chest. He continued to
work without noticeable symptoms until July 8 when
dyspnea, inspiratory chest pain, weakness and weight
loss incapacitated him. These symptoms persisted for
the next month, accompanied by fever and progressive
weakness. He entered the hospital on August 8. On
phragm. It was not removed from the remaining
parietal pleura. The usual closure with catheters was
carried out. Healing per prium occurred, and the patient
w'as ambulatory by the ninth postoperative day.
Figure 4 is a roentgenogram made three months after
decortication. At this time the patient was asympto-
matic and had regained 14 pounds.
This case is of interest because of the slow devel-
opment of a massive hemothorax following minimal
trauma and its subsequent spontaneous infection by he-
molytic staphylococcus aureus. This man was septic on
admission to the hospital and had been so for a month.
His sepsis continued despite penicillin parenterally, but
promptly subsided following decortication.
Case 6. — A fourteen-month-old infant was admitted to
St. Mary’s Hospital three weeks after the onset of left-
sided pneumonia which had been followed by pleural
effusion in six days. The infant had been treated with
sulfamerizine from the time of onset of pneumonia, with
normal temperature after the third day. The pleural
effusion became massive with displacement of the heart
to right, and catheter drainage was instituted the third
week but was ineffective.
A roentgenogram on admission showed a massive clot-
ted fibrino-thorax w'ith marked displacement of the
mediastinum. At this time the child’s respiratory rate
was above 60 in an oxygen tent. The pulse was 130
to 150 per minute. Thoracotomy with evacuation of the
fibrin was performed under local anesthesia. Only par-
tial expansion was obtained, as formal decortication
could not be carried out completely. Postoperatively,
the infant did w'ell out of oxygen, and on discharge
seven weeks later, the chest was closed and the left lung
was functioning despite the greatly thickened pleura re-
maining. Pulmonary, function could have been re-estab-
lished much more quickly and effectively in this case
12%
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
Fig. 5. Case 7. Roentgenogram one
week after onset of illness showing
parenchymal infiltration in right lower
lung field. Etiology at this time unde-
termined. Sputum negative for acid-fast
organisms on smear and concentration.
Fig. 6. Case 7. Roentgenogram sev-
enteen days after onset of illness. Note
the similarity to Figure 3. Massive
pleural effusion gives same x-ray pictures
as massive hemothorax and compresses
lung in same fashion.
Fig. 7. Case 7. Chest roentgenogram
three months after decortication. Lung
expanded, pleural space obliterated, tu-
berculous process in lower lobe clearing.
had the patient been old enough to withstand wide
costectomy with pulmonary and mediastinal liberation
without great anesthetic difficulties.
Comment — The type of empyema developing in this
case has become much more frequent since the introduc-
tion of sulfonamide drugs. Occasionally in the presulfon-
amide days, a pneumonic empyema would undergo auto-
sterilizaton and fibrinous organization and clotting, with
the production of a large intrapleural mass of gradually
organizing fibrin. Subsequently, infection usually re-
curred with suppuration and the development of a mas-
sive chronic empyema overlying a collapsed bound-down
lung. With the use of sulfonamides, however, sterili-
zation of the empyema has occurred much more fre-
quently, and fibrino-thorax has developed if the effusion
has not been promptly and completely evacuated by ade-
quate drainage.
Autosterilization or sterilization by the sulfonamide
drugs occurs gradually and incompletely, during which
time exudation of serum and fibrin continues, with
organization of the fibrin overlying the pleural surfaces
proceeding rapidly. Each day the irritating effusion
persists, more fibrin Is laid down on the pleural sur-
faces, and more of it undergoes fibroblastic organization.
A constrictive fibrino-pleurisy is occurring. Drainage
of the pocket after this process is well established (some-
times as early as three weeks) fails to re-expand the
lung, and chronic empyema is established unless the lung
be freed by decortication at time of drainage.
It may be that the treatment of early empyema by
parenteral and intrapleural penicillin and needle aspira-
tion will not result in this process so frequently.
With penicillin, much more rapid sterilization is ob-
tained, and in those patients I have followed, whose
empyemas have promptly become sterile with peni-
cillin, the purulent effusion has rapidly thinned out with
loss of fibrin content and ever-increasing ease of aspi-
ration. Satisfactory pulmonary expansion has occurred
in these cases. Penicillin will not dissolve the fibrin
already deposited on the pleural surfaces nor will it
prevent its deposition unless it promptly sterilizes the
pleura and the effusion is completely aspirated.
Case 7. — A nineteen-year-old girl was admitted to St.
Mary’s Hospital after seventeen days of illness which
had its onset with pain in chest, dyspnea, mild dry
cough, and fever. At time of admission she had been
on a sulfonamide drug two weeks. Figure 5 shows the
chest roentgenogram taken one week after onset of
illness. Figure 6 shows the chest at time of admission.
The patient was quite toxic with temperature ranging
up to 103° Fahrenheit at this time. Aspiration revealed
cloudy amber fluid, and 650 c.c. were removed.
Continued aspirations failed to expand the lung,
and on the thirty-ninth hospital day decortication was
carried out (fifty-three days after onset). The large
pleural pocket contained syrupy, greenish-yellow, slightly
sour fluid with several fibrin masses floating free. The
peel was from 3 to 8 mm. thick and separated easily
from the visceral pleural surfaces and diaphragm. It
was not removed from the parietal pleura. Figure 7
shows the chest three months later.
Postoperatively the patient did very well. The opera-
tive wound healed by first intention, and on the eighth
postoperative day the patient became completely afebrile
and remained so for the first time since the onset of
the illness.
Initially the possibility of a tuberculous pneumonia
with tuberculous pleurisy was suspected. The first
pleural fluid removed was sterile. Repeated sputum ex-
aminations were negative for acid-fast organisms. Later
a nonhemolytic streptococcus was recovered from the
pleural effusion. At the time of decortication, the diag-
nosis was postpneumonia empyema with constrictive
fibrino-pleurisy. Culture of the pus obtained, however,
revealed both non-hemolytic streptococcus and tubercle
bacilli, and the peel showed tuberculosis on microscopic
examination. Due to the development of sensitivity
to penicillin, this drug had been discontinued ten days
before operation. Three days preoperatively, simply as
the only available antibiotic which the patient could
tolerate, 1.8 grams of streptomycin daily was started.
This was continued for seven days postoperatively. She
also was given 400,000 units of penicillin daily along with
benadryl for the first eleven postoperative days, as
tests had shown the streptococcus to be insensitive to
December, 1947
1297
MINNEAPOLIS SURGICAL SOCIETY
Fig. 8. Section of a peel removed twenty-one days after
formation of a sterile hemothorax (Case 2). Note absence
of blood vessels and leukocytes. Masses of fibrin are still
being actively infiltrated by fibroblasts.
Fig. 10. Section of peel removed in Case 4. Infected
hemothorax of ten weeks’ duration. Leukocytic infiltration
very well shown, vascularity marked.
Fig. 9. Peel removed in Case 3. Hemothorax nine weeks ,
old. Note rich vascularity, complete infiltration of fibrin by
fibroblasts, and scarcity of leukocytes. Removal of this peel
was accompanied by brisk bleeding.
Fig. 11. Case 7. This peel is approximately eight weeks
old. It shows the same basic features as those arising in
hemothorax and in pyogenic empyemas. In addition, the giant
cells and necrosis of tuberculosis are apparent.
1298
Minnesota Medicine
MINNEAPOLIS SURGICAL SOCIETY
streptomycin but very sensitive to penicillin. During
these days the penicillin was well tolerated.
This patient certainly was saved a very prolonged
and difficult course of chronic tuberculous empyema
complicated by mixed pyogenic infection. She unques-
tionably would have come to thoracoplasty for obliteration
of the large pleural space and even at final recovery
would have been left with a bound-down seriously crip-
pled lung. However, decortication of the lung in tuber-
culous empyemas is not unreservedly recommended.
The considerations involved in the treatment of tuber-
culous empyema are beyond the scope of this paper.
Comparison of the fibrino-fibrous peels or membranes
from the pleural surfaces of the lungs in these cases
is of interest:
In the first case, no opportunity for a peel to form
was allowed and there is none to show. Case 2 was
twenty-one days old, that is, the hemothorax had
existed twenty-one days. Figure 8 shows this peel.
Note the fibrin being invaded by the actively poliferating
fibroblasts and the absence of new blood vessels. This
is the ideal time for decortication as the fibroblastic
proliferation has advanced far enough to make the
peel easy to remove. It wipes away in sheets. Bleeding
does not occur as the vascular proliferation from the lung
has not yet occurred to any degree. Infection had not
occurred in this case, and we find few leukocytes in the
peel.
Case 3, on admission, showed hemolytic streptococci
on aspiration of the hemothorax, but subsequently be-
came sterile. The microscopic sections show advanced
fibrosis of the peel with some leukocytic infiltration on
the lung side, but little deep in the peel. The vascularity
is marked, and Figure 9 shows this intense vascular pro-
liferation. These cases tend to bleed more during
decortication. This peel is nine weeks old.
In Case 4 futile efforts were made to evacuate the
hemothorax by aspiration. The hemothorax became
infected with staphylococcus aureus hemolyticus, coagu-
lase positive, and for some time prior to decortication,
was septic. This peel, ten weeks old, shows the same
general fibrosis and vascularity as the peel in Case 3
but in addition shows intense leukocytic infiltration.
Figure 10 shows this leukocytic infiltration and the usual
vascularization.
The peel from Case 7 on low-power magnification
shows the same general features as these others. In
addition, small miliary tubercles, giant cells, and micro-
scopic areas of necrosis characteristic of tuberculosis are
seen. These features are well shown in Figure 11.
In Case 4, the modification of a constrictive fibrino-
pleurisy membrane or peel by pyogenic infection is dem-
onstrated. This section of Case 7 demonstrates a tu-
berculous infection of a similar membrane or peel.
In comparing these sections it is readily apparent that
all represent the same process, namely, the progressive
fibrosis of a fibrin layer deposited over the pleural sur-
faces. Vascularization follows, and the various infect-
ing organisms elicit the same tissue responses here as
they do in other tissues. It is the fibrosis, however,
that binds down the lung and creates thereby the pleural
pocket which leads to chronicity.
In summary, it is well to emphasize that fibrino-pleu-
risy will occur whenever an effusion of some magnitude
persists in the pleural space long enough for fibrin to
be laid down over the pleural surfaces and become
organized. Once this process is well established, sim-
ple drainage by whatever means frequently fails to
bring about pulmonary re-expansion with obliteration of
the pleural pocket. Chronic empyema ensues and per-
sists until the space is obliterated. This can be accom-
plished by either collapsing the chest wall into the pocket
or liberating the lung and allowing it to reoccupy the
space. Modern anesthesia and antibacterial agents have
made excision of the empyema pocket feasible. This
allows re-expansion of the lung. Respiratory capacity
is salvaged by this procedure and hospital stay and dis-
ability greatly shortened. Decortication is applicable
to bacterial empyemas resulting in constrictive fibrino-
pleurisy as to those developing secondary to a clotted
hemothorax. Streptomycin may bring certain tuber-
culous empyemas occurring without underlying cavitary
disease into the same category as other becterial
empyemas.
Finally, here is a word of recommendation for early
adequate drainage of all pleural effusions, by frequent
aspiration till the pus is too thick for the needle and
then, if necessary, by costectomy. The best decortication
is the one avoided by early adequate pleural drainage,
and the best “deribbing and unroofing” is the one avoided
by decortication if the needle and tube have been either
too little or too late.
References
1. Burford, T. H. ; Parker, E. F., and Samson, Paul: Early
pulmonary decortication in, the treatment of post-traumatic
empyema. Ann. Surg., 122:163, 1945.
2. Delorme, E. : Sur un cas de decortication pulmonaire (Case
of L. Pique). Bull. Acad, de Med., 67:267, 1912.
3. Fowler, G. R. : A case of thoracoplasty for the removal of
a large cicatricial fibrous growth from the interior of the
chest, the result of an old empyema. M. Rec., 44:838, 1893.
4. Graham, E. A. : The surgical treatment of empyema in the
acute and chronic stages. In: The Medical Department of
the U. S. Army in the World War, Vol. 11, part 2, chap.
7, page 285. Washington, D. C. : The Government Printing
Office, 1924.
5. Lilienthal, H. : Empyema : exploration of the thorax with
primary mobilization of the lung. Ann. Surg., 62:309, 1915.
6. Paulson, Donald: Discussion on: the pathology of chronic,
traumatic hemothorax. By Hiram T. Langston and Wil-
liam M. Tuttle, et al. J. Thoracic Surg., 16:148, 1947.
7. Ware, H. W. : The trend of surgery in empyema of the
thorax. Ann. Surg., 65:320, 1917.
Discussion
L. Haynes Fowler, M.D. : This has been very inter-
esting to me. In the army we had quite a little experi-
ence with traumatic hemothorax, chiefly with noninfected
cases. I can only reiterate what Dr. Jensen has said.
In following the work of Dr. Burford who was stationed
near us, I found that the results from decortication were
remarkable. The ease with which decortication of the
lung is accomplished in the early cases is really astound-
ing. It is a most satisfying experience to open a chest
and see the lung bound by a thick fibrinous layer. With
all the pressure the anesthetist can give, the lung will not
expand. Peel that layer off, the anesthetist expands
the lung, and it comes out like a balloon right under
your eyes.
Later in the war we had a few cases of infected
pleural effusion and empyema in which we did this pro-
cedure. Although the x-ray pictures did not look as nice
as those with simple hemothorax, the clinical results were
good in the few cases we had. I haven’t had the op-
portunity to do any since returning to civilian life. It is
a question of judgment as to how long to w'ait for ex-
pansion before operating. I am sure Dr. Jensen will
December, 1947
1299
MINNEAPOLIS SURGICAL SOCIETY
agree that the sooner we can decorticate, the easier it
will be.
I was glad to hear Dr. Jensen discuss the question of
sterile pleural effusion, I recently had a case of a young
man who had a pneumonia. The pneumonic process had
cleared up as far as the internist could tell, but the
patient had effusion in the chest and was running a
septic temperature. I aspirated the chest and took off
a couple of hundred cubic centimeters of clear straw-
colored fluid. This was reported by the laboratory as
negative as far as smear and culture were concerned.
The patient continued to run a septic temperature, and
an x-ray showed a large shadow due to pocketed fluid in
the posterior right chest. He had been on penicillin. I
decided to aspirate again and aspirated 900 c.c. of clear
sterile fluid. The pocket disappeared and the temper-
ature dropped to normal and the patient got well. I
don’t know how to explain it, but we may be coming
to the stage with penicillin and sulfonamides when we
will have to pay more attention to complete, thorough,
and more frequent aspiration of apparently sterile fluid
from the chest.
I want to thank Dr. Jensen for a very fine and inter-
esting presentation.
Thomas J. Kinsella, M.D. : There is one point which
I would like to bring out. There is considerable difference
between the thin serous effusion of a tuberculous pleurisy
with effusion and the fluid of high fibrin content fol-
lowing a pneumonia or in a hemothorax. The former,
lying in a pleural membrane but slightly damaged, fre-
quently absorbs in a matter of days, weeks or months,
leaving but little evidence of its former presence except
an obliterated pleural space. The latter, because of the
high fibrin content and its deposit on the pleural sur-
faces, soon comes to lie in a fibrin-lined pocket from
which it is not absorbed. If the fluid is not removed,
additional fibrin is deposited and the lung becomes bound
down in the collapsed position and loses its function.
To avoid this, aspiration must.be started early and
carried out frequently (once or twice daily) and com-
pletely. Only in this way can we obtain results fol-
lowing empyema and hemothorax by aspiration alone.
Once fibrin becomes deposited in appreciable amounts,
it tends to increase, and then you are in a jam. If
bacteria were present, digestion of the fibrin mass by
enzymes from the bacteria and the leukocytes might take
place, but this does not occur in the sterile exudates.
Fibrin solvents may be of use, but if results are not
obtained promptly, decortication is mandatory if the func-
tion of the lung is to be restored.
Nathan K. Jensen, M.D. : The remarks of Dr.
Fowler are well made. In the one case presented tonight,
the pleural fluid contained a nonhemolytic streptococcus
which misled us and we missed the tuberculous infec-
tion until we obtained sections of the peel.
Doctor Kinsella I would answer this way. If a pa-
tient developing an empyema never gets any chemo-
therapy, the migration of leukocytes into the fluid is
intense and it rapidly becomes purulent fluid. The
leukocytes liberate trypsin which digests the fibrin.
If the pleural effusion is sterilized by chemotherapy or
if it occurs as the result of hemorrhage, the fibrin con-
tent remains high. Unless it is quickly and completely
aspirated, fibrin is laid down on the walls of the pocket,
and organization proceeds rapidly.
Humanity has always shunned responsibility. Even
today, though there is widespread intellectual acceptance
of the concept that much disease is preventable, the emo-
tional attitude is not much altered and illness is con-
sidered an intrusion, a misfortune due to factors beyond
control of the individual. As a whole we have not yet
awakened to the idea that the health of men and women
is their own responsibility. — Edward J. Stiegi.itz, M.D.,
A Future for Preventive Medicine, The Commonwealth
Fund, 1945.
TEN- YEAR HEART STUDY
AT UNIVERSITY
About 300 Saint Paul and Minneapolis businessmen
between the ages of forty-five and fifty-four are being
selected to serve as volunteer “human guinea pigs” at
the University of Minnesota in a ten-year study of fac-
tors influencing the development of arteriosclerosis and
hypertension.
The study, conducted under the direction of physiolo-
gist Dr. Ancel Keys, will attempt to discover whether
habits of diet and physical activity will prevent or delay
the development of degenerative cardiovascular dis-
ease. Effects of worry and nervous tension also will be
carefully studied.
Men participating in the study will undergo a thor-
ough examination of their cardiac and vascular con-
ditions once each year for five years at the University
laboratory of physiological hygiene, then will be checked
intermittently by investigators for the next five years.
Invitations to participate in the study have been sent
out to employes of twenty-three Twin Cities business or-
ganizations who are in the proper age group. Partici-
pants will be selected from the volunteers.
A special group of the 300 participants will be com-
posed of thirty men who have been following a syste-
matic program of exercise for a considerable period.
From this group Dr. Keys hopes to obtain information
as to any beneficial or harmful effects of systematic
exercise after the age of forty.
Supported by the United States Public Health Service,
the project has been endorsed by the Heart Committee
of the Minnesota State Medical Association and by the
Hennepin and Ramsey County Medical Societies.
USE OF RURAL HOSPITALS INCREASES
Rural Minnesotans are losing their “prejudice against
going to a hospital except as a last resort.”
That is the conclusion of a LTniversity of Minnesota
sociologist who has just completed a study of the dis-
tribution and use of Minnesota hospitals.
The greatest increase in the use of hospital beds be-
tween 1930 and 1946 has been in rural counties with no
towns of more than 2,500 population. Hospital beds in
those counties were only 50 per cent used in 1930; they
were 74 per cent used in 1946.
The study also showed that there are fewer small
hospitals in the state than in 1930, but that the number
of hospital beds has increased from 24,974 to 31,952.
Of this increase of 6,978 beds, 80 per cent have been for
mental patients. In spite of additional facilities there are
still thirteen rural counties without hospitals. Two-
thirds of the hospital beds in Minnesota are in the four
counties with the largest urban centers : Hennepin,
Ramsey, St. Louis and Olmsted.
Small general hospitals with fifteen beds or less —
too small for efficient operation — have tended to disap-
pear, the study showed. There were less than half as
many in 1946 as there were in 1930.
1300
Minnesota Medicine
C EPf
*“91 *Searle Aminophyllin contains
at least 80% of anhydrous theophylline
December, 1947
O of human anatomy and physiology, without stethoscope or
electrocardiograph, it is small wonder that physicians of
the 16th Century were helpless before many of the
conditions for which present day medicine possesses
efficient treatment.
Present day knowledge of the anatomy and physiology
of the heart and respiratory tract has led to the
widespread use of
SEARLE AMINOPHYLLIN*
to increase the cardiac output, stimulate diuresis, relax
bronchial musculature in such conditions as congestive heart
failure, paroxysmal dyspnea and bronchial asthma.
G. D. Searle & Co., Chicago 80, Illinois
i
RESEARCH IN THE SERVICE OF MEDICINE
Anatomy: Figure of male viscera
from toys Vasse’s Anatomical
Compendium, 1553 —
Courtesy, The Bettmann Archive.
SEARLE
1301
In Memoriam
ARNT G. ANDERSEN
Dr. Arnt G. Andersen of Minneapolis passed away
November 1, 1947 at the age of sixty-six.
Dr. Andersen was born in Minneapolis, December 31,
1880. He graduated from the University of Minnesota
medical school in 1904 and interned at St. Barnabas and
Swedish hospitals in Minneapolis. He practiced at Hills-
boro, North Dakota, from 1904 to 1914 before moving
to Minneapolis. He took postgraduate work in Vienna
in 1910 and again in 1927.
He was a member of the American College of Sur-
geons, the Hennepin County Medical Society, the Min-
nesota State and American Medical Associations. He
had a captain’s commission during World War I and
served on the Mexican border and in the national home
guard. For his services in World War II, he was
awarded the selective service medal and certificate of
merit. He was a member of Our Saviour’s Lutheran
church, Scottish Rite bodies, Zuhrah Temple of Shriners’
Legion of Honor and Masonic Order of Hillsboro, North
Dakota.
Dr. Andersen is survived by his wife, two sons, Arthur
R. of Minneapolis, and Wagner L. of St. Cloud, and a
daughter, Mrs. Noel M. Kiefer of Skokie, Illinois.
H. MILTON CONNER
Dr. H. Milton Conner, former consulting physician
at the Mayo Clinic and Assistant Professor of Medicine
at the Mayo Foundation, died October 18, 1947, follow-
ing an illness of fifteen years.
Dr. Conner was born May 21, 1881 at Morrison,
Illinois. He attended high school at Merrill, Kansas, and
the Hiawatha Kansas Academy and obtained his M.D.
degree in 1909 at the Kansas Medical College, Topeka,
Kansas. His interne year was spent at Stormont Hos-
pital in Topeka, and he took postgraduate work as a
special student in pathology at the College of Physicians
and Surgeons of the University of Illinois in 1910. He
was Professor of Pathology at the Kansas Medical Col-
lege from 1910 to 1913 and practiced in Topeka from
1910 to 1918. He became Assistant in Surgical Pathology
at the Mayo Clinic in 1918 and Assistant Professor of
Medicine at the Mayo Foundation in 1920.
Dr. Conner was a fellow of the American College of
Physicians, the Central Society for Clinical Research, the
Minnesota Society of Internal Medicine, the Southern
Minnesota Medical Association, the Olmsted-Houston-
Fillmore-Dodge County Medical Society and the Min-
nesota State and American Medical Associations. He
was also a member of Sigma Xi.
Dr. Conner married Pana Charlotte Adamson, June
18, 1902. He is survived by his widow and two daugh-
ters, Mrs. J. Stuart McQuiston of Cedar Rapids, Iowa,
and Mrs. H. C. Ochner of Indianapolis, Indiana.
HARRY LEE D'ARMS
Dr. H. L. D’Arms of Hector, Minnesota, died Septem-
ber 9, 1947 at the University Hospital. He was seventy-
nine years old.
Dr. D’Arms was born in Stillwater, Minnesota, May
14, 1868. After graduating from the Stillwater High
School, he attended the medical department of the Uni-
versity of Michigan in 1888. In 1891 he transferred to
the LIniversity of Minnesota medical school, from which
he graduated in 1892. After a year’s internship at the
Minneapolis City Hospital, he practiced for five years
at McKinley and Eveleth before going to Hector in
1898. From 1910 to 1912 he served as county coroner.
On September 27, 1893, he married Maude O. Bearley
of Minneapolis and both lived to celebrate their golden
wedding in 1943. He is survived by his wife and two
brothers.
Dr. D’Arms was an ardent worker for Hector and
its community. In early days, he was organist for several
churches in the town. In World War I, a boys and
girls victory campaign was organized in Renville County
with Dr. D’Arms as chairman. With the assistance of
Mrs. D’Arms, more than their quota was raised.
He was a member of the Camp Release County So-
ciety, the Minnesota State and American Medical As-
sociations.
-
PAUL W. GAMBLE
Dr. Paul W. Gamble, a member of the Gamble Clinic
at Albert Lea, Minnesota, passed away September 14,
1947, at the age of forty-nine. Death was due to cancer
of the lung. His death followed that of his brother, J.
Will Gamble, some six weeks previous who was also a
member of the Gamble Clinic.
Dr. Gamble was born July 25, 1898, in St. Paul. He
graduated with a degree of B.S. from the University
of Minnesota in 1922 and an M.D. in 1924. Internship
was served at Abbott Hospital, Minneapolis, and the
Ancker Hospital, St. Paul.
In 1924, he began practicing in Albert Lea with his
brothers, Will and Ross, in the Gamble Clinic. He was
active in numerous religious, civic, fraternal, and pro-
fessional organizations. He was a member of the First
Baptist Church and served as the president of its Board
of Trustees. He served one term as a member of the
Albert Lea district school board, was a member of the
Chamber of Commerce, the Rotary Club and a leader
in the Shellrock district of the Boy Scouts of America.
During World War I, he was in the Student Army
Training Corps and belonged to the American Legion.
In the past, he was president of the medical staff of
Naeve Hospital and at the time of his death was a mem-
ber of the planning board for the hospital addition now
under construction. He was president of the Freeborn
(Continued on Page 1304)
1302
Minnesota Medicine
FOR BETTER NUTRITIONAL
HEALTH IN THE AGED
Impaired strength and poor general
health in the aged, which have so
erroneously become associated with
senility, are in reality often due to
no more than a state of subnutrition.
Food dislikes, personal idiosyncrasies,
masticatory difficulties, and digestive
abnormalities are the usual contrib-
uting factors. The use of an easily
digested, nutritious food supplement
can do much in preventing these nu-
tritional deficiencies, and in giving
new strength and vigor to patients
well advanced in years.
The delicious food drink made by
mixing Ovaltine with milk is advan-
tageously employed in augmenting
the nutrient intake of the aged. This
well rounded dietary supplement im-
poses no digestive burdens, and pro-
vides in generous amounts the very
nutrients needed. Because of its low
curd tension, it leaves the stomach
quickly, and is easily digested. The
table indicates its rational nutritional
composition. Two or three glassfuls
daily bring to full nutritional accepta-
bility even a fair diet.
THE WANDER COMPANY, 360 N. MICHIGAN AVE., CHICAGO 1, ILL.
December, 1947
1303
IN MEMORIAM
(Continued from Page 1302)
County Medical Society at the time of his death and
a member of the Minnesota State and American Medical
Associations.
In 1924, Dr. Gamble married Jeanette B. Northam of
Minneapolis who, with three children, survives.
ALFONSO GRANA
Word has been received of the death of Dr. Alfonso
Grana, which occurred on August 26, 1947, in Uruguay.
Dr. Grana was born June 3, 1912. He came to the
Mayo Foundation in November, 1945, on a fellowship
of the Guggenheim Memorial Foundation. Previous to
this time he was an investigator for the Institute of Ex-
perimental Medicine at Montevideo, Uruguay. While
he was in Rochester Dr. Grana studied at the Laboratory
of Physiology at the Institute of Experimental Medicine.
He left in July, 1946, to return to Uruguay.
HOWARD ELMER JOHNSON
Dr. Howard E. Johnson of Bird Island died from a
heart attack, October 26, 1947, at the age of thirty-six.
A native of Benson, Minnesota, Dr. Johnson practiced
at Ortonville before locating in Bird Island four years
ago.
Dr. Johnson was secretary of the Renville County
Medical Society and a member of the Minnesota State
and American Medical Associations. He is survived by
his wife and two children — Mary, aged five, and Francis,
aged three.
NIELAMBER C. JOSHIE
Dr. N. C. Joshie, a native of India and a former fel-
low at the Mayo Foundation, Rochester, Minnesota, was
assassinated recently in India.
He was born at Almora, India, in 1888. He received
his medical degree from the Medical College of Lahore,
Punjab University, India, in 1913. After serving intern-
ships in Indian government hospitals from 1913 to 1917,
he took a three-year fellowship in surgery at the Mayo
Foundation. He returned to India in 1920, and it is
reported he had planned the construction of a clinic at
Dehra Dun in India when death came.
EDWIN JOHN KEPLER
Dr. E. J. Kepler, a member of the staff of the Mayo
Clinic, was found dead aboard his cabin cruiser on Lake
Pepin on October 20, 1947.
Dr. Kepler was born January 22, 1894, in Erie, Penn-
sylvania. He obtained a B.S. degree from Pennsylvania
State College in 1916 and an M.D. degree from the Uni-
versity of Minnesota in 1924. After interning at the
Philadelphia General Hospital, he took a three-year
fellowship at the Mayo Foundation. He became an
Associate in a section of the Division of Medicine in
the Mayo Clinic and an Assistant Professor of Medicine
in the Mayo Foundation.
Dr. Kepler was a member of the Olmsted-Houston-
Fillmore-Dodge County Medical Society, the Minnesota
State and American Medical Associations.
He is survived by his widow and two daughters.
May-O-Lite Helps Solve Reflection Problem
As you know, surfaces of glasses reflect light.
This in turn, produces out-of-focus “ghost
images.” These reflections interfere with the
transmitted image light, reduce definition and
contribute to eye strain.
Usually this is considered the normal burden of
a person who wears glasses. This need no longer
be so. By application of our Low Reflection
Lens Coating, most of these out-of-focus “ghost
images” are converted into transmitted light,
providing more transparent glass.
Let’s see what this amounts to.
Our Low Reflection Lens Coating,
1. Reduces out-of-focus surface reflections
75% to 90%.
2. Improves image definition.
3. Increases transmission of light — more trans-
parent glass.
4. Hardens the lens surfaces — reducing sur-
face scratching.
5. Provides better vision— less eye strain.
Developed for the armed services during the war
as a means to improve image definition in mili-
tary instruments, our Low Reflection Lens Coat-
ing is now available to your patients.
Explain this revolutionary new process to your
next patient! It is available through most manu-
facturing and dispensing opticians. Write for
descriptive pamphlet and coated sample of glass,
today.
May-O-Lite
developed by
MAY RESEARCH
126 South Third Street
Minneapolis 1, Minnesota
1304
Minnesota Medicine
IN MEMORIAM
Have a Coke
MUHLENBURG KELLER KNAUFF
Dr. M. K. Knauff, of Saint Paul, passed away July
17, 1947, at the Miller Hospital after an illness of six
weeks. Muhlenburg Keller Knauff was born in Philadel-
phia, Pennsylvania, on May 16, 1868. He was the son of
Henry W. and Catherine Eliza (Keller) Knauff, with
whom he came to Saint Paul in 1883. Here he completed
his high school education and then returned to Philadel-
phia University for his academic education. In 1895 he
was graduated from the University of Minnesota Medi-
cal School, and then served his internship at Ancker
Hospital, Saint Paul.
Dr. Knauff was associated with Dr. Bertram Sippy
prior to serving in the Spanish American War as the
Regimental Surgeon of the 1st Cavalry Division at Fort
Keogh, Montana. On June 20, 1899, he was married to
Anna Lillian Munson. In 1901 he practiced medicine
and operated the hospital in Two Harbors, Minnesota.
During this period he served two terms as the mayor of
Two Harbors and during the severe outbreak of ty-
phoid fever in 1912, he was instrumental in securing for
the city a safe water supply.
In 1914 he sold his hospital and with Mrs. Knauff
went to Germany for further study. Later he went to
England where he took postgraduate work in orthope-
dics under Sir Robert Jones. He returned to Saint
Paul and established a medical practice in which he was
active until May 27, 1947, when taken ill.
In 1945 he was honored with the fifty-year club
plaque. He was a member of Nu Sigma Nu Medical
fraternity. He served generously on the out-patient staff
of Ancker Hospital and Wilder Charity Dispensary.
Dr. Knauff was a charter member of the Reformation
Church of Saint Paul and took an active part in all the
activities of the church. He was also active in the Boy
Scout work of the church, and at the time of his death,
was a member of the Board of Directors of the North-
western Theological Seminary of the United Lutheran
Church of America. He was a member of the Spanish
American War Veterans’ Wirth Bagley Post No. 2,
Saint Paul.
Dr. Knauff was especially fond of music and poetry.
He had written poems as a hobby for many years and
was a member of the League of Minnesota Poets.
He is survived by his wife, Anna, and a sister, Mrs.
Emily Marshall of Minneapolis.
JAMES ROLLIN MANLEY
Dr. James R. Manley, well known obstetrician and
gynecologist of Duluth, passed away October 21, 1947,
at the age of sixty-two. He had been elected first vice
president of the Minnesota State Medical Association to
take office in 1948.
Born March 21, 1885, in Bellona, New York, Dr. Man-
ley came to Duluth in 1891. He obtained his medical
degree from the University of Minnesota in 1908 and
interned at St. Mary’s Hospital, Duluth. After prac-
ticing at Niagara, North Dakota, from 1909 to 1913,
he took postgraduate work at the Chicago and New
York Lying-In Hospitals. He also spent a year in
Vienna in 1925.
December, 1947
1305
IN MEMORIAM
North Shore
Health Resort
Winnetka, Illinois
on the Shores of
Lake Michigan
A completely equipped sanitarium for the care of
nervous and mental disorders, alcoholism and drug addiction
offering all forms of treatment, including electric shock.
SAMUEL LIEBMAN, M.S., M.D.
225 Sheridan Road Medical Director Phone Winnetka 211
Dr. Manley was a member of the American College of
Surgeons, the American Board of Obstetrics and Gyn-
ecology, the Minnesota Obstetrical Society, the Inter-
urban Academy of Medicine, the Central Association
of Obstetricians and Gynecologists, and in 1937 was
president of the St. Louis County Medical Society. He
was also a former chief of staff of St. Luke’s and St.
Mary’s Hospitals. In 1929, he was called to give a se-
ries of lectures on obstetrics by the Universities of Ne-
braska and Oklahoma. He was a member of the St.
Louis County Medical Society, the Minnesota State and
American Medical Associations.
In 1910, Dr. Manley married Dorothy L. Lucke, who
survives him. He is survived also by a daughter, Mrs.
Jesse D. Bradley, and a son, James R. Manley, Jr., a
brother, Howard G. Manley, and his father, R. F. Man-
ley — all of Duluth.
WILLIAM AUSTIN O'BRIEN
Dr. W. A. O’Brien, Professor of Preventive Medicine
and Health Education at the University of Minnesota
Medical School and well known for his radio broadcasts
and syndicated health articles, died suddenly of a cere-
bral hemorrhage on November 15, 1947, at the age of
fifty-four.
Bom in Fairbury, Illinois, February 28, 1893, Dr.
O’Brien attended St. Bede college at Peru, Illinois, and
Notre Dame University. He graduated from the St.
Louis University School of Medicine in 1913 and in-
terned at Mt. St. Rose Hospital and St. John’s Hospital,
both in St. Louis.
He practiced medicine in Detroit, Michigan, and
served from 1919 to 1921 with the Detroit Department of
Health. During World War I he served as first lieu-
tenant in the Army Medical Corps with the 15th Cav-
alry at Fort Bliss, Texas.
He did postgraduate work at the University of Min-
nesota from 1921 to 1923 when he became an instructor
in pathology. He became a full professor of Preventive
Medicine and Health Education in 1940.
Dr. O’Brien was a member of the Board of Directors
of the American Cancer. Society and president of the
Minnesota branch. For fifteen years he had been a mem-
ber of the Board of the Hennepin County Tuberculosis
Association and had been chairman of the Association’s
annual Christmas Seal Campaign for the past ten years.
Dr. O’Brien married Dorathy Beharrell on March 3,
1919, and to this union were born two children, William
Austin, Jr., and Margaret Jean. Mrs. O’Brien passed
away on March 10, 1934. On November 28, 1935, he
married Virginia Mary Benton of Minneapolis.
He is survived by his wife, and six children, William
Austin, Jr., Margaret Jean, Kathleen Ann, Patrick
James, Michael Paul and Molly.
HENRY W. REITER
Dr. Henry W. Reiter of Shakopee, Minnesota, died
October 30, 1947, at the age of eighty-three.
Dr. Reiter was born November 15, 1863, at Rockville,
1306
Minnesota Medicine
IN MEMORIAM
Minnesota. Graduating from the State Normal Col-
lege at St. Cloud in 1889, he taught school for a year
before attending the University of Minnesota medical
school where he graduated in 1893. He practiced in
Clara City and Kerkhoven from 1894 to 1897, then
located at Shakopee.
Dr. Reiter served as a member of the Shakopee Board
of Education, was city health officer at different times,
and was coroner from 1914 until last year. During
World War I, he was chairman of the local draft board.
In 1904, Dr. Reiter married Anna Mary Marschall,
who died several years ago. They had no children.
Dr. Reiter was a member of the Scott-Carver County
Medical Society, the Minnesota State and American
Medical Associations.
ROBERT E. MORRIS
Dr. R. E. Morris, a physician on the staff of Mineral
Springs Sanatorium at Cannon Falls since May, 1947,
died at Colonial Hospital, Rochester, October 25, 1947,
at the age of thirty-two.
Dr. Morris is survived by his wife and two sons,
Robert Earl and John.
ROOD TAYLOR
Dr. Rood Taylor, well-known pediatrician of Min-
neapolis, passed away on May 2, 1947. Dr. Taylor had
retired from active practice some time ago.
Rood Taylor was born May 12, 1885, at Columbia,
South Dakota. He received his M.D. degree from the
University of Michigan in 1910 and interned from 1910
to 1912 at the Northern Pacific Hospital in Brainerd,
Minnesota. From 1914 to 1917, he was a teaching fellow
in pediatrics at the University of Minnesota Medical
School and received the degree of Ph.D. in Pediatrics
from the University of Minnesota in 1917. He became
an associate in pediatrics at the Mayo Clinic in July,
1917, and left in February, 1919, to practice pediatrics
in Minneapolis. He was an associate professor of
pediatrics at the University of Minnesota.
Dr. Taylor, before his retirement, was a member of
the Hennepin County Medical Society, the Minnesota
State and American Medical Associations, the American
Pediatric Society, Phi Beta Pi, and Sigma Xi medical
fraternities.
HENRY EDWARD WUNDER
Dr. H. E. Wunder, recently Medical Director of Mud-
cura Sanatorium at Shakopee, died in October while
visiting a daughter in Milwaukee. He was seventy-
seven years of age.
Born in Ohio, June 2, 1869, Dr. Wunder settled in
Ely, where for twenty years he was physician for the
Oliver Iron Mining Company. He then moved to Duluth
where he practiced until the late twenties.
He was a former member of the Scott-Carver County
Medical Society and the Minnesota State and American
Medical Associations.
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♦ Reports and Announcements ♦
AMERICAN COLLEGE OF SURGEONS
The American College of Surgeons will hold six sec-
tional meetings, one of which will be at the Nicollet
Hotel, Minneapolis, March 15 and 16, 1948. These meet-
ings are open not only to members but to the medical
profession at large and to hospital personnel. Addresses
and panel discussions will be held daily on subjects in
each field of surgery by authorities in the various spheres.
Headquarters are at 40 E. Erie Street, Chicago 11, Il-
linois.
ARMY INTERNSHIPS AND RESIDENCES
The Army in 1948 is offering 200 rotating internships,
open to recent graduates. Pay schedules and allowances
will be those of a first lieutenant.
There will also be 350 residences for periods of one,
two, and three years in the various specialties. These
will be available in the various Army General Hospitals
to regular Army medical officers or applicants for the
regular Army who are graduates of approved medical
schools and have had a year of rotating internship in an
approved hospital.
The Technical Information Officer in the office of the
Surgeon General, Washington, D.C., may be contacted
for further information.
CHICAGO MEDICAL SOCIETY
The Chicago Medical Society will hold its Fourth
Annual Clinical Conference at the Palmer House, Chi-
cago, on March 2, 3, 4 and 5, 1948.
This Conference represents an intensive four-day
postgraduate course for the general practitioner and
specialist with leading teachers from all over the United
States.
The morning and afternoon lectures, the panel dis-
cussions, the clinicopathologic conference and the round-
table discussions each noon will cover newer methods
of diagnosis and treatment which will be of interest to
all physicians. The scientific and technical exhibits will
be of the highest quality and attractively presented.
The Chicago Medical Society is extending all physi-
cians a most cordial invitation to come to Chicago for
the Conference. Reservations should be made direct
with the Palmer House.
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Minnesota Medicine
REPORTS AND ANNOUNCEMENTS
Rx Q&1.
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held at the University of Minnesota Thursday, Friday
and Saturday, November 20, 21 and 22, 1947.
With the increasing use of the consultation process
as a technique used by all medical social workers, the
subject selected for discussion was “The Consultation
Process in the Field of Medical Social Work.”
Leading the discussion was Mrs. Elizabeth E. Payne,
associate professor of the graduate school of social
work at the University of Southern California. In ad-
dition, several members of the group attending presented
their own material on consultations in the fields of public
assistance programs, public health or medical programs,
federal or state hospitals and private hospitals or clinics.
MICHIGAN POSTGRADUATE CLINICAL INSTITUTE
The second annual Michigan Postgraduate Clinical
Institute will be held at the Book-Cadillac Hotel, Detroit,
Wednesday, Thursday and Friday, March 10, 11 and 12,
1948. Forty-nine outstanding clinicians and lecturers will
present a concentrated three-day postgraduate course
covering the newest developments in medicine, surgery,
obstetrics, pediatrics, dermatology, ophthalmo-otolaryng-
ology and general practice.
Two evening sessions will be held, the Wednesday
night presentation being a “question box” and the
Thursday evening program being a panel discussion on
“First Aid to the Acutely Injured Patient.”
All members of the American Medical Association
and of the Canadian Medical Association are cordially
invited to attend the Michigan Postgraduate Clinical In-
stitute. No registration fee.
MISSISSIPPI VALLEY MEDICAL SOCIETY
1948 ESSAY CONTEST
The eighth annual essay contest of the Mississippi
Valley Medical Society will be held in 1948. The society
will offer a cash prize of $100, gold medal, and a
certificate of award for the best unpublished essay on
any subject of general medical interest (including
medical economics and education) and practical value
to the general practitioner of medicine. Certificates of
merit may also be granted to the physicians whose
essays are rated second and third best. Contestants
must be members of the American Medical Association
who are residents of the United States. The winner
will be invited to present his contribution before the
thirteenth annual meeting of the Mississippi Valley Medi-
cal Society to be held in Springfield, Illinois, September
29, 30, October 1, 1948, the society reserving the exclu-
sive right to first publish the essay in its official pub-
lication, the Mississippi Valley Medical Journal (incor-
porating the Radiologic Review). All contributions shall
be typewritten in English in manuscript form, submitted
in five copies, not to exceed 5,000 words, and must be
received not later than May 1. 1948. The winning essay
in the 1947 contest appears in the January, 1948, issue
of the Mississippi Valley Medical Journal (Quincy, Il-
linois).
Further details may be secured from Harold Swan-
1309
December, 1947
REPORTS AND ANNOUNCEMENTS
CHICAGO MEDICAL SOCIETY
J’Oivdh- OnnwxL (^linked, Qon^shmcsL
March 2, 3, 4, 5, 1948
Palmer House, Chicago
Four full days of lectures, panel discussions and clinicopathologic con-
ferences presented by outstanding speakers and teachers from all sections
of the country.
Scientific exhibits well worth seeing.
Technical exhibits on the newer drugs and equipment.
If you have attended previous Conferences, you probably are planning to
come again in 1948. If you have not yet attended, you should make
plans now to be present.
MAKE YOUR RESERVATION AT THE PALMER HOUSE
berg, M.D., Secretary, Mississippi Valley Medical So-
ciety, 209-224 W. C. U. Building, Quincy, Illinois.
MINNESOTA SOCIETY OF
NEUROLOGY AND PSYCHIATRY
The regular meeting of the Minnesota Society of
Neurology and Psychiatry was held at the Town and
Country Club in Saint Paul on the evening of Novem-
ber 18, 1947.
Following dinner at 6:30 p.m., the scientific program
was presented, consisting of two inaugural theses. Dr.
Clifford O. Erickson, Minneapolis, presented as his thesis,
“Psychoses Arising in Combat,” while Dr. Philip K. Arzt,
Saint Paul, spoke on “Electroencephalogram Findings in
Central Nervous System Disease.”
MINNESOTA SOCIETY OF ANESTHESIOLOGISTS
On August 30, 1947, the Minnesota Society of
Anesthesiologists was formed. The following officers
were elected : Ralph T. Knight, M.D., Minneapolis,
president; T. Harry Seldon, M.D., Rochester, vice presi-
dent; Frank Cole, M.D., Duluth, secretary-treasurer.
All physicians interested in anesthesiology are invited to
apply for membership in this society. Address such ap-
plications for membership to Frank Cole, M.D., chair-
man, Membership Committee, St. Mary's Hospital,
Duluth.
SOUTHWESTERN MINNESOTA
MEDICAL ASSOCIATION
The 1947 annual meeting of the Southwestern Min-
nesota Medical Association was held at Worthington on
October 28.
Principal speaker at the evening meeting was Dr.
Clarence Dennis, professor of surgery at the University
of Minnesota Medical School, who talked on “Small
Bowel Obstructions.”
Dr. F. L. Schade, Worthington, was elected president
of the association, while Dr. John Lohmann, Pipestone,
was named president-elect. Dr. Gerrit Beckering, Edger-
ton, was elected vice president, and Dr. B. O. Mork, Jr.,
Worthington, was re-elected secretary-treasurer. Named
to the board of delegates were Dr. Schade and Dr. S. A.
Slater, Worthington, with Dr. Lohmann and Dr. Mork
as alternates. Dr. C. L. Sherman, Luverne, and Dr.
W. A. Piper, Mountain Lake, were chosen members of
the board of censors.
WRIGHT COUNTY SOCIETY
The annual meeting of the Wright County Medical
Society was held at the home of Dr. John Catlin in
Buffalo on October 7. A scientific program was pre-
sented in the afternoon, followed by a banquet at six
o’clock and election of officers of the society.
Dr. Hartwig Roholt, Waverly, was elected president ;
Dr. Vincent Ryding, Howard Lake, vice president, and
Dr. John Catlin, Buffalo, secretary-treasurer. Twenty-
two physicians attended the meeting.
1310
Minnesota Medicine
Woman’s Auxiliary
MEMBERS of the Medical Auxiliaries are deeply
shocked to learn of the death of Dr. Wm. A.
O’Brien. His friendly smile and talks will be missed by
all.
Olmsted-Houston-Fillmore-Dodge
Members of the Olmsted-Houston-Fillmore-Dodge
County Medical Auxiliary held their November meeting
at the Mayo Foundation House. Miss Eleanor Smith,
science instructor at the Kahler School of Nursing, led
a discussion on “present-day problems of the nursing
profession.” “Raise the nurses’ status,” suggested Miss
Smith. “By making the professional status of nursing
more attractive, the present shortage of nurses will be
eased,” she said.
Mrs. W. A. Merritt of Rochester presided over the
meeting and Mrs. A. B. Hagedorn poured.
On Tuesdays and Fridays members meet at the home
of Mrs. M. S. Henderson in Rochester, and work on
cancer dressings.
Redwood-Brown
t
The Redwood-Brown County Medical Society and
Auxiliary entertained the Blue Earth and Nicollet Coun-
ty Societies on October 22 at New Ulm. After a dinner
served at Turner Hall, the Auxiliaries enjoyed a pro-
gram which included a talk by Mrs. Carl Fritsche on
her recent trip to Alaska.
Renville County
The members of Renville County Auxiliary were en-
tertained at a turkey dinner when the doctors met for
their annual meeting at Hector on November 11. Guest
speaker for the evening was Dr. W. A. Hanson of
Minneapolis. While the doctors held their business
meeting, members of the Auxiliary were entertained at
the home of Dr. and Mrs. R. E. Erickson. Several sub-
scriptions to Hygeia were taken.
I N wishing you a Merry Christmas this
year we would capture for you as much
of the old time holiday spirit as possible.
Accept our sincere thanks for your gen-
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source of real encouragement to us in
1947.
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Minnesota State Dental Association East Central Minnesota Medical Society
Minnesota State Pharmaceutical Assn. Hennepin County Medical Society
Minnesota Auto Dealers Association Hennepin County Bar Association
December, 1947
1311
Of General Interest
♦
Dr. L. M. Klefstad, formerly of the More Clinic in
Eveleth, has opened an office for the practice of medicine
in Greenbush.
• * * *
In the middle of October, Dr. J. J. Stratte arrived in
Isle to open offices for the practice of medicine. Dr.
Stratte formerly practiced in Page, North Dakota.
* * *
Dr. Clyde Undine, Minneapolis, attended the regional
meeting of the American College of Physicians, held at
Milwaukee on November 14 and 15.
:Jc
Speaker at a meeting of the Blue Earth County Medical
Society in Fairmont on November 20 was Dr. J. H.
Tillisch, Rochester, who discussed “Medical Observa-
tions in the Orient.”
* * *
At the annual meeting of the New England Patho-
logical Society in Boston on November 20, Dr. J. W.
Kernohan, Rochester, presented a paper entitled
“Mechanical Effects of Expanding Intracranial Lesions.”
* * *
“Treatment of Injuries of the Peripheral Nerve” was
the title of a paper presented by Dr. W. M. Craig,
Rochester, at a meeting in Boston, November 15, of the
Association of Military Surgeons.
* * *
Word has been received that Dr. W. L. Benedict,
Rochester, has been elected executive secretary-treasurer
of the American Academy of Ophthalmology and Oto-
laryngology.
* * *
“Film Identification” was the title of an address giv-
en by Dr. A. L. Abraham, Duluth, at a meeting of the
Arrowhead Society of X-Ray Technicians on Novem-
ber 12 at St. Luke’s Hospital, Duluth.
* * *
First president of the Marshall Community Chest is
Dr. J. E. Murphy, Marshall, who was elected to office
at the initial meeting of the new organization on Oc-
tober 9.
* * *
During the last week of October, Dr. W. L. Herbert,
(Columbia Heights) Minneapolis, journeyed to Omaha,
Nebraska, to attend a medical meeting and to visit rela-
tives in that city.
Dr. Neill F. Goltz has become associated with Dr.
A. W. Hilger and Dr. Jerome A. Hilger in the practice
of otolaryngology and broncho-esophagology, with offices
at 444 Lowry Medical Arts Building, Saint Paul.
* * *
Formerly with the Mesabi Clinic in Hibbing, Dr.
Frederick Phillips has moved to Mora and become as-
sociated in practice with Dr. W. F. Nordman of that
city.
* * *
Heart diseases and the Heart Hospital were discussed
by Dr. E. D. Anderson, Dr. M. J. Shapiro, and Dr. Paul
Dwan at a meeting of the Minneapolis Junior League on
November 3.
* * *
Dr. Harry B. Zimmermann, Saint Paul, was elected
president of the Western Surgical Association at its
meeting in Colorado Springs early in December. Dr.
Zimmermann has been the association’s recorder for
several years. He is succeeded in that office by Dr.
Michael L. Mason, Chicago.
* * *
The University of Louisville honored Dr. J. E. McCoy,
Thief River Falls, in October, by presenting him with
a certificate commemorating his fifty years of service
to the medical profession. Dr. McCoy was graduated
from the school in 1897.
* * *
In Little Falls, Dr. G. M. A. Fortier has moved from
his former offices into a new one-story office building
upon which construction began last June. The new
structure has a waiting room and four consultation rooms
for examination and treatment.
* * *
Dr. E. J. Huenekens, Minneapolis, has resigned as
medical director of parent counsel clinics for the Com-
munity Health Service and has been replaced by Dr.
Edward Dyer Anderson, Minneapolis, pediatric psychi-
atrist.
* * *
A fellowship in pediatrics at the University of Wiscon-
sin has been awarded to Dr. Edward Zupanc, former
resident of Gilbert, who is completing an internship at
St. Luke’s Hospital in Duluth. A graduate of the Uni-
versity of Minnesota Medical School, Dr. Zupanc will
begin the fellowship in January, 1948.
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Minnesota Medicine
OF GENERAL INTEREST
The final organization meeting of the Minnesota Heart
Association, Inc., was held November 1 in Hotel Lowry,
Saint Paul. Elected as president of the organization was
Dr. Paul F. Dwan, Minneapolis, while Dr. L. F. Rich-
dorf, Minneapolis, was named first vice president.
* * *
In Austin on November 1, Dr. Paul A. Robertson
moved into new office quarters on the second floor of a
building housing the Holtz Drug Store. Dr. Robertson’s
former office location has become part of the studio of
the Cedar Valley Broadcasting Company.
t- * *
After practicing for a year and a half at Evansville,
Dr. Gordon Paulson has moved to Panama to become
resident physician at Gorgas Hospital and to take a special
course in patholology. Before the war he interned at
Gorgas Hospital.
* * *
A former Thief River Falls physician, Dr. William W.
Johnstone returned to the United States in September
after spending a year in Africa with the Sudan Interim-
Mission. He visited friends in Thief River Falls early
in October.
* * *
Two meetings attended during October by Dr. Charles
W. Vandersluis, Bemidji, were the annual meeting of the
Interstate Postgraduate Association of North America,
held in St. Louis, Missouri, and a meeting of the execu-
tive committee of the Minnesota Heart Association in
Saint Paul.
Among the Minnesota physicians who attended the
International Medical Assembly held October 14 to 17
in St. Louis, Missouri, were Dr. C. G. Sheppard, Hutch-
inson, and Dr. John Gridley, Glencoe, who drove to St.
Louis together on October 13.
t- * *
Among the speakers at the annual meeting of the
American Cancer Society, held October 27 in New York
City, were Dr. John J. Bittner, University of Minnesota
Medical School, and Dr. C. P. Oliver of the University
of Texas, formerly of the University of Minnesota.
* * *
Principal speaker at a meeting of the Red River Val-
ley Medical Society, held in Thief River Falls on Oc-
tober 28, was Dr. Francis W. Lynch, Saint Paul, who
talked on recent advances in the treatment of skin dis-
orders.
* * *
Dr. Leo G. Rigler, chief of radiology and physical
therapy at the University of Minnesota, presented the
seventh annual Pancoast lecture at the University of
Pennsylvania, Philadelphia, on November 6. His sub-
ject was “The Limitation of Roentgen Diagnosis.”
* * t-
Chest clinics were held in Owatonna on October 27 and
in Austin on November 12 by Dr. Karl J. Pfuetze, super-
intendent and director of Mineral Springs Sanatorium,
for former patients of the sanatorium and other interest-
ed local residents. Mantoux tests were administered with-
out charge to all volunteers.
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5511 Lyndale Ave. So. LO. 0773 Minneapolis, Minn. I
~< 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 II 1 1 1 1 1 1 1 II I1 1 1 1 1 H 1 1 1 1 1 1 1 1 II 1 1 1 1 1 1 1 1 1 1 1 II I II 1 1 II 1 1 1 1 M 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i 1 1 1 II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 f 1 1 1 1 1 1 1 1 1 1 ■ II 1 1 1 1 1 1 1 1 1 1 1 It 1 1 1 1 1 1 1 1 1 II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 M 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 II 1 1 1 1 1 f I 111 I II 1 1 III 1 1 1 1 1 1 (II 1 1 1 M M 1 1 1 1 1 1
REST HOSPITAL
A quiet, ethical hospital with therapeutic facilities
for the diagnosis, care and treatment of Nervous
and Medical cases. Invites cooperation of all
reputable physicians who may supervise the treat-
ment of their patients.
PSYCHIATRISTS IN CHARGE
Dr. Hewitt B. Hannah
Dr. loel C. Hultkrans
2527 2nd Ave. S., Minneapolis, Phone At. 7369
December, 1947
1313
OF GENERAL INTEREST
Kalman & Company, Inc.
Investment Securities
Members:
Chicago Stock Exchange
Minneapolis-St. Paul Stock Exchange
ST. PAUL MINNEAPOLIS
RADIUM
35 Beruuce to
the Concert ^lliec&pUt
Modern Laboratories
arid Equipment; Exper-
ienced Technical Staff;
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RADIUM & RADON CORP.
Telephone Ran. 8855 • 25 E. Washington St.
CHICAGO 2, ILL.
9 to 5 Mon. through Fri. • Sat. 9 to 12
Diagnosis and symptoms of rheumatic fever were dis-
cussed by Dr. Evelyn Harris, medical director of the
Diagnostic Clinic for Rheumatic Fever, at a meeting in
Saint Paul on October 31 attended by public and paro-
chial school nurses and county and family nursing serv-
ice nurses.
* * *
During the week of November 17, the Los Angeles
Urologic Society at its Postgraduate Study Course
heard Dr. J. R. McDonald, Rochester, present five pa-
pers entitled “Tumors of the Kidney,” “Tumors of the
Testis,” “Carcinoma of the Urinary Bladder,” “Carcino-
ma of the Prostate Gland” and “Cancer Cells in Urinary
Sediment.”
* * *
Two Mayo Clinic physicians, Dr. E. D. Bayrd and
Dr. C. G. Morlock, presented papers at the November
11 meeting of the Iowa Division of the American Cancer
Society in Des Moines, Iowa. Dr. Bayrd’s paper was
entitled “Therapeutic Use of Radioactive Isotopes,”
while Dr. Morlock’s subject was “Cancer of the
Stomach.”
* * *
Authors of an article in a recent issue of Radiology,
publication of the Radiological Society of North Ameri-
ca, are Dr. Leo G. Rigler and Dr. G. M. Kelby of the
Department of Radiology and Physical Therapy at the
University of Minnesota Hospitals. Their article de-
scribes an early x-ray sign indicating tbe presence of
bronchogenic cancer.
* * *
Dr. Bertha Van Hoosen, who was born in Rochester
eighty-four years ago, is the author of a recently pub-
lished book, Petticoat Surgeon. Educated at the Uni-
versity of Michigan, Dr. Van Hoosen has spent most of
her professional life in Chicago since 1892 and has
taught obstetrics, gynecology and embryology at Illinois,
Northwestern and Loyola Universities.
;(c
Announcement has been made that Dr. Roy T. Pear-
son has become associated with his brother, Dr. B. F.
Pearson in the general practice of medicine in Shakopee.
Following his graduation from the University of Min-
nesota, Dr. Roy T. Pearson served in the navy in the
Pacific, then returned after his discharge to take post-
graduate work at the University Hospitals.
* * *
Founder of the first consumer-controlled hospital and
clinic in the United States, Dr. Michael A. Shadid, Elk
City, Oklahoma, was in Duluth on November 10 to speak
to committeemen and solicitors of the Arrowhead Health
Center, Inc. The health center has established new
headquarters in Webber Hospital, which it has con-
tracted to purchase for $100,000, and intends to offer
various health services under a special membership plan.
* * *
A new addition to the staff of the Bratrud Clinic in
Thief River Falls is Dr. John Lehman, formerly of
Glendive, Montana, who joined the clinic early in Oc-
tober. After graduating from the University of Minne-
sota in 1943, Dr. Lehman served his internship at Miller
1314
Minnesota Medicine
OF GENERAL INTEREST
OMEWOOD HOSPITAL is one of the
Northwest's outstanding hospitals for the
treatment of Nervous Disorders — equipped
with all the essentials for rendering high-grade
service to patient and physician.
Operated in Connection with
Glenwood Hills Hospitals
HOMEWOOD HOSPITAL
Corner Penn and Plymouth Avenues North
Minneapolis Minnesota
The Birches Sanitarium, Inc.
2391 Woodland Avenue
Duluth 3, Minnesota
A hospital for the care and treatment of
Nervous and Mental disorders. Quiet, cheer-
ful environment. Specially trained personnel.
Recreational and occupational therapy.
Psychiatrists in Charge
L. R. Gowan, M.D. L. E. Schneider, M.D.
Hospital, Saint Paul, and later held a fellowship in
ophthalmology, after which he was associated in private
practice with Dr. Frank E. Burch, Saint Paul.
ifi Jj{ sjs
New member of the staff of the Mankato Clinic is
Dr. J. Donald Sjoding, who recently completed a three-
year fellowship in otolaryngology and broncho-esophag-
ology at the University of Minnesota Hospitals.
After graduating from the University of Minnesota in
1942, Dr. Sjoding served for two and a half years in the
medical corps of the army air forces, fifteen months of
the period in the India-Burma theater.
* * *
A graduate of the University of Minnesota Medical
School in 1929, Dr. Frank P. Light has been appointed
chief of the Department of Obstetrics and Gynecology
of Long Island College Hospital, succeeding Dr. Alfred
C. Beck, who recently resigned. Dr. Light joined the
teaching staff of the Long Island College of Medicine
in 1935 and was appointed clinical professor of ob-
stetrics and gynecology in 1946.
^ ^ ^
Resignation of Dr. Edwin J. Simons, Swanville, as
chief of the medical services unit of the State Division
of Social Welfare, was announced on October 21. Dr.
Simons has resumed his practice at Swanville, where
he has been located since his graduation from the Uni-
versity of Minnesota in 1925.
In 1940 Dr. Simons was named a member of the
state-wide medical advisory committee of the Division of
Social Welfare, and he served in that capacity until
January 1, 1942, when he was named chief of the med-
ical services unit. In 1946 he was president of the
Minnesota State Medical Association.
* * *
Recently named chief medical consultant for Europe
of the International Children’s Emergency Fund of the
United Nations, Dr. H. F. Helmholz, Rochester, is now
in Paris where he is helping to organize and direct a
European technical staff of pediatricians, nutritionists,
nurses and child welfare consultants in the work of child
feeding, health and welfare. Dr. Helmholz has been
granted a year’s leave of absence from the Mayo Clinic
to carry out the European assignment.
* * *
Speaking at a tuberculosis continuation course at the
University of Minnesota on October 30, Dr. Percy T.
Watson, director of local health services in the State
Board of Health, declared that the health of Minnesota’s
24,000 Indians and Mexicans was periled by a Federal
cut in tuberculosis control funds. Because $30,000 was
removed from Federal appropriations, the state sana-
torium at Walker was being forced to turn away many
Indians with active tuberculosis, Dr. Watson said.
* * *
Vice chairman of the newly organized Lake County
Advisory Health Council is Dr. Ralph Papermaster,
Two Harbors, who was elected to office at a meeting
held in Two Harbors on October 7. The newly formed
organization will promote individual and community
December, 1947
1315
OF GENERAL INTEREST
Government Surplus
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Minneapolis, Minn. LI. 7561
AT YOUR CONVENIENCE,
DOCTOR . . .
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and modern prescription pharmacy located on
the street floor of the Foshay Tower, 100 South
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With our expanded facilities we will be able
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health, co-operating with officials and agencies interested
in public health, co-ordinating the school health program
with the community program, and interpreting the health
program to the community.
- * * *
Physical examinations were done on 127 crippled chil-
dren at an orthopedic clinic held October 25 in Crook-
ston. At the clinic, which was under the sponsorship of
the Red River Valley Medical Society auxiliary, physi-
cians examined the following numbers of children from
eleven northwestern counties : Polk, 37 ; Marshall, 27 ;
Pennington, 12; Red Lake, 8; Roseau, 10; Kittson, 8;
Norman, 17; Mahnomen, 8; Clearwater, 3; Clay, 1, and
Becker, 2.
* * *
At the annual dinner meeting of the medical faculty
of the University of Minnesota, held in Coffman Me-
morial Union on November 6, Dr. Victor H. Johnson,
director of the Mayo Foundation at Rochester, was the
principal speaker. Significant developments in the medi-
cal school during the past year were reviewed at the
meeting, and an outline of future plans was discussed.
New medical faculty members were introduced and wel-
comed at a reception after the dinner.
* * *
Four papers were presented by Dr. M. B. Dockerty,
Rochester, at a postgraduate course on tumors held in
Galveston, Texas, in November, by the Department of
Pathology, the John Sealy Hospital Tumor Clinic and
the Postgraduate Division of the School of Medicine of
the University of Texas. The four papers were en-
titled “Malignancies of the Breast,” “Carcinoma of the
Cervix and Fundus Uteri,” “Carcinoma of the Fallopian
Tubes and Ovaries” and “Tumors of the Salivary
Gland.”
^ ^ ^
“Dr. Hagen Day” was celebrated on November 16
when residents of Butterfield and the surrounding area
gathered to honor Dr. O. E. Hagen, seventy-six-year-old
physician who has practiced in Butterfield for forty-
four years. Plans for the occasion were worked out by
representatives of the village churches, council, school
board, community club and school faculty. A special
program was held in the local high school auditorium
in the afternoon, and tribute was paid to Dr. Hagen for
his many years of work in the field of medicine.
* * *
Announcement has been made that Dr. S. C. G. Oel-
jen, Waseca, has been certified by the American Board
of Ophthalmology and will remain in Waseca, limiting
his practice to ophthalmology. A graduate of the Uni-
versity of Minnesota, Dr. Oeljen has also studied at
Columbia University, New York City, at George Wash-
ington University, Washington, D. C., and at the Chi-
cago Eye, Ear, Nose and Throat Hospital. He has taken
postgraduate work in Vienna, Austria, under ophthal-
mologist Dr. Adalbert Fuchs.
* * *
One of sixty prominent Ripon College (Wisconsin)
alumni to receive citations at the college’s pre-centennial
celebration November 1, Dr. J. Allen Wilson, Saint Paul,
was honored by the college for his work in the field of
1316
Minnesota Medicine
OF GENERAL INTEREST
medicine. A graduate of the college in 1922, Dr. Wilson
began practicing medicine in Saint Paul in 1930. During
the war he served in the navy, being discharged in 1946
with the rank of captain. At present he is a clinical
instructor in medicine at the University of Minnesota and
a consultant in medicine at the Veterans Hospital.
J-C jfi
A former resident of Ivanhoe, Dr. Arthur R. An-
drejek became associated with the Madison Clinic on
October 1. After graduating from the University of
Minnesota in 1946, Dr. Andrejek served a sixteen-month
internship at Henry Ford Hospital, Detroit, Michigan,
then took postgraduate work in obstetrics and gyne-
cology for four months before moving to Madison. In
addition to Dr. Andrejek, the staff of the Madison Clinic
now includes Dr. Walter N. Lee, Dr. Magnus West-
by and Dr. Nels Westby.
* ❖ *
As the fifth son of Dr. W. F. C. Heise to enter medical
practice with his father in Winona, Dr. Phillip R. Heise
joined the staff of the Heise Clinic on November 3. The
unique medical family became complete on that date, with
father and five sons in practice together.
Dr. Phillip Heise was graduated from the University
of Arkansas, served his internship at Baptist Memorial
Hospital in Memphis, Tennessee, spent three years in the
army medical corps, then took postgraduate work in ob-
stetrics and gynecology at St. Barnabas Hospital, Min-
neapolis, and John Gaston Hospital, Memphis, before
returning to Winona to join his brothers and father at
the Heise Clinic.
* * Jjc
The U. S. Army and Air Force require 30,000 re-
cruits monthly to maintain personnel to man occupation
areas, to train for national defense, and to conduct re-
search and development programs.
The Army and Air Force offer unusual opportunities
for interesting careers or for training for future civilian
jobs. Enlisted men are entitled to compete for officer’s
training schools; all personnel may advance their educa-
tion by enrolling in any of the hundreds of courses of-
fered by the U. S. Armed Forces Institute ; pay is high ;
thirty days of vacation are allowed.
Further information may be obtained from the
Military Personnel Procurement Service, Room 5D675,
Pentagon Building, Washington 25, D. C.
* * *
Valuable clinical and research data often remain un-
published because a physician does not have time or
facilities for checking and editing a manuscript. Sub-
mission of manuscripts can thus be delayed and an
author’s productivity limited. Available now to ease the
burden of the physician-writer are the services of an or-
ganization called Manuscript Service, Inc.
Located at 6432 Cass Avenue, Detroit 2, Michigan,
Manuscript Service, Inc. will provide abstracts of litera-
ture, compile data from the literature, suggest methods
of assembling or compiling author’s material, suggest
organization of manuscripts, design tables and charts,
verify references, check bibliographies, and compile in-
dexes.
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December, 1947
1317
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1909 1947
RHEUMATISM
RELIEVED
Thirty -eight years of success-
ful treatment o( rheumatism
under the same manage-
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M. D., Resident Physician.
Tel. Shakopee 123
HAKOPEE
MINNESOTA
U.S. Hwy. 212
anitarium
Cook County
Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY — Two-Week Intensive Course in Surgical
Technique starting January 19, February 16, March
15.
Four-Week Course in General Surgery starting Feb-
ruary 2, March 1, March 29.
Two-Week Course in Surgical Anatomy and Clinical
Surgery starting February 16, March 15.
One-Week Course in Surgery of Colon and Rectum
starting March 8, April 26.
Two-Week Course in Surgical Pathology every two
weeks.
GYNECOLOGY — Two-Week Intensive Course starting
February 23, March 29.
OBSTETRICS — Two-Week Intensive Course starting
March 15, April 12.
MEDICINE — Two-Week Intensive Course starting April
26.
Two-Week Course in Gastroenterology starting April
12.
Two-Week Personal Course in Gastroscopy starting
March 29, April 19.
Four-Week Course in Electrocardiography and Heart
Disease starting February 16, May 3.
CYSTOSCOPY — Ten-Day Course starting January 5,
January 19, February 2.
DERMATOLOGY — Two-Week Formal Course starting
April 26.
General , Intensive and Special Courses in all Branches
of Medicine, Surgery and the Specialties
TEACHING FACULTY — ATTENDING
STAFF OF COOK COUNTY HOSPITAL
Address:
Registrar, 427 S. Honore St., Chicago 12, 111.
The Ward Burdick medal of the American Society
of Clinical Pathologists was awarded to Dr. Charles
Sheard, Rochester, at a meeting of the society in Chi-
cago, October 28. The citation was made to Dr. Sheard,
who is director of the division of biophysical research
at the Mayo Clinic and professor of biophysics in the
Mayo Foundation, in recognition of his contributions to
the theoretical, experimental and instrumentational devel-
opments in the field of spectroscopy, photelometry and
spectrophotometry.
At a November meeting in Chicago, the American
Academy of Ophthalmology and Otolaryngology elected
Dr. Sheard to honorary fellowship in recognition of his
contributions to theoretical and applied physiological
optics.
•t* ^ ^
November 7 was the one hundredth anniversary of
the acceptance of Elizabeth Blackwell as the first woman
medical student in the United States.
Eleven medical schools had refused admission to
Elizabeth Blackwell in 1847 when the Geneva, New York,
Medical School finally accepted her, more or less as an
experiment, after a vote of the student body. She was
graduated with high honors, the first woman physician
in the country.
At present there are approximately 8,000 women physi-
cians in the United States, with 518 licensed in Minne-
sota as of June 1, 1947. Of sixty-nine approved medical
schools, the AMA reported in 1946, only three refuse to
accept women as students. At the University of Min-
nesota Medical School, each class of 100 now has an
average of ten women students.
* * *
During October and November, twelve rural school
health clinics were held in Goodhue County to give
rural school children the same health benefits that are
available in town and city schools.
Physicians of Goodhue County traveled to twelve rural
schools to inoculate children for smallpox and diph-
theria and to administer Mantoux tests.
This year’s series of clinics was the third held since
1942 when Goodhue County established the first rural
school health clinic of its kind in the country. Cost of
the clinics was about fifty cents per child, and county
officials estimated that more than 1,500 children took ad-
vantage of the voluntary checkup this year.
The clinics are sponsored jointly by the county agent’s
office, the county Farm Bureau Federation, the county
rural schools, and the local physicians.
* * *
Rural counties in Minnesota have only one-fourth as
many physicians for every 1,000 persons as the state's
more urban counties, it was pointed out recently in a
study published by the Minnesota Agricultural Experi-
ment Station.
The survey indicates, however, that urban centers
provide medical service for rural people, so the ratio
is not as disturbing as it might seem.
Distribution of physicians in Minnesota counties va-
ries from one for every sixty- three persons in Olmsted
County, home of the Mayo Clinic, to one physician for
1318
Minnesota Medicine
OF GENERAL INTEREST
every 4,129 persons in Cass County. Hennepin County
(Minneapolis) has 480 persons per physician; Pine
County has 3,068.
In addition, counties having less than five physicians
to serve their entire area are Cook, Lake of the Woods,
Hubbard, Clearwater, Kanabec, Traverse, Red Lake,
Kittson and Mahnomen.
% H*
With the addition of a general practitioner to its
medical faculty, the LTniversity of Minnesota Medical
School is attempting to strike a better balance between
the two approaches to medical work, specialization and
general practice.
In line with a growing interest in general practice dis-
played by both undergraduate and graduate students,
the Medical School has secured the services of Dr.
Thomas E. Eyres, a general practitioner at Pequot Lakes
for nine years, to put a greater emphasis on medical
training for that type of work.
For the next year Dr. Eyres will conduct a three-point
program: (1) give advice to medical students who plan
to enter general practice, (2) assist in arranging continu-
ation study courses for general practitioners, and (3)
compile reports on characteristics of teaching in rela-
tion to needs of the general practitioner. In addition, dur-
ing winter and spring quarters, Dr. Eyres plans to teach
an elective course on general practice to senior medical
students.
* * *
Public health administration in Minneapolis was at-
tacked by Dr. Gaylord W. Anderson, director of the
University of Minnesota School of Public Health, in a
speech made at a Health Action Committee executive
board meeting in Minneapolis, October 22.
Dr. Anderson stated that failure to adopt modern
methods of public health administration is costing the
people of Minneapolis a heavy price in sickness and
money. He accused the city of (1) unwillingness to
unify health administration on a joint city-county basis,
(2) too much dependence on charitable voluntary agencies
for doing essential anti-disease jobs, (3) keeping pub-
lic health work under the board of public welfare, pri-
marily a relief-administering agency, and (4) failing
to change public health emphasis from infectious dis-
eases to today’s major problems, such as cancer, heart
disease, mental illness.
Urging the city to drop its horse-and-buggy-age meth-
ods, Dr. Anderson advocated the setting up of a separate
public health department with a chief health officer
and semi-legislative responsibilities.
* * *
At ninety years of age, Dr. George I). Haggard is
still practicing medicine at his home in Minneapolis.
Born in a cabin north of Rochester in 1857 when
Minnesota was still a territory, Dr. Haggard is probably
the oldest practicing physician in the state. Thirty-
three years of age before he decided to become a phy-
sician, Dr. Haggard was graduated from the University
of Minnesota in 1893, the oldest man in his class.
Shortly after he began practice, he was appointed assist-
ant city health officer in Minneapolis and served in that
capacity for four years. He then taught physiology and
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December, 1947
1319
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1 75.00 weekly indemnity, accident Quarterly
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chemistry in the medical school for six years. During,
the early 1900’s, while working for the state health de-
partment, he battled typhoid, smallpox and poliomyelitis
epidemics both in Minneapolis and in northern Minne-
sota. Shortly before World War I, he was Prohibition
Party candidate for governor, gathering 32,000 votes in
the election.
Although Dr. Haggard stopped going out of his home
more than a year ago, he still sees patients who come
to him. Some of them are from families in which four
generations have been treated by the aged physician.
* * *
Three Mankato physicians met November 1 with city
officials of North Mankato and Parents and Teachers
Association representatives to oppose the city’s plan to
have a second county nurse hired.
Dr. H. J. Nilson, spokesman of the medical group
which consisted of Dr. Hobart Johnson and Dr. A. A.
Giroux, North Mankato, stated at the meeting that Min-
nesota hospitals need 2,500 nurses and that an attempt to
hire a second county nurse would only aggravate the
situation. On that basis Dr. Nilson said he opposed the
plan “practically but not in principle.”
PTA representatives had stated that there was an ur-
gent need for an additional nurse since the Nicollet
County nurse could spend only one day per week in
North Mankato’s public school. After the local superin-
tendent of schools pointed out that there was not enough
work for a full-time school nurse, the city council sug-
gested that the county commissioners could be asked to
hire a second county nurse who could be based in North
Mankato, serving also as city and school nurse. The
protest of the local physicians then arose.
* * *
.Formation of a cancer control advisory committee was
announced on October 30 by Dr. A. J. Chesley, secretary
and executive officer of the Minnesota Department of
Health. The committee will aid the Division of Cancer
Control of the state health department in planning and
carrying out a program of cancer control.
Named as members of the advisory group, with or-
ganizations they represent, were :
Dr. A. H. Wells, Duluth, Minnesota State Medical As-
sociation ; Dr. Clayton Swanson, Minneapolis, Minnesota
Dental Association ; Dr. D. W. Pollard, Minneapolis,
Minnesota Hospital Association ; Dr. William A. O’Brien,*
Saint Paul, Minnesota Division, American Cancer Soci-
ety; Dr. Owen H. Wangensteen, Minneapolis, University
of Minnesota Medical School ; Dr. Kano Ikeda, Saint
Paul, Minnesota Society of Clinical Pathologists.
Named as members-at-large were : Dr. E. T. Bell,
Minneapolis; Dr. James Johnson, Minneapolis; Dr. Wil-
liam W. Will, Bertha; Dr. D. P. Anderson, Jr., Austin;
Dr. W. C. Popp, Rochester; Dr. Joseph Bierkson, Roch-
ester, and Sister Patricia, St. Mary’s Hospital, Duluth.
* * * /
Fifty members of the Bloomington (Minneapolis sub-
urb) 4H Club have launched a project, which may be-
•Deceased.
1320
Minnesota Medicine
OF GENERAL INTEREST
come a nationwide campaign, to raise funds for the bat-
tle against heart disease in children.
Under the Bloomington plan, club members will
“sponsor” a young calf, taking care of it for a year
on a co-operative basis. When the calf has reached
top market stage, it will be sold and the proceeds will
go into a special fund to cover the cost of treatment
for any member who may develop rheumatic fever or
any other heart disease. Some of the money may be
used for related educational efforts.
The project, which is sponsored by the Minnesota
Heart Association, will vary in type as it is taken up
by other 4H clubs throughout the state. Some clubs
may devote acreage to a special crop of grain for the
heart disease campaign instead of raising livestock.
Several farmers have already indicated a desire to con-
tribute starting stock to the project. State 4H execu-
tives and Minnesota Heart Association officers are con-
vinced that the idea will be taken up on a national scale
in a comparatively short time.
sfc # %
The part played by physicians in the synthesis of sci-
ence was described by Dr. Richard E. Scammon at the
first fall meeting of the Medical History Society in
Rochester, October 17.
Principal speaker at the meeting of the society, which
was organized one year ago by a group of men inter-
ested in medical history, Dr. Scammon is former dean
of medical sciences of the University of Chicago and
is distinguished service professor emeritus of anatomy
at the University of Minnesota. He was introduced to
the group by Dr. H. A. Wilmer, Rochester, who com-
mented on Dr. Scammon’s versatility as an anatomist,
artist, biometrician and scientific historian, adding that
many former medical students remember Dr. Scam-
mon for his ability to draw with both hands at the same
time while lecturing on anatomy.
In his talk Dr. Scammon described the bringing to-
gether of scientific knowledge and scientific workers, a
synthesis of science that first took place during the cen-
tury following the middle 1600’s. He traced the forma-
tion of scientific societies throughout Europe and the
United States, emphasizing the work of numerous physi-
cians in starting and maintaining the trend towards or-
ganization. He indicated the possibility of another great
synthesis of science in this century and expressed the
hope that medical men would be as useful in it as they
had in the past.
* * *
Minnesota leads the nation in the hospitalization of
tuberculosis patients, it was stated at the annual Christ-
mas Seal dinner of the Minnesota Public Health Asso-
ciation, held October 31 at Hotel Nicollet in Minneapolis.
Authority for the statement was Dr. Herbert L.
Mantz, president-elect of the National Tuberculosis As-
sociation, who stated that 84 per cent of the deaths
from tuberculosis in Minnesota were hospital cases.
“This figure reflects the effectiveness of precautionary
care undertaken by the state,” he said. In comparison
Dr. Mantz pointed out that in his home state of Kansas
65 per cent of tuberculosis deaths occur in homes.
Quoting from a 1945 survey by the New York City
Tuberculosis and Health Association, Dr. Mantz said
that Minneapolis has the lowest tuberculosis death rate
among the larger cities of the country.
Other speakers on the dinner program were Dr. Hil-
bert Mark, Minnesota director of the division of tuber-
culosis control, and Dr. H. A. Wilmer, author of Huber
the Tuber and fellow in the Mayo Foundation. Earlier
in the day, Christmas Seal workers heard, among other
speakers, Dr. James E. Perkins, a former Saint Paul
resident, now managing director of the National Tuber-
culosis Association.
With the election of officers at the meeting, Mrs. John
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December, 1947
1321
PRESIDENT’S LETTER
A. Thabes, Sr., Brainerd, became the first woman presi-
dent of the organization in its forty-one-year history.
Also named to office were N. Vere Sanders, Albert Lea,
first vice president ; Albert A. Anderson, Buffalo, second
vice president; Mrs. Clarke Dodds, Baudette, secretary,
and John B. Burke, Saint Paul, treasurer.
* * *
Seventy-five years of public health work were cele-
brated November 14 when the Minnesota Department
of Health observed its diamond jubilee with an all-day
session at the Hotel Radisson in Minneapolis.
The celebration was marked by the first annual meet-
ing of the Minnesota Public Health Conference, an or-
ganization which supersedes the former state sanitary
commission.
During the day, conferences were held for physicians
and health officers, public health nurses, environmental
sanitation personnel, and health education and school
health workers. Among the speakers at the group meet-
ings were Dr. A. J. Chesley, secretary and executive
officer of the Minnesota Department of Health, Dr. Dean
F. Smiley, consultant in health and physical fitness for
the AMA, and Dr. E. L. Tuohy, chief of laboratories at
St. Mary’s Hospital, Duluth.
At the evening banquet which honored the state or-
ganization, Dr. T. B. Magath, Rochester, served as
toastmaster, introducing Governor Luther W. Youngdahl
and other prominent guests who congratulated Dr. Ches-
ley, state health officer since 1921, on the outstanding
achievements of the Minnesota Department of Health.
Dr. Floyd M. Feldman, Rochester, president of the Min-
PHYSICIANS
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MEDICAL PLACEMENT REGISTRY
916 Medical Arts Building, Minneapolis Ge. 7839
“Four offices to serve you” — Minneapolis, St. Paul,
Duluth, Long Beach, Calif.
nesota Public Health Conference, delivered his presi-
dential address at the banquet.
New officers of the Minnesota Public Health Con-
ference, elected at a meeting earlier in the day, are Dr.
J. Lawrence McLeod, Grand Rapids, president ; Melvina
Palmer, Minneapolis, first vice president ; S. P. King-
ston, Rochester, second vice president, and Dr. Charles
E. Sheppard, Hutchinson, treasurer.
* * *
Outdoor living, wild-life conservation, and experi-
mental farming compete with medicine for the attention
and time of Dr. M. M. Hargraves, staff member of the
Mayo Clinic and state president of the Izaak Walton
League.
To Dr. Hargraves conservation means more than
maintaining a supply of fish and game ; it means the
preservation of human values and all natural resources,
particularly the soil. With that belief he and four part-
ners recently purchased a farm north of Rochester, a
farm with hills, an erosion problem, a spring, a view
and possibilities for improvement. There Dr. Har-
graves and his associates are putting into practice all
principles of conservation, with development of con-
tour fields, elimination of old gullies, and planting of
permanent grass. They have a small herd of Holsteins
and a herd of Angus beef cattle, all registered animals.
A fish pond, to be stocked with bass, bluegill and trout,
is planned as soon as a dam can be built below the
spring.
Dr. Hargraves, who has been at the Mayo Clinic since
1935, finds little time for rest with his double duties
as physician and as state president of the Izaak Walton
League. A fairly typical twenty-four hour schedule for
him includes a full day at the clinic, a late afternoon
or dinner talk to some conservation group in Olmsted
County, an evening meeting in the Twin Cities, and a
morning look at the farm before starting another ses-
sion at the clinic. Every other Friday evening he con-
ducts a radio program on fundamental conservation over
a Rochester station.
Not content with this, Dr. Hargraves looks forward
to the founding of a permanent state educational foun-
dation for conservation, with motion pictures, a speakers
bureau, and an annual short course of two or three
days at some lake, to inform and educate the public
as to the importance of generalized conservation.
DANIELSON MEDICAL ARTS PHARMACY, INC.
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414 SOUTH SIXTH ST., MINNEAPOLIS, MINN.
INSTRUMENTS ■ TRUSSES • EQUIPMENT • PHARMACEUTICALS • DRUGS
MAIN 2494
1322
Minnesota Medicine
OF GENERAL INTEREST
HOSPITAL NEWS
More than $1,000,000 will be spent to enlarge Min-
nesota’s oldest and largest mental institution, the St.
Peter State Hospital, where construction work on the
new expansion project has already started.
Two new buildings, to house ISO senile patients each,
will be constructed on the bluffs in the rear of the old
receiving ward, while a new service building will house
a kitchen, storage rooms and other shops. It is antic-
ipated that when the new buildings are completed, fifty
additional attendants and possibly six more physicians
will be added to staff the increased facilities.
Construction of a new cattle barn for the institution,
to replace the one destroyed by fire a year ago, has
already begun, and the work is expected to be completed
in January.
* * *
Announcement was made early in November by Dr.
W. C. Heiam, Cook, that the modernization and re-
modeling of the Cook General Hospital had been com-
pleted.
The building has been completely rewired, and new
plumbing and heating facilities have been installed. An
addition has been built onto the structure to house more
hospital beds and provide better operational facilities.
Floors have been covered with asphalt tile, and the
entire building has been repainted. New therapeutic and
nursing equipment has been installed. Cost of the re-
modeling was more than $10,000.
* * *
The problem of coping with increasing operational
costs of a hospital was studied at a one-day institute
November 13 at Northwestern Hospital, Minneapolis.
Speakers at the meeting included James Hamilton,
professor of hospital administration at the University
of Minnesota, and Dr. Arthur C. Bachmeyer, director
of the University of Chicago Hospital and Clinics.
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223 So. 6th Street Minneapolis 2, Minn.
Classified Advertising
Replies to advertisements should be mailed in care of
Minnesota Medicine, 2642 University Avenue, Saint
Paul 4, Minn.
WANTED — Associate, Catholic preferred, for general
practice in Saint Paul. This is an interesting and lu-
crative situation with possibility of taking over prac-
tice. Address E-49, care Minnesota Medicine.
FOR SALE — Office equipment used less than one year.
Includes examining table, two instrument cabinets,
Castle sterilizer, microscope, Rose short-wave ma-
chine, ultra-violet lamp, stool, desk and chair, office
supplies and instruments. Located thirty-five miles
from Minneapolis. If interested, write Box 1587, San
Haven, North Dakota.
EXPERIENCED LABORATORY TECHNICIAN de-
sires position in doctor’s office, Saint Paul. No x-ray.
Address E-50, care MINNESOTA MEDICINE.
IDEAL LOCATION FOR PHYSICIAN— With two
dentists, on Selby-Lake carline in Midway Saint Paul.
Address Dr. M. L. Norman, 1812 Selby Avenue, Saint
Paul 4, Minnesota.
\\ ANTED — Experienced x-ray technician in suburban
office. Forenoon work only, five days a week; Satur-
days free. Address E-51, care Minnesota Medicine.
WANTED — Assistant for General Practice with view
to permanent association. Southern Minnesota, county
seat city, population 4,500. Active general practice
with some major surgery. New hospital to be erected
in near future. If interested, write, giving full par-
ticulars concerning self. Address E-47, care Min-
nesota Medicine.
FOR SALE — Unopposed, well-established, southern
Minnesota practice. Population 500. Large territory,
good roads and school. Retiring. Address E-48, care
Minnesota Medicine.
POSITION WANTED — Laboratory technician, under-
graduate nurse, desires position with Minneapolis
(loop) physician. Urologist preferred. Five years’
experience. Telephone Mrs. Polly Akins — Lincoln
4927 (Minneapolis).
WANTED — Surgical assistantship, preferably in or near
Twin Cities, by young doctor expecting army sepa-
ration in February, 1948. Eighteen months’ general
surgery- resident training. Desire position under Dip-
lomate, American Board of Surgery, if possible. Write
E-52, care Minnesota Medicine, for details.
WANTED TO BUY — Office equipment. Must be in ex-
cellent condition. Address E-53, care Minnesota
Medicine.
EYELID DERMATITIS
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December, 1947
1323
you
a
«
/
oL we III
one
We wish to take this opportunity to extend our sincere
thanks for the excellent co-operation you have afforded our
nursing program over the past year. The many prospective
candidates that you have referred to us have made it pos-
sible for the Nursing School to furnish an added number
of well trained nurses to the medical profession. With your
splendid support this work will continue to grow.
V
j ‘FacuTT £
to the X
+****& \
^ Hohd« Se®011 \
VletrY n i
and a ft
u°tz°^s \
The two-fold purpose for which this school was founded
■ — to offer to the student a short but complete course in
nursing and also provide to the doctor and hospital a sup-
ply of capable nurses, well trained in patient care — can
only be realized to the fullest with your support.
The need for additional nurses is great. The gratifying
way in which you continue to assist in increasing the num-
ber of student nurses now in training indicates an early
relief to this shortage.
SCHOOL OF PSYCHIATRIC AORSIOG
Tuition is free. Regular classes begin in January, June
and September. A few openings still available in the Jan-
uary class. For full information write Glenwood Hills Hos-
pitals, School of Nursing, Helen A. Rascop, R.N., Supt. of
Nurses.
enwaod
1 s os
mas
3501 Golden Valley Road
Route Seven Minneapolis, Minn.
1324
Minnesota Medicine
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