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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 
Under the Direction of Its 

E. M. Hammes, M.D., Chairman, St. Paul Puitie F. Dononve, M.D., St. Paul 
T. A. Pepparp, M.D., Secretary, Minneapolis C. B. Wricut, M.D., Minneapolis 
Tuomas Gace CLEMENT, M.D. Duluth O. W. Rowe, M.D., Duluth 
WALTMAN WALTERS, M.D., Rochester H. W. Meyerpvinc, M.D., Rochester 
C. L. Oppecaarp, M.D., Crookston B. O. Mork, Jr., M.D., Worthington 

Cart B. Drake, M.D., St. Paul 

W. F. Braascnu, M.D., Rochester 
Henry L. Urricu, M.D., Minneapolis 




2642 University Avenue - - - - - - - = Saint Paul, Minn. 
J. R. Bruce 


Minnesota State Medical Association, 87th Annual Meeting, Rochester, Minnesota, April 22, 23, 24, 1940 


Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern 
Minnesota Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society 


JANUARY, 1940 

Volume 23 — Number 1 40 cents a copy — $3.00 a year 


FAce. Minnesota State Medical Association ........... 54 
—— ° on 
Gordon B. New, M.D., and John B. Erich, M.D., a a es 55 
ee: DEIN ois dp cts cacdoscceuvenaies 1 

Eve Injures Due 10 MECHANICAL CAUSES. PE neo canccncnio meqsuke eee woawereedtobesead 56 
D. L. Tilderquist, M.D., Duluth, Minnesota...... 8 

Center for Continuation Study..... ............. 57 

DYSPHAGIA, : ; The Minnesota Medical Foundation.............. 57 
N. Logan Leven, M.D., Saint Paul, Minnesota.... 13 

Cs aan Ae ike ee eee 57 

E. M. Rusten, M.D., Minneapolis, Minnesota..... 16 The Bach Tradition... .............-.-+-sseeeeee 58 

Preseriptioms Boaived.. ...... «x... 6.3566s0005% sacews 58 
SuccESTED BY IT. _ ' MeEpicaL EcoNoMICcs: 
Henry W. Woltman, M.D., Rochester, Minne- OE Oh I ih since vod tease ete 59 
NE Rae ge een cadena tar coRaeniee wees a 19 . 
a ees eee 2 ee Ss — 
| Some CrinicaL VaGaRies ASSOCIATED WITH BAcTE- Pe I ois aide Gd nates les & “Soe 60 
| Alfred Hoff, M.D., Saint Paul, Minnesota....... 25 On Medical Economics..............+.-++-+++++ 62 
| a a Insurance Pitfalls for Patients................... 63 
Thomas E. Keys, M.A., Rochester, Minnesota.... 34 “Why the Medical Advisory Committee”......... 64 
CysToGRAPHY IN THE Stupy or Dirricu.ties Fot- Take Your Choice..... aa snow SS pom amad ease eats 64 


Minnesota State Board of Medical Examiners... 65 
Theodore H. Sweetser, M.D., Minneapolis, Min- 

IGS Sk Vice cman eedcdndabudadsed ur enien 40 OF SRA TINE, «nnn soo ene ci snnsnenanns - 
i IIR? oo stain ads caret ws moon cue 66 
ns Case REPORT: : 
Perforation of Meckel’s Diverticulum by Fish REPORTS AND ANNOUNCEMENTS..............eceeees 67 
R. V. Williams, M.D., Rushford, Minnesota... 44 SOcIETY : 
a ee ee ae Mesting of October 5, ited Dis ati secs masa anerecatacare 68 
History of Medicine in Hennepin County. (Con- Chronic Duodenal Stasis. 
dened) Arthur Metz, M.D., Chicago, Illinois..... ..... 68 
i Fos sob ew onde cred besmcons 45 POE PEIN 6 oo coed oecend shea wale dt aoe 70 

Contents of Minnesota MeEpICINE copyrighted by Minnesota State Medical Association, 1940 

imtered at the Post Office in Minneapolis as second class mail matter. 

lis, Accepted for mailing at the special rat i i 
Section 1103, Act of October 3, 1917, authorized July 13, 1918, ee ae ae ae oe 

Printed in U.S. A. 




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Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota 
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society 

Volume 23 

JANUARY, 1940 

No. 1 


Rochester, Minnesota 

N recent years, motor accidents have become 
so common that nearly every clinician, wheth- 
er internist, surgeon, or specialist, is called upon 
in one capacity or another to treat patients who 
have been injured in automobile accidents. When 
such traumatic wounds involve the face, the ef- 
fects of treatment are usually of particular inter- 
est to the patient, since in this region the esthetic 
outcome is as significant to him as is the func- 
tional result. The more or less popular opinion 
that the majority of traumatic facial injuries 
which are vital neither to the life of the patient 
nor to the functions of the body are inconse- 
quential and therefore deserving of little imme- 
diate consideration is a misconception. On the 
contrary, it has been our experience that many 
patients are so concerned with post-traumatic 
deformities of the face that emotional disturb- 
ances develop. In short, the end-results of the 
surgical management of facial injuries affect not 
only the final appearance of the part involved but 
ultimately the patient’s mental and emotional 
processes as well. This fact bears emphasis and 
should stimulate the surgeon to give every pri- 
mary facial wound, no matter how insignficant, 
careful attention in an effort to prevent or mini- 
mize subsequent disfigurement. 

A complete discussion of the care of automo- 
bile injuries involving the soft and bony tissues 
of the face is entirely too broad a topic to con- 
sider in these few pages. In consequence, we 
are forced to disregard technic and details for 
those general principles which we have found 

*From the Section on Laryngology, Oral and Plastic Surgery, 
The Mayo Clinic, Rochester, Minnesota. Read before oy 
nual Meeting of the Minnesota State Medical Society, Minne- 
apolis, Minnesota, June 1, 1939. 

January, 1940 


useful and essential in the treatment of such in- 
juries. Furthermore, it is well to remember that 
no amount of minute elaboration can alter the 
fundamental character of these principles. It is 
true that a great many of these injuries require 
some form of individual consideration and a few 
necessitate the construction of special appliances. 
However, without a knowledge of the underlying 
principles which govern the treatment of auto- 
mobile injuries of the face, it is certain that the 
surgical management not only will usually be 
ineffective but also will continually become less 

The care of automobile injuries of the face 
may be divided into primary and secondary treat- 
ment. The former refers to the initial wound; 
the latter, to facial deformities which may fol- 
low the original injury. We are confident that 
the immediate repair of traumatic wounds of the 
face is distinctly advantageous. It stimulates 
prompt healing, limits the degree of inflamma- 
tory reaction and, in turn, minimizes the subse- 
quent scarring. However, early treatment does 
not infer the employment of hasty or careless 
time-saving methods which some surgeons seem 
to regard as emergency measures. No doubt 
many facial deformities and subsequent plastic 
operations could be avoided if more care and 
time were given to the treatment of the primary 
injury. It is safe to say that the more time 
spent in precise execution of each detail of 
surgical’ technic, the more pleasing will be the 
ultimate result. 

In certain cases, it is neither possible nor al- 
ways advisable to care for the wounds immedi- 
ately (Figs. la and 2a). Treatment of serious 



and complicated fractures of facial bones, in 
which there is much displacement of the frag- 
ments, is preferably postponed until satisfactory 
roentgenograms can be secured; if the fractures 
involve the jaws, dental roentgenograms and 
dental plaster of paris study models are fre- 
quently necessary as well. Only with such ac- 
cessory diagnostic agencies and only after a 
great deal of preoperative planning can one ac- 
curately determine the best method of reducing 
the fractures and immobilizing the fragments. 
A patient who is in shock should be put to bed 
and surgical intervention, other than such meas- 
ures as are necessary to control bleeding, should 
not be instituted until his condition improves. 
There also are those cases in which the general 
condition of the patient is so critical, owing to 
associated injuries or to a fracture of the skull, 
that it is not in accordance with good judgment 
to attempt any type of immediate treatment of 
the facial wounds. However, if possible, the 
soft tissue injuries should receive attention with- 
in a few hours after the accident, while manage- 
ment of any fractures of the facial bones is bet- 
ter deferred indefinitely. 

In cases in which there are lacerations about 
the face, hydrogen peroxide is a most effective 
agent for the removal of débris and coagulated 
blood; it leaves the injured tissues clean and 
fresh. The ultimate formation of scar tissue in 
any wound is always diminished by sharp exci- 
sion of ragged or macerated margins. Portions 
of skin in which the blood supply is so poor that 
sloughing is virtually assured should be prompt- 
ly removed. However, in many instances it is 
surprising to observe how a comparatively nar- 
row pedicle will maintain the vitality of a rather 
large dermal flap. Since the formation of a 
hematoma is most undesirable, it is extremely im- 
portant that a wound never be closed before the 
bleeding has been completely controlled by ligat- 
ing every vessel which continues to ooze. In the 
repair of lacerations, we employ a minimal 
amount of chromic catgut to bring together the 
subcutaneous tissues and interrupted sutures of 
fine silk to approximate the edges of the skin 
(Fig. 1b). The use of heavy dermal sutures 
which include large amounts of tissue is to be 
condemned because they produce a great deal of 
unnecessary scarring. Neat, meticulous suturing 
and ample drainage are essential in securing a 


satisfactory cosmetic result. In large under- 
mined wounds, we prefer Penrose drains, but 
in those of smaller dimensions we use ordinary 
rubber bands; the latter make excellent drains 
and leave but little scarring on removal. Very 
superficial lacerations, after being cleansed, may 
be safely closed without any form of drainage. 
Of the utmost significance immediately after 
suturing a wound is the application of a pres- 
sure dressing which should be left undisturbed 
for at least forty-eight hours; this further obvi- 
ates the possibility of the formation of a hema- 

Regardless of the absence of gross contami- 
nation, every open wound sustained in a motor 
accident undoubtedly is invaded by pyogenic 
bacteria. However, with proper care, lacera- 
tions about the face of healthy individuals 
rarely show clinical signs of infection. By the 
phrase “proper care” we do not allude to the use 
of any type of antiseptic solution, but refer to 
such measures as débridement of the wound, 
complete hemostasis, adequate drainage and pre- 
vention of a hematoma. Probably no factors so 
favor the development of active infection in a 
wound as does the presence of a hematoma or 
the lack of sufficient drainage. Although, with 
appropriate management, infection of facial in- 
juries is remote, every physician continually en- 
counters suppurating, traumatic wounds in cases 
in which patients do not seek treatment early. 
In these cases, we adopt a most conservative 
regimen of therapy; we leave the wounds en- 
tirely alone except for the continuous applica- 
tion of hot, moist dressings until the acute in- 
flammatory process has subsided. Recognition 
of the potential seriousness of a hematoma 
should prompt one to remove such a blood clot 
thoroughly from any wound whether or not the 
latter has been previously sutured. 

Losses of tissue are frequently observed in 
automobile injuries about the face. In properly 
selected cases, such wounds afford great oppor- 
tunity for the use of plastic procedures. When 
a small portion of skin is missing, if the mar- 
gins of the defect are deeply undermined by 
sharp dissection, a gratifying closure can be ob- 
tained. In cases in which a large amount of 
skin has been lost, such treatment can only re- 
sult in much distortion of the involved part; in 
these cases the immediate application of a skin 



graft is an excellent procedure, provided that 
gross contamination is not evident. If the de- 
nuded region is not too large, dissected dermal 
grafts from the upper eyelid or the posterior 

a b 

Fig. 1 a, 

the resultant deformity; the wounds are left 
open for several weeks until healing is complete 
and until the subsequent inflammatory thicken- 
ing and induration have entirely disappeared. 

Laceration of face and badly comminuted fracture of nasal bones of a guest passenger who was thrown against the 
windshield of an automobile; treatment was postponed for eight hours because the patient was in severe shock; 

b, photograph taken 

after the lacerations were cleansed and sutured; one Penrose drain and several rubber-band drains were used; the skin was closed 
with interrupted sutures of fine black silk; c, photograph taken six months after treatment of the injury; a cartilage implant will 

be required to correct the deformity of the nose. 

auricular region are preferable because the color 
of the skin obtained in these situations very 
closely resembles that of the rest of the face. 
However, when a large graft is required, one 
is forced to resort to the employment of a dis- 
sected or shave transplant taken from the inner 
aspect of the arm or thigh. The act of adapt- 
ing a dermal graft to a region recently de- 
nuded of skin is usually met with considerable 
success, and thus scarring and distortion are pre- 
vented which is inevitable when such a wound 
is left to become epithelized spontaneously. In 
badly contaminated wounds, of course, skin 
grafting is entirely out of the question. Instead, 
we apply warm dressings and ‘defer the trans- 
plantation of skin until the infection has entirely 
disappeared. It cannot be doubted that were 
skin grafts employed more frequently the cos- 
metic result in many traumatic wounds of the 
face would be greatly enhanced. 

The immediate repair of such defects as the 
loss of an extensive portion of the lip, cheek, 
nose or eyelid is impossible. Fortunately, such 
frightful injuries are relatively uncommon. In 
these cases, we elect to disregard temporarily 

January, 1940 

Then with the use of one of the delayed pedicle 
or tubed flaps, which was illustrated in figure 
1 in an article which we wrote recently* recon- 
struction of the missing part may be undertak- 
en. Owing to the limited length of this paper, 
a discussion of this type of reparative surgery 
cannot be attempted. 

To the surgeon and patient alike, deep facial 
lacerations in which the seventh cranial nerve 
or the parotid duct, has been severed are most 
distressing. The former injury results in a fa- 
cial palsy, the latter in an external salivary 
fistula. Should the main trunk of the facial 
nerve be divided, an endeavor should be made 
to suture the cut ends. If this procedure does 
not induce regeneration of the nerve, then the 
problem becomes one for the neuro-surgeon. 
Less serious is the severance of the peripheral 
fibers of the seventh cranial nerve, many of 
which will eventually regenerate. Occasionally, 
as previously indicated, a penetrating laceration 
of the cheek will include Stenson’s duct and re- 
sult in an external salivary fistula. To direct 
the flow of saliva into the mouth rather than 
through the fistula, we favor the method of 



Glascock. Briefly, this procedure involves the 
use of strands of silkworm-gut which are in- 
serted from the oral cavity through both distal 
and proximal segments of the duct and which 

that is, the frontal, nasal, maxillary or malar 
regions. In spite of the fact that the driver is 
able to brace himself against the steering post 
and thereby ward off much of the brunt of the 

Fig. 2 a, Injury of the frontal region which exposed the frontal sinus and fractured the frontal nasal and maxillary bones and 
the malar bone; treatment was not instituted until ten days after the accident, for fear of inducing meningitis; b, photograph of 
patient taken after completion of initial treatment; right malar bone was elevated by intra-antral manipulation and immobilized by 
an intra-antral iodoform pack; the fragments of the comminuted nasal bones were molded into their correct position and immo- 
bilized by the apparatus shown; this has two wires which hold the nasal bones forward and has two lateral adjustable pads which 

produce pressure on the sides of the nose and keep the bridge narrow; c, photograph of patient taken six months after initial 

finally emerge on the external surface of that 
portion of the cheek which overlies the parotid 
gland. A Penrose drain passed from the mouth 
to the lacerated region, through a stab wound 
adjacent to the distal part of the duct, is of 
great value in carrying away the excess of sa- 
liva. The external wound may then be tightly 
sutured. Such management encourages the flow 
of saliva to follow the Penrose drain into the 
mouth and opposes the development of an ex- 
ternal salivary fistula. Serving as a framework 
along which epithelization can occur, the strands 
of silkworm-gut assist in restoring the normal 
continuity of the duct. 

In automobile wrecks, it has been pointed 
out by Straith that passengers riding in the 
front seat not only are more frequently injured 
than is the driver but are subject to more seri- 
ous injuries. Since the guest passenger lacks 
the support of the steering wheel, during the 
impact of a collision he is thrown violently 
downward as well as forward against the in- 
strument panel or the windshield. His injuries 
are likely to involve the upper half of the face, 


impact, his head may strike the steering wheel 
with considerable force. His resultant injuries 
usually involve the lower part of the face, main- 
ly the chin and mandible. 

The nasal bones are more often fractured 
than are other bones of the face. The treatment 
of simple nasal fractures is well known. Inter- 
nal or external manipulation is all that is re- 
quired to reduce these fractures, and, generally, 
no means of fixation is needed. In some cases, 
an intranasal pack or an external splint is neces- 
sary to maintain the nasal bones in proper align- 
ment. Occasionally, in severe fractures of the 
nose, the nasal bones are badly comminuted and 
driven back into the ethmoid region. In such 
cases, owing to the probability of an associated 
fracture of the ethmoid bone, manipulation of 
the nasal bones should be postponed at least 
ten days for fear of inciting the development 
of meningitis. When the nasal bones are se- 
verely comminuted and depressed, it is useless to 
elevate them unless some form of fixation is 
available for holding the bones in the desired 
position. We have made an instrument which 



ee ares 

hae Gmsets 



possesses all of the necessary mechanical re- 
quirements for supporting the nasal bones in 
correct alignment; its principle is not original 
with us, but its design has been changed to suit 
our needs. This appliance is attached to a plas- 
ter head cast and has two wires which are in- 
serted in the nostrils for elevating and immobil- 
izing the nasal bones (Fig. 2b). In addition, it 
has two adjustable pads which maintain lateral 
pressure to keep the bridge of the nose narrow. 
In many of our cases, this instrument has proved 
its value in the final result (Fig. 2c). 

The great majority of permanent nasal de- 
formities following automobile accidents are due 
to neglect of the primary nasal fracture or are 
the result of poor immediate treatment. How- 
ever, in an occasional fractured nose, even after 
the utmost care has been taken to restore the 
nasal bones to their original position, some de- 
formity persists. If a patient wishes his nasal 
deformity corrected, it is preferable to wait at 
least six months after the accident before at- 
tempting a plastic repair. The most common trau- 
matic nasal deformities are the crooked nose, 
which may deviate to one or the other side and 
which is usually associated with a deflection of 
the septum, the hump nose in which the nasal 
bones are abnormally elevated, the bulbous or 
broad nasal tip in which the lower lateral cartil- 
ages are markedly flared, the saddleback nose in 
which the nasal bones are depressed, and com- 
binations of the foregoing deformities (Fig. 1c). 
The first three types of deformities are remedied 
by intranasal operations; displaced nasal bones 
are refractured and molded into their proper 
position ; a prominent hump is removed by means 
of a saw or chisel and mallet, and a broad tip 
is corrected by readjustment of the lower lat- 
eral cartilages. Marked deflection of the septum 
which produces symptoms of nasal obstruction 
should be corrected by means of submucous re- 
section ; this operation should be performed three 
or four weeks in advance of the nasal plastic 
operation. When a saddleback deformity ex- 
ists, the normal contour of the nose can be re- 
stored by means of a cartilage or bone implant. 
If the nose requires no treatment other than the 
insertion of the graft, we prefer to use bone ob- 
tained from the crest of the ilium, but if the de- 
formed nose requires refracturing or some other 
form of manipulation or if there is any possibil- 

January, 1940 

ity of infection, cartilage is a more desirable 
tissue to transplant since its innate qualities to 
withstand infection or an inflammatory process 
are superior to those of bone. 

Malar bones are often fractured in such a 
manner that they retain their continuity with 
little or no comminution. In these cases, the 
fractures occur along the normal suture lines, 
that is, through the frontozygomatic suture 
above, through the temporozygomatic suture lat- 
erally and through the inferior orbital foramen 
below. The bone is generally depressed down- 
ward and backward. Without the aid of a roent- 
genogram, there is often difficulty in the diag- 
nosis of such a fracture because of the excessive 
swelling of the overlying soft tissues. Roent- 
genograms are absolutely essential, and we pre- 
fer a vertical profile view, the rays being directed 
from the chin toward the vertex. Such a roent- 
genogram shows very nicely the relative posi- 
tion of the two inferior orbital margins and 
the degree of displacement of malar bone on the 
involved side. When there is no comminution 
of a fractured malar bone, treatment is not diffi- 
cult. A steel hook, inserted through a small 
incision in the skin, is an effective method of 
elevating the displaced portion of bone into 
position. The hook may be introduced so as to 
grasp the lower border of the fractured malar 
bone or may be inserted along the floor of the 
orbit to the inferior orbital fissure. Consider- 
able force is necessary at times to bring the 
fragment into correct position, but, with few 
exceptions, no form of fixation is required. 
When a malar bone is badly comminuted and 
there is involvement of the wall of the maxillary 
sinus, we recommend reducing the fractures by 
an intra-antral operation. An opening is made 
through the mouth into the maxillary sinus, and 
by finger pressure within the antrum, the frag- 
ments are manipulated into their correct posi- 
tion. For immobilization, an iodoform pack is 
inserted within the maxillary sinus and left in 
place until the fragments have united, a period 
usually of about three weeks. 

Ocular palsies resulting from injury to the 
floor of the orbit are unfortunate complications 
of fractured malar bones. Manipulation of the 
fragments from within the maxillary sinus will 
sometimes correct the ocular disturbance, but 
in many cases it is not possible to reduce the 



fractures so that the extra-ocular muscles will 
function normally; in such instances, the ocular 
palsy remains a permanent condition. Enoph- 
thalmus, another complication of some fractured 
malar bones, is disagreeable and incurable. The 
floor of the orbit may be so bady comminuted 
and depressed that the eyeball will drop down 
a few millimeters owing to lack of support. 
If manipulation of the fragments does not ele- 
vate the globe, a cartilage implant along the floor 
of the orbit will often overcome the deformity. 
However, in some cases even a cartilage im- 
plant is ineffective in restoring the eye to its 
proper position in the orbit. A depressed frac- 
ture of the malar bone which is left untreated 
will produce a flattening of the involved cheek. 
Attempts to correct this deformity by refractur- 
ing the bone and manipulating the fragments in- 
to their proper position are usually met with 
little success. In these cases, we believe that 
symmetrical proportions of the two cheeks can be 
secured most easily by the use of a cartilage 
implant to build up the depressed region on the 
injured side. 

The treatment of any fractured jaw is suc- 
cessful only when the continuity of the bone 
has been established and when the normal masti- 
catory mechanism has been restored. The frag- 
ments of a fractured jaw may be firmly healed 
by bony union, but the end-result is a failure 
if the original occlusion of the teeth has not 
been reéstablished to insure normal mastication. 
No single word has greater significance in any 
discussion on fractures of the jaws than does 
the term “occlusion.” Nearly every fracture of 
a jaw in which there is the least displacement 
of the fragments causes some disturbance of 
occlusion, and unless the teeth can be brought 
into their normal relationship the fragments will 
not be restored to their original position. No 
factor serves as a better guide for determining 
the position of the fragments than does the 
occlusion of the teeth. Frequently, in cases of 
fracture of the jaws, it is almost impossible to 
tell by visual inspection of the mouth what rela- 
tionship actually existed between the upper and 
lower teeth before the fracture occurred; this 
may be the result of loss of many teeth in each 
dental arch or it may be due to primary maloc- 
clusion of the teeth. In these cases, the prepara- 
tion of plaster models of the dental arches will 


materially aid in determining the original form 
of occlusion. It can be said that fractures of 
the jaws cannot be satisfactorily reduced unless 
one is certain of the original position of the teeth 
in each individual case. 

Innumerable methods of reduction and im- 
mobilization have been described in the treatment 
of fractured jaws. Each has advantages and 
disadvantages ; each is adaptable to certain types 
of fractures. No one method is suitable for 
every case. A few produce excellent results 
in the hands of some surgeons but not in the 
hands of others. Consequently, it is a mistake 
to attempt a comparison of the various methods. 
It is our opinion that ‘those procedures w th 
which the surgeon is acquainted and finds satis- 
factory are the methods he should employ. 

It is a generally accepted fact that open oper- 
ations for the reduction or fixation of fractures 
of the jaw usually are disastrous and only re- 
sult in infection, necrosis of bone and ultimate 
loss of union. One must rely on intraoral pro- 
cedures for the care of fractures of the mandible 
and maxilla. 

The great majority of fractures of the maxilla 
that we see at the clinic are transverse (horizon- 
tal) in character. The entire upper jaw is freed 
from the rest of the skull and is usually pushed 
upward and backward. This injury results in an 
open-hite type of deformity which makes masti- 
cation impossible. The principle of treatment 
of a transverse fracture of the maxilla is to 
reduce the fracture so that the teeth of the 
upper dental arch will occlude normally with 
the teeth of the lower jaw. Regardless of how 
freely movable the fractured upper jaw may 
be, it usually is not possible to manipulate the 
maxilla into its correct position manually. To 
secure good occlusion of the dental arches in a 
case of transverse fracture of the upper jaw, one 
must rely on elastic traction as a means of re- 
ducing the fracture. We first wire arch bars 
to the upper and lower dental arches. This is 
followed by the application of a plaster cast to 
the head. A rubber band passed from the upper 
arch bar to a rod that is fixed to the head cast 
will pull the upper jaw forward. Vertical rub- 
ber bands stretched between the arch bars pull 
the teeth of the maxilla downward into occlu- 
sion with those of the mandible. When the 
upper jaw is freely movable, traction wires for 



@ . 

* rE SE 


immobilization are attached to the upper arch 
bar, passed through the cheeks, and fixed to 
adjustable hooks on the head cast after the meth- 
od described by Federspiel. In cases in which 

gion on the involved side (described by Ivy, 
Fig. 3b). A wire inserted through the posterior 
fragment and rubber band stretched from this 
wire to the hook will pull the posterior frag- 


Fig. 3 a, Wax moulage of skull of patient injured in an autombile accident, showing fracture of right body of mandible and a 
transverse (horizontal) fracture of the maxilla; b, wax moulage of same patient; the fractures have been reduced by intermax- 
illary wires attached to hooked arch bars; the upper jaw has been immobilized by two traction wires attached to the upper arch 
bar, passed through the cheeks, and attached to adjustable hooks on a plaster head cast. 

the maxilla is edentulous, the traction wires 
are fixed to an artificial denture worn by the 

The use of intermaxillary wires, arch bars 
and rubber bands, the ribbon arch mechanism, 
and the edgewise arch mechanism in the treat- 
ment of simple fractures of the mandible is 
well understood. We recommend that a dental 
root in the line of fracture should be removed 
unless it is the only tooth in the posterior frag- 
ment. In such a case, it is well to preserve the 
tooth for fixation of the fragment. When but 
one tooth is present in a fragment, we generally 
apply an orthodontia band to this tooth so that 
it can be used for immobilization. When the 
fracture of the mandible is situated behind the 
third molar tooth (Fig. 3a), the posterior frag- 
ment is often displaced forward and upward 
by muscular traction. To reduce this type of 
fracture, we first wire the teeth in occlusion in 
order to fix the anterior fragment; next, we 
apply a head cast in which is incorporated a 
hook that emerges in the posterior auricular re- 

January, 1940 

ment back into proper position. Many of the 
mandibular fractures which we see are several 
weeks old and in such cases elastic traction is 
essential in reducing the fracture. Subcondylar 
fractures are better left alone except for wiring 
the teeth in occlusion for a period of three or 
four weeks. If the condyle is displaced, its 
removal or replacement is contraindicated; we 
have never seen such a case in which the dis- 
turbed condyle interfered with the normal move- 
ments of the mandible. In cases of fracture of 
the horizontal ramus of the mandible in which 
the patients are children, we prefer to use a cast 
silver bite splint which can be cemented to the 
teeth of the lower dental arch; by means of cir- 
cumferential wires passed around the mandible 
and fixed to the casting, the lower jaw is thor- 
oughly immobilized. This gives the child free 
mobility of his jaws during the healing period. 

An edentulous mandible which is fractured 
anterior to the third molar tooth on either side 
may be nicely immobilized by the use of cir- 
cumferential wires attached to a lower artificial 



denture. However, if the fracture is situated be- 
hind the second molar tooth, a Gunning double- 
arch splint is required ; should the posterior frag- 
ment be pulled forward by muscular traction, 
a wire inserted through this segment of the bone 
and fixed to a head cast may be necessary to 
maintain this fragment in its normal position. 

In conclusion, we would like to mention two 
uncommon but potentially possible complications 
of every fracture of the jaw. The first is non- 
union of the fracture; the second is an osteo- 
myelitis with sequestration and loss of bone. 
When either one of these conditions involves the 
mandible, a repair can be accomplished only by 
means of a bone graft. For this purpose, we 
elect to use bone obtained from the crest of the 
ilium. Before the insertion of such a graft, 
it is most important to immobilize both frag- 
ments of the mandible thoroughly. After expos- 
ing the free ends of the fragments, the bone is 
cut to the desired shape and is inlayed and fixed 
between the two fragments. In these cases, one 
may anticipate good results if the oral mucous 
membrane is not accidentally incised; even a 
small nick insures infection of the wound by the 
entrance of secretions from the mouth. 

An analysis of post-traumatic deformities of 

the face has confirmed our belief that many such 
defects could be prevented if only the surgeon 
would devote more time and give more consid- 
eration to the primary wounds. To obtain satis- 
factory cosmetic results in the treatment of facial 
injuries sustained in motor accidents, we desire 
to emphasize the significance of early treatment 
of proper débridement of the wound, of complete 
hemostasis, of adequate drainage, of the use of a 
minimal amount of catgut, and of the insertion 
of fine skin suture material. Much unnecessary 
scarring and disfigurement of the face can be 
prevented by the immediate application of der- 
mal grafts to large regions denuded of skin. 
Finally, in the management of fractured facial 
bones, we wish to stress the importance of care- 
ful preoperative planning, which aids materially 
in surmounting those difficulties and discouraging 
problems that unavoidably arise in the care of 
these injuries. 


. Federspiel, M. N.: Maxillo-facial injuries. Wisconsin M. 
J., 33:561-568, (Aug.) 1934. 
Glascock, Harold, Sr., and Glascock, Harold, Jr.: Repair of 
traumatic fistulas of Stenson’s duct. Surg., Gynec. and 
Obst., 65:355-356, (Sept.) 1937. 

. Ivy, R. H.: Fractures of the jaws. Philadelphia, Lea and 
Febiger, 1931, 180 pp. 

. New, G. ., and Erich, J. B.: Repair of postoperative de- 
fects of the lips. Am. J. Surg., 43:237-248, (Feb.) 1939. 

. Straith, C. L.: Management of facial injuries caused b 
motor accidents. Jour. A.M.A., 108:101-105, (Jan. 9) 1937. 


Duluth, Minnesota 

K Gongs paper deals with injuries of the eye due 
to mechanical causes. It aims to present a 
few simple principles which may aid the phy- 
sician who first sees an eye injury to determine 
the approximate severity of such an injury. 

In any injury to the region of the eye due to 
mechanical causes, swelling of the soft parts 
around the orbit and of the lids, and wounds of 
these parts, will be evident at once. Marked 
swelling and distortion of the soft parts may 
hide a possible fracture of the bones of the face, 
of the nose, or of the orbit. When the swelling 
subsides it may then be discovered that there is 
a bony deformity, which by that time may be 
very difficult to correct. Since the zygoma is a 

*Read before the annual meeting of the Minnesota State 
Medical Association, Minneapolis, Minnesota, June 1, 1939. 


prominent structure of the face, a blunt, severe 
blow may fracture it without causing any other 
bony fractures. There have been two instances 
in our practice in which this has resulted from a 
blow of a fist. A fracture and displacement of 
the zygoma should be detected by bony deform- 
ity of the face, by notching of the rim of the 
orbit, and by a displacement of the eyeball due to 
encroachment upon the orbital contents by the 
displaced bone. The x-ray is our best single 
means of diagnosing this condition accurately. If 
nothing is done, the displaced bones may cause 
interference with the action of the extraocular 
muscles, or cause other disturbances in the func- 
tioning of the eye. A displaced zygoma can near- 
ly always be replaced to a normal position, if the 



Ss coc 0 AeAt0 Aa ete HH OO 

attempt is made within a few days, or not more 
than a week after the injury. 

Wounds of the lids involving the margins of 
the lids should be repaired at the earliest possible 
time, for if allowed to heal without careful re- 
placement of the parts, deformity of the lids is 
apt to occur. This is very difficult to correct af- 
ter the parts are scarred and contracted. 

The conjunctival sacs and the eyeball should 
be inspected if possible at the first examination. 
At such an examination, no elaborate instrumen- 
tarium is called for. A good flashlight, if nothing 
else is available, is splendid for this purpose. A 
solution of 4 or 5 per cent cocaine, instilled be- 
tween the lids after these have been cleansed 
carefully, will often be of great advantage. A lid 
elevator is also useful, but a small smooth hook, 
or any small smooth instrument available, may be 
used to lift the lids if this procedure should be 
necessary to aid in the examination. 

The cornea, the conjunctiva, and the conjunc- 
tival sacs should be inspected for wounds, 
bruises, areas of subconjunctival hemorrhage, 
and for foreign bodies. Injuries to the cornea 
are detected by a cloudiness of the cornea at the 
site of the injury, and by a break in the contin- 
uity of the normal reflex of the surface. Even 
if the lids are greatly swollen, all parts of the 
cornea can be brought into view through a very 
narrow opening between the lids by having the 
patient shift his point of fixation with the other 
eye. The presence of a foreign body can usually 
be suspected by the history of a scratching or of 
sharp pain on movement of the eyes. Pieces of 
glass are sometimes the most difficult of all for- 
eign bodies to find, for their transparency in- 
creased by the moisture of the tears sometimes 
hides them very effectively. It is often a good 
plan to have the patient localize as exactly as pos- 
sible the site of the pain or tenderness before 
any local anesthetic is instilled, for after that this 
means of localization may be gone. 

Any manipulation about the eye, however, 
should be carried out with the utmost gentleness, 
for the damage resulting from a serious injury, 
such as a perforating wound of the eyeball, can 
be increased greatly by rough and careless han- 
dling of the eye. 

There is one simple test which helps a great 
deal in determining the seriousness of any injury 
to the eye, and that is the determination of the 

January, 1940 


acuity of vision. This can be carried out quite 
easily if the patient is in such a condition that co- 
operation is possible. It need not be done with 
any degree of refinement but may be done rough- 
ly by the reading of the letters of any printed 
matter at hand, by the counting of fingers, by 
observing hand movements, or finally by the 
recognition of light. One must be sure that the 
vision is not obscured by external causes such as 
swelling of the lids, blood, or even tears between 
the lids. Marked photophobia is often present, 
and this may interfere. 

If the vision is not reduced but seems to be 
the same as that of the other eye, there is a fair 
degree of assurance that the eye is not severely 
injured. If there is a definite reduction of 
vision of an eye the injury should be considered 
serious, at least for the time being. 

Injuries to the eyeball may be either non-per- 
forating or perforating. Non-perforating injuries 
may or may not be serious. If the causative blow 
has not been severe, the eye may rapidly become 
free of symptoms. A hard blow may cause severe 
internal injuries to the eye such as rupture of 
the iris, of the lens, detachment of the retina, 
et cetera, or rupture of a blood vessel causing 
intraocular hemorrhage. 

A non-perforating injury may give no special 
findings on inspection beyond more or less con- 
gestion of the eyeball. A dilated pupil, or a dis- 
placed pupil, for which there is no other appar- 
ent cause, or a streak of blood in the anterior 
chamber, indicates internal ocular injury. A mas- 
sive intraocular hemorrhage gives a very char- 
acteristic picture, a dark red, or sometimes alto- 
gether black, highly polished appearance of the 
cornea. Such a condition is always serious. 

A perforating injury of the eyeball, no mat- 
ter how small the perforation may be, is always 
a major injury on account of the possibility of 
infection, of injury to the delicate internal struc- 
tures of the eye, and of the entrance of a for- 
eign body. Any perforating injury carries with 
it the possibility of an eventual loss of vision, 
and even of the loss of the eyeball. 

A perforation may be easily visible at first 
sight as a large gash in the cornea or sclera, or 
in both, through which iris, vitreous or other 
structures may be protruding. But if the perfo- 
ration is small, it may: be obscured by swollen 
conjunctiva or by blood-stained fluid and may 



not be detected. A pear-shaped pupil is indic- 
ative of a perforation near the edge of the 
cornea with a possible incarceration of the iris 
in the wound. 

In any perforation of the eyeball there is 
usually loss of aqueous through the wound with 
the consequent immediate reduction of the intra- 
ocular tension, and often with the complete col- 
lapse of the eyeball. Therefore, in any case in 
which there is a suspicion of a perforation, this 
may be determined by trying the tension of the 
eye with the tips of the two forefingers in the 
same manner as fluctuation in a suspected abscess 
is determined, using the other eye for compar- 
ison. Usually, the difference is so marked that 
even the inexperienced should be able to detect 
it readily in one trial. Again, let me emphasize 
the need for great gentleness in making this test 
in order that the damage to the eye may not be 
increased by the test. 

There is one type of perforation in which this 
test is of no value. A very tiny perforation may 
be produced by a finely pointed instrument, or 
by a very tiny flying foreign body (usually a 
metallic one), so small that no intraocular fluid 
will escape. The tension of the eye then remains 
normal. The vision, too, may not be disturbed, 
depending on the part of the eye affected by the 
foreign body. It is a good plan to have roent- 
genograms taken of all eye injuries in which 
there is a possibility that small high velocity 
particles might be involved. 

A few illustrative cases are appended. For 
the sake of brevity, only the positive findings are 

Case Reports 

Case 1.—A. K., male, aged twenty. 

Three weeks before this patient was seen he had had 
a collision with another player at a basketball game 
and received a blow on the left side of the face. He 
became unconscious and was so for upwards of four- 
teen hours. The face and the eye swelled up a great 
deal. At the time he was seen, the swelling had sub- 
sided considerably. 

On examination, there was a depression of the zy- 
gomatic prominence, a notching of the lower rim of 
the orbit, and some degree of anesthesia of the skin 
of the left side of the nose. The skin surrounding the 
left eye was discolored. There was ptosis of the left 
upper lid, moderate protrusion of the eyeball and a 
paralysis of the external ocular muscles. The eye could 
be rotated only very slightly in any direction. The 
pupil was dilated, failed to react to light, and very 
slightly to accommodation. The media were clear, and 


the fundus normal. Vision was 20/100; through a 
pin hole, 20/30. 

A roentgenogram showed a fracture of the lower 
and lateral rims of the orbit, separation of the frontal 
and maxillary zygomatic sutures, and a complete trans- 
verse fracture through the small wing of the sphenoid 
bone just lateral to the sella turcica on the left. 

In this case there was a paralysis of the third, fourth, 
and sixth nerves. It was believed that this was due 
either to an injury of the nerves by the fragments of 
bone in the posterior orbit, or to hemorrhage in the 
posterior orbit. 

The loss of function in this instance was undoubted- 
ly due to the injury; possibly to injury of the nerves 
from the fractured fragments. It is impossible to say 
if any improvement could have been obtained if the 
bony fragments had been restored to their normal 
positions, but the attempt should have been made. 

Case 2—M. L., male, aged thirty. 

On January 11, 1938, while working with a road 
crew and using a pick on the frozen ground some- 
thing flew into his right eye. His vision was imme- 
diately nil. 

Examination at the office a few hours later showed 
a horizontal cut running through the cornea into the 
sclera for a distance of five or six millimeters, the 
edge of the cornea being about the middle of the cut. 
The pupil was oval with the apex pointing towards 
the cut, but there was no hernia of the iris in it. 
There was some blood in the anterior chamber. There 
was no vision, not even the recognition of light. 

A roentgenogram showed a large foreign body in- 
side of the eyeball. 

In this case, it was very apparent from the very 
outset that there was an injury so severe, and the prog- 
nosis so hopeless, that there was no hesitation in 
recommending the immediate removal of the eyeball 
as the quickest and most effective way of recovery. 
Consent to this was refused. 

The foreign body, which proved to be steel and 
magnetic, was removed from the eye. Tetanus serum 
was administered, and other measures taken to coun- 
teract inflammation and infection. 

There was no return of the vision, and the eye was 
finally enucleated to avoid the possibility of sympa- 
thetic inflammation in the other eye. 

Case 3.—P. K., male, aged forty. 

In 1920, while hammering on a brake connection, 
something hit him in the left eye. Examination then 
had showed a small perforation of the lower lid, but 
no suspicion of anything further. The vision seems 
to have been clouded for a while and then became al- 
most normal. In 1922, two years after injury, the 
vision began to fail quite rapidly. He visited an oph- 
thalmologist, who found the iris rust-colored, a con- 
dition known as siderosis, and made the diagnosis of 
tiny piece of steel in the eye. 

The fragment was removed (by the magnet?) but 
no promise was made of return of the vision. The 



eye remained quiet, but with a vision limited to recog- 
nition of light until in January, 1938, when a glaucoma 
with a very high tension and with marked pain de- 
veloped. On account of this the eye finally had to be 

I believe that, if this eye had been watched more 
carefully, and the vision taken several times following 
the first injury, it would have been found to have been 
reduced, and thereby given rise to a suspicion of some- 
thing wrong in the eye in time to remove the fragment 
of steel before the eye had been ruined. 

Case 4—J. B., male, aged twenty. 

On May 17, 1937, a companion shot a broken wire 
paper clip by means of a rubber band at the patient. 
One prong of the clip penetrated the upper lid of the 
left eye, stuck there and was pulled out by the pa- 
tient. The vision, as the patient remembered it, was 
not disturbed. He visited an ophthalmologist after a 
few hours, who evidently did not think anything serious 
had happened for he instructed the young man to wear 
a bandage for about a week and then to return. 

Everything went well until the third day, when the 
eye became inflamed and the vision somewhat reduced. 
The next morning the eye was very painful and the 
vision very poor. He came to our office on the fourth 
day. The eyelids of the injured eye (the left) were 
very swollen, the upper lid showed a very tiny red 
spot in the upper temporal aspect of the lid, which 
the patient stated was the point of penetration by the 
clip. The conjunctiva was red and congested, the 
cornea steamy. No wound of the cornea or conjunc- 
tiva could be seen. The pupil was contracted, the iris 
swollen and discolored, the media cloudy, and the 
eyeball tender. The vision was limited to recognition 
of light. 

This was a severe, acute panophthalmitis, the evi- 
dent assumption being that the infection had been in- 
troduced into the eye by the paper clip perforating 
not only the lid but also the sclera. 

A hole in the conjunctiva as small as this is usually 
not visible. It may too be possible from the position 
of the puncture of the lid that the clip penetrated the 
sclera entirely posterior to the conjunctival fold, thus 
producing no mark whatsoever on the conjunctiva. As 
the puncture was likely about at the equator of the eye- 
ball, it would not have been visible with the ophthal- 
moscope through the pupil. With a normal vision, a 
normal tension of the eyeball, the physician cannot be 
blamed for assuming that the injury’ was a harmless 
one. In retrospect the only circumstance that might 
have given rise to apprehension on the part of the 
physician would have been the fact that perforations 
of the eyeball occur very easily from small sharp mis- 
siles coming at great velocity. 

In spite of all treatment, matters went from bad to 
worse, all recognition of light disappeared, the pain 
persisted, and the eye finally had to be enucleated to 
stop the pain and end the disability. 

Case 5—E. G., male. 
On November 3, 1937, this patient came to the of- 

January, 1940 

fice stating that four days before, while hammering on 
a cold chisel in repairing a big chain, something flew 
from the chisel and hit him in the right eye. He be- 
lieved that the eyelids were open at the time and that 
he was looking directly at the chisel. The object which 
hit him was apparently a large one for it gave him a 
blow so severe that he staggered and the pain almost 
made him faint. However, he recovered quite prompt- 
ly and kept working that day and also the next day. 
Towards evening of the second day the eye began 
to be painful, and the vision became cloudy. 

Examination of the right eye showed the conjunctiva 
of the eyeball to be reddened, mostly on the temporal 
side. The cornea was clear. The iris was somewhat 
swollen and its normal markings indefinite. There was 
a small amount of exudate in the anterior chamber. 
The eyeball was tender but tension was normal. The 
media were cloudy. The vision was reduced to recog- 
nition of light. 

A roentgenogram was obtained and that showed a 
very tiny spot which might be from a foreign body in 
the eye, but after taking several films its presence was 
still a matter of doubt. 

Here it is very evident that a more or less serious 
injury to the eye had taken place from the fact that 
the vision was very much reduced, and there was cloud- 
ing of the media of the eye. This could happen from 
a blow from a large blunt object, but the presence of 
a tiny foreign body in the eye could not be ruled out. 
If there was a foreign body in the eye, it would in all 
chances be steel and magnetic. Two courses of pro- 
cedure were here open: First, to make an opening in 
the eyeball, insert the tip of the magnet and search 
for the foreign body. In that case, if there were then 
no foreign body found, the manipulation would give 
added risk to the eye. If, on the other hand, a foreign 
body were present, and no attempt were made to re- 
move it, the eye would become ruined. Second, to in- 
stitute temporary conservative treatment and watch 
the eye very carefully for developments. The latter 
course was followed. 

No serious infection in the eye occurred, and after 
two months the cloudiness of the eye had largely dis- 
appeared and some degree of vision had returned. It 
was then possible to examine the fundus with the oph- 
thalmoscope. A very tiny black speck was found on 
the retina about ten millimeters below the disc. An 
incision was now made in the eyeball, the tip of 
magnet inserted, and the foreign body removed. The 
eye went on to eventual recovery and restoration of 
perfectly normal vision. 

Case 6.—L. C., male, aged twenty-three. 

On December 16, 1935, this patient was seen on ac- 
count of an injury to his right eye which had been 
sustained two days before by a blow on the eye. He 
had not thought that the injury was very severe. His 
vision had remained good until the afternoon of that 
day, when it had suddenly failed. 

On examination, the eye appeared reddened. The 
cornea of the eye showed a brownish black shiny 



color. There was no iris nor any other details of the 
interior of the eye visible. The eyeball was hard. 

This eye presented a very evident intraocular hem- 
orrhage—how extensive, it was impossible to tell. If 
it were limited to the anterior chamber only, then 
there might be some hope of saving the eye with some 
restoration of vision. If the blood filled the whole 
eye, the prognosis would be hopeless. 

The eye was watched for a few days, then an inci- 
sion was made into the anterior chamber, and an at- 
tempt made to wash out the blood. Some clots were 
removed but others still protruded through the pupil 
from the posterior part of the eye. Following the 
operation, treatment did not produce much result. The 
tension of the eyeball remained high. The eye re- 
mained blind, painful, and irritable, and enucleation 
was finally advised. 

Case 7—J. H., male, aged twenty-eight. 

In September, 1938, this man was on a vacation trip 
in the lake region north of Duluth with a party of 
friends from out of the State. While out fishing, 
the hooks of a casting plug caught in the patient’s right 
eyelids and right eye. Since it was impossible for the 
man’s companions to remove the hooks, they cut the 
hooks off close to the eye with pliers, and then 
brought the patient to Duluth as promptly as pos- 

On examination, it was found that there was a 
wound in the right eyebrow in which the end of a steel 
fishing hook could be seen. Another end of a hook 
was located in the right upper lid about 5 mm. above 
the lid margin. There was a cut five millimeters deep 
on the margin of the upper lid about the junction 
of the lateral and middle thirds. The eyeball showed 
a penetrating wound of the cornea three or four milli- 
meters long in the upper temporal quadrant. Pro- 
truding in this was a tag of the iris and a little 

In spite of the distortion of the structures of the 
eye, there was a good recognition of light from all 

This case is reported to show that even in a very 
evident severe penetrating injury of the eyeball the 
outlook is not necessarily hopeless. The facts that 
some vision was present, and that the inside structures 
of the eye did not seem too much lacerated, gave some 

The patient was taken to the operating room. Very 
careful cleansing treatment was given, the hooks were 
removed from the lids, and the lid margin repaired. 
The protruding iris in the wound in the eyeball was 
excised, and both eyes bandaged. Tetanus antitoxin 
was administered, and a course of other foreign pro- 
tein treatment given. 

The eye showed no signs of infection at any time, 
which was remarkable, and the wound went on to rapid 

The patient was discharged from the hospital after 
twelve days, was allowed to return to his home, and 
was referred to a local ophthalmologist for further 


treatment. A report at the end of December, 1938, 
over three months later, stated that the vision had be- 
come better all the time, and in November he had taken 
an examination for Civil Service and was accepted. 
He had found that he could use the eye for rifle 
shooting but not quite so successfully for pistol shoot- 

Case 8.—E. C., male, aged twenty-eight. 

On August 17, 1938, while riding in the front seat 
next to the driver, a collision with another car oc- 
curred and the patient was thrown against the wind- 
shield and sustained rather extensive cuts about the 
left side of the face, the nose, and the left eye. He 
was seen soon after by his physician, who repaired the 
cuts. On account of the marked swelling, no view 
of the eyeball was obtained. During the next three 
days the patient made no complaints excepting that 
at times he would have a sharp pain in the left eye. 
On the fourth day, the swelling had subsided some- 
what, and the eyeball was inspected and a wound of the 
cornea was discovered. He was then referred for con- 
sultation. On examination, a perforating wound was 
found in the cornea near the center in which the iris 
had become incarcerated. There were no signs of in- 
fection. He recognized light from all directions. We 
were about to terminate the examination when, upon 
taking a final look into the conjunctival sacs, we found, 
much to our astonishment, a thin, flat piece of glass 
which happened to be curved so that it lay quite snug- 
ly against the side of the eyeball and was not readily 
noticeable. A roentgenogram revealed no sign of any 
intraocular foreign body, nor any fracture of bones. 
Since it was impossible to replace the protruding iris, 
it was cut off and the portion adherent to the wound 
was cauterized. The patient made a good recovery 
with a final vision of 20/30. 

Here is illustrated the necessity of the earliest pos- 
sible examination of the eyeball, and, too, even though 
one lesion may be found, a thorough examination for 
other lesions should not be neglected. 

1. If the injury in the region of the eye is 
gross, always consider a fracture of the zygoma 
as a possibility. A roentgenogram will usually 
determine this. 

2. Always inspect the eye for evident inju- 
ries to the eyeball, or for foreign bodies within 
the lids. 

3. If there is a definite reduction of vision of 
the injured eye, consider the injury a serious one 
until the contrary can be ascertained. 

4. If the tension of the eyeball is definitely 
reduced there is in all likelihood a perforating 
wound of the eye. A perforating wound of the 
eye is always a grave injury. 


ROR OT agen 






Clinical Assistant Professor of Surgery, University of Minnesota Medical School 
Saint Paul, Minnesota 

ee is a symptom which frequently 
brings the patient to the doctor. It is seen 
at all ages and must always be carefully con- 
sidered even when the examiner feels that the 
patient has no organic lesion. It is better to re- 
gard a case as organic and find eventually that 
it is functional than to make the diagnosis of a 
functional disorder and then find, at a later less 
hopeful stage, that there is something organically 

A brief explanation of the normal process of 
deglutition should precede a discussion of the 
causes of dysphagia. After the food has been 
placed in the mouth, chewed, and covered with 
saliva, the bolus of food is passed backwards to 
the pharynx by closure of the lips and pressure 
of the tongue against the palate. From the back 
of the tongue to the clavicular level the bolus of 
food is largely carried by negative pressure cre- 
ated when the hypopharynx is opened with the 
mouth, nasopharynx and larynx closed.’ The 
food is thus tipped over the back of the tongue 
and sucked into the open mouth of the laryngeal 
pharynx and some distance down the esophagus. 
This initial impetus may carry liquids to the 
cardiac opening but solids usually are propelled 
by peristalsis. When liquids are swallowed with 
the head at a lower level than the rest of the 
body, each mouthful is propelled along the 
esophagus by peristalsis as in the case of de- 
glutition of solids. The cardia of the stomach 
then relaxes and the bolus passes into the stom- 

These facts are mentioned because any defect 
in the act of swallowing from the opening of the 
mouth to receive the food to the final relaxation 
of the cardiac orifice leads to dysphagia of 
greater or lesser degree. 

The cases of dysphagia may be placed in three 
groups :° 

A. Those due to pain. 

B. Those with mechanical difficulty. 

C. Those having nervous disability. 

*Read before the annual meeting of the Minnesota State 
Medical Association, Minneapolis, Minnesota, June 1, 1939. 

January, 1940 

Dysphagia Due to Pain.—Infection or carci- 
nomatous ulcerations of the mouth, tongue, ton- 
sils, pharynx and larynx may make swallowing 
of even liquids difficult. Retropharyngeal ab- 
scess may be a common cause of dysphagia in 
children. One of the worst symptoms of ad- 
vanced tuberculous ulceration of the larynx is 
the great pain on swallowing. 

In the esophagus, foreign bodies, peptic ulcer 
or esophagitis may cause dysphagia due to pain. 

Mechanical Causes of Dysphagia.—Inability 
to open the mouth because of trismus due to 
tetanus, affections of the temporo-mandibular 
joint or the muscles of mastication, and stenosis 
of the mouth due to caustics may make the in- 
gestion of food difficult. Scarring, fixation or 
partial loss of the tongue result in considerable 
difficulty in swallowing. Lack of saliva may also 
be a cause of dysphagia. 

Lesions of the palate such as congenital or 
acquired defects and new growths interfere with 
normal swallowing. Carcinoma of the pharynx 
may cause dysphagia early in its course. 

In the esophagus, foreign bodies, congenital, 
benign and malignant strictures and perforation 
of the esophagus may block the esophagus. Com- 
pression stenosis of the esophagus by substernal 
thyroid, aortic aneuryms and mediastinal masses 
and hiatus hernias are similarly mechanical 
causes of dysphagia. 

Nervous Causes of Dysphagia.—Facial paral- 
ysis (N. VII), pharyngeal paralysis (N. IX, X, 
XI), and paralysis of the tongue (N. XII) inter- 
fere with the well codrdinated mechanism of 
deglutition. In myasthenia gravis, dysphagia is 
present as an early symptom. 

The Plummer-Vinson syndrome called by some 
hysterical dysphagia™’ has often been included 
under the nervous causes of dysphagia. Kelly® 
believes that spasm at the entrance of the esoph- 
agus is the primary condition. More correctly 
this dysphagia is part of a syndrome of hypo- 
chromic anemia occurring in middle aged women 



and probably due to chronic blood loss. These 
patients have glossitis, with atrophy of the mu- 
cosa of the mouth, tongue, esophagus and some- 
times stomach, and often achlorhydria. In on- 
ly 10 to 15 per cent of these cases does dys- 
phagia occur. 

There is another group of neurotic patients in 
which the dysphagia is purely functional. How- 
ever, it should be remembered that there is no 
reason why a neurotic individual may not have 
an organic lesion in the esophagus. 

The lesions of the esophagus will now be 
considered in more detail. 

Pharyngeal Pouch.—By confusion of terms, 
this condition has often been considered as an 
esophageal lesion. However, this pouch origin- 
ates in middle aged persons, at the site of a 
small gap in the fibers of the inferior constric- 
tor of the pharynx. These patients early note 
an irritation and an increase of mucus in the 
throat. As the diverticulum increases in size a 
characteristic gurgling noise is noted on swallow- 
ing. Regurgitation of unaltered food, usually 
that taken at the beginning of the meal, occurs. 
In the late stages, the weight of the contents 
of the sac pulls on the esophagus until it becomes 
a narrow slit causing increasing dysphagia. The 
treatment of choice is a two-stage surgical ex- 
cision of the pouch. 

Other Diverticula of the Esophagus.—Traction 
diverticula occur in the thoracic esophagus as 
the result of adhesions of inflammatory bron- 
chial nodes dragging on the wall of an esophagus 
already fixed, producing a tent-like projection 
of the wall. These diverticula are usually with- 
out symptoms and require no treatment. 

Congenital diverticula of the esophagus which 
occur most commonly just above the diaphragm 
are likewise without symptoms. 

Foreign Bodies.—A careful history to deter- 
mine the character of the foreign body and any 
previous dysphagia is very important. The dys- 
. phagia may be complete or incomplete. Sub- 
sternal pain with radiation to the back may be 
present. In many cases in which a foreign body 
has been swallowed, as for instance a fish bone 
or a small meat bone, the patient often com- 
plains of pain when swallowing for some days 


afterwards, but actually has little difficulty in 
swallowing his food. The mucous membrane has 
probably been scratched at the time the foreign 
body was swallowed but this heals quickly. Com- 
plicating symptoms of perforation may occur 
after a foreign body has become lodged in the 

Congenital Atresia—In about 80 per cent of 
the cases of congenital atresia of the esophagus 
there are associated tracheo-esophageal fistulz.® 
In this most common type of atresia of the 
esophagus the upper segment terminates blindly 
just above the bifurcation of the trachea, while 
the lower segment has a fistulous communication 
with the trachea about 0.5 to 1.0 cm. above its 

The symptomatology associated with this 
anomaly is so characteristic that it should be 
readily recognized. At birth the child appears 
to be well nourished and usually well developed 
but has difficulty with large amounts of frothy 
mucus filling the mouth and pharynx, and drool- 
ing from the side of the mouth. When fed, the 
child eagerly takes the breast and after a few 
swallows stops, ceases to breathe, becomes cyan- 
otic, and regurgitates frothy mucus and feedings 
through the nose and mouth. The child appears 
as if it would drown, but after a period of life- 
less relaxation usually recovers and repeats this 
episode with each subsequent feeding. These 
infants rapidly lose weight due to starvation and 
dehydration and often develop an aspiration 

The diagnosis is confirmed by passage of a 
catheter or bougie which meets obstruction 10 
to 12 cm. from the alveolar margins, and by 
x-ray visualization of the blind pouch with 
lipiodol filling. The presence of air in the stom- 
ach in association with atresia of the esophagus 

is evidence of a fistulous communication with the 

The prognosis in these cases has usually been 
considered hopeless but survival of some of 
these patients for more than three months fol- 
lowing surgery has lent encouragement to this 
type of treatment.® 

Acquired and Benign Stricture—In these 
cases a history of swallowed caustic or acid, of 
antecedent trauma to or infection of the esoph- 



agus can be elicited. In the case of swallowed 
caustic there is early pain, salivation, and often 
complete dysphagia. Then the dysphagia sub- 
sides as the edema lessens and swallowing may 
seem quite normal. In about six weeks the dys- 
phagia increases when cicatricial contraction 
takes place. 

The treatment is gradual dilatation by grad- 
uated sounds passed over a swallowed twisted 
silk thread. Treatment should be persisted in 
until a size No. 45 French sound is passed, when 
the caliber of the stricture is large enough to 
pass solid foods. 

Carcinoma of the Esophagus.—About 40 to 50 
per cent of all lesions of the esophagus are due 
to carcinoma*?? and 4 to 5 per cent of all can- 
cer deaths are the result of carcinoma of the 
esophagus.’° Ninety per cent are squamous cell 
carcinomas and are highly malignant.** Men are 
five times as frequently affected as women.” 
The average duration of the disease is seven to 
nine months with a history of gradually in- 
creasing dysphagia—first to solids, then soft 
food and later to liquids. Pain may occur early 
in lesions high in the esophagus but is late in 
the low lesions and when it occurs there, usually 
indicates extension beyond the esophagus. The 
common complications are: involvement of the 
recurrent laryngeal nerve, causing hoarseness due 
to vocal cord paralysis; perforation into the 
trachea or bronchi forming an esophago-tracheal 
fistula and leading to aspiration pneumonia; and 
hemorrhage which may be fatal. 

In treatment, the best means of palliation is 
dilatation by means of graduated sounds passed 
over a swallowed thread as a guide. Gastros- 
tomy, unless done early, carries a high mor- 
tality.’ Definite relief is obtained in some cases 
by irradiation but in others the reaction inci- 
dent to irradiation only seems to add to the dis- 
comfort. : 

In recent years, more frequent successes by 
surgical extirpation of cancer of the esophagus 
should make us aware of the value of early diag- 
nosis.* Esophagoscopic examination has chiefly 
been used to verify an-established diagnosis. 
For early diagnosis all patients with subjective 
abnormality in swallowing should be promptly 
examined with the esophagoscope. Steadily in- 
creasing dysphagia in a man past fifty is in- 
dicative of cancer of the esophagus. 

January, 1940 

Cardiospasm.—In cardiospasm there is a dif- 
fuse dilatation of the esophagus without anatomic 
stenosis, a spasm being present at the cardiac 
end of the esophagus. Dysphagia in these cases 
is noted with liquids as well as solids, and is 
especially severe in the case of cold liquids. 
The obstruction may be intermittent at first, but 
becomes progressively worse. The patient can 
often wash food down with water but cannot 
swallow water alone. Epigastric pain, present 
in the majority of these cases, often disappears 
with the onset of dysphagia. This pain may 
radiate to the back and retrosternally. 

Regurgitation at first is immediate on swallow- 
ing and later when the esophagus has dilated 
may be delayed hours or even days. Noc- 
turnal regurgitation is common. This is of- 
ten accompanied by aspiration of food causing 
choking and later chronic pulmonary suppura- 

Medical treatment using amyl nitrate or nitro- 
glycerine is sometimes effective in relaxing the 
cardia. Dilatation of the area of spasm by the 
Plummer hydrostatic bag is the most effective 
method of treatment. In cases which fail to 
respond to all other therapy, cervical sympathec- 
tomy has proved of value.” 

Perforation of the Esophagus.—A history of 
previous instrumentation, swallowing of a for- 
eign body, a previous esophageal lesion or an 
attack of violent vomiting, preceding the per- 
foration, is usually obtained. The patient com- 
plains of severe retrosternal or epigastric pain, 
dyspnea and dysphagia. He appears prostated, 
has an elevated temperature, tachycardia and 
shallow rapid respirations. Emphysema in the 
neck or over the chest may be noted. 

A few of these patients recover without surgi- 
cal intervention, but the vast majority will die 
if nothing is done. 

Comment.—In most of the cases of dysphagia 
the diagnosis may be readily made. Careful in- 
spection should reveal any abnormalities in the 
mouth or pharynx. The hypopharynx and larynx 
are easily accessible to examination with a laryn- 
geal mirror. In the diagnosis of lesions of the 
esophagus a careful history will usually indi- 
cate a correct diagnosis. The most valuable and 



safest method of examination of the esophagus 
is by the x-ray. 

Blind passage of bougies or sounds is to be 
condemned because of the danger of perfora- 
tion of the esophagus. However,: passage of 
graduated sounds over a swallowed twisted silk 
thread as a guide according to the method of 
Plummer is a safe procedure and most valuable 
as a diagnostic aid and a method of treatment. 

The esophagoscope is an important adjunct 
in confirming the roentgen diagnosis and in many 
instances may give more accurate information 
concerning certain intra-esophageal lesions. For 
the early diagnosis of carcinoma of the esoph- 
agus, any patient with subjective difficulty in 
swallowing, especially a man over fifty years of 
age, should be examined by the esophagoscope. 


. Barclay, A. E.: The digestive tract. London: 
University Press, pp. 126-142, 1936. 

. Craig, W. McK., Moersch, H. J., and Vinson, P. P.: 
Treatment of intractable cardiospasm by bilateral cervi- 
cothoracic sympathetic ganglionectomy: Report of a case. 
Proc. Staff Meet. Mayo Clinic, 9:749, 1934. 

Garlock, J. H.: The surgical treatment of carcinoma of 
the thoracic esophagus. Surg., Gynec. and Obst., 66:534, 

Guisez, J.: Malignant tumors of 
Laryng. and Otol., 40:213, 1925. 
Kelly, A The significance of dysphagia of nervous 

Clin. Jour. 61:469, 1932. 

. Leven, N. L.: Surgical management of congenital atresia 
of the esophagus with tracheo-esophageal fistula. Jour. 
Thor. Surg., 6:30, 1936. 

Martin, H. E., and Watson, W. L.: The original Janeway 
gastrostomy. Surg., Gynec. and Obst., 56:72, 1933. 
= W. M.: Dysphagia, Guy’s Hosp. Gaz., 


the esophagus, Jour. 


48 :280, 

Rosenthal, A. H.: Congenital 
with tracheo- -esophageal fistula. Arch. Path., 12:756, 1931. 
Souttar, H. S.: Treatment of carcinoma of the esophagus. 
Brit. Jour. Surg., 15:76, 1927. 

. Vinson, P. P.: Hysterical dysphagia. Minn. Med., 5:107, 

. Vinson, P. P.: Malignant disease of the esophagus, North- 
west Med., 32: 320, 1933. 
Vinson, P. P., and Broders, A The degree of malig- 
i =f one of the SS Arch. Otolaryng., 

8, 1 

atresia of the esophagus 


Minneapolis, Minnesota 

gun treatment of atopic dermatitis is a sub- 

ject of general medical interest, most partic- 
ularly to dermatologists, allergists and pediatrists. 
It involves two considerations: first, treatment 
directed at the cause, if demonstrable; and, 
second, symptomatic relief. The former, as far 
as allergy is concerned, leaves much to be de- 
sired. The latter is often inadequate. However, 
better therapeutic results can be obtained in a 
greater percentage of patients if both factors 
are considered in treatment, rather than relying 
on either one alone. 

Allergic Considerations 

The enthusiasm for food as the cause of 
atopic dermatitis is decreasing. It does occur, 
but the results from diet restriction alone are 
generally unsatisfactory. The errors, in the past, 
were due in part to improper evaluation of skin 
tests and to general enthusiasm because of an 
occasional startling result. Skin tests, either 
scratch or intradermal, have, however, a place 
in the diagnosis of atopic dermatitis if their 

*Read before the annual meeting of the Minnesota State 
Medical Association, Minneapolis, Minnesota, May 31, 1939. 
From the Division of Dermatology. University of Minnesota, 
H. E. Michelson, Director, and the Department of Dermatology, 
General Hospital, Minneapolis, S. E. Sweitzer, Chief. 


limitations are appreciated. They are about 25 
per cent accurate in this condition, in all age 
groups, being more accurate in children and de- 
creasing with age, even though the number of 
positive skin reactions increases as the indi- 
vidual becomes older. Skin tests with food ex- 
tracts are difficult to interpret, as well as un- 
reliable. Their value depends upon the ex- 
perience of the physician, 

The direct testing of infants, even when done 
with utmost care, is difficult to interpret because 
most irritations produce varying degrees of ery- 
thema and urticaria. This same factor is en- 
countered in patients with urticaria and der- 
mographism. Reactions in this group have more 
clinical significance when obtained by the pas- 
sive transfer method of Prausnitz and Kustner. 
Therefore, positive cutaneous tests should serve 
only as a starting point of elimination manage- 
ment. The benefit derived from omission of an 
ingested substance can be evaluated in five to 
seven days. If there is improvement, they 
should be added to the diet individually to as- 
certain specific clinical importance. To accom- 
plish this accurately, the physician must have a 
knowledge of what composite foods contain, so 


that the patient can be correctly informed. By 
so doing, a comparatively short period of time 
is necessary to establish the status of a number 
of suspected substances. There should be no 
prolonged restricted diets of months’ duration, 
without both patient and physician knowing that 
ingestion of a substance, either qualitatively or 
quantitatively, causes an aggravation of symp- 
toms. This can be accomplished by instructing 
the patient to eat specified amounts and as to the 
interval at which a food may be taken. Often, 
when several substances have been omitted for 
a period of weeks or months, repeated ingestions 
may be necessary to resensitize the patient, as 
there is a definite relationship between clinical 
sensitivity and the frequency with which a 
food appears in the diet. Some patients have an 
aggravation of eruption by most ingested mate- 
rials; to avoid all of these for a considerable pe- 
riod of time is more dangerous than their dis- 
ease. In such cases, some type of non-specific 
therapy should be tried. 

Elimination diets may be used, but they are 
of value only in detecting ingestant factors. They 
are in principle a restricted, specified menu of 
uncommonly used foods. This method of study 
used by Rowe® and Alvarez‘ is practical in a 
limited group of patients. They should be ob- 
served frequently and regularly, in order that 
accurate deductions can be made from omission 
and addition of specified substances. The great- 
est difficulty encountered is in interpreting cumu- 
lative effect, because of limitation of foods per- 

Substances referred to as inhalants are some- 
times called contact reactors, but are in reality 
multiple positive scratch tests. The substance, 
air-borne or by contact, is deposited on an ex- 
coriated or irritated skin, which causes an exac- 
erbation of symptoms and signs, the degree of 
which varies directly with the amount and type 
of reagin and the sensitivity of the individual. 
The increase of eruption and pruritus in addi- 
tion to scratching sets up a vicious cycle. This 
contention is supported by the fact that very 
few of these substances cause eruptions when 
applied as patch tests to the unbroken skin. 
This conception is in accord with the views of 
Hill,? who found that when using the environ- 
mental allergins which were positive by scratch 
tests the patient had positive patch tests when 

January, 1940 


the skin was abraded, but negative when applied 
to the intact skin. Many of these are common 
environmental substances, such as house dust, 
orris root, feathers, silk, sheep wool, goat hair, 
et cetera. It is also probable that these are 
oftentimes secondary or irritating factors and 
if the underlying cause can be successfully avoid- 
ed they are no longer effective. This may ex- 
plain in part the’ improvement which follows 
hospitalization of patients with atopic dermatitis. 
Bland ointments, especially pastes and Unna’s 
occlusive dressings, when applied to an eczema- 
tized skin, serve as a protective covering against 
irritating substances. 

Inhaled materials can also cause atopic der- 
matitis and neurodermatitis. Sulzberger and 
Vaughan,® in experiments on patients with silk 
hypersensitivity, state: “The most plausible ex- 
planation of this phenomenon seems to be that 
the silk allergin is absorbed in the blood stream 
(by way of the respiratory tract) of the patient 
and disseminated to the vascular hypersensitive 
areas of the skin.” Zakon’ and Taub have re- 
ported atopic dermatitis due to the inhalation 
of house dust and horse dander. The respira- 
tory tract as a portal of entry is not rare and 
should be considered in all patients with large 
skin reactions, especially seasonal and occupa- 
tional eruptions or those associated with rhinitis, 
bronchitis or bronchial asthma. When food ex- 
tracts give large scratch, intradermal or passive 
transfer reactions, comparable to pollen antigens, 
they should be considered not only as ingestant 
factors but also as inhalant causes. Although 
this is demonstrated most frequently in adults, 
it should not be neglected as a consideration in 
the treatment of infants and children. 

Treatment by avoidance in this group of pa- 
tients is not always possible nor practical. The 
intimate association with dust, feathers and ani- 
mal epithelials is such that desensitization by sub- 
cutaneous injection should be attempted. It 
should be given a trial in occupational disease, 
because of the economic factors involved. The 
results of these treatments, if used in adequate 
dosage and over a sufficient period of time, are 
effective in some patients in the alleviation of a 
portion of their symptoms. Whether the effect 
of this treatment is specific, has not been satis- 
factorily explained, as all cases showing clinical 
improvement do not show a comparable diminu- 



tion in the skin test reaction. Generally, how- 
ever, patients receiving the most benefit show 
a decrease in intensity of the cutaneous test. 
Systemic reactions can and do occur following 
this type of treatment and are most commonly 
manifested by increase in pruritus, dermatitis, ur- 
ticaria, rhinitis and bronchial asthma. There- 
fore, injections should follow dilutions, sched- 
ules and precautions as used in pollen desensi- 

Symptomatic Therapy 

Palliative treatment is essential in the majority 
of patients with atopic dermatitis and should be 
used in conjunction with specific therapy when- 
ever possible. Oftentimes it is the only method 
which can be used to any advantage. The mul- 
tiplicity of medications and treatments used by 
competent observers indicates that none is ade- 
quate in all instances. There are, however, cer- 
tain important factors that appear to benefit the 
majority of these patients. Among the most 
important are: changes in environment, non- 
specific therapy, physiotherapy, and local medi- 
cation. Change in environment is most easily 
accomplished by hospitalization where contact 
factors can be reduced in number, and diet 
and medication can also be supervised. Most 
patients have temporary improvement from this 
procedure. Occasionally change of occupation 
is necessary. Others gain relief after moving to 
a warmer climate. Neurocirculatory instability 
is present in a high percentage of atopic patients, 
and such cases are helped by physical and men- 
tal rest and correction of the underlying instabil- 
ity and exhaustion.” 

Various types of non-specific therapy have 
been used in treatment. Perhaps the simplest 
is autohemotherapy. This results in some im- 
provement in a few instances. Intravenous ty- 
phoid, sodium, thiosulphate, Ekzebral, hyperpy- 
rexia, intramuscular milk, and splenic extract 
have been tried with varying results. Histamine‘ 
has also been used recently. Most of these, if 
effective, tend to lose their efficacy if given over 
a period of time and eventually are useless or 
appear to aggravate the symptoms. 

Ultraviolet light, in tonic doses, appears to 
benefit some patients if used for a considerable 
period of time. Oftentimes symptoms and erup- 
tion are increased, especially if the dosage be 


sufficient to produce erythema. Superficial x-ray 
therapy may be used in older patients if other 
palliative measures fail, and then only with cau- 
tion and realization that atopic dermatitis is a 
chronic recurring disease and that repeated ex- 
posures may result in radio-dermatitis, a condi- 
tion more serious than the atopic dermatitis. 

The choice of local medication is based upon 
the presenting primary and secondary lesions. 
For purposes of treatment, they can be divided 
into acute, subacute and chronic. Acute erup- 
tions, manifest by bright erythema, papuloves- 
icles, edema, often respond satisfactorily to 
astringent wet compresses of lead acetate and 
alum solution, boric acid or normal saline. This 
is suitable if lesions are located on the extrem- 
ities or face. The presence of secondary infec- 
tions, pustules, and impetigenized areas may be 
treated with dilute copper and zinc solutions 
or potassium permanganate. When crusting is 
localized or extensive, Ung. acid boric or Ung. 
diachylon can be used for a short period until 
crusts are removed, following which the treat- 
ment is as previously mentioned. 

Soothing alkaline antipruritic lotions may be 
of benefit in extensive eruptions where exudation 
is not marked, or where packs are unsuitable. 
Restraints aid in keeping medication in place 
as well as preventing scratching and excoria- 

Treatment should be continued until there is 
maceration of vesicles, decrease of edema and 
erythema. When this occurs, symptoms will 
decrease and the eruption may be treated as 
subacute or chronic. 

Subacute or chronic stages, present as papules, 
papulovesicles, dull erythema and lichenification ; 
secondary lesions consist of excoriations, scales 
and crusts. In these stages the most valuable 
medication is ointments containing tar, particu- 
larly crude coal tar ointments, the percentage 
varying from one-half to six per cent. Pastes are 
preferable to greasy ointments. Irritation is not 
uncommon; however, this can be avoided if a 
small trial area is used and if weaker dilutions 
are prescribed. A common occurrence is to 
have a rapid favorable response, followed by 
sudden irritation; therefore, the patients should 
be instructed to discontinue the paste if this 
occurs. Tar used in hair-bearing areas over 
long periods is prone to produce folliculitis and 


SS aS 


pyodermas. This disappears rapidly on discon- 
tinuance of the medication. Multiple keratoses 
may also appear after prolonged use of tar 
ointments; they also disappear on cessation of 
this treatment. Crude coal tar, although very 
effective, has many disagreeable features, and 
substitutes may be tried. Bland ointments, such 
as zinc paste, with 0.5 to 1 per cent phenol or 2 
to 10 per cent ichthyol may be used; drying 
lotions, such as calamine or zinc lotion, with 5 
to 10 per cent liquor carbonis detergens, may give 
desired results. 

Greasy ointments with or without medication, 
and soapy water, tend to aggravate eruptions. 
A few medications intelligently used, and a 
knowledge of their indications, contraindications 
and methods of application, is of utmost im- 


The best results in the treatment of atopic 
dermatitis can be obtained by therapy directed 

at specific cause and by palliative measures. 
Skin tests are of value in detecting some causa- 
tive factors. Local therapy is indicated in most 
patients and if this is based on presenting clini- 
cal signs is a valuable aid in obtaining symptom- 
atic relief. 


1. Alvarez, W. C., and Hinshaw, H. C.: Foods that commonly 
disagree with people. Jour. A.M.A., 104:2053-2058, 1935. 

2. Becker, S. William: Dermatosis associated with neurocir- 
culatory instability, generalized and localized pruritus, neu- 
rodermatitis, dyshidrosis, urticaria, and angioneurotic edema, 
lichen planus, neurotic excoriations, alopecia areata, derma- 
titis herpetiformis and scleroderma. Arch. Derm. and Syph., 
25:655, 1932. 

3. Hill, Lewis Webb: Sensitivity to environmental allergens 
in infantile eczema. New England Med. Jour., 214:135, 
(July 25) 1935. 

4. Laymon, Carl, and Cumming, Harvey C.: Histamine in the 
treatment of urticaria and atopic dermatitis. (Preliminary 
report.) (To be published.) 

5. Rowe, Albert H.: Elimination diets for diagnosis and 
treatment of food allergy. Amer. Jour. Digestive Diseases 
and Nutrition, 1:387-92, 1934. 

6. Sulzberger, Marion, and Vaughan, Warren T.: Experiments 
in silk sensitivity and the inhalation of allergen in atopic 
dermatitis (neurodermatitis disseminatus). Jour. Allergy, 
5:554-560, 1933-34, 

7. Zakon, Samuel S., and Taub, Samuel J.: The inhalation of 
house dust and horse dander as an etiological factor in 
— dermatitis. Chicago Society of Allergy, (April 18) 




grates is a complaint so common that 
remedies for it are disbursed through slot 
machines and so vaguely understood that most 
headaches have been attributed by different writ- 
ers to disorders of the gastro-intestinal tract, 
to allergic reactions, to disease of the nose, 
and most of them, indeed, almost without ex- 
ception, to the eyes. It is, therefore, deserving 
of at least passing notice. A further excuse, if 
one were needed, for dwelling on the subject 
of headache, is that a few fragments have been 
added to our knowledge of it. 

Oftener than not, headache is a symptom 
that occurs without signs. It is this situation 
I should like to discuss. Here all we have to 
lean upon is the answers to a few questions. 
These are fragile reeds at best, especially so, if 
we fail to understand, not what the patient 
says, but what he thinks he says. Let us ask 

*From the Section on Neurology, The Mayo Clinic, Roches- 
ter, Minnesota. Read before the meeting of the Minnesota 
State Medical Association, Minneapolis, Minnesota, May 31, 

January, 1940 


him, for example, what he means by headache. 
It need cause us no surprise when he says that 
it means a sensation of ants crawling over the 
scalp. To the question, “Did you never have 
a headache previous to three months ago?” he 
may reply, “Oh, yes, I’ve had headaches all of 
my life, but they did not trouble me until three 
months ago.” Having just said that they occur 
only on the right side of the head, he may admit 
that they sometimes do occur on the left. 

Likewise, we should inquire into the fre- 
quency, duration and exact location of the head- 
aches; the hour of night or day and the day of 
the week they may occur; whether they are 
becoming better or worse; whether there is an 
aura; what influence a delayed meal, late sleep, 
worry, fatigue, and use of the eyes have on the 
headache; whether stooping, jarring or shaking 
of the head influences the pain; whether cold 
drafts or local heat affects them; whether there 
is a family history of headache, hay fever, 



asthma, eczema, urticaria or angioneurotic edema, 
and whether particular foods precipitate a head- 
ache ;- whether there is evidence of infection or 
obstruction in the nose or ears; whether the 
menses or pregnancy influences the headache, and 
finally what previous treatment was given. Nor 
must we forget that a patient may have two 
kinds of headache, the one, perhaps, of little 
consequence; the other, perhaps, the symptom 
of a fatal illness. 

Let us return to the patient and see what his 
story suggests. 

The Headache of Increased Intracranial 

Perhaps the headache is relatively recent in 
onset, and is causing more and more discomfort ; 
it is located in the front or in the back of the 
head, or, if predominantly one-sided, recurs in 
the same location. Possibly also the headache 
awakens the patient early in the morning, and 
may be accentuated or precipitated by coughing, 
stooping, straining, or shaking the head. There 
may be associated with it also sudden vomiting, 
especially before breakfast, and the pulse, if 
felt- carefully for two or three minutes, may 
be observed to become slow and irregular at 
times. Such a headache suggests organic intra- 
cranial disease, increased intracranial pressure, 
and this in turn suggests the possibility of tumor 
of the brain. To be sure, there may be no head- 
ache whatever with tumor, even when the intra- 
cranial pressure is elevated, and there may be 
headache with tumor, even when the intracranial 
pressure is low.** Tapping of the ventricles may 
either relieve the pain or cause it.2 The injec- 
tion of histamine may reproduce the headache, 
which suggests that, even with tumor, the pain 
may arise from the arteries.*® 

An intense, recurring occipital or frontal 
headache, of sudden onset and termination, last- 
ing a few minutes to a few hours, which is asso- 
ciated at that time with nystagmus, vertigo, 
rigidity of the neck, often in extension, less often 
in flexion, which may be associated with hiccup 
and slowness and irregularity of the pulse, a 
headache in which these symptoms are present 
at the time of the seizure but not during the 
intervals, suggests an intermittent hydrocephalus, 
and this in turn a tumor in the ventricular sys- 
tem. Choking of the disks is often absent. Dur- 


ing such an attack the patient may look as 
though he were about to die, and he often does; 
during the interval he may appear to be in the 
best of health. 

The ingestion of large amounts of fluid or the 
giving of a standard enema may lead to disas- 
trous results. Spinal puncture, especially in cases 
of supratentorial tumor, and, according to the 
usual advice, in cases of infratentorial tumor, 
is unsafe. The intravenous administration of 
hypertonic solutions may relieve such a headache 
but this may be followed later by a severe reac- 
tion. The restricted intake of sweetened fruit 
juices and the instillation of a hypertonic enema 
may be helpful. 

The headaches of sinus thrombosis, meningitis 
and encephalitis lack well defined characteristics, 
save that they are often severe and stubborn. 
More often than not they are attended by signs 
of disease that at least cause us to flounder 
among opinions regarding the many possibilities. 

Headaches Associated with Decreased 
Intracranial Pressure 

Occasionally an occipital or frontal headache 
comes on only when the patient is up and about 
and leaves when the patient lies down. Such a 
headache is often associated with a low pressure 
of the spinal fluid. Thus it resembles post- 
puncture headache. Often it suggests an arterio- 
sclerotic basis, but it may occur in younger per- 
sons, who, presumably, are free from arterio- 

Ruptured Aneurysm 

In a young, healthy person who, we may 
learn, has just been shoveling snow or pushing 
an automobile, the sudden onset of an excruciat- 
ing occipital headache or of pain behind one eye 
suggests a ruptured aneurysm. There is often 
rigidity of the neck, a slow, irregular pulse, 
and clouding of consciousness. Also there may 
be backache, legache and a positive Kernig’s 
sign. Paralysis of the third nerve on one side 
and hemiplegia on the other are commonly pres- 
ent, since such aneurysms usually occur in the 
circle of Willis. A spinal puncture discloses free 

A similar story but with a lateralized head- 
ache and often with less evidence of meningeal 
irritation, in a person with hypertension, sug- 
gests a cerebral hemorrhage. 


QS mst & hm 4 Alm 

— iS Zt OF ae fo. 

Hypertensive Headaches 

An occipital or frontal headache that may be 
present on awakening but one that does not 
awaken the patient, a headache that may wear 
away as the day progresses, that tends to occur 
daily, then leaves, and then recurs, suggests a 
hypertensive headache. The behavior of hyper- 
tensive headaches is often confusing. An especial- 
ly disabling headache seems to result from the 
combination of migraine with hypertensive head- 
aches. In diffuse arteriolar disease with hyper- 
tension, group IV, the pressure of the spinal fluid 
is commonly elevated and there is usually 
papilledema, but there is not necessarily head- 
ache, and spinal drainage may or may not relieve 
the headache. 

In a noteworthy study of seventeen such cases 
with necropsy, Rosenberg found destructive cere- 
bral lesions in 71 per cent. These included scat- 
tered large and small hemorrhages, infarcts of 
various sizes and numbers, periarteriolar lymph- 
ocytic cuffing, suggestive of an inflammatory re- 
action, gliosis, and local or general edema of the 
brain. Conceivably any of these lesions may be 
related to hypertensive headache. The results of 
treatment may be discouraging. Reduction in 
physical and emotional tension through construc- 
tive advice, rest, sedation, spinal punctures, and 
venesection may be helpful. . 

The passive congestion produced by intra- 
thoracic tumors and the distention of the vessels 
in polycythemia, may cause distressing and per- 
sistent headache. 

Arteriosclerotic Headaches 

Dull, heavy bregmatic or frontal headaches 
or occasionally stabbing, sharply localized head- 
aches occur in 44 per cent of patients for whom 
a clinical diagnosis of cerebrospinal arterio- 
sclerosis is warranted. In this group, 64 per cent 
of patients have an average blood pressure of 
130 mm. of mercury systolic and 78 mm. di- 

In a review of 100 cases with a pathologic 
diagnosis of cerebral arteriosclerosis, three times 
as many had had hypertension as had a normal 
blood pressure. About one-third of the patients 
of each of these groups, eliminating those in 
whom intense headache symptomatic of a ter- 
minal massive hemorrhage into the brain had 

January, 1940 


occurred, had complained of headache. Obvious- 
ly this is a field deserving of further study. 

Headaches Due to Anomalies or Inflamma- 
tion of the Arteries 

A sharply localizing headache of a duration 
of months or years induced or accentuated by 
coughing, stooping or straining, may result from 
some vascular anomaly, such as the passage of 
an artery through a canal in the bone. Possibly 
traction on the anchored vessel may be the cause 
of the pain. 

Inflammation of the extracranial arteries may 
be painful. Excision of the firm and tender 
vessel may provide immediate relief. Most 
carefully studied, perhaps, have been those cases 
of temporal arteritis.° Inflammation and trauma 
of the superficial nerves may likewise be the 
cause of distressing headache. Palpation of the 
skull is so simple a procedure that it is often neg- 
lected. The flashing pains of occipital neuralgia 
ought be distinguished from the more persistent 
pains of neuritis, although local anesthetization 
as a test and section of the offending nerve may 
be helpful in either case. 

Post-traumatic Headaches 

Following injuries to the head, often trivial 
injuries, there may occur persistent local or gen- 
eral headaches, that are usually accentuated by 
work of any kind. The features may be drawn 
and careworn or grim and determined. Often 
there are a sullen demeanor and complaints of 
giddiness and loss of memory. Too often, alas, 
the issue is befogged by concern over compensa- 
tion payments and the records are littered with 
the documents of solicitors. All of this would 
be much less disconcerting to the physician if his 
knowledge of these complaints were greater. A 
settlement of the claim does not always cure the 
patient. Fortunately, encephalograms may reveal 
cortical damage, which, when it is the only objec- 
tive evidence available, is helpful, but cortical 
damage does not always parallel the complaints. 
The therapeutic benefits of encephalography it- 
self are not so commonly achieved as it was at 
one time hoped. 

It is well to note that a fracture of the skull 
is usually not found with that more serious com- 
plication, chronic subdural hematoma. The ac- 
celerating tempo with which mental and motor 



signs appear when this is present calls for 
prompt action if a fatality is to be averted. 

Toxic Headaches 

The throbbing, frontal headache associated 
with fever is a good example of so-called toxic 
headaches. Their relationship to some more ob- 
vious cause is usually the reason for classifying 
them as such. 

Headaches Associated with Disorders of 
the Special Sense Organs 

“As very characteristic of eyestrain, we in- 
clude especially frontal and parietal headaches, 
or an ache in or around the eyeball itself. But 
occipital and nuchal pain are frequently symp- 
toms of eyestrain, and, at times, eyestrain leads 
the patient to complain of pain as low down as 
between the shoulder blades, which, of course, 
can hardly be thought of as a headache and yet 
is closely related to it,” says Crisp. 

When headaches are related to the ear, the 
history or signs of infection involving this organ 
usually lead us to consider this possibility. The 
retro-orbital pain of petrositis and the pain at- 
tending epidural abscess may be of long duration. 
Such situations challenge our courage, since the 
treatment involves no halfway measures. 

The headaches caused by disorders of the 
nose, sinuses and nasopharynx incidental to in- 
fection, ventilation, contacts and tumors may be 
intense, but when appropriate treatment is given 
they often disappear at once.”* Such terms as 
sphenopalatine neuralgia, great superficial pe- 
trosal neuralgia, and vidian neuralgia remain 
confusing to all but those who know what is 
meant by “typical.” 

Rheumatic Headaches 

A more or less constant, rather superficial 
pain, often lasting many months, located over the 
occipital, nuchal, and upper trapezius regions, 
which may be tender, a pain that is brought on 
by exposure to a cold draft or by tension of 
these muscles, and that is relieved by the local 
application of heat, suggests a nodular, rheu- 
matic, or fibrositic headache. The eradication of 
foci of infection, local hot packs and heavy mas- 
sage are helpful. 


Headaches Related to Endocrine 

Probably often migrainous in their character- 
istics, headaches related to endocrine activities 
require further definition. We shall return to 
these under the heading of migraine. 

A continuous, generalized headache may occur 
with pituitary tumors, even when these have not 
broken into the cranial cavity. Radiation of the 
pituitary region may bring quick relief. Rynear- 
son has treated with at least temporary success 
such a headache of several years standing, by the 
weekly administration of 25 mg. of male sex hor- 
mone. Similar head pains in acromegaly may 
depend on the same factors that sometimes cause 
constant pain in the acral parts of the extremi- 


Commonest of all headaches, with an incidence 
twice as high in women as in men,” and gen- 
erally picking out the ambitious members of 
society,*" with hereditary appearance almost the 
rule, with a history of recurrence over many 
years, in which the earliest headaches may have 
been as severe as any of the later ones; head- 
aches that often appear under stress and at the 
menstrual period, but that may disappear tem- 
porarily during pregnancy, and permanently, but 
not always, at the climacteric; such headaches 
suggest migraine. The migrainous attack itself 
is often introduced by warnings, such as scoto- 
mas. The headache itself usually occurs on one 
side of the head but not always on the same 
side, or in the same location. Vomiting is not 
a necessary accompaniment. In 90 per cent of 
such cases, the headache is relieved by the ad- 
ministration of ergotamine tartrate,’* which, inci- 
dentally, serves to identify it as migraine. 

Much has been learned in recent years con- 
cerning the cause of these headaches. The com- 
mon explanation that the pain results from 
edema of any part of the brain has not been 
proved. It is known that the larger vessels of 
the dura and probably adjacent parts of the dura 
are sensitive, that the larger arteries at the base 
of the brain are sensitive, that the venous sinuses 
are probably sensitive,* and that the tentorium 
may be. The brain itself and the vessels of the 
brain and pia are not sensitive.* It seems re- 
markable that the seventeenth century Willis*’ 



could write regarding the headaches of Lady 
Anne Conway, “Certainly it seems most likely, 
that the invincible and permanent cause so long 
and yet not deadly Headache proceeds from such 
a thing, viz., A Scirrhous Distemper of Dura 
mater, the Pia mater being in the mean time 
safe.”*7 Obviously there has been little opportu- 
nity to investigate the auras of migraine. It 
seems likely that constriction of the pial arteries 
accounts for the scotomas and paresthesias. Loss 
of appreciation of passive movements has been 
demonstrated during a paresthetic aura. This 
indicates that more than the dural vessels take 
part in the.attack* and suggests that the cortical 
vessels may go into a state of spasm. Subse- 
quently those vessels dilate.** 

While migraine involves a widespread neuro- 
vegetative reaction, of which little is known, the 
pain itself has been studied carefully. With the 
help of recording devices Graham and Wolff ob- 
served that the height of the headache coincides 
with an excessive pulsation of the temporal 
artery. They also observed that the injection of 
ergotamine tartrate, which stimulates smooth 
muscle, results, not only in the reduction of the 
headache, but also in the reduction of the 
amplitude of pulsations of the temporal 
artery. Direct inspection of the middle menin- 
geal artery revealed that the injection of ergo- 
tamine tartrate caused a constriction of 20 per 
cent in the caliber of this vessel. The caliber 
of the sylvian artery or vein, however, was not 
altered. They observed further that manual com- 
pression of the temporal, carotid and occipital 
arteries caused the pain to subside in the regions 
supplied by these vessels. Ligation of the tem- 
poral artery brought about a reduction of pain 
at the corresponding site. The residual pain 
probably arose from within the skull. Follow- 
ing the injection of histamine the pulsations in- 
creased again and the pain retuined to its for- 
mer location. Histamine itself does not cause 
the pain since there was no return of pain until 
after the injection of histamine had been dis- 
continued ;* this means that the systemic blood 
pressure must return before the impact of the 
column of blood upon the cerebral vessels is 
sufficient to cause pain. Thus, it would seem 
that the pain of migraine results from the 
stretching of relaxed dural arteries by the shock 
of arterial pulsation. 

January, 1940 

The pulsation of the cerebrospinal fluid or its 
pressure could not be correlated directly with 
the intensity of the pain, nor were these con- 
stantly influenced by the injection of ergotamine 
tartrate. Other observers, however, have re- 
ported that a rise in the pressure of the spinal 
fluid occurs after the injection of ergotamine 
tartrate.*° Any increase in pressure of the spinal 
fluid. would, to be sure, tend to support the 

The injection of ergotamine tartrate also in- 
creases the blood flow and the oxygen-carrying 
capacity of the arteries and veins.’* Possibly this 
may be correlated with the recent observations 
of Alvarez that the inhalation of oxygen may 
relieve migraine, especially if given early. 

These observations seem to explain the relief 
from pain that occurs in 90 per cent of cases fol- 
lowing the administration of ergotamine tar- 
trate.** The early administration of 1 mg. given 
orally twice daily during an attack of pain, or 
of 0.5 mg. given subcutaneously, gives strikingly 
good results.** Placed under the tongue ergo- 
tamine tartrate is much more effective than when 
swallowed directly.*° Some observers give as 
much as 5 mg. orally in a single dose, and 1 to 
2 mg. each hour thereafter until a total dose 
of 10 to 12 mg. in twelve hours has been given. 
The initial subcutaneous dose is generally 0.25 
mg. ; not more than 0.5 mg. should be given sub- 
cutaneously in twelve hours. Contraindications 
to the use of ergotamine tartrate are coronary 
disease, peripheral obliterative disease, acute in- 
fections, hepatic and deficiency diseases. Gastro- 
intestinal symptoms, a sensation of pressure in 
the breast, pain and paresthesias in the limbs may 
be relieved by the administration of calcium or 
of atropine.?®*4 

As an interval treatment ergotamine tartrate 
is not recommended. Calcium gluconate and 
viosterol may be prescribed as_ prophylactic 
measures, especially for patients who complain 
of gastro-intestinal symptoms or allergic phe- 
nomena.** Chondroitinsulfuric acid also may be 
helpful in this situation.’ 

Migraine often disappears during pregnancy, 
when the follicular hormone is circulating. Some 
patients respond very well to 5 c.c. of amniotin 
administered orally in three divided doses per 
day.** Progynon has been recommended, partic- 
ularly for the pale, round faced, fat women in 



whom the onset of menses was late, on whom 
ovarian operations have been performed, or who 
are in the climacteric.**° Emmenin also may be 

In the treatment of migraine attention should 
be given to physical and emotional stresses, 
refractive errors, gastro-intestinal disorders, 
allergic disturbances,”* and faulty habits of all 
kinds. Vacations are often helpful. The ad- 
ministration of % grain (0.03 gm.) of pheno- 
barbital three times daily over an extended 
period of time may be useful. 

“Erythromelalgia of the Head” 

A unilateral headache, without hereditary in- 
cidence or an early history of migraine, a head- 
ache of sudden onset and termination, in which 
the pain tends to awaken the patient at night, 
which is eased by the erect or sitting posture, 
which is associated with lacrimation and stuffi- 
ness of the nostril, and which is often precipi- 
tated by taking alcohol, is suggestive of “erythro- 
melalgia of the head.” There are no scotoma- 
tous or gastro-intestinal accompaniments. The 
injection of 0.3 mg. of histamine will produce an 
attack. Desensitization to histamine by the in- 
jection twice daily of 0.05 mg. for two days and 
subsequently increasing the dose to 0.1 mg. for 
two or three weeks may result in relieving the 
patient entirely.* 

Headaches are said to occur occasionally with 
gastritis. The insertion of a jejunal catheter for 
feeding may relieve the headaches. The head- 
aches may recur promptly, however, should the 
catheter slip, inadvertently, into the stomach, as 
may be determined by fluoroscopy.’* Gastric dila- 
tation and atony of the stomach during an at- 
tack of migraine have been observed roentgen- 

Psychoneurotic, Psychotic, Neurasthenic 
and Exhaustive Headaches 

A headache that has been present constantly 
for months on end, one that is often poorly and 
resentfully described by the patient, is suggestive, 
not of an organic disease, but of a psychiatric 
disturbance. The sensation of pulling or drawing 
in the occipital region, or of a weight on the 
head, is commonly mentioned by patients who 
are depressed. In hysteria there may be a strik- 
ing indifference to the headache when subjects 


other than the pain are discussed. It is some- 
times, no doubt, a means of escaping responsi- 
bility.2 In schizophrenia also the complaint of 
more or less constant discomfort in the head is 
not unusual. 

When headache is the patient’s chief com- 
plaint, the causes to be considered are almost 
without number. A thoughtfully taken history 
should lead one into paths that call for further 
investigation. A detailed examination may not 
be neglected. Nor should a careful inquiry into 
the emotional state, which so often plays a signif- 
icant role in the production of headache, be dis- 

Among the more recent advances in our under- 
standing of this common complaint I should 
mention three. First, the observations made by 
Wolff and his colleagues, namely, that in mi- 
graine an increased arterial thrust upon the 
toneless but sensitive dural and extracranial 
arteries is the cause of the pain, and that the 
administration of ergotamine tartrate, by restor- 
ing tone to these vessels, lessens the violence 
of the pulsations and thus reduces the pain. 

Then I should mention the searching studies 
made by Rosenberg of so-called malignant hy- 
pertension, in which he demonstrated the extent 
of cerebral damage that is associated with this 

Finally, reference should be made to the segre- 
gation by Horton, MacLean and Craig, of a type 
of headache that has certain clinical character- 
istics and that is amenable to desensitization with 
histamine, and to which they have given the 
name, erythromelalgia of the head. 


. Alvarez, W. C.: 
Staff Meet., 
. Brewer, E. 
currence and si 
raphy. Bull. 
. Christiansen, Viggo: 
de la migraine. Acta psychiat. et neurol., 12:4 937. 
. Clark, Dean, Hough, H., and Wolff, H. G.: Experimental 
studies on headache; observations on headach produ: 
Chay) 1936. Arch. Neurol. & Psychiat., 35: 1054-1069, 
risp, W. -: Symposium on headache. B. 
standpoint a ‘the ophthalmologist. 
PP. 97-108, (Sept.) 35. 
. Critchley, MacDonald: 
2:35-36, (July 4) 1936. 
. Graham, R., and Wolff, H. G.: Mechanism of mi 
headache and action of ergotamine tartrate. Arch, 
and Psychiat., 39:737-763, (Apr.) 1938. 
Horton, B. T., MacLean, A. R., and Craig, W.- McK.: 
A new syndrome of vascular headache: results of treatment 
with histamine; preliminary report. Proc. Staff eet., 
Mayo Clinic, 14:257-260, (Apr. 36) 1939. 
. Horton, B. T., Magath, T. B., and Brown, G. E.: 
undescribed form of arteritis of the tem 
Proc. Staff Meet., 

new treatment for migraine. Proc. 
Mayo Cumin 14:173-174, (Mar. 15) 1939. 

D.: The etiology of headache. II. The oc- 
ificance of headache during ventriculog- 
eurol. Inst. New York, 6:12-18, (Jan.) 

Contributions 4 la patho- patterns 

From _ the 
Tr. Am. Acad. Ophth., 
Prognosis in migraine. Lancet, 


ral vessels. 
Mayo Clinic, 7:700-701, "(Dee. 7) 1932. 



10. Kaufman, J., and Levine, I.: Acute gastric dilatation of 
stomach during attack of migraine. Radiology, 27 :301-302, 
(Sept.) 1936. 

11. Lennox, W. G. newer concepts 
and treatment. 19 :284-. 28% _ Aug.) 1938. 

12. Lennox, W. G., and Leonhardt, H. low and con- 
centration of blood as influenced by S23 alkaloids and as 
influencing migraine. Ann. Int. Med., 11:663-670, (Oct.) 

13. Lennox, W. G., von Storch, T. J. C., and Solomon, 
Philip: The effect of ergotamine tartrate on non-migrainous 
headaches. Am. Jour. Med. Sc., 192:57-60, (uly) 1936. 

14. Lewin, L.: Klinische Beobachtungen iiber den Zusammen- 
hang von Kopfschmerzen und Erkrankungen des Magen 
darmkanals. Schweiz. med. Wehnschr., 67:190-191, (Feb. 

27) 1937. 
Some observations on headache. 

15. Northfield, D. W. C.: 
(Hunterian lecture, abridged). Brain, 61:133-162, (June) 
M. E., and Raybin, V. T.: 

Priifung verschiedener Migranbehandlungen. 

Migraine and epilepsy: 
Jour. Med., 

16. O’Sullivan, Vergleichende 

Schweiz. med. 

Wcehnschr., 67: 1182-1184, (Dec. 11) 1937. 
17. Owen, G. The famous case of Lady Anne Conway. 
Ann. Med. Hist., 9:567-571, (Nov.) 1937. 

18. Paterson, J. E.: The mechanism 4 | Saaeae. 

Med. Jour., 128:210-219, (Nov.) 1937 


19. Pool, J. L., von Storch, T. J. C., and Lennox, W. G.: 
Effect ‘of ergotamine tartrate on pressure of cerebrospinal 
fluid, and blood during migraine headache. Arch. Int. 
Med., 57 :32-45, (Jan, 1936. 

20. Rosenberg, E, F.: The brain in malignant hypertension. 
Proc. Staff Meet., Mayo Clinic, 14:217-222, (Apr. 5) 1939. 

21. Rynearson, E, H Personal communication to the author. 

22. Sippe, C. Migraine from the allergic viewpoint; results 
of treatment in 105 cases. Med. Jour. Australia, 1:893- 
895, (May 21) 1938. 

23. Soltz, Ss. , Brickner, R. M., Riley, H. A., and Salmon, 

A.: The use of orally administered ergotamine tart- 

A, amniotin and phenobarbital in the treatment of mi- 

graine. Bull. Neurol. Inst. New York, 4:432-441, 1935- 


24. von Storch, T. J.: The migraine syndrome; comments on 
its diagnosis, etiology and treatment. New England Jour. 
Med., 217 :247-251, (Aug. 12) 1937. 

25. Vail, H. H.: Symposium on headache. <A. From the 
standpoint of the otolaryngologist. Tr. Am. Acad. Ophth., 
pp. 85-96, 1935 

26. Wilson, H.: Psychogenic headache. 1 :367-370, 

(Feb. 12) 1938. 
27. Wolff, H. G.: Personality features and reactions of sub- 
Neurol, and Psychiat., 37 :895- 


jects with migraine. Arch, 
921, (Apr.) 1937. 


Saint Paul, Minnesota 

|“ egermgeed only little interest can be aroused 

by the discussion of a disease such as bac- 
terial endocarditis where therapeutically we are 
beaten from the start and where the diagnosis 
appears to be easily made. 

The affliction as a rule is readily suspected 
when the usual criteria of fever, anemia, embolic 
phenomena and evidence of a damaged heart 
valve or a congenital heart defect are all present.‘ 
When these embolic phenomena are obvious as 
indicated by petechial hemorrhages in the con- 
junctiva, fingers or toes, the diagnosis is assured. 

However, it is little appreciated that embolic 
manifestations concealed in deep structures may 
dominate the clinical picture of this disease and 
frequently obscure the true nature of the affec- 
tion. Under these circumstances the correct 
diagnosis may be missed and only made at 

During the past few years opportunity has 
been given me to follow personally with one ex- 
ception a series of thirteen cases of bacterial 
endocarditis in which the diagnosis has been con- 
clusively established at the postmortem table. 
This experience offers rather convincing evi- 
dence that we not infrequently fail to make the 
diagnosis, even under conditions where all diag- 
nostic facilities are available. 

It is generally admitted that congenital heart 

*Read before the Ramsey County Medical Society, March 27. 

January, 1940 

disease or a previous attack of rheumatic fever 
predisposes an individual to this affliction.*%7 
Usually there have been no recurrent attacks of 
rheumatic fever and relatively good health has 
been maintained since the initial infection.* This 
coincidence has led some writers to the inference 
that its development is conditioned upon an estab- 
lished immunity to rheumatic fever, because the 
organisms unable to maintain a continued exist- 
ence in a highly immune blood stream seek a 
safe refuge in a platelet thrombus on a damaged 
heart valve where the blood is unable to pene- 
trate and destroy them.*®7 

In this series where a positive past history of 
rheumatic fever was obtained, about eight years 
of good health preceded the onset of the symp- 
toms of the fatal episode. 

The ultimate crippling valve defect of mitral 
stenosis has been considered the result of a 
chronic low grade rheumatic infection with re- 
curring episodes of a non-articular character 
over a considerable period of time.’ If so, im- 
munity to rheumatic infection has not been estab- 
lished and upon this foundation one may attempt 
to explain the relative rarity of mitral stenosis 
and its associated auricular fibrillation in sub- 
acute bacterial endocarditis. 

Bell and Clawson believe that rheumatic infec- 
tion and subacute bacterial endocarditis merely 
represent different manifestations of the same 



disease. However, there is little unanimity of 
opinion as to just what specific organism is the 
cause of rheumatic fever. Streptococcus viri- 
dans is the causative organism in the great ma- 
jority of cases of subacute bacterial endocar- 
ditis.»**, An infection occurs usually upon a 
previously damaged heart valve.*? It is general- 
ly conceded, however, that it is possible for some 
bacteria to focalize and continue to survive upon 
a previously undamaged valve.® 

One may be permitted to say that a diagnosis 
of subacute bacterial endocarditis may be dis- 
missed when no murmur is audible unless other 
characteristic signs of the disease are pres- 
ent.**? A murmur may be absent in a rapidly 
beating heart. 

A transient bacteremia without endocarditis 
may follow tonsillectomy, extraction of teeth or 
an upper respiratory infection,® so that a single 
finding of this organism in the blood stream, un- 
supported by signs of a past rheumatic infection 
in the form of a damaged valve, or a congenital 
heart defect upon which to thrive, is insufficient 
evidence to support a diagnosis of the subacute 
variety.© On the other hand the blood culture 
may remain negative throughout the course of 
the disease.** 

The purpose of this paper is to illustrate with 
selected cases some of the clinical vagaries as 
well as to show some of the more common fea- 
tures of this disease. 

An effort has been made to chart these cases 
after the method of Keefer* under headings 
which are of diagnostic significance and to briefly 
summarize the associated necropsy findings as 
determined by Dr. John F. Noble and his asso- 
ciates at the Ancker hospital. 

These cases have been grouped according to 
the presenting symptoms on admission to the 

Group I. Those with symptoms of progres- 
sive congestive heart failure. 

Group II. Those with symptoms of pneu- 
monia and meningitis. 
Group III. Miscellaneous types. 
1. Symptoms of angina pectoris and hemop- 

2. Those with neurological manifestations 

a. Hemianesthesia. 
b. Meningitis. 
c. Brain abscess. 


3. Symptoms of hyperthyroidism with sple- 
nomegaly and anemia. 

Group I 

Cases of subacute bacterial endocarditis with 
progressive congestive heart failure (Chart I). 

There were five patients in this group, three 
males and two females. Their ages varied from 
twenty-three to seventy-eight years. 

Three gave a past history of rheumatic fever, 
ten, eight and thirteen years respectively prior 
to the onset of the terminal infection. They 
all gave a good subsequent health record and on 
admission definite signs of rheumatic heart dis- 
ease in varying stages of congestive failure were 

Sustained irregular fever and moderate to 
severe anemia were present in all. Three 
showed streptococcus viridans in the blood 
stream. In the remaining two, blood cultures 
were not made. Early embolic phenomena were 
seen in two cases. 

The duration of recorded symptoms before 
entry varied from one and one-half years to four 
months, while the longest stay in the hospital was 
forty-seven days and the shortest four hours. 

All showed traces of albumin and occasional 
red blood cells in the urine. The pathological 
diagnosis in all cases was subacute bacterial en- 
docarditis, with the heart valves showing evi- 
dence of past rheumatic involvement and super- 
imposed soft friable vegetations involving the 
aortic and mitral leaflets in two and the mitral 
alone in three cases. 

No instance of diffuse glomerular nephritis 
was found but embolic involvement of the kid- 
neys was common. 

Representative of this group with symptoms 
referable to progressive congestive heart failure 
is the following case. 

Case 3—Mrs. V. E. A., aged thirty-eight, was ad- 
mitted to the hospital December 1, 1938. In 1930, this 
patient had rheumatic fever characterized by a migra- 
tory polyarthritis. She never had symptoms of decom- 
pensation following the attack. Four years ago follow- 
ing the onset of a chronic cough, she noted on one 
occasion a blood-streaked sputum. One and a half 
years ago the patient developed a progressive weakness 
and pain and tenderness in her legs. Six months later 
she noted pleurisy in her right chest which was located 
under the shoulder blade. June 15, 1938, the patient 
developed coryza. Since that time she had a productive 
cough which increased in severity. The sputum was at 



times blood-streaked. She had recurrent chills and 
fever and severe night sweats until the time of her 
admission to the hospital. Three weeks before her ad- 
mission her legs, ankles, and feet became edematous 
and she noted some dyspnea on exertion, and palpita- 
tion of the heart. The urine was at times coffee- 
colored and she had some dysuria. She lost ten pounds 

faint trace of albumin, occasional casts, a few leuko- 
cytes, but no red blood cells were ever found. The 
hemoglobin was 54-36 per cent; leukocytes, 10,200 and 
31,100.. The polymorphonuclears were 77-94 per cent 
with toxic cells seen at one time. The sedimentation 
rate was 80 mm. per hour. The urea nitrogen, 32.2 mil- 
ligrams and creatinine 1.8 milligrams. 

Signs Signs | Signs 
Age | Previous |Subsequent ADM. < age s i$ Blood ation Necropsy 
Sex | Rheumatic! Health Diagnosis Damaged Embolic | Heart | Findings | Hosp Findings 
Name} History |Condition Valves Infection Phenom.| Failure | Culture |2ays 
. Ve ds..Ao-M.vis. 
-1. oneattack Subac. B.E; irred.temg Petechial Bilstevel Pos. olde] ol, Bretn é P 
G very "| Sys-Dias. «| hems. | Hydro. ‘Vir |4 mal "Sertenin 
severe Combined 98°. 103 Hg¢.62% a 
23 good Murmurs Terminal |thor 4 | inf.-Sp.- Ki 
yr, minal | thorax in.e.c. sum) d - 
M. poy" ago |Rh. Val.Dis) Ao. na M. P. 100-130 nemiplegia Reg. rhy.|w.8cus00| in. a 
ps P tin ro: un. | ¥ds-- settvel. Walt 
i in an aoete 
EW.| patient | not tds 2 Soe Morale lone orang none edema reseed ir "Dia Ings 
7 ivrational known | cong. fail, at apex | P. no. venting made Hosp] Giver - Spleen 
’ Thg. Thy. ney 
5 | : Pos. Bid.C. |) yr,| Veds.-Ao-M.Vis. 
IEAl"aueggo| ford | Rheum. | Syevura| chs é | Edematew, Stain | OP | a Sa co 
syphilis |until air med over | temp | none | aZoleaeshetcrcsccl el state 
F | !?yr. age — es ~~" emsaabel es-10¥ ote wec_g1,100| "8 geste Splenitis 
2 52266 Bilat.. Hydro-th 
~~ loudsyst.| irre : ' 6 ety , 
= one attack | good —— mur over | COUTS® one Ge 4.00000 1eda.| od hel defect 
FAIS yr. aG0| 3 laborer cong. fail poor 008.1025 Spareeat Rec - $308 i” Lett Avricle” 
. yanosis+ = © Bil Hydrethorax 
| good Petechial | Moderate |B. Pes. stv. Veds,. Mitral. Val. 
5. x ..8 Rheum, | loud syst. one hems.. congestion|#460.50%|5 mo. apa Acrisle 
C.H. none structive! Ht.dis | Precord| ,.° 13° ROC 3.6. SdaBil —" 
51 one extremities) of Lungs | ae ss o00) in Pat 
7m bladder | Eni murmur = WBC 18,000) 105 or 
M Mp.loyr) prostate on Reg, rhy. |wec..6pe0 Pl Liver and Spleen 

in weight since June, 1938. Her past history revealed 
that the patient had chickenpox and diphtheria as a 
child. Seventeen years ago she contracted syphilis. 
This was characterized by primary and_ secondary 
lesions. She was treated with mercury for a short 
time. For the past four years she has been treated 
continuously for syphilis. Her husband died of syphilis. 
She came in contact with tuberculosis on one occasion. 

Physical examination revealed that the patient was 
underdeveloped and emaciated. She did not appear 
acutely ill. The blood pressure was 123 over 38, tem- 
perature 102.4°, and pulse 100. The skin was pale and 
moist. The right pupil was larger than the left and 
neither pupil reacted to light. Examination of the fundi 
was negative. The breath sounds were:found to be 
decreased on the right and there were a few rales 
present in the left base of the lung field. The heart was 
enlarged to the left and there was a rough systolic and 
a soft prolonged diastolic murmur heard over the en- 
tire precordium but most marked at the second left 
interspace. The heart rate was irregular and numerous 
extrasystoles were heard. The spleen was not palpable. 
There was no tenderness nor rigidity in the abdomen. 
Examination of the extremities showed a slight club- 
bing of the finger tips. There were ecchymotic areas 
over the anterior surfaces of both thighs. 

Laboratory examinations: The urine contained a 

January, 1940 

The serum globulin was 1.4 grams; albumin, 3.22 
grams, and the sulphanilamide determination on Janu- 
ary 6, 1939, was 9.3 milligrams per 100 cc. of blood. 
Examination of the sputum was negative for tubercle 
bacilli. Of five blood cultures taken, one was positive 
for streptococcus viridans. The icteric index was eight 
and the VandenBergh .1 milligram bilirubin. The blood 
smears were negative for malaria. The agglutinations 
were negative. The blood Wassermann was 4+. 

The electrocardiogram showed auricular fibrillation, 
right axis deviation, and ventricular muscle damage. 
The x-ray examination of the chest showed the heart 
to equal 60 per cent. There was a generalized enlarge- 
ment with straightening of its left border and promi- 
nence of the conus pulmonalis. There was thickening 
of the interlobar pleura on the right and increased 
bronchovesicular markings. Later x-ray showed an in- 
creased enlargement of the heart with congestion of 
both lungs. There was an area of consolidation in the 
lower portion of the right lung due to pneumonia or 

The patient’s clinical course was characterized by 
cough, night sweats, and occasional chills with a mod- 
erately high fever. The temperature ranged from sub- 
normal to 104°. It was mainly irregular but was at 
times typically septic. The heart continued to fibrillate. 
Two weeks after admission the patient developed 


edema of the legs and rales were heard in the chest. 
On December 19, 1938, the blood culture was positive 
for streptococcus viridans. Neoprontosil was then giv- 
en for two weeks and was followed by prontylin. She 
was very emotional and at times confused and irra- 
tional. Weakness and listlessness were pronounced. She 
was cyanotic and finally became involuntary. Her tem- 
perature terminally was subnormal. No petechie were 
ever found on any portion of the body. The patient 
expired January 17, 1939. 

Necropsy findings—as determined by Dr. John F. 

Diagnosis: (1) Old valve defect (mitral). (2) Old 
valve defect (aortic). (3) Subacute bacterial endocar- 
ditis (mitral, aortic, and left ventricular wall). (4) 
Thrombosis (purulent) of left aurécular appendage and 
auricle. (5) Bilateral hydrothorax. (6) Ascites. (7) 
Pericardial effusion. (8) Bilateral atelectasis of the 
lungs. (9) Thrombosis and infarction of left lung. 
(10) Passive congestion of lungs-liver-spleen-kidneys. 
(11) Acute splenitis. 

Note: Culture from the septic thrombus of the 
heart at autopsy shows streptococcus viridans. 

Comment. This is a case of subacute bacterial 
endocarditis occurring in a patient with definite 
mitral stenosis and auricular fibrillation giving a 
past history of rheumatic fever eight years pre- 
viously followed by a relatively good health 
period, without cardiac failure, until the onset 
one and one-half year before death of symptoms 
of recurrent chills, fever and night sweats, ter- 
minating seven months after onset in progressive 
congestive heart failure, auricular fibrillation and 
marked edema. 

This patient failed to respond to sulphanila- 
mide therapy. 

Group II 

Cases of bacterial endocarditis with acute 
septic onset with symptoms of pneumonia and 
meningitis (Chart II). 

Not infrequently a patient enters the hospital 
with symptoms of an acute fulminating infection, 
suggestive of pneumonia and terminating as a 
meningitis, or with meningeal symptoms from 
the start. 

Of these there were four patients, three males 
and one female. One was fifty-one years old, 
one sixty and two were twenty-four years old. 

None of these gave a previous history of rheu- 
matic fever and in only one was a heart murmur 
heard. The heart was definitely enlarged in two 
and the rate was rapid in all. The onset was 
acute, following apparent good health, with 



chills, high fever, delirium and signs of menin- 
geal irritation. On admission to the hospital the 
clinical diagnosis was pneumonia and meningitis. 

The temperature was septic and the anemia 
was not significant. Three presented suggestive 
embolic signs. The blood culture was negative in 
one and not made in the thers. 

The duration of symptoms before entry ranged 
from two weeks to two days while the stay in 
the hospital of two patients was twenty-four 
hours and thirty-six hours and the others nine 
days and twelve days respectively. 

Subacute bacterial endocarditis was found in 
three cases and the infection was acute in one. 
The mitral leaflets were involved in two and the 
aortic in one Bronchopneumonia, _in- 
farcts and petechial hemorrhages in the brain 
were seen in the two cases with meningeal 
symptoms. One patient had a syphilitic aortitis 
without a syphilitic valvulitis. The aortic leaflet 
showed a rheumatic deformity with a superim- 
posed bacterial endocarditis. 

The case of acute bacterial endocarditis oc- 
curred in a woman. The aortic leaflet disclosed 
evidence of rheumatic involvement and _ the 
mitral leaflet a very large, soft, friable vegetation. 
The uterus was normal in size and its endome- 
trium absolutely smooth. 

The following are two illustrative cases. 


Case 1. W. S., aged sixty, white, male, admitted to 
the hospital August 4, 1938. Five days before admission 
he had become acutely ill with a cough and developed 
chills, fever and generalized weakness. He was treated 
by a local physician for a few days. During this period 
he had coughed mucus but no blood. He did not have 
any chest pain. His appetite had been poor and he had 
been constipated during the present illness. Previous 
to the present complaint he had been well. 

Physical examination at the time of admission dis- 
closed an acutely ill, elderly white male whose tempera- 
ture was 104°, pulse 118, and blood pressure 130 over 
70. Examination of the chest revealed the respiratory 
rate to be 26 with dullness to percussion over the left 
postero-lateral aspect of the chest. Some bronchial 
breathing was heard at this site. There were many 
rales anteriorly in the left chest. Occasional rales were 
heard in the left base. The heart was rapid; no mur- 
murs were recorded. Examination of the abdomen 
revealed it to be tympanitic with no palpable masses 
or tenderness. The liver edge was palpable but not 
tender. There were a few superficial abrasions about 
the trunk. 

The urine showed albumin, granular casts and a few 
white and red blood cells. The sputum was negative 
for pneumococcus. The hemoglobin was 80 per cent 



and the white blood cells 15,000, of which 89 per cent 
were polymorphonuclears. The sedimentation rate was 
95 millimeters in one hour. The blood urea nitrogen on 
admission was 60.2 milligrams per cent. 

On the following day the patient was lethargic, con- 
fused and answered questions with difficulty. There 
was some neck rigidity. His temperature had increased 

atheromatous streaking. The auricular appendages con- 
tain no thrombi. The ventricular walls are definitely 
thicker than normal and there is some dilatation. Mi- 
croscopic examination of sections of the heart valves 
shows them to be composed for the most part of con- 
nective tissue fibers forming a dense plate.” 

Head: “Examination of the head shows the sub- 

\Peect Signs ; Signs |Si La 
Age Previous |Subsewwatt] apy, | S'dr* | signe | Sigs (NS! Blood LING | Necropsy 
Bl oe ‘tion (Diagnosis | Damaged | 152 ction | Sreeuie |Hemt mang Hosp | Fi ndings 
¢| History | Condition Valves ¢ e failure! Culture pays 
None ol Rigid neck 2 _| Subac.BE.. veg. 
HE [Tonsillectomy ree: Meningitis| tenlangedPos.Kernig & B.Cul.N.M | 4895] on mitral valve 
24yn “— ago ae 4 set] NO UT MU Pos Babinet None ko a 2) oe 
M.|.. ter Rate Rapid temp.i0z106 pe ig Better a 
Bese deleriym P P Edema Cell.ct.88) in 
Heart Dis, /10 daago |Coeriem FR ere Cell.ct.88 Nevd ey 
None | Frequent! Pneumonia He. 3 | Subac.Bact-Endo. 
Prevmonia| Respiratory] Acule onset) Ht. enlarged Temp. | R pon days Vegs. aorficvalve 
RC.| and infections | with [eth..interSp 101-108) Ry |REC-37MY GIs huttic aortitis 
- Pleurisy | and | chills and |no murmorg P. 0-180) Thumb WweC- IT “Ws Porulent pericard 
Syna Pleuri fever | BR.135/e0)| !FTationa Wass, 4+ Bronchopnevmonia 
ttiaaailh Whnattieed Culture neg)"°®Pl int. Spin. Kidys. 
- x : iii Chang ios 2 fe Sow. Ende. 
rs. eumonia eptic ein Hg. -60%) WKS. Aortic v.tirm veg. 
ELG! None Well {atte onset —S temp. character gRBC.32.M - Camece ate 
24yr, with chills) ayijjq (995-105 | of WBC.12600| 48Y5 Chr Supp salpingitis 
F | and fever p12 |Htmurmer, Of iBCoLN.M i Cul tube_B. Coli 
Lungs hosP! Hemolytic Staph. 
104.106 H¢.-e07/ 5 Subac Bact. 
|Nomurmur Petechial WBC! s |ule . 
WS.) None ne Pneumonia| pulse 120 ry hems, N a sheen, 
60ytobtained Prrwret qimeningitis! R26 Lethardic Conjunctival "°"*) 66 om ‘x m Bilat Bronchpn. 
M. | | BP 130/20] Kernig_+ |Extremities| — /acul, nmm.fhosplpemnas em i” 
Neck moat |Brain,Kidneysint. 

to 104.8. The respiratory rate remained the same and 
his pulse increased to 130. There was a positive Ker- 
nig’s sign and the spinal fluid was bloody with 266 cells 
per cu. mm., 94 per cent being polymorphonuclears. He 
became progressively worse. The treatment consisted 
of sulphanilamide. His temperature rose to 106.4° and 
on the following day he died approximately thirty-six 
hours after admission. 

Notes—Drs. Maun and Dick on the heart and head: 

Heart: “The heart weighs 525 grams. The tricuspid, 
pulmonic, and aortic valves are normal in appearance. 
Examination of the mitral valve reveals the leaflets to 
be slightly thicker than normal and somewhat opaque. 
There is slight contraction in the leaflets. Examination 
of the leaflet of the mitral valve reveals it to be 
thickened and in the center of it there is a soft necrotic 
area which has perforated the valve. This measures 
approximately one centimeter in diameter. About it, 
the valve is soft, edematous, and slightly red in color. 
There are no free vegetations on the margins of the 
valves. The coronary arteries are normal in appearance. 
The myocardium is firm and on cut section it is swollen 
and cloudy in appearance. 

“Scattered throughout the ventricle there are small 
light yellowish areas which do not appear to be con- 
nective tissue. There is no gross evidence of excess 
fat. The root of the aorta shows a mild degree of 

January, 1940 

aponeurotic surface of the scalp to be ecchymotic over 
the vertex on the right side and the calvarium shows 
nothing of note. The surface of the brain shows a 
number of petechial hemorrhages of varying sizes dis- 
tributed uniformly over the brain surface. On cut 
section there are numerous petechie of varying sizes 
throughout the gray and white matter involving the 
falx cerebrum, and cerebellum. There are larger areas 
in the brain substance’ measuring up to .5 centimeter in 
diameter. These are essentially in the right parietal 
lobe, the right occipital lobe, four in the parietal lobe, 
and several are seen in the white matter of the cere- 
bellum. At approximately the junction of the occipital 
and parietal lobes in the right cerebral hemisphere is 
seen an area of softening, which surrounds one of these 
ecchymotic areas described. There is no other evidence 
of tumor, hemorrhage or softening.” 

Diagnosis (Necropsy)—(Drs. Mark Maun and Fred 
Dick): (1) Subacute bacterial endocarditis. (2) Old 
valve defect (mitral). (3) Bilateral bronchopneumonia. 
(4) Infarction of kidneys—brain. (5) Emboli—gastro- 
intestinal tract. 

Case 2. H. E—This patient was a white man aged 
twenty-four who was admitted to the hospital on August 
30, 1939, at 7:44 p.m. He was delirious and in a semi- 
conscious condition. The history was obtained from 
his wife. He had been married ten days ago and had 


been perfectly well until August 28, when he complained 
of pain in his stomach after eating. That night his 
wife was awakened at 12:00 p.m. and found that he did 
not recognize her. He was delirious and remained 
so until his admission to the hospital. Two days after 
onset he coughed considerably and complained of a 
violent headache. He was very restless. Nausea and 
vomiting occurred. A doctor was called on August 30 
and diagnosed the case as pneumonia. 

His tonsils had been removed at a local hospital last 
fall. His wife said that he had had heart trouble and 
for that reason was kept in the hospital several weeks 
after his tonsils were removed. He had been short of 
breath on exertion and had had palpitation of the heart 
but never edema of the feet or ankles. He also had 
had frequent colds and a chronic unproductive cough. 

Physical examination showed the pupils to react 
sluggishly to light. There was a slight discharge from 
the nose. The chest showed numerous coarse rhonchi 
throughout. Posteriorly, there was dullness at the right 
lung base. The heart was enlarged to the left, the 
apex being in the seventh interspace in the anterior 
axillary line. There were no murmurs. The rate was 
rapid. The abdomen was distended. The legs and 
ankles showed multiple areas of brownish pigmentation. 
There was marked rigidity of the neck. The Kernig 
was positive, and the Babinski was positive on the 
left. The knee jerks were decreased. There was no 

A spinal puncture was done and 20 c.c. of fluid was 
removed under increased pressure. The cell count was 
88. The white blood cells were 14,500. He bled from 
his nose and mouth. The temperature varied from 102 
to 106; the pulse from 100 to 160. He died twenty-four 
hours after admittance. 

Notes—on the heart and brain by Dr. John F. Noble: 

Heart: “The heart weighs 361 grams. The tricuspid, 
pulmonary and aortic leaflets are normal in appearance. 
The mitral leaflets appear about normal in thickness, 
and there is no definite evidence of a past infection on 
inspection. Along its free superior surface of one 
leaflet there are large, raised, soft, friable, thrombotic 
lesions. These are continuous over the entire upper 
surface of the upper valve along the point of contact. 
The coronary vessels show nothing of note. The 
myocardium is pale and swollen in appearance, and 
shows small fatty looking areas. At the tip of the 
left ventricle, the muscle shows an opaque white spot 
which appears to be scarring. The root of the aorta 
shows a mild degree of atheromatous streaking.” 

Head: “Examination of the brain shows no definite 
evidence of meningitis save in the parietal lobe of the 
left hemisphere where there is a small but definite area 
of infarction, the center of which is yellow. This 
measures about 5 mm. in diameter. On cut section the 
brain shows numerous petechial hemorrhages particu- 
larly in the white substance, and in some places in- 
volves, to a less degree, the cortex. There is no gross 
evidence of hemorrhage or softening. The cerebral 
vessels show nothing of note.” 

Diagnosis (Necropsy)—(Drs. J. F. Noble and C. H. 
Drenkhahn): (1) Subacute bacterial endocarditis, mi- 



tral. (2) Hemorrhagic bronchopneumonia, bilateral. 
(3) Infarction of the liver, kidneys, spleen and brain. 
(4) Cloudy swelling of the heart, liver and kidneys. 

Briefly summarized we have two patients with 
subacute endocarditis without demonstrable heart 
murmurs, possibly because of the rapid heart ac- 
tion, entering the hospital with signs and symp- 
toms of pneumonia and meningitis, who die 
shortly after admission, one in two days and the 
other in twenty-four hours, both of whom give 
a past history of their usual state of apparent 
good health until the onset of the symptoms 
initiating the terminal event. 

The speed of the fatal developments in these 
cases suggests that the insidious nature of this 
disease permits the patient to continue at his 
daily work for an indeterminate period until a 
major embolic accident interrupts the even 
course of the affliction. 

As a result the true nature of the condition is 
unsuspected and the diagnosis comes as a sur- 
prise at necropsy. 

Group III 

This is a miscellaneous group and included 
three patients whose presenting symptoms also 
depended upon the early localization of major 
embolic phenomena. 

1. Severe gastro-intestinal symptoms termi- 
nating in right hemiplegia. 

2. Symptoms of angina pectoris and hemop- 
tysis with sudden and unsuspected death. 

3. Sudden onset with right hemianesthesia. 

Two of these patients had a previous rheu- 
matic history occurring ten and eight years pre- 
viously and one an osteomyelitis twenty years 

Each had enjoyed good health until the onset 
of his present complaint. 

Definite evidence of valvular heart disease, 
signs of infection and moderate anemia were 
present in all, while two displayed embolic 
phenomena. Blood culture was positive in one 
case. The symptoms at onset were sudden and 
their character determined by the localization of 

Case 1. P. O. T. complained of abdominal pain, 
nausea and vomiting and after forty-five days in the 
hospital he was suddenly seized with severe abdominal 
pain, became pulseless and died shortly afterwards. 

At autopsy, about 1,500 c.c. of fluid blood was found 
in his peritoneal cavity due to a ruptured mycotic 



aneurysm of a branch of the mesenteric artery, the 
cause of which was a subacute bacterial endocarditis. 

This patient had three negative blood cultures. 

Case 2. R. W. had complained of moderate angina 
on effort for three months. He continued working until 
ten days before admission, when he had hemoptysis and 

of twenty-four, eight years prior to his admission and 
developed a stricture which had been dilated three 
times in the eight-year interval. During this period he 
had several exacerbations of gonorrhea and also com- 
plained of difficulty in micturition. 

Examination: The patient was not acutely ill. A 
blowing systolic murmur was heard at the apex. The 

Age| Previous |Sub: Signs | Signs | Signs | Signs Blood | Duration 
Sex \Rheumatic| Health heca | Me Embolic acnet Findings | Wespitat Findings 
Name! History |Condition |" "S valves |'"fection| benom|Failure| “ture | Days 

Severe Gastro-Intestinal Symptoms Terminating in Right Hemiplegia 

Subac. BE) Earl BE. 
1c BEN oudbasal| if Hq.60% Oldval.def Ao.+M. 
POT! Yes | Good abd syn syst+ diast a progeny aot RBC-3.6".|— E soft ve +. 
23yn 10 yrs. Base balll adam murmurs cm Fingerstt. | | jen | W8C-29p00 4 5 days|Inf_ Bra ah x4 
M. Player| "8¥S?4 |Loud syst. Terminal | Wass. 4+ in hos m 
ago y vesting at apex | ~'O% palp seqbldCubl Vessel 
Symptoms of Angina Pectoris and Hemoptysis with sudden and unexpected death 
RW| None |, °——, |Rheumatic|Loud Syst | temp. Sudden lg. rs% 
Sly Stee |Memerhei| heart |mecontm |'2°% | None | “yatened] REC4sn 
yelitis < : ‘ 
M. |20 yr.ago Angangeet disease |trans.toax |P. 9O- Liver + |W8C.12j50 
Sudden onset with right hemianesthesia 
: Hg. 70.58% 
LES) yes ae Systoli c| Remittent! ee RBC_4.5m| ! Day Seent case 
I8yr| 8 yrs.| Good| Disease | murmur |temp.ioz |Petechial |i... WBC.17000|28 days ‘ 
Hemi.| at |P 90.120/hem-finger pom aay Living 
F | ago Me 3Bid cult |" h*r 
anesthesia; ape x and foot cuir. 
+Strept. vir: 

a severe attack of anginal pain which necessitated hos- 
pitalization. While apparently in good condition, he 
suddenly and unexpectedly died, two days after his 

At autopsy, “the right main branch of the coronary 
artery in its distal portion where it supplies the septum 
between the right and left ventricles shows a definite 
thrombosis and in the region of the septum near the 
auricular ventricular sulcus, there is a definite abscess 
formation and the entire wall of the left ventricle in 
proximity to the septum shows a large, well-defined 
yellowish area of infarction. A soft ulcerative throm- 
botic vegetation is found on the aortic leaflet to be 
exactly opposite the orifice of the right coronary 

The following two cases are of sufficient interest to 
merit a more detailed history of their symptoms, prog- 
ress and autopsy findings. They carry a more practical 
significance than the more common types of the disease 
just cited and illustrate the value of alertness in 
recognizing the possibility of multiple embolic mani- 
festations as a causative factor in obscure and uncer- 
tain clinical pictures. 

Case 3. P. R. F., male, aged thirty-six, last entered 
the hospital April 8, 1938. His first admission was in 
July, 1934, when he complained of a severe pain in 
the sacro-iliac area, making it almost impossible for 
him to walk. He had acquired gonorrhea at the age 

January, 1940 

prostate was slightly enlarged and on massage pus 
could be expressed from the urethra. 

The sacro-iliac region was acutely inflamed and a 
diagnosis of an acute arthritis was made. 

The blood, including Wassermann, was normal, the 
urine negative except for a faint trace of albumin and 
the sedimentation rate was 78 millimeters per hour. 

He left the hospital markedly improved, but he re- 
entered the hospital five months later (November, 
1934) complaining of inability to think clearly, shooting 
pains in the head, both of four days duration. He 
said that while driving an automobile he lost control 
of it and that he had also noted a slight loss of mem- 
ory for recent events. 

The patient showed a delay in his answers and was 
slow mentally. His memory was poor and he had 
difficulty naming objects. The blood pressure in the 
right arm was 76 over 50 and the left arm 134 over 
70. There was a weakness of the left facial muscles 
and a dilated right pupil. A systolic apical murmur 
was heard. The blood picture was again normal. The 
urine examination showed a faint trace of albumin. 
A radiograph of the skull was negative and one of the 
chest showed the heart to have a 50 per cent cardio- 
thoracic ratio with an increased prominence in the left 
auricular area. 

He left the hospital under protest and was next seen 
in the out-patient department in 1935, when he com- 



plained of photophobia. 
this time was negative. 
He was readmitted to the hospital in November, 1936, 
in a stuporous condition. From relatives it was learned 
that since his last admission in 1935 he had been in 
an auto accident and had been unconscious for a short 
period. He remained well for a short time but later 
began to lose his memory and his condition gradually 
progressed until he became semi-stuporous. 
Examination on this admission revealed his blood 
pressure, temperature and pulse to be within normal 
limits. The pupils were dilated, fixed and equal. He 
gave unintelligent answers to questions. There was a 
slight rigidity of the neck while the Kernig and Babin- 
ski signs were positive bilaterally. The deep reflexes 
were slightly increased. An apical systolic murmur was 
again noted. The spinal fluid was cloudy and contained 
a trace of globulin. There were 495 cells present. The 
colloidal gold curve was negative. Subsequent examina- 
tion showed 296 cells with 97 per cent polymophonu- 
clears. The sedimentation rate was 46 millimeters and 
the visual field normal. X-ray of the skull showed an 
irregular mottling in the left frontal area. The tongue 
deviated slightly to the left and the deep reflexes were 
increased. He had a left sensory aphasia and was un- 
able to execute orders. The spinal fluid cell count 

The fundus examination at 

gradually dropped to 16 cells. Occasional slight exacer- 
bations of a low grade constant temperature were 
present. A diagnosis of a chronic brain abscess in the 
left temporal area was made. 

After six months he had improved markedly and was 

discharged from the hospital, but four months later was 
again readmitted with similar complaint. At this time 
the hemoglobin was 55 per cent, the W. B. C. 7,000 
and a normal differential count was present. The urine 
examination showed a faint to a heavy trace of albumin 
with an occasional hyaline and granular cast, many 
leukocytes, and a few erythrocytes. The spinal fluid 
disclosed a faint trace of globulin, one cell and a typical 
paretic curve. He was discharged in an unimproved 

About six months later on April 8, 1938, he again 
entered the hospital for the last time. He had fallen 
out of his bed and was unable to give an intelligent 
history of previous events. 

His blood pressure was 128 over 88, temperature 
98.2°, and pulse rate 120. There was a sutured lacera- 
tion at the left parietal area. The pupils reacted to 
light and accommodation. The apex beat was palpated 
two centimeters to the left of the nipple line and a 
systolic murmur was heard which was transmitted to 
the axilla. A number of rales were present over the 
chest. His blood showed a 26 per cent hemoglobin and 
1,400,000. erythrocytes and 11,000 leukocytes. He con- 
tinued to fail rapidly, and expired April 10, 1938, two 
days after his admission to the hospital. 

Necropsy notes by Dr. John F. Noble: 

Heart: “The heart weighs 420 grams. The aortic, 
tricuspid, pulmonic valves are normal in appearance. 
Examination of the mitral valve reveals a slight thick- 
ening of the free margin with a number of soft friable 
vegetations particularly on the auricular surface. These 


vegetations apparently extend from an ante-mortem 
adherent mural thrombus and this is seen in the left 
auricle. It is extremely soft in consistency and appears 
to be recent in origin. The coronary vessels are normal 
in appearance. The myocardium is somewhat flabby 
and on cut section is swollen and cloudy in appearance. 
Near the posterior aspect of the left ventricle there is 
a large area of fibrosis measuring approximately one 
centimeter in diameter. Scattered throughout the pos- 
terior aspect of the left ventricle there are also several 
smaller areas of fibrosis. There is no gross evidence 
of excess fat. The root of the aorta is free from 
atheromatous streaking. The auricular appendages show 
no thrombi. 

“Microscopic sections of the heart muscle show 
numerous areas in which the fibers are replaced by 
connective tissue and fat. These areas are invaded by 
a small number of chronic inflammatory cells showing 
evidence that this was probably the site of old inflam- 
mation that was probably rheumatic in nature. Sections 
of the heart and the mural endocardium adjacent to 
the mitral valve show a similar process with the heart 
fibers. The endocardium and the portion of the valves 
shown in this section shows the valves to be markedly 
thickened and fibrous in nature. This thickening is pro- 
duced by connective tissue and the presence of a large 
number of chronic inflammatory cells invading it. Here 
and there the valves show a few foci of inflammatory 
cells, which are close to the free margin. This appears 
to be a more acute process. Along the free margin one 
can also find round bacteria occurring in strings which 
are apparently streptococci. The free margin of the 
valve also shows definite palisading of the inflammatory 
cells occurring there. These would undoubtedly be 
histiocytes. This process is to some extent related to 
the small foci of inflammatory cells. Attached along 
the margin of the valve one can also see pink-staining 
homogeneous masses which represent thrombi. The en- 
tire process would suggest that the patient had an old 
rheumatic process producing myocardial damage. It 
was followed by a long continued rather low grade 
endocarditis and a terminal acute bacterial endocarditis 
superimposed upon the latter process.” 

Head: “On opening the head there is seen to be the 
previously mentioned laceration in the lateral aspect 
of the left frontal area. The calvarium shows nothing 
of note. On opening the dura there is found to be a 
small amount of adherent blood to the undersurface 
of the dura in both the anterior, middle and posterior 
fossa. The blood, however, appears to be recent in 
origin and can be easily pushed from the dura with 
the examining finger. There is no evidence of organiza- 
tion in it. Examination of the cerebral surfaces of the 
hemispheres reveals a deep pit in the left parietal area. 
On cut section the cut surface of the left cerebral 
hemisphere shows the frontal lobe to be normal. On 
cut section through the parietal area there is a large 
area of softening extending throughout the entire 
parietal lobe and partially into the occipital lobe. This 
area lies in the lateral aspect of the lenticular nucleus 
and in the gray substance of the brain. In its largest 
area it measures approximately 2 c.c. in diameter. At 



one point in the parietal lobe it encroached upon the 
cortex to produce the deep pits previously mentioned. 
At the midportion it resembles an abscess cavity but 
the wall of it is irregular and could be produced by 
simple infarction. Examination of the right cerebral 
hemisphere reveals a similar area of softening in the 
parietal lobe lying lateral to the lenticular nucleus. It 
is much smaller and measures approximately one centi- 
meter in diameter. It only extends through the distance 
of several convolutions. Further examination of the 
brain reveals no evidence of hemorrhage or tumor 
mass. The middle ears and mastoids are normal in 
appearance. There is no evidence of skull fracture. 
Examination of the entire cranial vault shows no evi- 
dence of erosion or tumor mass. 

“Examination of the brain reveals the meninges to be 
markedly thicker than normal and they are somewhat 
hyaline in character. There is a faint trace of fluid 
beneath the arachnoids. Sections of the brain in the 
region of the abscesses show them to be infarcted. The 
entire parenchyma of the brain shows a rather marked 
degree of gliosis and the areas about the vessels show 
small collars of round cells. In some sections the vessel 
walls themselves appear to have thickened. The entire 
process suggests a chronic inflammation.” 

Cultures of autopsy: 

1. Diphtheroid bacilli in the abscesses of spleen. 

2. Hemolytic streptococci in the prostatic abscess 
and in the brain. 

All cultures are negative for gonococci. 

Diagnosis: (necropsy)—Drs. J. F. Noble and Mark 
Maun: (1) Prostatic abscess. (2) Splenic abscess. (3) 
Bacterial endocarditis. (4) Mural thrombus. (5) Cere- 
bral malacia (bilateral infarction). (6) Infarction of 
kidneys. (7) Bilateral confluent bronchopneumonia. 
(8) Old cholecystectomy. (9) Appendectomy. (10) 
Subdural hemorrhage. 

Comment. Here is a patient with a definite 
systolic heart murmur, signs of infection and 
severe anemia, who for a period of four years 
had signs and symptoms of intracranial pathol- 
olgy diagnosed as a primary cerebral abscess, 
who at autopsy shows conclusive evidence of an 
old rheumatic valvulitis with a superimposed 
bacterial endocarditis and multiple infarction of 
the brain with necrosis. 

At the present time evidence exists that all 
cases of endocarditis lenta do not inevitably die, 
but that recovery occasionally takes place.® The 
usual duration before its fatal outcome is con- 
sidered to be from six months to one year.*®” 

Many cases are observed in large city hos- 
pitals where patients frequently delay entry until 
absolute necessity makes them seek relief and 
then death quickly occurs. 

Undoubtedly a not inconsiderable number con- 
tinue at their daily work in an active stage of 

January, 1940 

the disease, often. without medical attention or 
with an incorrect diagnosis. Some of these may 
go into a spontaneous remission but after an in- 
determinate period of time relapse again into 
an active stage of the disease with fatal results. 

The duration of four years in this patient 
suggests such a possibility. 

Case 4. W. J. L., male, white, aged fifty-five, en- 
tered the hospital October 10, 1937, died October 28, 
1937, eighteen days later. On admission the patient did 
not give a clear history. He said that he had noted 
nervousness, a tremor of the hands, weakness, insomnia 
and palpitation of his heart for a period of about ten 
years. His physician had considered his condition to 
be due to a toxic goiter. A subtotal thyroidectomy had 
been performed in 1935 without apparent relief of 
symptoms. Another thyroidectomy was done in May, 
1937, shortly before admission. This also failed to give 
him relief. He then received two courses of deep x- 
ray therapy. The last course was given in September, 
1937, shortly before his entry in the hospital. He stated 
that he had lost 60 pounds in weight during the past 
ten months. No definite history of rheumatic fever 
was obtained. 

He was an undernourished white male lying rest- 
lessly in bed. He was not acutely ill. The blood pres- 
sure was 130 over 40. The pulse rate 132 and the 
temperature 100° on one occasion; otherwise normal 
during his hospital stay. The left pupil was irregular 
and smaller than the right. Both reacted to light. The 
ocular fundi disclosed numerous small hemorrhages 
throughout. In the left there was a large hemorrhage 
superior and nasal to the disc. The heart was enlarged 
to the left on percussion. No thrill was palpated. A 
soft systolic and diastolic murmur was heard over the 
aortic area. A positive Duroziez’s sign and a Corrigan 
pulse was elicited. A soft round liver edge and the 
spleen could be palpated about three inches below the 
costal margin. 

The hemoglobin varied between 36 and 46 per cent 
and the red blood count was 1,600,000 cells. The 
leukocyte count was 6,000 and 14,000 cells and dif- 
ferential count was not significant, The blood smears 
disclosed some anisocytosis and some hyperchromasia. 
The blood Wassermann was negative but the floccula- 
tion was positive on two occasions. The icteric index 
was five. The basal-metabolic rate was plus 35 per cent. 
The urine showed a faint trace to a heavy trace of 
albumin with an occasional hyaline and granular cast 
and a few leukocytes and red blood cells in all speci- 
mens examined. X-ray examination of the abdomen 
showed enlargement of the spleen and liver. The car- 
dio-thoracic ratio was 53 per cent and there was con- 
siderable congestion in both lungs. Throughout his 
entire hospital course, the patient was somewhat dis- 
oriented. He developed moderate pitting edema of 
the extremities and died on October 28, 1937. 

Notes by Dr. J. F. Noble on the heart: “The heart 
weighs 547 grams, Examination of the aortic valve 
shows two of the aortic leaflets to be firmly sealed 


together, definitely shortened and calcified. Along the 
free margins of the aortic leaflets there are numerous 
raised grayish friable vegetations. The mitral leaflet 
of the aortic valve shows the largest mass of vegeta- 
tions and this process has completely destroyed the 
leaflet, undoubtedly causing an insufficient valve. The 
mitral leaflets appear to have been normal except for an 
acute process seen on them. Here the vegetations are 
somewhat smaller but still thrombotic in appearance 
and friable in consistency. The tricuspid and pulmonary 
leaflets show nothing of note.” 

Diagnosis: (necropsy)—Drs. J. F. Noble and Mark 
Maun: (1) Subacute bacterial endocarditis. (2) Fi- 
brinous pericarditis. (3) Infarction of the myocardium 
and spleen. (4) Lobar pneumonia (right). (5) Fi- 
brinous pleuritis (right). (6) Old pleural adhesions 
(right). (7) Cloudy swelling of heart-liver-kidneys. 
(8) Splenitis. (9) Edema. (10) Congestion of liver. 

Comment. A case of subacute bacterial endo- 
carditis with splenomegaly and anemia terminat- 
ing in congestive heart failure and pneumonia 
was diagnosed within a year of death as a toxic 
goiter. One thyroidectomy was performed about 
a year and the second one four months before 
his death. He was also given two courses of deep 
x-ray therapy, the last one immediately before 
his final admission to the hospital. 


1. This paper is a clinical review, including 


necropsy findings in thirteen cases of bacterial 

2. These cases have been classified according 
to their presenting symptoms and signs on ad- 
mission to the hospital. 

3. Embolic manifestations concealed in deep 
structures may dominate the clinical picture of 
this disease. 

4. Asa result one may fail to make the cor- 
rect diagnosis, which comes as a surprise finding 
at necropsy. 

I wish to acknowledge my indebtedness to Dr. 
John F. Noble and his associates at the Ancker 
Hospital for the autopsy records of these 


1. Clawson, B. J.: An analysis of 200 cases of endocarditis 
with s wear reference to the subacute bacterial type. Arch. 
Int. d., 33:157, 1924. 

2. Clawson, B. J., and Bell, E. T.: A comparison of acute 
rheumatic = subacute bacterial endocarditis. Arch. Int. 
Med., 37:66, 6. 

3. Feldman, - a Trace, I. M.: Subacute bacterial endo- 
carditis following the removal ‘of teeth or tonsils. Ann. 
Int. Med., 11:2124, 8. 

4. Fulton, Marshall N., and Levine, Samuel A.: Subacute 

bacterial endocarditis, with special reference to the valvular 
Jour. Med. Sc., 183:60, 1932 
. Hamman, Louis: ealed bacterial endocarditis, Ann. 
Int. Med., 11:175, 1937. 
. Keefer, Chester §.: Subacute bacterial endocarditis: Active 
cases without bacteremia. Ann. Int. Med., 11:714, 1937. 

. Willius, Frederick A.: Rheumatic heart disease. Minn. 

Med., 19:711, 1936. 

lesion. Am. 

Nun WM 



KEYS, M.A.+ 

Rochester, Minnesota 

oe of an understanding of the fundamental 

principles of medical bibliography among 
those who are seriously interested in medicine 
is regrettable. Too often, medical students are 
unfamiliar with the literature of medicine, to 
say nothing of methods of compiling a bibliog- 
raphy on a particular subject. The reason for 
this ignorance among medical students may be 
referable to the system of pedagogy employed in 
many medical schools, a system whose applica- 
tion is not limited to medicine but seems almost 
to be universal. It is the textbook method of 
reading. Its weaknesses were pointed out by 
Dr. Robert Watt® of Glasgow more than 125 
years ago. He wrote, “The reading of the stu- 
dent is too often confined to systems and com- 

tReference Librarian, The Mayo Clinic, Rochester, Minne- 


pilations which are generally the work of men 
of no experience or of men writing under the 
influence of preconceived opinions. To obtain 
correct views of medicine, it is necessary to have 
recourse to original authors, to such as write 
from actual observation who have seen and 
treated the diseases they describe.” 

The textbook system of reading makes small 
allowance for the student’s acquaintanceship with 
the classic descriptions of disease which might 
be supplied by courses in medical history and 
bibliography. Medical bibliography, then, offers 
a fundamental approach to the study of medicine 
and its teaching should not be neglected. 

Many writers and publishers of medical books 
and articles are seemingly indifferent to the bib- 
liographic aspects of their work. Among these 
persons the complaint is often heard: “Bibliog- 



raphy never sold a book,” or “This article is 
merely the result of my own experience,” or 
“Bibliography is a nuisance.” Yet, if such a 
writer or such a publisher would consider the 
fundamental relationship of bibliography to the 
proper fulfillment of an author’s or publisher’s 
work, perhaps the most serious efforts would be 
devoted to an understanding of it. 

Bibliography is the systematic description of 
that which has been written; it forms the foun- 
dation for new writing. By means of bibliog- 
raphy alone is it possible to reconstruct the work 
in medicine and surgery of our forbears. With- 
out medical bibliography, the splendid indices of 
medical literature now available would never 
have been written, and consequently many im- 
portant contributions would have been lost. Some 
time ago, Mr. Frank Place® suggested that, “The 
science and art of medicine is so dependent upon 
its literature that reference to authorities is a 
recognized part of medical composition. The 
quantity of such printed matter is very great and 
quotation of sources is as necessary in medical 
literature as in any other field of human en- 

Search of the literature and compilation of a 
bibliography have always been considered impor- 
tant steps in the solution of a problem in re- 
search. A review of the literature may provide 
the research student with methods and results 
which might be applied to the presentation or 
solution of his own problem. Furthermore, a 
student contemplating a work of investigation is 
naturally desirous of knowing what has been 
written that concerns his subject, so that he may 
have the benefits of a proper background for 
his study. It is of importance to him to find 
out whether or not he is duplicating the work 
of other investigators in his field. 

If he uses the works of others in pursuing 
his own investigation, it should be a tenet of 
medical ethics that credit be given to the original 
writer. If it should happen that a worker ac- 
tually duplicated the work of another, consider- 
able embarrassment might have been spared him 
had he known that writers before him had prior 
claim to a discovery that was new to him. A 
knowledge of bibliography would seem, there- 
fore, to be an indispensable part of a medical 
writer’s equipment. 

To the general practitioner, a most practical 
reason for acquaintanceship with medical bib- 

Tanuary, 1940 

liography is that such an acquaintanceship pro- 
vides him with a better understanding of new 
developments in medical science. New develop- 
ments are published first of all in the medical 
journals, and later as monographs or books, but 
unless the physician as a reader is acquainted with 
medical indices and their use, rather than the 
contents of such journals themselves, he will not 
be able to keep up with the discoveries, because 
the huge avalanche of literature he would have 
to read if he did not use indices would bury 

Recently, Dr. William Bulloch,’ emeritus pro- 
fessor of bacteriology in the University of Lon- 
don, made an enlightening study which showed 
the enormity of one aspect of the medical bib- 
liographic problem. From the World List of 
Scientific Periodicals, published in 1934 by the 
Oxford University Press and containing the 
names of more than 23,000 periodicals published 
between 1900 and 1933, Dr. Bulloch estimated 
5,000 of such periodicals to be medical. If, ac- 
cepting Dr. Bulloch’s figure of 5,000, it is as- 
sumed that the average medical publication is a 
monthly and that it contains about fifty pages 
per issue, then in the world’s periodical medical 
literature more than 3,000,000 pages are pub- 
lished annually! 

Dr. Bulloch investigated in detail the vast 
output of literature on various medical subjects. 
In studying the Index-Catalogue of the Surgeon 
General’s Office (the index to the most complete 
medical library in the world), he found that 
about 7,000 articles and books had been pub- 
lished on the subject of syphilis alone up to the 
year 1893. From 1893 to 1912, 14,000 new ar- 
ticles on that subject were published, and from 
1913 to 1932, 21,000 articles on the subject were 
published. In the course of twenty years, 6,780 
articles have been published on cardiac disease; 
7,000 on pregnancy, including 116 on the occur- 
rence of quadruplets! Between 1913 and 1932, 
according to Dr. Bulloch’s figures, 1,280 papers 
were published on the excision of tonsils. 

Thus, a knowledge of medical bibliography is 
an entrée to medical literature. In defense of 
an important aspect of medical bibliography, 
namely, the medical library, Dr. Archibald Mal- 
loch,’ librarian of the New York Academy of 
Medicine, recently said that physicians should be 
insured against certain risks which they may en- 
counter after graduation, and he enumerated 



these risks as follows: (1) the risk of being sat- 
isfied with methods of diagnosis and treatment 
learned in medical school, (2) the risk of being 
content with what is good instead of striving 
for what is better, (3) the risk of intellectual 
laziness which threatens those in an extensive 
practice, and (4) the risk of becoming rusty. 

For insurance against these dangers, Dr. Mal- 
loch suggested: (1) the study of disease among 
private patients as well as among hospitalized 
patients; (2) discussions of problems at meet- 
ings of medical societies; (3) publication of 
brief papers about important cases; and (4) the 
perusal of medical journals and books, so that 
regular reading becomes a habit. 

Before becoming involved in a discussion of 
bibliographic fundamentals, it seems to me that 
it might be wise to mention that it is not always 
necessary that an author give evidence of bibli- 
ographic search of the literature. As suggested 
by Dr. C. V. Weller,?° the factors which influence 
the use of bibliography in literary endeavors de- 
pend upon: (1) the character of the subject; (2) 
the degree of familiarity with it which the in- 
tended readers possess; and (3) the method of 
approach employed by other authors. If a 
well known author is preparing a popular ar- 
ticle or a book for the laity, it is assumed that 
he is well versed in the literature of his subject 
and external bibliographic evidence would not 
be of value in such works. Similarly, it is ob- 
vious that if an author reviews his own technic as 
a contribution to the medical literature, it is not 
necessary for him to append a long list of refer- 
ences to his article. 

But the more limited the topic, the more pre- 
cise its application, the more necessary does it 
become for the author to give evidence of famil- 
iarity with the literature of his subject. In fact, 
even though the author’s thesis may give internal 
evidence of his acquaintanceship with the litera- 
ture, it may yet be adjudged as inadequate be- 
cause of its lack of external evidence when read 
by the inexpert. Thus, it has come about that a 
criterion invariably applied to the written presen- 
tation is whether or not it is accompanied by an 
adequate bibliography. Dr. J. F. Fulton* even 
goes so far as to suggest that the character of 
the bibliographic citations contained in an or- 
iginal contribution provides an almost unfailing 
index to the scientific merit of a given work and 
to the care with which the manucript as a whole 


has been prepared. Carelessly made and inade 
quate references suggest careless and inadequat: 
thinking. On the other hand, if references ar 
accurate and are in good bibliographic form, it 
can be assumed that the writer is scientific in his 
thinking. It is, of course, conceivable that an 
author may have a perfect bibliography and that 
his written work may be of no value whatever, 
although such is not often the case. 

One very bad result which accompanies the 
adjudging of papers by their bibliography is the 
use of coarse, bulky, undigested and unassimilat- 
ed bibliography to give volume and dignity to 
articles altogether unworthy of such appendages. 

Another and more regrettable corollary of 
the aforementioned practice is that there is trans- 
mitted by many of these authors the perpetuation 
of bibliographic error. Errors occur because a 
careless author generally does not go to the or- 
iginal source for either his reading, a procedure 
which would seem to be essential, or the com- 
pilation of his bibliography. Instead, he trusts 
that the authors from whom he quotes, without 
verifying their references, have done _ this. 
Hence, careless or hasty bibliographic work often 
results in the perpetuation of error, misquota- 
tion, false translation, and above all, incorrect 

It is important, therefore, that persons serious- 
ly interested in medicine pay attention at least to 
two fundamentals of medical bibliography, name- 
ly, (1) the systematic description of medical 
writings and (2) the verification of references. 

Bibliography is defined in Webster’s New In- 
ternational Dictionary as: (1) “The history or 
description of books and manuscripts, with no- 
tices of the editions, the dates of printing, et 
cetera,” and as (2) “A list of writings relating to 
a given subject or author; also a list of an au- 
thor’s or printer’s works.” 

In its earlier meaning, now obsolete, the word 
bibliography (derived from the Greek, bibliog- 
raphia) referred to the writing of books (bib- 
lia) and consequently, “bibliographer” was the 
name given to the writer of books; that is, not 
the author, but the copyist. In accordance with 
the newer definition, a bibliographer is a person 
who writes about books, describing their author- 
ship, printing, publication, and other pertinent 
bibliographic facts. If bibliography is narrowed 
down to its commonly accepted meaning, it is 
thought of as “A list of books of a particular 



author, printer, or country, or those dealing with 
any particular theme; the literature of a sub- 
ject,” the quotation being the fourth meaning of 
“bibliography” in the Oxford New English Dic- 

In its broader sense, bibliography is much 
more than the art of listing the publications on 
special subjects. First of all, it is the science of 
the description of books. Proceeding under such 
a definition of duties, the bibliographer is con- 
cerned with the different methods at his disposal 
for the description of the physical aspects as 
well as the subject-matter of books. The science 
of the description of books also concerns itself 
with the integration of research. To achieve this 
desirable end, the bibliographer must have a clear 
understanding of the relationship of the prin- 
ciples of the classification of books to the use 
of books. His task, in this capacity, is to bring 
together related works, and thus have sources 
on the entire medical literature at his finger 
tips. In making an analysis of the literature, 
the bibliographer is performing an indispensable 
service for medicine. 

An important part of bibliography is in its his- 
torical aspects. There is no more fascinating 
subject than the history of the care of the book 
through the ages. From the papyrus roll of the 
Egyptians and later the Greeks, the parchment 
book of the medieval period, the printed book of 
the middle Fifteenth Century to the well printed 
and bound volume of modern times may be gath- 
ered a great story embodying much of the de- 
velopment of scholarship. The introduction of 
printing by means of movable types has contrib- 
uted much to modern concepts of culture, but is 
only one of the many pleasant topics rewarding 
study in the realm of bibliography. 

An important concept of bibliography is one 
that has recently been advocated by Dr. John F. 
Fulton,® Sterling professor of physiology in the 
Yale University School of Medicine. Dr. Fulton 
describes his point of view in the following 
terms: “A modern bibliographer must anatomize 
his books. He dissects them with infinite pa- 
tience, lifting their epidermis to find what lies 
beneath; he is concerned with their joints and 
ligaments, and has great delight in discovering 
parts which have been artificially replaced; he 
seeks for errors in the hand of the maker, but he 

*A new English dictionary on historical principles . . . ed. 
by J. A. H. Murray. Oxford, The Clarendon Press, 1888. v. 1, 
pt. 2. “B”, p. 846-847. 

January, 1940 

reviews with charitable amusement all signs of 
human frailty. Bibliography is indeed an all-ab- 
sorbing occupation, but its devotee is frequently 
face to face with those who fail to understand 
the source of his enjoyment. A mere list of bib- 
liographical idiosyncrasies with mistaken signa- 
tures, pagination and gatherings has little appeal 
to any not a collector of books; . . . a bibliogra- 
pher .. . has difficulty in justifying his existence 
if he fails to make himself useful to those not 
pursuing his specialized field. He must reveal 
something more than the mechanics of bookmak- 
ing. He can endeavor to assess the importance 
of a book; he may say how the author came to 
write it, or investigate the influence which it ex- 
erted upon his contemporaries.” 

Dr. Fulton also believes that the fundamental 
service of bibliography is the indication of the 
contents of books, and for this reason he assigns 
due credit to Albrecht von Haller® as the first 
bibliographer to take a great step toward the hu- 
manization of bibliography. So-called humanized 
bibliography includes, in addition to the descrip- 
tion of books: (1) a brief statement concerning 
the author; (2) an indication of the contents of 
the book ; (3) significance of the book in history ; 
and (4) a list of references indicating where 
further information may be found. 

It may be well, for a moment, briefly to review 
the fundamentals of the description of medical 
writings. A bibliographic description of a book 
or article includes the following features: 
(1) the author, (2) the title; (3) the publisher ; 
(4) the date of publication; and (5) the pagina- 
tion. In special cases, other important but sub- 
ordinate bibliographic points should be included, 
such as (A) exact collation, (B) the illustra- 
tions, (C) the size of the book, and (D) the spe- 
cial features, such as appended bibliography, per- 
sonal autographs, association notes and the like. 
But, for practical purposes, points one to five are 

1. The author.—The author’s name identifies 
the writer of the book or article. The surname 
should be set down, followed by the author’s giv- 
en names. Example: Alvarez, Walter Clement. 
It is the practice of some institutions and pub- 
lishing houses to initial the given names.* Ex- 
ample: Alvarez, W. C. But if the author has 
only one given name, it is generally written in 
full.* Example: Amberg, Samuel. If the author 

*This is the practice of The Mayo Clinic Library. 


is a woman, it is necessary to write her Christian 
name in full in order to distinguish her sex. Ex- 
ample: Flock, Eunice V. If two deceased au- 
thors have identical names they may be distin- 
guished by appending their dates of birth and 
death to their names. Example: Adams, John 
(1735-1826) ; Adams, John (1819-1892). Euro- 
peans sometimes distinguish identical names by 
adding to each name the place of the author’s 
residence. Example: Hoffman, Julius (Jena) ; 
Hoffman, Julius (Wirzburg). 

2. The title—The title distinguishes the pa- 
per or book from other publications by the same 
author. It should be copied exactly as it appears 
on the title page. Words in a title are never ab- 
breviated, but insignificant words may be omit- 
ted. Three dots indicate an omission. Example: 
A treatise on headache and neuralgia . . . with 
an appendix . .. by David Webster .. . ed. 3. 
It is customary to capitalize the first word and 
proper names and adjectives in a title. Other 
words are written in small letters. If the title is 
in the German language, all nouns should be cap- 

3. The publisher—Another aid in identifying 
a bibliographic reference is its publisher. In re- 
ferring to a book, it is customary to include the 
place of publication as well as the name of the 
publisher. Example: New York, Macmillan. In 
case the work is the American edition of an Eng- 
lish book, the American place of publication is 
given. Example: New York, Oxford in lieu of 
London and New York, Oxford. 

For a reference to a journal, the name of the 
journal is given as the publisher. This name may 
be in abbreviated form and many bibliographers 
accept the abbreviations as listed in the Quarterly 
Cumulative Index Medicus.; A more universal 
list may be found in A World List of Scientific 
Periodicals . . . London, Oxford, 1934. In case 
two journals have identical titles, the place of 
publication may be added. Example: Archives 
of Surgery (London) and Archives of Surgery 

4. The date.—The date establishes the worth 
of a work as to its timeliness. It is, therefore, 
a most important bibliographic point. To estab- 

*It is common practice among librarians not to capitalize the 
first letter of nouns in a German title. Such a practice not 
only has no valid basis, but is actually intrinsically wrong, be- 
cause the genius of the German language, as well as its philo- 

logical aspects, demands that nouns have capitalized initial 

tIncluded in Morris Fishbein’s book (op. cit.). 

lish the date of publication of books, it is proper 
to write down the copyright date, which is found 
on the verso of the title page. Often the imprint 
date (found at the bottom of the title page) is in 
disagreement with the date of copyright because 
the imprint date refers only to the year of print- 
ing of a particular edition. Misinterpretation of 
the imprint date has led countless people to be- 
lieve that they were consulting relatively new 
books, when in reality the information in the 
books consulted was actually obsolete and prac- 
tically worthless. 

It is, of course, true, as Dr. Paul White™ has 
shown, that a late date on a book in no way 
proves that book to be good. A classic or lead- 
ing textbook of the past is far more valuable 
than a second rate volume of the present. But, 
when a physician is led to believe by the imprint 
date on the title page of a book that he is reading 
the latest data concerning, for instance, physiol- 
ogy or pathology, it is almost fraudulent to have 
him thus gulled by a reprinted copy of an old 
book. An aid to the identification of the date of 
a book is the number of the edition in which it 
is issued, in case the book has been issued in 
more than one edition. This information should 
be added after the date of publication. In de- 
scribing a reference to a journal it seems advi- 
sable to include the name of the month or the 
date of issue, in addition to the year. This infor- 
mation is for the convenience of the reader who 
makes use of unbound journals. 

5. The pagination.—In order to differentiate 
a major opus from a pamphlet, the number of 
pages should be included in the bibliographic de- 
scription of a book. If a work is published in 
more than one volume, however, the number of 
volumes in the set should be substituted for the 
pagination. In case the author is citing the work 
of another to prove a point, the exact page num- 
ber of the medical work in question should be 
included in either the text itself or a footnote, 
but it should not be incorporated in a bibliogra- 
phy. If reference is made to a paper published 
in a journal, the complete pagination should be 
given in the bibliography. An additional aid to 
the identification of an article is the inclusion of 
the volume number of the journal. 

Attention to these points greatly facilitates the 
usefulness of a bibliography, and utility, it would 
seem, is the primary reason for the compilation. 
Moreover, the more bibliographic points that are 



added, the more the possibility of error is re- 
duced. That is, if the volume number is incor- 
rectly given, chances are that the year or the 
pagination will serve to help locate a “lost” 

Examples: Correct re‘erence to a book: Wil- 
lis, H. S.: Laboratory diagnosis and experiment- 
al methods in tuberculosis. Baltimore, Thomas, 
1928. 330 p. 

Correct reference to a journal article: Wilder, 
R. M.: Hyperparathyroidism: tumor of the 
parathyroid gland associated with osteitis fibrosa. 
Endocrinology. 13:231-244 (May) 1930. 

Correct reference to a chapter in a book by 
several authors: Allchin, W. H.: Tuberculosis 
of the peritoneum. In: Allbutt, T. C., and Rol- 
leston, H. D., eds.: System of Medicine. Lon- 
don, Macmillan, 1908, vol. 3, pp. 957-978. 

The author in preparing his bibliography for 
publication should, of course, remember to pat- 
tern his references after the custom of the pub- 
lisher who is to publish his work. That is, a pa- 
per submitted to the Journal of the American 
Medical Association should follow the rules of 
citation of that publication, and a paper submit- 
ted to the American Journal of Physiology 
should conform in its bibliography to the form 
used by that journal. The form employed can 
be easily determined by consulting the particular 
journal. Another point might be emphasized: 
The author should be consistent in citing refer- 
ences. He should learn to make them correctly, 
adhering to this procedure until accuracy and 
care become habitual, so that reference work 
eventually will not be any trouble to him, to his 
readers or to his publishers. 

After the author has compiled his bibliography 
and has prepared his article for publication, his 
task is still incomplete until he has verified his 
references. Verification would be a waste of 
time if all writers were 100 per cent accurate in 
citing their sources. But the possibilities for er- 
ror in bibliographic work are endless. How 
often are mistakes made in copying the volume 
number, the page number, the year, the author’s 
name, and even the title of a publication! 

There is much in the literature on the subject 
of the perpetuation of errors in medical bibliog- 
raphy. A recent article by Dr Clifford Dobell? 
traces the birth and death of Dr. O. Uplavici 
(1887-1938), who turned out to be a wholly fic- 
titious personage. According to Dr. Dobell, “Dr. 

January, 1940 

Uplavici, though a pure Czech, had a Greek fa- 
ther and a German mother. He was born in 
1887, published his only paper in the same year, 
obtained his doctor’s degree later in the United 
States, and now—after a checkered career in 
many countries—breathes his last . . .” After 
much search in the literature, Dr. Dobell found 
Dr. Jaroslav Hlava (1885-1924), a distinguished 
Czech physician, to be the author of an article on 
amebic dysentery which for fifty years had been 
falsely attributed to a Dr. Uplavici. The error 
was perpetuated because Dr. Hlava’s original pa- 
per had been published in Casopis lékari Cesk¥ch 
(Journal of the Czech Physicians) of Prague in 
v. 26, No. 5, for Jan. 29, 1887. Hlava’s paper 
was written wholly in the Czech language and 
was entitled, “O wuplavici Predbézné sdéleni” 
(On dysentery: preliminary communication). 
Because no translation of the paper in any lan- 
guage had been published, the original is still 
known to most workers by a brief abstract of it 
which was published in German in the Central- 
blatt fiir Bacteriologie und Parasitenkunde, v. 
1, p. 537; 1887. But by some extraordinary mis- 
take, the author’s name was entirely omitted 
from the German abstract, and the title of his 
paper, “O uplavici” was given as Uplavici, O., 
so that it appeared to be the author’s name. 

In this strange manner, a new worker, O. Up- 
lavici of Prague, made his first appearance in the 
literature on amebic dysentery. This particular 
confusion of title with name led to much con- 
fusion in the literature, and Hlava’s name has 
been incorrectly referred to as O. Hlava (instead 
of J. Hlava) and also as Hlava, Uplavici, and 
O. Uplavici. Dr. Dobell adds that in a recent pa- 
per both Hlava and Uplavici were mentioned as 
two different workers who studied dysentery 
among cats in the early days. 

Many other examples of the perpetuation of 
error in medical bibliography might be given, 
but the aforementioned instance should suffice to 
make the reader realize the necessity for verifica- 
tion of all references. It is most important that 
an author take the trouble to verify a statement 
he is quoting from another, for the writer from 
whom he quotes may himself be quoting another 
author inaccurately. If the original source is 
unobtainable, mention should be made of the 
writer from whom it was obtained. The author 
should not only verify the bibliography in his 
manuscript, but he should also verify it in the 



printed proofs of his paper, for more errors may 
have crept in since his original manuscript left 
his hands. 

To do a perfect job of verification, the original 
books and articles should be compared with the 
bibliography and all bibliographic points should 
be proved. Verification should not be done from 
the indices to the medical literature except on 
those rare occasions when an author has read the 
original reference elsewhere, not in his own local 
library. If he has used a secondary source, then 
mere literary honesty demands that he quote that 

To borrow a conclusion from Mr. Frank Place 
because it cannot be stated any better: “Take no 
reference for granted. Verify the reference that 
your best friend gives you. Verify the reference 
that your revered chief gives you. Verify, most 
of all, the reference that you yourself found and 

jotted down. To err is human, to verify is nec- 


- Bulloch, William: Medical wy literature. Reviewed 

in Brit. Med. Jour., 2:810-812, (Oct. 2 

- Dobell, Clifford: Dr. O. Uplavici iss? 1938). 
30:239- 241, (June) 1938. 

. Fishbein, Morris: Medical writing: the technic and the 
art. Chicago: American Association, 1938, 212 pp. 

. Fulton, J. F.: The principles of bibliographical citation; 
an informal discourse addressed to writers of scientific 
papers. Bull. Med. Library Assn., 22:183-197, (April) 1934. 

. Fulton, J. F.: Bibliography of the Honourable Robert Boyle, 
fellow of the Royal society. New Haven, Connect.cut, pri- 
vately printed, 1932, 171 pp. 

. Fulton, J. F.: Annual oration of the Boston Medical Li- 
brary: aller and the humanization of e-em New 
England Jour. Med., 206:323-328, (Feb. 18) 1932. 

- Malloch, Archibald: A short talk on medical libraries. Jour. 
Connecticut Med. Soc., 2:223-226, (May) 1938. 

. Place, Frank, Jr.: Verify oof references. A word 
medical writers. New York Med Jour., 104:697-699, (Oct, 
7) 1916 

. Watt, Robert: Quoted by Finlayson, Pn ty Medical bib- 
liography and medical education: Dr. Robert Watt’s library 
for his medical students in 1812. Edinburgh Med. Jour., 
46 (old series) :344-348, 1898. 

. Weller, C. V.: Medical a, and the perpetuation 
of a Jour. A.M.A., 76:539-540, (Feb. 19) 1921. 

y ms Doctors and books. 

218:338- 343, (Feb. 24) 1938. 


. Whit New England Jour. 


Minneapolis, Minnesota 

discussed the principle 

I HAVE previously’ 

that the preoperative diagnosis of vesical 
neck obstruction should be made as completely 
and accurately as possible with the least possible 

disturbance to the patient. I maintained that 
cystography has much value in such a program, 
a concept well recognized in the literature but 
apparently not widely followed in practice. If 
such a principle applies to the primary study of 
vesical neck obstruction, how much more should 
it be applicable to the study of difficulties fol- 
lowing operations on the prostate and vesical 
neck. Such a study demands not only thorough- 
ness and a clear demonstration of the condition 
present, but also tact, diplomacy and usually 
some regard for the expense of the proceed- 

A fairly extensive literature regarding cystog- 
raphy and urethrocystography has grown up in 
the last twenty years, but this valuable means 
of diagnostic study seems still to be neglected. 
Several prominent urologists have told me that 
tudes at Guake, Neen aes St ne So 


they do not use cystography nearly as much as 
they should, and one or two recently have asked 
what I could determine from cystography that 
I could not determine from cystoscopy, especial- 
ly with the retrospective telescope. 

Cystoscopy, including inspection of the blad- 
der neck with the right angle and retrospective 
lenses and inspection of the prostatic urethra 
by direct and foroblique vision, has long been 
the standard method of study. But I think 
you and the men with personal experience will 
agree that cystoscopy should be the last rather 
than the first preliminary examination, especial- 
ly in old and feeble men. Cystoscopy is some- 
times technically difficult or impossible in these 
patients previously operated upon because of 
distortion or stricture of the urethra, and it 
sometimes fails to give complete or accurate 
information because of bizarre irregularities. 

Urethrocystography has been used with skill 
and excellent results in certain clinics in this 
country and abroad. Without question it can 
be made to furnish a more complete picture 
than cystography but requires more skill and 



experience in production and interpretation, and 

therefore is not apt to become as practical for 

the man of less than large urologic practice. 
Excretory urography may be made to give 

‘ Saran. 
Fig. 1. This patient, about 
eight months after suprapubic 
prostatectomy, complained of fre- 
quent urination without any re- 
sidual urine after voiding. The ed 
cystogram shows a small rigid 
bladder and a rigid irregular non- 
collapsing prostatic space. 

in 1923; 
means since. 

Fig. 2. This patient had vesical 
and prostatic calculi 
trophy of prostate when supra- 
pubic prostatectomy was perform- 
he has had 
removed by 
One can see the 
shadows of calculi 

more clearly than cystoscopy, especially when 
interpreted in conjunction with rectal examina- 
tions, and it gives a graphic permanent record of 
the findings for later comparisons. Although it 

Fig. 3. This patient had a 
suprapubic prostatectomy sixteen 
years ago. his recent cystogram 
showed a typical benign prostatic 
hypertrophy, and 40 grams of tis- 
sue were removed by suprapubic 

and hyper- 


in the pros- 

tatic space, and the thin layer of 

tissue between 
bladder cavity. 

Fig. 4. This patient had a Fig. 5. 
suprapubic prostatectomy seven- time of 
teen and one-half years ago and 
a transurethral prostatic resection 
three and one-half years ago, 
with removal of 20 to 25 grams 
of tissue. At the time of this 
cystogram the residual urine still 
measured 375 c.c. Further resec- mal 
tion of 27 grams gave a com- 
pletely satisfactory result. The 
irregular projections into the 
bladder base indicate a combina- 
tion of adenomas and scar tissue. 


good cystograms if the renal excretion is satis- 
factory, but it is not always definite and is 
relatively expensive. 

Cystography is a simpler procedure than 
urethrocystography and is less disturbing to the 
patient than cystoscopy. Excellent cystograms 
have been made by several of my friends in 
general practice. Cystography may show the 
status of the bladder and bladder outlet even 

January, 1940 

This patient, at the 
months after transurethral resec- 
tion, was having difficulty in void- 
he later underwent another 
There is a slightly con- 
vex elevation of the bladder base 
around the urethra with the nor- 
curve of the bladder base 
farther to the side. 

them and _ the 

Fig. 6. This patient underwent 
transurethral prostatic resection, 
after which he emptied his blad- 
der completely but had _persist- 
ently frequent and difficult urina- 
tion. The cystogram showed a 
large, though faintly seen, mass 
projecting into the bladder an- 
terior to the catheter; the trickle 
of fluid down the urethra far an- 
terior to the catheter further 
demonstrates the size of the lat- 
eral lobe enlargement. By supra- 
pubic enucleation I removed a 
large mass of tissue consisting of 
the anterior part of one lateral 
lobe of the prostate. 


may not be accepted as advisable for routine 
follow-up after a primary operation, especially 
when there are no signs of trouble, still cystog- 
raphy is a simple and safe means of checking 
the result. 

Certain errors in technic and interpretation 
are possible but such may be said of any method 
of examination. I have several times wished 
that I had made a preliminary cystogram, 



especially the oblique view, before undertaking 
cystoscopy. This has been true in cases studied 
after previous operative treatment even more 
than in cases with no such previous history. 

= 2 


Fig. 7. 
one week apart and was 

amount of tissue suprapubically or by transure- 
thral resection (Fig. 3). 

After transurethral prostatic resection, com- 
plete or partial failure to empty the bladder is 


This patient had two transurethral prostatic resections about 
having a rather stormy convalescence two 
weeks later when the cystogram (a) was made. 

It showed incomplete 

filling of one side of the bladder and also the remaining intravesical 
prostatic tissue and the fair channel where tissue was resected. Eight 

months r 
the bladder outline but still 

later the cystogram (b) showed complete rounding out of 
some persistent 
patient is now so well and so well satisfied wit 

yrostatic shadow. The 
his present condition 

that he has not availed himself of my offer for another cystogram. 

Fig. 8. 

again having trouble. 

This patient had a cystotomy followed by transurethral 
prostatic resection elsewhere in April, 1935. 

In August, 1937, he was 

Flat radiograph of the pelvis (a) showed calculi 

of such size and number that I removed them and some remaining 
prostatic tissue suprapubically. He has been very well since; a cysto- 
gram (b) in November, 1938, showed a satisfactory bladder outlet and 

no calculi. 

Prostatic obstruction being removable by 
transurethral resection or by enucleation supra- 
pubically or perineally, difficulties may follow 
any of the methods. My experience with the 
perineal operation is too limited to mention. 

After suprapubic prostatectomy, continuing 
infection occasionally results in persistence of a 
large, rigid, infected prostatic space and an irri- 
table bladder of small capacity (Fig. 1). Some- 
times this rigid space contains calculi and may 
be separated from the bladder partially by a 
shelf of scar tissue and internal sphincter muscle 
(Fig. 2). Several times I have seen recurrence 
of obstruction fifteen or twenty years after 
prostatectomy, and have removed a fairly large 


due to incomplete removal of prostatic tissue 
projecting into the bladder or into the urethra 
(Figs. 4, 5). If remaining tissue is situated 
anteriorly in the lateral lobes or in the anterior 
lobe, the difficulty may be recurring hematuria 
or dysuria and bladder irritability without fail- 
ure to empty the bladder (Fig. 6). In one case 
during a stormy convalescence we found evi- 
dence of damage or inflammatory reaction of the 
bladder wall in addition to incomplete removal 
of the prostate (Fig. 7). Occasionally the 
hematuria and irritability are due to calculi, as- 
sociated with some remains of the prostatic 
obstruction (Fig. 8a). After one has given 
appropriate treatment of the patient’s difficulty, 



cystography (Fig. 8b) is a simple and safe 
means of rechecking the adequacy of the treat- 
ment. Occasionally the source of difficulty some 
time after a prostatic resection is some other 


caution, it should be available at least as a pre- 
liminary means of study to those not equipped 
to do cystoscopy. Cystography may be done as 
a step in excretion urography, or separately by 

Fig. 9. This patient underwent suprapubic cystotomy and_cauteri- 
zation of a bladder carcinoma elsewhere in June, Prostatic 
resection was done in November, 1937, because of a _ persistent 
suprapubic sinus. This cystogram * of April, 1938, shows no vesical 
neck obstruction and no trouble in the scar of the previous cauteri- 
zation (to right of catheter tip on radiograph). Note large tumor 
projecting into the bladder from its vault (to left of catheter tip on 

Fig. 10. This patient had prostatic resection in California two 
years ago. Two months ago, also elsewhere, he had two resections 
(18 grams and 7 grams). Urography shows no vesical neck ob- 
struction, but evidence of left hydronephrosis and a very marked 
osteoblastic involvement of the left side of the pelvis and lumbar 
spine evidently originating from carcinoma of the prostate. 

lesion, such as carcinoma of the bladder (Fig. 9) 
or metastases from carcinoma of the prostate 
(Fig. 10). 

In conclusion, I wish to offer cystography as 
a simple and safe means of investigation of 
difficulties following prostatic surgery. With 

catheter injection of air or radiopaque fluid. 
In my opinion it should usually be used in such 
cases before deciding on cystoscopy. 


1. Sweetser, T. H.: Cystography, 
raphy, as guide in treatment o 
Urol., 40:285, (August) 1938. 


"vesical neck 

esions. Jour. 


Testimony before the Sub-committee of the Committee on Education and Labor of the 
United States Senate, by Dr. Thomas Parran, Surgeon General of the United States 
Public Health Service: “In connection with balancing the budget, Mr. Chairman, I hope 
that this Congress will give more attention to balancing our health budget. It is cheaper 
to keep a woman from dying in childbirth than to take care of the orphans in an orphan 
asylum or to give aid to the dependent children. It is cheaper to aid in building tubercu- 
losis sanatoria than it is to pay for the deaths from tuberculosis and the widows and 
children who are left. The State Health Officer of Tennessee estimates that it costs on the 
average of $150 to bury a person in Tennessee, and on that basis it is costing that State 
more to bury people dying from tuberculosis than expense for its entire health program 
including tuberculosis and all the other diseases.” 

January, 1940 



Report of Case 

Rushford, Minnesota 

ECKEL’S diverticulum was first described by 
Johann F. Meckel in 1809 and 1812 and accord- 
ing to Gray’s Anatomy it is described as follows: 

“Meckel’s diverticulum consists of a pouch which 
projects from the lower part of the ileum in about 2 
per cent of subjects. Its average position is about one 
meter above the ileocolic valve, and its average length 
about five centimeters. Its calibre is generally similar 
to that of the ileum and its blind extremity may be 
free or may be connected with the abdominal wall or 
with some other portion of the intestine by a fibrous 
band. It represents the remains of the proximal part 
of the vitelline duct, the duct of communication be- 
tween the yolk sac and the primitive digestive tube in 
early fetal life.” 

Roy Shannon in the Archives of Pediatrics, Decem- 
ber, 1928, said: 

“According to Fitz, in the newborn it lies about 
12 inches above the ileocecal valve, while jn the adult 
this is increased to about three feet. The diverticulum 
may be long or it may be short, or may or may not 
have a separate mesentery; or may be contained with- 
in the mesentery of the small bowel. It may be fixed 
at its distal extremity to the umbilicus or to any 
structure within the abdominal cavity. It is often 
conical in shape with the base large, even approaching 
in size the diameter of the small bowel at this point. 
According to Christopher, it usually has the same coats 
as the intestine, the mucous coat containing Lieber- 
kuhn’s glands and Peyer’s patches. This same writer 
quotes Ascoff as saying that it may contain gastric 
glands, ciliated epithelium and even pancreatic anlage. 
A certain number of Meckel’s diverticula are associated 
with deformity of the umbilicus, and marked retrac- 
tion of the naval therefore always brings to mind this 

The incidence of Meckel’s diverticulum, according 
to the literature on this subject, has changed consider- 
ably in the past forty years. The earlier authors quoted 
the incidence as 1 per cent, while the literature written 
the last five years, which has been quite extensive, 
quotes the incidence as 2 and 3 per cent. This change, 
I think, can be fairly stated as due to the fact that 
the surgeon has become more and more diverticulum 
minded. Meckel’s diverticulum is apparently found 
more often in males than in females, the ratio being 
about 2:1. : 

Case History 

The patient, male, sixty-two years old, was born in 
Fillmore County, Minnesota, of Norwegian parents 
and for the last twenty-six years has been a rural mail 

*Read before the meetin 
Association, New Ulm, 


of the Southern Minnesota Medical 
innesota, September 18, 1939. 

Previous history —At the age of fourteen years, or in 
1891, the patient was taken rather suddenly with severe 
“abdominal cramps” as he remembers the symptoms and 
also with vomiting. The nearest doctor was sent for, 
but he was twelve miles away and twelve hours elapsed 
before he could get there. By this time the symptoms 
were pretty well over. He was left with considerable 
soreness over the right side of the lower part of the 
abdomen which he remembers very well to this day. At 
the age of nineteen years he had pleuropneumonia 
which was followed by an empyema. He was operated 
on at a La Crosse, Wisconsin, hospital. He was in the 
hospital for five weeks and recovered fully. Since 
this date, 1896, he never suffered any illness of im- 
portance, but in his own language had had a day or 
two with a severe “bellyache” which came on at inter- 
vals of from two to five or six years without any 
particular reason and always centered in the right lower 
quadrant. He never passed any blood to his knowledge 
but sometimes he would have some bowel disturbance, 
and there was always some tenderness which lasted 
for a day or longer. 

Present history.—About three days previous to April 
28, the date I was called, the patient began having 
an attack similar to those described previously and 
differing only in that there was no let-up and every 
day the pain was just a little bit worse. He kept right 
on making his usual rural mail route trips and in the 
afternoons would busy himself preparing an acre of to- 
bacco ground. During the afternoon of the third day 
of this attack he pitched fertilizer. About 5 o’clock he 
got’ some very sharp stinging pains and reached home 
with considerable difficulty. He was nauseated but did 
not vomit. I was called about 7 o’clock in the evening. 

Examination.—The patient was a large robust man, 
5 feet 11 inches tall, and his weight was 190 pounds, 
which had been his usual weight for many years. His 
temperature was 101.4° F. and the pulse 96. Heart and 
lungs were normal. The abdomen was slightly dis- 
tended. There was a great deal of tenderness over 
the entire abdomen and a marked amount of rigidity. 
This tenderness and rigidity were much more evident 
over the right lower quadrant. Every few minutes he 
would say, “There comes another of those terrible 
sharp pains,” and the abdomen would become very 
rigid. The urine was negative and the blood count 
showed over 16,000 leukocytes. 

An extensive peritonitis was quite evident, probably 
due to a ruptured appendix, and an immediate opera- 
tion was advised. The patient was taken to a La 
Crosse, Wisconsin, hospital and was operated on about 
10:30 p. m. 

Operation.—A split muscle opening was made and a 
large amount of dark watery fluid presented itself first. 
The appendix was easily found and showed no signs 
of either present or former inflammation. Upon in- 
vestigation it was found that the seat of the trouble 
was toward the median line and could not be reached 

(Continued on Page 66) 



(Continued from December issue) 

The directories for 1867 give the list of physicians in Minneapolis and Saint 
Anthony as follows: 

Minneapolis Saint Anthony 
Ames, A. E. and A. A. Huntington, T.,R. Dibb, Wm. D. 
Butler, L. Leonard, W. H. Jewell, Geo. P. 
Bowen, J. S. Linn, J. J. Jewell, L. P. 
Elliot, A. F. Ortman, A. Johnson, A. E. 
Elliot, J. S. Shippen, Edward McKay, John 
Evans, O. J. Snell, E. Stockton, E. A. 
Hatch, P. L. Weisel, W. Stockton, E. H. 
Hill, N. B., and Lindley, A. H. Wheat, J. N. Rankin, S. F. 

Daily Tribune, November 28, 1868: 

“At a meeting of the Union Medical Society held last evening at the office of Drs. Hill 
and Lindley the following named officers were chosen for the year: President, A. E. 
Ames; Secretary, N. B. Hill; Librarian, A. H. Lindley. The Society is at present com- 
posed of the following named members: Drs. A. E. Ames, G. H. Keith, W. D. Dibb, 
A. Ortman, N. B. Hill, O. J. Evans, W. F. Hutchinson, J. J. Linn, C. A. McCollom, 
H. A. DuBois, C. G. Goodrich, H. H. Kimball,‘C. J. DuBois. The next regular meeting 
will be held on the first Saturday in December at the office of Dr. W. F. Hutchinson.” 

Some time in the course of this year, during Dr. Ames’ absence in California, 
Dr. N. B. Hill was made president of the society, but I could find no record of 
the occasion in the daily papers. 

Daily Tribune, Dec. 4, 1868: 

“At a meeting of the Union Medical Society last Tuesday it was unanimously agreed 
that in future all bills should be presented for payment within sixty days after the termina- 
tion of treatment of a case. Mr. J. C. Hall has been chosen collector for the Society.” 

Daily Tribune, March 20, 1869: 

“The regular meeting of the Union Medical Society will be held this evening at the 
office of Dr. W. F. Hutchinson in Centre Block.” 

No account of the April meeting has been found. 
Daily Tribune, May 16, 1869: 

“At the annual meeting of the Hennepin County Medical Society the following officers 
were chosen for the following year: President, A. E. Ames; Vice President, N. B. Hill; 
Secretary, W. F. Hutchinson; Librarian, O. J. Evans. The following committees were 
appointed: Ethics—Goodrich, Linn, Ortman. Publications—Lindley, McCollom, Kimball. 
A special committee was also appointed to assist the Health Officer in the discharge of his 

January, 1940 


Evidently the change in name of the society occurred between March 20, 

1869 and May 16, 1869. 
Daily Tribune, June 12, 1869: 

“A special meeting of Hennepin County Medical Society to be held this evening at the 
office of Dr. Hutchinson. All members are requested to be present. W. F. Hutchinson, 

Daily Tribune, Sept. 18, 1869: 

“In September, 1869, Minneapolis was visited by Sir Henry Holland, the eminent English 
physician [eminent he certainly was if his experience was as extensive as is indicated in 
the notes that follow in the Tribune]. He was consulted in Napoleon’s last illness, at- 
tended Mrs. Thrale (Dr. Johnson’s friend), was the physician and friend of the poets, 
Campbell, Moore and Rogers, as_ well as of Madame D’Arblay, Joanna Baille, Lord 
Brougham, Sydney Smith, Macaulay and others. He was present at the deathbed of 
Channing and knew Madame de Staél, Talleyrand, Byron and Sir Philip Francis.” 

Daily Tribune, June 8, 1870: 

“Hennepin County Medical Society held its annual meeting yesterday. It was chiefly 
a business meeting. A new constitution and by-laws was adopted, modeled after that of 
the State Society. The election of officers for the ensuing year resulted as follows: 
President, A. E. Ames; Vice President, N. B. Hill; Secretary, Geo. H. Keith; Treasurer, 
O. J. Evans. The president appointed the following standing committees: Ethics—C. G. 
Goodrich, A. H. Lindley, J. J. Linn. Membership—M. D. Stoneman, W. G. Hutchinson, 
H. H. Kimball. Dr. Kimball was appointed to prepare and read an essay at the next 
regular meeting.” 

This is the first reference I have found in the papers to any program, though, 
according to Dr. Phillips, it was by no means the first paper. 
Daily Tribune, Aug. 2, 1870 (Tuesday) : 

“Regular meeting this afternoon at two o’clock at the office of Drs. Hill and Lindley.” 

It was evidently at this meeting that Dr. Ames presented the paper referred 
to at the beginning of this chapter. According to his statement the society had 
enrolled up to that date thirty-nine members, of whom four had died and seven- 
teen had moved away, leaving eighteen members at that time in the society. The 
four who died were the following: 

Dr. C. W. LeBoutillier, who was a graduate of the University of Paris, came 
to St. Anthony in 1854, and died in 1863. He is referred to elsewhere in this 

Dr. E. Denny Olds, who was made a member of the Society on December 
17, 1855, later left Minneapolis, and went to Mexico, where he was assassinated 

in 1858. 

Dr. F. C. Lowenburg, who was a graduate of Leipsig University, came to 
St. Anthony in 1855, and died in 1864. 

Dr. J. White, who was a graduate of the Medical College of Brunswick, 
Maine, came to St. Anthony in 1853, and died in 1856 at thirty-three years of age. 

The list of those who had moved away is as follows, and is specially interest- 
ing as showing how widely distributed these former members of the society had 
already become in 1870: 

Dr. John H. Murphy came to Saint Anthony in 1849. After the close of the 
war he took up his residence in Saint Paul, where he still resided. 

Dr. J. W. Wheelock had moved to and then resided in Clearwater, Minnesota. 



Dr. Charles L. Anderson came to the city in 1853, and in 1861 moved to 
Carson City, Nevada, where he remained two or three years. In 1870 he was 
residing in Santa Cruz, California. 

Dr. J. Wilkin had remained in Minneapolis but a short time, and his address 
in 1870 was unknown. 

Dr. W. H. Gould lived for many years in Saint Anthony and practiced 
dentistry. In 1870 he resided in Boston, Massachusetts. 

Dr. M. R. Greely came to Minneapolis in 1857, and was at this time residing 
in South Weymouth, Massachusetts. During the Civil War he served as assist- 
ant surgeon to the 3rd Minnesota Regiment of Infantry. 

Dr. D. C. Ayres remained about two years. His address in 1870 was not 

Dr. Henry Gilbert remained in Minneapolis about one year, and in 1870 was 
living in Brooklyn, N. Y. 

Dr. R. H. Ward was in Minneapolis but a short time, and devoted his atten- 
tion to microscopy. He was then residing in Troy, New York. 

Dr. Albert A. Ames was a graduate of Rush Medical College and practiced 
medicine in the city about three years, and was later surgeon in the Seventh 
Regiment. He left for California in 1868, and in 1870 was living in Portland 
and was editor of the Portland Daily Bulletin. 

Dr. A. Judson Grey was in the cities one year, and in 1870 was residing in 
Providence, R. I. 

Dr. J. J. Bowen was living at La Grange, Indiana. 

Dr. H. A. DuBois was an active member of the society about one year. In 
1870 he was practicing in San Rafael, California. 

Dr. C. J. DuBois was a member of the society for a short time and in 1870 
was living in the Island of Capri. 

Dr. John H. Churchill came to Saint Anthony for his health, and later removed 
to New York City, where he resided in 1870. 

Dr. Edward A. Barden remained for a time in Minneapolis, but moved 
later to Alexandria, where he resided in 1870. 

Dr. James A. Baldwin remained in the cities but a short time, and then moved 
to Kansas City, where he was practicing in 1870. 

Toward the conclusion of his article, Dr. Ames writes as follows, evidently 
referring to himself: 

“One is here today who saw this locality in its infancy; then it was listening to the 
voice of praise of the great organ of nature. That member took an active part in the 

organization of this Society, and has given to its aid and support: since it was formed. 
He will soon go out and you will write up his record.” 

The above appears a very modest statement to be made by one who had 
founded the society, and had served it so long and so prominently. At some 
time previous to the death of Dr. Ames, at the request of his children, he wrote 
his biography in a little booklet, which afterwards was in the keeping of Mrs. 

In looking through this book it is notable that Dr. Ames refers infrequently 
and very briefly to his medical experiences, but apparently took great pride in his 
relation to the Masonic Brotherhood, to the founding of the Horticultural 
Society, and to the political offices which he had held. Probably he assumed 
that his very great interest in medical matters would be taken for granted. 

January, 1940 


He was the first president of the permanently organized Old Settlers organ- 
ization (announced in State Atlas of January 16, 1867), was foreman of the 
Grand Jury in the first court held by Judge Meeker after the organization of 
Hennepin County, and was president of the Minneapolis Farmers Club, and of 
the Hennepin County Bible Society. In November, 1851, Dr. Ames called the 
Masons together and subsequently established Cataract Lodge, and was its Grand 
Master on February 3, 1853, and was also subsequently Grand Master of the 
Grand Lodge of Minnesota, and was one of the ruling elders of the First Pres- 
byterian Church organized here. 

The Tribune Directory of Minneapolis and Saint Anthony gives the follow- 
ing list of physicians, 1871-1872: 

Allopathic Eclectic 
Ames, A. E. Blecken, Charles H. 
Cummings, Ralph W. Elliot, A. F. 
Evans, O. J. Elliot, J. S. 
Goodrich, C. G. Haynes, S. C. 
Hammond, J. H. Kimball, B. W. 
Hill, N. B., and Lindley, A. H. Loar, Jacob 
Hutchinson, W. F. Stanton, W. B. 
Johnson, Geo. B. a ey 
Kimball, H. H. an, m Vv. 
Linn, J. J. Homeopathic 
McLain, J. L. Goodwin, D. M. 
Phillips, E. Hatch, P. L. 
Rouse & Johnson Humphreys, Otis M. 
Teengs, W. J. Huntington, T. R. 
Chute, S. H. Leonard, W. H. 
Johnson, A. E. Penneman, W. A. 
McBain, A. E. Miscellaneous 

Ortman, A. Etzler, C. H. 

Rouse, W. H. Hale, Miss Mary 
Stockton, E. H. Reinhold, F. K. 
Townsend, G. F. Smith, James A. 

The Tribune Directory for 1873-1874 says: 

“Hennepin County Medical Society was organized in 1855 and is in an interesting and 
satisfactory condition. Its president is the very oldest physician and surgeon now prac- 
ticing in Hennepin County and a gentleman well worthy of the honor of the position. 
Meetings are held every two weeks at the office of one of the members. Officers are: 
A. E. Ames, President; N. B. Hill, Vice President; Geo. B. Johnston, Treasurer; O. J. 
Evans, Secretary.” 

The Daily Tribune, Friday, June 6, 1874: 

“The Hennepin County Medical Society met at Dr. Ames’ office and after reading the 
minutes of the last meeting elected Drs. Salisbury and Bedford as members of the Society, 
after which the election of officers took place. Dr. A. E. Ames was unanimously elected 
president; Dr. Charles Simpson, vice president. Dr. C. C. Clark, secretary; and Dr. Bed- 
ford, treasurer. Committee on Ethics—Goodrich, Lindley, Johnson. 

Rogers, Phillips. Printing—Smith, Salisbury and Ortman.” 

Campbell and Davison’s Directory gives a list of officers for the year differ- 
ing decidedly from this, and being practically identical with those of the year 
before. Here is the list: A. E. Ames, president; N. B. Hill, vice president; 
O. J. Evans, secretary. 

Dr. A. E. Ames died on September 23 of this year (1874) and the following 


January, 1940 


history of his life is taken partly from a contemporary account in the Tribune 
and partly from Minnesota Biographies: 

Dr. A. E. Ames was born in Colchester, Vermont, in 1814. His parents 
were poor and as a child he was so sickly that he was not expected to grow up. 
Later the family moved to Orwell, Ohio, and in the common schools of these 
two places he acquired his education. While teaching. in 1834 he met Miss 
Martha Pratt, whom he married in 1836, and a month after his marriage he 
went to Chicago, then a town of 3,000, mostly half-breeds. From there he 
followed the Indian trail west to a place later called Amesville, now Garden 
Prairie. Here he took a claim of 160 acres, and built a log house. In April, 
1837, he returned to Chicago and worked for $52 a month at brick-making. On 
November 25, 1838, he walked to Vandalia, then the capital of Illinois, and was 
there introduced to Alex. Field, Secretary of State, by Stephen A. Douglas, and 
was appointed Deputy Secretary of State and also Private Secretary to Governor 
Carlin ; and in these positions he earned $6 a day. In 1839 he was again Deputy 
Secretary of State, Secretary to the Governor, and chief of the staff of clerks, 
earning thus $10 a day. 

In 1840 he began to attend medical lectures at Rush, and in 1841 he studied 
with Dr. Maloney of Belvidere. At this time he was in very poor health. 
He was elected a member of the House of Representatives of Illinois in 1842. 
In March, 1843, he was made postmaster at Belvidere. In July, 1844, he resigned 
and moved to Roscoe, Illinois, where he began the practice of medicine, and was 
made postmaster December 16. In February, 1845, he graduated from Rush. 
In 1849 he was elected State Senator, and made paymaster general on the 
Governor’s staff. He started three Masonic lodges in Rockton, Roscoe, and 
Rockford, Illinois. In October, 1851, he left Roscoe for Saint Anthony, going 
by wagon from Roscoe to Galena, thence by the famous Dr. Franklin No. 1 
to Saint Paul. He secured a permit to make a claim on the Reserve, now 
Minneapolis, and in November, 1851, built his claim cabin on the lot now occu- 
pied by the Court House. Immediately following his arrival he entered into 
a partnership with Dr. Murphy of Saint Anthony. In the spring of 1852 he 
brought his family from Illinois. The same year he was made contract surgeon 
at Fort Snelling and in October was elected to the territorial legislature. Octo- 
ber 10, 1854, he was made probate judge. In January, 1856, he was appointed 
postmaster. In 1857 he was chairman of the committee on school lands and 
university, and in 1860 was a member 6f the State Normal school board, serving 
during the organization of that system. In 1861-1862 he delivered a course 
of lectures before the high school of Minneapolis on anatomy and hygiene, 
being thus, doubtless, the first to give public instruction in Minnesota on a med- 
ical subject. In 1852 he went east to visit the hospitals. In 1868 he again 
went east, and then to California, where he had some idea of remaining, offering 
his home and property here for sale, but returned. “He was always actively 
interested in all educational matters. In fact, he was never idle and scarcely 
ever allowed to remain in private life. He was a member and almost always 
a leader in the medical society.” This is almost the only reference in the above 
accounts to his medical life, though, curiously enough, he was probably presi- 
dent of Hennepin County Medical Society practically continuously from its 
inception in 1855 to his death in 1874, almost twenty years. 

Dr. Ames was a member of the American Medical Association, had been 
president of the Alumni of Rush Medical College, and was much devoted to 


his profession, to which he had given many years of hard labor. In a memorial 
notice given in the Transactions of the Minnesota State Medical Society for 
1875, Dr. O. J. Evans says of him: “The most prominent probably of Dr. 
Ames’ characteristics was that most commendable of all the graces—charity. 
During an acquaintance of nine years, I think I never heard him speak an ill 
word of any person.” 

On February 5, 1875, occurred the death of Dr. Nathan B. Hill, who, though 
not one of the founders of the Hennepin County Medical Society, was one of its 
earliest and most influential members. Dr. Hill was born in Randolph County, 
North Carolina, on May 13, 1817. After graduating from Haverford College, near 
Philadelphia, he entered mercantile life with his father, but later decided to 
enter medicine, and attended Jefferson Medical College during the session of 
1842-1843. In May, 1845, he married, and in the winter of 1847-1848 moved 
to Cincinnati, where he attended lectures at Ohio Medical College and graduated 
in 1848, after which he returned to North Carolina and practiced until 1861. 
He was a strong anti-slavery man and was interested in the underground route 
for the freeing of slaves, to the great detriment of his practice and danger of 
his life. In May, 1861, in company with Dr. Lindley, he came overland to 
Indiana, crossing the Ohio River at Louisville, and in September came to Min- 
neapolis, where he and Dr, Lindley formed a partnership which continued to 
the death of Dr. Hill. At the time of his death he was president of the State 
Medical Society, the annual meeting of which he had called to order but a 
few hours before his death. His address was read by Dr. Hewitt. Dr. Hill 
was a devout member of the Society of Friends, and was a man of fine 
susceptibilities, generous impulses, and of the highest integrity, and, with his 
natural ability, his superior education and kindly ways, he became a very 
prominent physician in this community. 

There are many others among the older physicians of whom special mention 
might be made did the limits of this paper permit, but it will not be considered 
an invidious distinction, I think, if I refer particularly to the following: 

Dr. C. W. LeBoutillier was a native of the island of Jersey, emigrated to 
this country about the year 1850 and settled in Iowa. In 1853 he came to 
Saint Anthony and commenced the practice of medicine, and soon became 
known as an honorable, skillful and successful physician. On April 29, 1861, 
he was commissioned as assistant surgeon in the lst Minnesota Infantry, and 
the State Atlas of July 24, 1861, carried the news of his death at the battle of 
Bull Run, and gave an account of his life and work; but a telegram of August 
16 announced that he was alive and well, had elected to remain with his 
wounded and was a prisoner in Richmond. The ten federal surgeons in Rich- 
mond were divided into two groups and Dr. LeBoutillier was placed in charge 
of one group. In this position his assiduous care and kindness to the wounded 
won grateful praise from those to whom he ministered. The Pioneer of 
September 17, 1861, contained a letter from him, dated August 15, and described 
some of his surgical experiences among the soldiers. Paroled, he returned to 
Minnesota, where he remained with his family until the time of the Indian 
outbreak, when he became surgeon of the Ninth Regiment, October 10, 1862, 
and went to Saint Peter, where he remained on duty until his death April 3, 
1863, aged about thirty-seven. He was buried with military honors in Saint 
Anthony. Dr. LeBoutillier left the record of an honorable and _ successful 
physician, a good citizen and a brave soldier. He seems to have been held in 
particularly high esteem by his fellow practitioners. 



Dr. A, Ortman located in Saint Anthony in 1857, was later active as a city 
and county physician and was one of the oldest members of the State Medical 
Society, of which he was made an honorary member without dues. He was a 
very excellent man, notable for his high ethical standards and kindly disposition. 

Owing to the development of cataracts, he became blind several years before 
his death. 

Dr. A. H. Lindley was born in North Carolina in 1821. He came to Min- 
neapolis in 1861 and began practice with his brother-in-law, Dr. N. B. Hill. 
He was a well educated, reliable, conscientious and successful physician, promi- 
nent in the sanitary interests of the city, and its first health officer. As a result 
of judicious investments he became very wealthy, and died in Minneapolis at 
the advanced age of nearly eighty-four years. 

Levi Butler came to Minnesota in 1855 from Indiana. He was married and 
had practiced ten years before his arrival. He had a moderate fortune and 
became interested in educational, moral and temperance activities. In 1861 he 
recruited a company of volunteers, and was made captain and afterwards surgeon 
of the Third Regiment of Minnesota Infantry, of which his company was a 
part. He was commissioned November 11, 1861, and went south. When his 
regiment surrendered at Murfreesboro he returned to assist in the suppression 
of the Indian outbreak. He later rejoined the service and was in campaigns 
in Kentucky and Louisiana, He resigned and came home in September, 1863. 
Dr. Butler was one of the large number of tuberculosis patients who came to 
Minnesota in search of health, and it was on account of a return to his old 
trouble and a condition of protracted ill health that he was discharged in 1863. 
In the following year he was appointed by the governor to visit southern camps 
and hospitals to improve sanitary conditions and relieve the suffering of sick 
Minnesota volunteers. At the return of peace he did not engage in practice 
but went into the lumber business with T. B. Walker and H. W. Mills, under 
the name of Butler, Mills and Walker. He died in 1868. 

Dr. William H. Leonard was born in Mansfield, Connecticut, December 2, 
1825, and graduated from Yale Medical School in 1853, and settled in Min- 
neapolis in 1855, The initial meeting of the Hahnemann Medical Society was 
held in his office and he was the first president of that organization. He was 
successively assistant surgeon and surgeon to the Fifth Minnesota Regiment of 
Infantry, and served from November 22, 1862, to September 6, 1865, and 
was discharged with his regiment. He died in the city of Minneapolis, April 
9, 1907. 

Dr. A. A. Ames was graduated from Rush Medical College in February, 
1862, and shortly after began practice in Minneapolis. In August, 1862, he 
helped to raise Company B, Ninth Minnesota Infantry, himself and brother 
enlisting. The same month he was commissioned assistant surgeon to the 
Seventh Minnesota and departed for duty on the frontier where the Indian 
war was raging. In the fall of 1863 he went south and engaged in field service 
until the end of the war and was mustered out at Ft. Snelling August 18, 1865. 
In March, 1868, he went to California and engaged in newspaper work. In 
September, 1874, he was summoned to the death-bed of his father and, in 
company with Dr. Salisbury, took up his father’s practice. A card in the 
Minneapolis Daily Tribune of May 25, 1867, announced that Dr. A. A. Ames 
will hereafter attend only surgical cases, diseases of a surgical nature and 
office practice, the first instance of surgical specialism I have found. He later 

January, 1940 


entered politics, and through his efforts the Minnesota Soldiers’ Home was 

Dr. George Keith was born in 1825 and graduated from the Medical College 
at Woodstock, Vermont. After living in New York two years he decided to go 
to Minneapolis, where he had two brothers. In Minneapolis he began the 
practice of dentistry and medicine, but devoted his attention almost wholly to 
the former. He was a member of the First State Legislature of 1858-1859. 
During the Indian war of 1862, he was surgeon to the expedition sent to the 
relief of Ft. Abercrombie. In 1863 he was made provost marshal for the 
Second District of Minnesota, a position he retained until the end of the war. 
He resumed practice and was made postmaster in 1871 and reappointed in 1875. 

Dr. O. J. Evans was born in New York in 1840, and graduated from the 
Albany Medical College of New York, and went immediately to the front as 
assistant surgeon to the Fortieth New York Volunteers. The following summer 
he became surgeon to the regiment and was detailed on the operating staff of 
the brigade, which duty he discharged until the end of the war, when he was 
made Chief of the Medical Department of Farnsville, Virginia, where there 
was a cluster of Confederate hospitals filled with Union and Confederate 
wounded. Of these hospitals he had general supervision. He took part with 
his regiment in the Grand Review in 1865 in Washington, and was mustered 
out some time later. In September, 1865, he came to Saint Peter, and ten weeks 
later removed to Minneapolis where he remained in practice up to his death 
on October 17, 1916. He served two terms as city health officer of Minneapolis, 
was a member of the Board of Education, and a member of the legislature, 
and was largely interested in business as well as in professional matters. 

There are many other members of the profession whose experience in the 
war preceded their arrival in Minneapolis, and these include, among others, 
Drs. Abbott, DuBois, Phillips, Goodrich, and others. 

Dr. C. G. Goodrich came to Minneapolis in 1868, and at once entered on an 
extensive practice. He was wealthy when he came, and invested largely in 
real estate. He was a modest, truthful, faithful, and generous man and was the 
first elected president of Hennepin County Medical Society following the death 
of Dr. Ames. 

Daily Tribune, June 5, 1875: 

“The fifth annual meeting of Hennepin Society was held at the office of Dr. Evans in 
his new block on Bridge Square last evening. Nearly all the members were in attendance, 
the meeting being particularly important and peculiarly interesting. Drs. R. J. Hill and 
A. H. Lindley were duly elected and installed members, after which the election of the 
officers for the ensuing year took place. The following was the result: President, C. G. 
Goodrich; Vice-president, O. J. Evans; Secretary, A. S. Salisbury; Treasurer, W. C. 
Bedford. At the close of the election Dr. Simpson, the retiring president, made a few 
apt and timely remarks as did also Dr. Evans, who, in the absence of the president in 
the east getting married, acted as presiding officer. 

“The fee bill for the Society was discussed and slightly amended, among other changes 
it being resolved to charge an invariable fee of $25 for holding a post-mortem examination. 

“Dr. Clark was appointed essayist for the next meeting and Dr. Simpson for the one 
following, after which the meeting adjourned.” 

The above note on post-mortems may have some connection with the 
following very unpleasant article which had appeared in the Tribune of De- 
cember 3, 1872: 



“The Minneapolis Post-Mortem Club—The Club met today pursuant to adjournment, 
Dr. A. S. S. Jones in the chair. Dr. D. M. Phule, Secretary, read the minutes of the 
last post-mortem. Committee on Mortality reported two deaths since last meeting. 

“Dr. I. M. Some introduced the following resolution: That the H. O. G., this city, 
be instructed to notify this Club of all deaths occurring within the limits of the city. 

“And, resolved that for the benefit of science this Club shall immediately take possession 
of the bodies and post-mortem the same with as little delay as practicable, that being 
the only method of arriving at a correct diagnosis in any case. 

“And, resolved that with the sole object of enlightening the benighted public upon 
scientific medicine, the proceedings of this Club be published in the daily papers in case 
they do so gratuitously. * * * 

“Gentlemen, you befog your own brains. Every post-mortem made by this Club since 
the organization has ventilated your own ignorance. The people ask for a little more 
knowledge of disease before death and fewer post-mortems; for less advertising and 
less braggadocio and more careful, earnest practice. The disgusting frequency of post- 
mortems in this city is a disgrace to the profession, which the people will ere long rebuke.” 

It was about this time that Dr. Tanner, an herb doctor of Minneapolis, 
acquired widespread notoriety through his fasting demonstration, which ap- 
pears to have been an advertising scheme carried on in Market Hall at Hennepin 
and First Avenue South. I have not located the exact date or description of 
Tanner’s activities. After the close of his fasting exhibition he went on the 
lecture platform, and seems to have disappeared from Minneapolis. 

(To be continued in the February issue) 


If the average case of minimal tuberculosis admitted to the sanatorium stays eight 
months, and the average case of moderately advanced tuberculosis stays twenty-three 
months, how much could be saved by early diagnosis? 

In Connecticut where it costs about $1,000 to keep a patient in the state sanatorium for a 
year and where only 10 per cent of the admissions are in the minimal stage, it is esti- 
mated as hundreds of thousands of dollars by the Connecticut State Tuberculosis Com- 

Unfortunately, the situation in Connecticut is not unique among the states. Every- 
where admissions to sanatoria are largely in the later stages, and everywhere the result 
is a longer hospital stay—a tragic waste whether human suffering, disability or money is 

January, 1940 

President, Minnesota State Medical Association 


President’s Letter 

M EDICAL science today has attained its highest development in world history. Never 
before has the physician been able to do so much to aid the sick, injured or disabled. 

Our own country leads the world in sickness prevention, in lowering the incidence of 
preventable disease, in reduction of time loss due both to injury and disabling disease, and 
in lengthening the average span of life. These things have been accomplished, in large 
measure, by our American system of medical practice which allows for freedom of action 
by the doctor and also provides the stimulus of competition. 

These facts are everywhere acknowledged and, in spite of them, some of our people 
would do away with the American system of medical care and put in place of it some 
form of government controlled medicine, European style. Among those who clamor loudest 
for a change are the politicians who regard it as a source of votes and the social workers 
who see in it a means of obtaining unlimited medical care for the very poor, not realizing 
that it also means a cheap and inferior service. 

We must remember that the European systems had their beginning with Bismarck, 
who needed votes to defeat the opposing political party in 1883; and that Lloyd George 
had the same objective when he started the Panel system in England in 1911. 

We must remember that 1940 is election year in the United States, also, and we must 
watch out for comparable attempts to change our own system in the coming campaign. 

Dr. Mountin, assistant to Surgeon General Parran of the United States Public Health 
Service, expressed his confident belief, on a recent visit to Minnesota, that the next Con- 
gress would pass a health bill. The Wagner bill of last year was a trial balloon only, he 
said ; but even that bill would have passed if the usual pressure had been applied. Physicians’ 
organizations were opposed to that bill and would be opposed to any measure drawn up 
on similar lines, not only because of the exorbitant costs but because they do not believe 
such a bill would aid good medical practice. 

There is no doubt that medical practice has declined in efficiency wherever the govern- 
ment has been in control; that preventable diseases are increasing in prevalence in European 
countries; that time loss from disease and injury has grown; that medical services are 
poor in quality and that there is little incentive for the physician to study and improve him- 
self. Not only is the service in general poor, but the doctors themselves are underpaid, 
overburdened with petty detail and forced to spend their time in making interminable 
reports. They are also forced too often to perjure themselves in making allowances for 
disability in order to retain their panel clientele and they must curry favor with politicians 
in the government positions. If another health bill is introduced this year in Congress it 
must be examined closely. If it is the Wagner bill of last year in new dress or a similar 
measure—every doctor must exert his utmost effort in time, money and public propaganda 
to defeat it. 

BertrAM S. ApaAms, M.D., President 
Minnesota State Medical Association 

January, 1940 55 




Published by the Association under the direction of its Editing 
and Publishing Committee 

Putte F. Donoxnve, Saint Paul Tuomas G. CLEMENT, 
E. M. Hames, Saint Paul O. W. Rowsg, Duluth 
H. W. Meverprnc, Rochester T. A. Pepparp, Minneapolis 
Wattman Watters, Rochester C. B. Wricut, Minneapolis 

C. L. Opprcaarp, Crookston 
B. O. Mork, Jr., Worthington 


Cart B. Drake, Saint Paul, Editor 
W. F. Braascu, Rochester, Associate Editor 
Giisert Cottam, Minneapolis, Associate Editor 

Annual Subscription—$3.00 Single Copies—$0.40 

Foreign 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 accompany order. 

Display advertising rates on request. 

Address all communications to Minnesota Medicine, 2642 Uni- 
versity Avenue, Saint Paul, or Suite 308, National Bldg., 
Minneapolis. Telephone: Nestor 2641. 

J. R. Bruce 

Volume 23 JANUARY, 1940 Number 1 


ITH the arrival of a new year comes the 
urge to reflect on the past year and to an- 
tic‘pate the year to come. 

World War II has been in progress for four 
months with strange alliances and war activities 
limited to the sea in a type of warfare directed 
toward subjugation of the enemy through eco- 
nomic pressure. A prolonged conflict can only 
prove disastrous in its political, economic and 
moral aspect to both winner and loser. 


While our attention has been shifted from do- 
mestic to foreign affairs, and we can feel truly 
thankful that as a nation we are at peace with 
the world, we have our own economic problems 
which are vital in their importance. 

On the pretext of emergency need Congress 
has delegated its powers to the executive branch 
of the government, which has been nothing loath 
to apply experimental methods, which have large- 
ly been contrary to established principles of 
finance and the proper sphere of governmental 
activities. As a result every type of business has 
found the government a competitor. Proposals 
such as the Wagner Bill have emanated from 
governmental circles, involving the expenditure 
of millions, yes billions, of the taxpayers’ money 
for the development of governmental activities in 
medical care. As preparation for such activities 
an attempt was made by the Department of Jus- 
tice to discredit the medical profession. The re- 
fusal of Congress to pass the Wagner Bill at the 
last session offered proof of the tendency of 
Congress to reassert itself. We have reason to 
believe, however, that some proposal resembling 
the Wagner Bill will again be introduced in the 
Congress just convened. It behooves the medical 
profession to make available the facts regarding 
medical needs of this country and the type of 
medical service which will best serve the country. 
The A.M.A. has published its platform, so the 
public knows our point of view. The National 
Physicians’ Committee for the Extension of 
Medical Service affords the medium for dissem- 
inating information and deserves the support of 
the entire medical profession. 

Medical care is one of the important items in 
the life of any individual. Numerous European 
governments have provided various types of 
medical care for their citizens, none of which 
would be acceptable to American citizens. We 
fear that in the coming Republican and Demo- 
cratic conventions the temptation to include a 
party platform plank providing certain govern- 
mental medical care will be too strong to resist. 
If one party does so the other is likely to go the 
first one better. The advisability of any such pro- 
cedure should be decided on its merits and the 



proposal should not be made a political issue in 
the coming election. 

MINNESOTA MEDICINE wishes to take this op- 
portunity of expressing to the officers and mem- 
bers of the Association its appreciation of the co- 
operation manifest the past year and in pledging 
its continued support of all of the activities of 
the Association the coming year, and to wish all 

our members a prosperous and Happy New 


HE Center for Continuation Study at the 

University of Minnesota is unique. So far as 
we know there is no similar center anywhere in 
the country. The beautifully equipped headquar- 
ters building in the nature of a small first class 
hotel with moderate prices, the concentration of 
courses and the personnel of the instructors pro- 
vides one desirous of adding to his knowledge in 
his particular field, the opportunity for doing just 
that at a minimum of time and expense. 

A generation ago physicians found it worth 
while to take a trip to Vienna for a few weeks 
of postgraduate study. Then there was little op- 
portunity in this country to obtain postgraduate 
work of high order in a short space of time. 
Now there is little or no opportunity abroad and 
teachers and material in this country are unsur- 

That the Continuation Center is dispensing 
postgraduate study opportunities of high order is 
attested by the enrollment so far. The program 
of the winter quarter appears in this issue. Full 
use will doubtless be made of the opportunity af- 
forded general practitioners especially to obtain 
instruction in subjects of special interest. 


b bors appearance of the first issue of the Bul- 
letin of the Minnesota Medical Foundation 
in November, 1939, is evidence of beginning ac- 
tivities of the Foundation. In November, too, 
the first meeting of the Advisory Committee and 
others interested in this new organization was 
held on the University Campus and helped the 
Committee on Organization to draw up By-Laws. 

The Foundation, as was stated in an editorial 
in our November number, is an organization of 

January, 1940 

medical alumni students and friends of the med- 
ical school of the University of Minnesota, whose 
purpose is primarily to further medical education 
in undergraduate, postgraduate and research ac- 

The Bulletin will keep alumni posted regarding 
the activities of the medical school and the 
alumni. This, however, is only one activity of the 
Foundation. Contributions are being received, 
the income from which will be used to provide 
scholarships, loans to students and the means 
for carrying on medical research. Contributors 
of $1,000 or more will be designated patrons, 
while life membership can be obtained through a 
contribution of $100. A substantial source of 
support, however, wil! come from annual mem- 
bership dues which have been set at $10. While 
the organization provides the mechanism for 
the devotion of large bequests to medical prog- 
ress in Minnesota, a large membership is ab- 
solutely necessary for its success, 

Memberships may be obtained from the office 
of the Minnesota Medical Foundation, 132 Med- 
ical Science Building, University of Minnesota, 


ONSULTATION is often desirable. Alas, 

consultation too often results to the detri- 
ment of the physician referring the patient. This 
should not be. The ideal relationship between 
physician and consultant results in help, not harm 
to the former. 

Charlatans and quacks do not refer patients. 
Imitators of charlatans and quacks among in- 
ferior physicians do not refer patients. The 
higher type of physician is more apt to refer 
patients than the lower type. What leads him to 
refer a patient? It is honesty, conscientiousness, 
keen concern for the welfare of the patient, and 
desire to do the best for him. Referring a patient 
is not necessarily a confession of weakness nor 
of inferiority ; it may be an indication of strength. 

It is perfectly true that no higher motive than 
self interest need induce the consultant to be 
helpful to the physician who refers the patient. 
If confidence in the referring physician is aug- 
mented, he will be in a position to refer more 

More mistakes are made by the referring phys- 



ician not accompanying the consultant in his visit 
to the patient. Physicians in the preceding gen- 
eration were very meticulous in the manner in 
which consultations were carried out. The refer- 
ring physician entered the room first and on 
leaving the room, followed the consultant. The 
reason was obvious. They then retired to discuss 
the patient in private. The discussion of the case 
in private was a fundamental part of the consul- 
tation which might well be perpetuated. Telling 
the patient about findings or giving advice on 
the part of the consultant is not to be tolerated 
unless he is specifically requested to do so. 

The consultant must feel a kindly attitude to- 
ward the ability of the referring physician. Af- 
ter all, he may be the better physician. Any lack 
of respect for the referring physician is sure to 
color the consultant’s remarks to the detriment 
of the former in the eyes of the patient. 

The referring physician places a very precious 
possession in the keeping of the consultant: his 
reputation and prestige. The trust should not be 
betrayed. The consultant has a right to feel hon- 
ored at being consulted. His words and actions 
should show every respect for the patient’s phys- 
ician. Any other attitude often acts as a boom- 
erang to the discredit of the consultant. 

The whole purpose of a consultation is the pa- 
tient’s welfare. Only by careful observance of 
the details mentioned will the patient obtain the 
greatest benefit from a consultation and credit 
accrue to both physicians.—C. G. K. 


ECAUSE there were forty-nine good musi- 

cians, twenty of them noted, in seven genera- 
tions of the Bach family it has been very gen- 
erally considered to be, as one writer states, “the 
most remarkable instance of hereditary genius in 
all history.” It certainly looks like it, but one 
can’t help but wonder if environment did not 
play an important part in the production of this 
remarkable situation. 

They lived in an atmosphere of music, for 
Thuringia, where they were born and lived from 
generation to generation, was traditionally mu- 
sical, and close by, in Saxony, was the most 
famous organ building district in the world. 
Then, from old Veit Bach, the baker who only 
played ihe zither in his spare time and died in 


1619, down to the last Bach of any musical 
consequence, in a period of two hundred and 
fifty years, they lived in their own family atmos- 
phere of music, teaching their younger brothers 
and sisters, their children and their children’s 

In this firmament of musical talent appeared a 
star of the first magnitude, the great Johann 
Sebastian Bach. In his period all musical instru- 
ments were still very primitive, as compared with 
those of today, and it is difficult to understand 
how he, thus handicapped, could produce music 
which today stands unmatched, at the very top. 
His preludes and fugues for the organ call for 
all the resources of the modern instrument and 
only a few performers can really play them. He 
was the father of twenty children, only two of 
whom became well known in music. In another 
hundred years the strain died out. 

The question of environment is interesting in 
connection with this unique group of talented 
people and its single genius, but again we are 
puzzled when we think of the many others whose 
genius survived the most uncompromising ob- 
stacles. Perhaps it’s the chromosomes, after all. 

—G. C. 


gene new Federal Pure Food, Drug and Cos- 
metic law is now in effect. 

The F. D. A. has issued a regulation prohibit- 
ing the sale of the following drugs, except on 
prescription: acetanilid in combination with bro- 
mides if the dose is more than 7% grains a day, 
aminopyrine and its preparations, benzedrine sul- 
fate, cinchophen and its preparations, neocincho- 
phen and its preparations, sulfanilamide and its 
preparations, thyroid and its preparations. 

Such a ruling is a step in the right direction 
in an effort to stop promiscuous use of drugs and 

To be effective 100 per cent, however, it is the 
duty of the physician to write prescriptions for 
the above mentioned drugs and the pharmacist 
shall not dispense these drugs except upon pre- 

Co6éperation of all allied medical professions is 
needed in this work. 




Edited by the Committee on Medical Economics 

of the 

Minnesota State Medical Association 
W. F. Braasch, M.D., Chairman 


The National Physicians’ Committee for 
the Extension of Medical Service is off to 
a good start. 

Information has been received to the ef- 
fect that the movement is being enthusias- 
tically backed by large numbers of physi- 
cians in all parts of the country. Not alone 
have they backed it with their moral sup- 
port, but, to a surprising degree, with gen- 
erous contributions. The widespread sup- 
port of the objectives of the Committee 
promises well for its future success. While 
it is still in the formative stage, its future 
activities are already being planned. 

Every member of the medical profession 
who sends in his name and contribution for 
membership automatically becomes a mem- 
ber of this nation-wide committee. 

The active codperation of every physi- 
cian who enrolls will be sought. Literature 
will soon be sent out in a form attractive 
to the layman and all members of the Com- 
mittee will be counted on for its distribu- 
tion. The combined efforts of its member- 
ship should be a powerful factor in the fu- 
ture support of American médicine. Have 
you filled in your application blank? 

A Minnesota Branch of the National 
Committee has been formed in order to ex- 
pedite the activities of the National Com- 
mittee. Its Executive Committee has had 
several meetings and will undoubtedly be of 
great aid in furthering the national objec- 

January, 1940 


It is of interest to note that the first state 
branch of the National Committee for Exten- 
sion of Medical Care in the country was organ- 
ized in Minnesota. 

It was formed under the chairmanship of Dr. 
F. J. Savage of Saint Paul and now embraces as 
members and contributors, medical leaders from 
all parts of Minnesota. 

The Minnesota organization will serve as the 
local agency for distribution of literature to 
members and it will enlist the aid of key repre- 
sentatives of the other professions who are inter- 
ested as citizens and as professional men in the 
philosophy behind the physicians’ movement. 

To Spread Information 

The Minnesota branch will carry out the gen- 
eral program of the national organization. It 
will throw its influence behind any local exten- 
sions of medical service that may be shown to 
be needed in Minnesota and it will spread infor- 
mation to all parts of the state on the kind and 
quality of services available in Minnesota ; on the 
extraordinary progress made in Minnesota in the 
control of communicable disease and the lower- 
ing of maternal and child death rates. In these 
respects and in many other key tests of the ade- 
quacy of medicine and the public health services, 
Minnesota stands at or near the top among all 
the states of the United States. It is important 
for the citizens of Minnesota to be familiar with 
these facts so that social experiments in medicine 
with their dubious results elsewhere may be 
properly evaluated in the light of accomplish- 
ments here. 

Committee Is Independent 

It should be noted that the Minnesota branch 
of the National Committee of Physicians for Ex- 
tension of Medical Care is in no way fostered by 



nor subservient to the Minnesota State Medical 
Association. It is an independent committee of 
physicians, organized for special purposes and 
financed by contributions of its members. 


Marked expansion in the public health educa- 
tion program of the Minnesota State Medical 
Association will begin in several directions in 

Information about the elementary principles of 
good health and about available medical services 
is regarded, on all hands, as an immediate and 
practical method open to physicians to aid in 
solving medical-economic problems. 

There is a great weight of untreated illness 
due—not to lack of resources or lack of medical 
facilities—but to sheer ignorance and neglect. 

For Public Education 

Increase in facilities and increase in appropria- 
tions of funds will not lift this weight; but con- 
centration by medical organizations upon the 
problem of public education is a step in the right 
direction and a step upon which all physicians 
now agree. 

Accordingly the Council approved extensions 
in nearly all activities of the Committee on Pub- 
lic Health Education as follows: 

1. A Question and Answer Column sponsored 
by the committee, will replace the regular health 
news story which has been sent each week to 
country newspapers in the state through the Min- 
nesota Editorial Association. The new service 
will provide opportunity to rural newspaper sub- 
scribers to send their questions, a few of which 
will be published each week, to competent au- 
thorities for answer. Rural papers which cannot 
afford the syndicated health columns will thus re- 
ceive a free, authoritative service. 

To Aid Speakers 

2. The Speakers’ Library will be enlarged by 
lantern slides on popular subjects. Slides are fre- 
quently requested but until now no appropria- 
tions or facilities have been available for supply- 
ing them. Committee chairmen will be asked to 
aid the new Speakers’ Library with outlines for 
specimen talks to accompany the slides. 

. 3. The association’s popular radio program 
conducted by Dr. W. A. O’Brien over WCCO 
will be enlarged to embrace the smaller radio 


stations in many parts of the state. The ques- 
tion of whether local speakers should be utilized 
is being investigated ; also the possibility of mak- 
ing recordings of Dr. O‘Brien’s talks for re- 
broadcasts over these stations. 

The regular college lecture courses of the as- 
sociation will be continued and the committee 
will codperate closely with the Committee on 
Hospitals and Medical Education and other sci- 
entific committees of the association to carry for- 
ward and amplify the Codrdinated Medical and 
Public Health Program inaugurated with such 
success last January. Monthly packets will be 
continued for the year and the subjects drawn 
up at a preliminary meeting depart considerably 
from the 1939 subjects in order to insure interest 
for the 1940 packets. 

“The Only Way...” 

Minnesota physicians will codperate closely 
with the newly organized Division of Social Wel- 
fare of the (Department of Social Security) in 
the solution of all problems connected with med- 
ical care of relief clients and recipients of the So- 
cial Security Aids. 

An advisory committee of the state association 
was approved by the Council to meet regularly 
with social welfare officials, Mr. Walter Finke, 
director, and Dr. H. E. Hilleboe, medical chief. 
The committee is composed of the following: 
Drs. A. W. Adson, Rochester ; L. L. Sogge, Win- 
dom; C. A. Stewart, Minneapolis; W. A. Cov- 
entry, Duluth; E. J. Simons, Swanville; with 
Dr. Hilleboe, Dr. A. J. Chesley of the State 
Board of Health, and Mr. R. R. Rosell as ex- © 
officio members. 

Working Method 

A suggestion for a working method of bring- 
ing physicians and welfare boards together lo- 
cally to handle joint medical problems was pro- 
posed by Mr. Finke in person to the Council and 
cordially approved. The County Contact Com- 
mittees will figure in this plan when it is officially 
announced and their réle will be to consult with 
local welfare officials on medical care for all wel- 

‘fare clients. 

“There are many things we don’t know yet 
about our medical relief problem in Minnesota,” 
Mr. Finke told the Council. “We don’t know 
how much money is being spent for medical care 
in this state, for one thing. We are going to try 



to find out what is spent, however, and how it 
can best be spent. But we shall make no deci- 
sions and inaugurate no policies without consult- 
ing the medical profession. As a professional 
man, myself, I am convinced that the only way 
we can arrive ‘at a solution of our medical dif- 
ficulties is through the medical profession. We 
began our work by asking for an advisory com- 
mittee from your body. We shall continue to 
work only through this committee and your as- 

Teaching Demonstration 

An obstetric teaching demonstration and home 
delivery service to be used in connection with 
obstetric teaching at the University Medical 
School was proposed by Dr. A. J. Chesley, sec- 
retary and executive officer of the State Depart- 
ment of Health, as a means of utilizing an appro- 
priation which may: be made available to Minne- 
sota out of unexpended funds of the Children’s 
Bureau, provided that agency approves the pro- 
posal. This teaching service would give medical 
students an opportunity, not now available, of 
making deliveries in homes in the vicinity of Min- 
neapolis. The object is, of course, to prepare 
students for obstetrical emergencies they will 
meet in practice. 

The Council expressed its interest and re- 
quested that the program be referred for ap- 
proval to the Hennepin County Medical Society. 

Does Not Initiate Legislation 

The United States Public Health Service does 
not initiate legislation, Dr. J. W. Mountin, As- 
sistant Surgeon General of the United States 
Public Health Service and guest of Dr. Chesley, 
informed the Council. “Legislation in social 
fields arises with outside groups and is often well 
on the way to committee hearings before health 
service officials are informed of it. As you know, 
we are specifically prohibited from either initiat- 
ing or supporting any legislation and the policy 
of the Public Health Service is based upon pro- 
grams formulated by state health officers.” 

On the other hand, the organization of State 
Territorial and Provincial Health Officers can 
and does take an active interest in legislation. 
For instance, the health officers’ association is 
currently opposed to transference of Industrial 
Hygiene and Occupational Diseases from the 
public health service to the Department of Labor 

January, 1940 

and also to removal of the Division of Vital Sta- 

tistics from the health service. 

Cancer Education 

Thirty thousand people all over the’ United 
States took part in the Women’s Field Army 
Against Cancer program last year, according to 
Dr. F. L. Rector, field secretary of the American 
Society for the Control of Cancer, who spoke 
briefly on the work of the women’s organization. 
Forty-eight thousand talks were given about 
cancer, 42,000 of them by physicians, the others 
being organization talks by society representa- 
tives. The new women’s organization has been 
in existence for three years. It raised $165,000 
during its third year, of which 30 per cent went 
to the National Society for the Control of Can- 
cer and 70 per cent was retained for local cancer 
education work. Some 4,000,000 pieces of litera- 
ture were distributed on cancer last year and 
1,500 exhibits were shown at fairs and meetings. 

Neither the national cancer organization nor 
the Women’s Field Army is in the clinical field, 
Dr. Rector said. Its program is entirely under 
control of physicians and no clinical use will ever 
be made of funds raised in Minnesota unless 
the Minnesota physicians ask for it. 

To Study Fees 

Fees for medical relief are far from uniform 
in various parts of the state. Discussion of in- 
equalities and occasional difficulties that arise 
from them prompted a request by the Council 
for a study of the situation on the part of the 
Committee on Low Income and Indigent Prob- 
lems. The committee will accumulate figures and 
data not only on fees but on all phases of the re- 
lief problems from the point of view of physi- 
cians. Information thus gathered will be present- 
ed at the County Officers’ meeting scheduled for 

New Committees 

Two timely new committees have been ap- 
pointed by President B. S. Adams with Council 

One of these, the Committee on Vaccination 
and Immunization, will take the lead in a coérdi- 
nated state-wide effort on the part of members 
of the association to carry on community vacci- 
nation and immunization programs. Dr. L. R. 
Critchfield, formerly chairman of the Committee 



on Public Health Education, was appointed to 
chairmanship of the new committee and a state- 
wide plan drawn up at the request of the Coun- 
cil by Dr. C. A. Stewart of Minneapolis, was ten- 
tatively approved and referred to the new com- 

The second is the Committee on Industrial Hy- 
giene and Occupational Disease, of which Dr. 
J. L. McLeod of Grand Rapids will be the first 

For Civil Service 

A special committee will also be appointed by 
the president and the chairman of the Council to 
work with the new Civil Service Board in draw- 
ing up examinations for physicians who engage 
in state institutional work. 

Public Health Meetings Approved 

An expression of official approval for promo- 
tion of vaccination and immunization was re- 
quested by the State Sanitary Conference at an 
earlier meeting. The approval of the Council 
was given and the recommendation made that 
county and district medical societies hold at least 
one meeting each year on public health problems. 
Speakers for these meetings will be provided on 
request by the State Board of Health. 


Following a plan developed with great success 
two years ago, subcommittees of the Committee 
on Medical Economics met separately and then 
joined in a general dinner meeting of the entire 
committee recently in Saint Paul. 

Below are brief abstracts of reports made by 
subcommittee chairmen at the dinner. 

We Are Fortunate 

Dr. W. F. Braasch, chairman: A thorough 
trial is being made of health insurance by medi- 
cal societies in many states. We are fortunate 
in Minnesota that no political emergency exists 
which might serve to push us into premature ex- 
perimentation with these new forms of service. 
Our best policy, it seems to me, is to watch de- 
velopments in other states and avoid costly ex- 

In the meantime, it appears that a closer co- 
operation is highly desirable between physicians 
and county welfare boards throughout the state. 


This is one effective method of seeing that the 
under-privileged receive adequate medical serv- 
ice under our present system of practice in 

For Up-to-date Information 

Dr. W. A. Coventry, Duluth, chairman of the 
Sub-Committee on Low Income and Indigent 
Problems: At the direction of the Council, a 
questionnaire has been compiled to send to all 
members of County Contact Committees. By 
means of this questionnaire we hope to get up-to- 
date information on details of handling medical 
relief in all parts of the state so as to lend assist- 
ance where it may be needed. 

In that connection it is interesting to note that 
physicians in Wright county, after careful study 
of the plan, decided not to enter into any co- 
operative arrangement with the Farm Security 
Administration to provide medical care for Farm 
Security clients (See Medical Economics Sec- 
tion for December). Existing machinery was re- 
garded as adequate to care for these clients and 
the need was not acute enough to warrant so un- 
certain a departure from ordinary methods of 

Marked Progress 

Dr. B. J. Branton, Willmar, Chairman of the 
Medical Advisory Committee: The Medical Ad- 
visory Committee has made demonstrable prog- 
ress, as witnessed by the greatly improved mal- 
practice situation in Minnesota. The work of the 
committee is particularly noticeable in the decid- 
ed change which has come about in the last few 
years in the attitude of lawyers toward the med- 
ical profession. In marked contrast to the condi- 
tion a few years ago, there is now close codpera- 
tion between the two professions. 

Clinics Planned 

Dr. T. H. Sweetser, Minneapolis, Chairman of 
the Sub-Committee on State Health Relations: 

The American Legion plans to launch a pro- 
gram of child welfare which is to provide speak- 
ers on child welfare and Child Welfare Clinics 
in Minnesota. If the plan is carried through, it 
should be done with caution and with strict medi- 
cal supervision. It is our suggestion that the 
clinic program be referred to the Committee on 
Child Welfare of the Committee of Public 
Health Education for study with the recommen- 



dation to the Legion that nothing be done with- 
out consulting the Child Welfare Committee. 

Problems in Ethics 

Dr. L. A. Buie, Rochester, Chairman of the 
Sub-Committee on Medical Ethics: 

I believe that this committee has a function 
and that something valuable can come from its 
work, in spite of the fact that there was a negli- 
gible response to a letter sent to all county medi- 
cal secretaries by this committee asking for in- 
formation concerning infringements of the code 
of ethics. A few instances have come to our at- 
tention through other sources and the members 
involved have been interviewed with entirely sat- 
isfactory results. It needs only a slight infringe- 
ment of ethics to produce a malpractice case and 
anything that we can do to prevent such infringe- 
ments is of great assistance to the individual in- 
volved, as well as to the organization. It has 
been suggested that we might draw up artificial 
problems based upon actual instances and publish 
them for the information of all members in 

Position Endorsed 

Dr. Stephen Baxter, Minneapolis, Chairman of 
the Sub-Committee on Industrial Relations: 
Relations between the profession and the better 
insurance companies are satisfactory. The com- 
mittee fully endorses the position of the state so- 
ciety against the practice of medicine by fra- 
ternal orders. 


The success of the non-profit Minnesota Hos- 
pital Service Association has pointed a new way 
to profit for commercial insurance companies. 

These companies are writing hospital insur- 
ance policies for a large number of persons, and 
physicians who are asked about these policies 
should be informed of possible pitfalls into 
which unwary subscriber-patients may tumble. 

The financial standing of any insurance com- 
pany can be checked with the insurance commis- 
sioner but it is also necessary to study the policy 
and methods even of the most reliable of them. 

All policies make certain necessary restrictions 
upon payment of benefits, some more than oth- 
ers. In most cases it is important to study the 
policy closely since many exceptions are cloaked 

January, 1940 

from casual perusal and appear to leap into be- 
ing only when benefits are refused. 
Sinus Rider 

‘Still others appear to have a disconcerting 
habit of attaching riders to the original contract 
and sending them to the subscriber after his ap- 
plication is made and noted and the premium ac- 
cepted. Thus, there is one recent instance on 
record of a subscriber who had noted a sinus in- 
fection in her application. The sinus infection 
was the only ailment she had been obliged to re- 
port in her application. The first policy shown 
her had contained no mention whatever of sinus 
infection; but a rider which informed her that 
hospital benefits would not be paid for sinus 
trouble was atiached to the policy sent her after- 
wards from the main office. 

If she had confessed to dyspepsia or rheuma- 
tism or fallen arches a different kind of rider 
might conceivably have accompanied her policy. 
Mail Order Business 

The company which sold the policy minus si- 
nus privileges is actually old and reliable and well 
known. Other companies which may or may not 
be approved by the insurance commissioner are 
now embarking upon a mail order business in 
hospital insurance in order to take full advan- 
tage of what looks like a profitable field. 

It works this way. The applicant sees an ad- 
vertisement, writes for information and receives, 
along with a contract, a glowing promise of cov- 
erage for all hospitalized illness plus the doctor’s 
bill while he is in the hospital, all for $3.65 a 
quarter. He signs and returns to the company 
the sheet which bore the sweeping promises. He 
retains in his possession only the policy which, on 
closer inspection, reveals that benefits are ac- 
tually available only to the fortunate and the 
adroit. The owner of this policy is protected 
against hospital bills for all illnesses except pep- 
tic ulcer, cancer, heart disease and accidents due 
to external violence, to name only part of the 
exceptions—a complete list of which covers most 
of the afflictions which get people into hospitals. 
It is part of the mail order technic that the policy 
should be in force and the applicant liable for the 
premiums if the policy is not returned to the in- 
surance company within ten days. Thus, 
through carelessness or accident the hapless an- 
swerer of “ads” may find himself the unwilling 
owner of an all but worthless document for 
which he will pay an exorbitant fee. 



Coverage for Doctor 

It should be noted in considering abuses of 
hospital insurance that there are also non-profit 
plans in existence which offer as an additional 
attraction, a partial coverage of the doctor’s bills 
while the subscriber is in the hospital. It is too 
soon, perhaps, to judge of the practicability of 
this extra coverage but the result in a number of 
cases has not been all that the sponsors antici- 
pated. The allowance for the doctor’s bills is, in 
most instances, partial and inadequate but the 
patient upon receiving a larger bill, has objected 
strenuously and refused to pay. Naturally, he 
believed that he had purchased complete protec- 
tion against his bill. 

Minnesota Hospital Service is in a far better 
position because it has hesitated to offer any cov- 
erage that fringes upon insurance for medical 

{Monthly Editorial Prepared by the Medical Advisory 

Recently, the chairman of The Medical Ad- 
visory Committee was asked: What is the func- 
tion of The Medical Advisory Committee? 

In the constitution and by-laws of the Minne- 
sota State Medical Association adopted May, 
1937, it is stated that: “Its function shall be to 
investigate and disseminate knowledge as to the 
cause of malpractice.” 

It is, therefore, a fact finding committee as 
well as a correlator and dispenser of the infor- 
mation gained through investigations. It is in 
no way an insurer against malpractice, pays no 
indemnities and gives no legal advice. 

As has been said, experience is a good and 
probably the best teacher. So it has been with 
your committee. The general knowledge of 
cause and cure of the malpractice menace gained 
by the committee in the last several years should 
and will be of inestimable value to the Associa- 
tion and its members in the solidifying of the 
membership behind its objectives, and concrete- 
ly showing a result in lessened premiums paid 
by the members for protection. 

Continued observation of the general attitude 
of the membership shows a cooperative spirit 
which we believe is probably more noticeable 
than in any other profession, a growing criterion 
of good brotherhood. 


Your committee believes that common sense i 
an indispensable part of its work; that a clea 
analysis of various problems as they arise is 
proper and just; that there are two sides to 
every case; that the great majority of the mem- 
bership of our Association are honest with their 
clientele; that most members of the Bar Asso 
ciation would not bring an action against our 
profession if they were given the true facts in a 
case by the plaintiff; and that a miscarriage of 
justice in the courts of our state in this type of a 
case is at a minimum. Study shows it to be a 
fact that those things of common interest to us 
all are much more important and essential than 
our differences. 

B. J. B. 


There are interesting discrepancies between 
the book on Soviet medicine by Medical Histo- 
rian Henry E. Sigerist of Johns Hopkins and the 
account of personal experience with Soviet med- 
icine published a few years ago by one-time com- 
munist newspaper correspondent, Eugene Lyons. 

Say Dr. Sigerist: 

“Nobody can deny that Soviet medicine, in the short 
period of twenty years and under most trying cir- 
cumstances, has stood the test and has created power- 
ful measures for the protection of the people’s health. 
It has demonstrated that socialism works in the med- 
ical field, too, and that it works well, even now, in the 
early beginnings of the social state. It is a system full 
of promise for the future—the very near future.” 

Says Mr. Lyons: 

“We came, unluckily (through illness of Mrs. Lyons) 
to know a lot more about Soviet medical practice than 
most of our colleagues. Like the “stable” currency 
and the wonderful educational methods, socialized med- 
icine under the official statistical surface was a snarl 
of contradictions, shortages and ineptness. Doctors and 
dentists regarded their obligatory work for the state 
as exaction and depended on private practice for their 
real income. The more famous medical specialists did 
not budge for less than 50 or 100 rubles; often it re- 
quired pull to get their services at any price. The pub- 
lic health service was by all odds inferior to the free 
public and charitable health services available to the 
poor in cities like New York and Chicago. ...” 

“Ever after (Mrs. Lyons’ experience in a Soviet 
hospital), the glowing reports of socialized medicine in 
Russia in American books and magazines have been a 
source of amusement to us. Always we have wished 
their authors only one punishment—a week or so as 
patients in the second-best hospital in Russia.” 




Julian F. Dubois, MLD., Secretary 

Minneapolis Physician Sentenced to 5 to 20 Years 
at Hard Labor Following Conviction 
for Manslaughter 

Re State of Minnesota vs. R. J. C. Brown, M.B. 

On November 25, 1939, Richard J. C. Brown, Negro 
physician of Minneapolis, was sentenced to a term of 
not less than 5 and not more than 20 years at hard 
labor in the State Prison at Stillwater, Minnesota, by 
the Honorable Arthur W. Selover, Judge of the District 
Court of Hennepin County, following Brown’s convic- 
tion, on November 22, 1939, by a jury, of the crime of 
manslaughter in the first degree. Brown was arrested 
on August 16, 1939, by the Minneapolis Police De- 
partment on the complaint of the father of a 22-year- 
old Minneapolis girl, upon whom it was alleged that 
Brown had performed a criminal abortion on July 31, 
1939. At that time, Brown was charged with the crime 
of abortion. However, the girl died at the Minneapolis 
General Hospital on August 23, 1939, and prior to her 
death she made a statement: naming Brown as the one 
who had performed this criminal abortion. Subsequent- 
ly, Brown was indicted on August 29, 1939, by the 
grand jury of Hennepin County along with one Mar- 

tin Schmidt. The indictment charged them with man- | 

slaughter in the first degree. Both defendants entered 
pleas of not guilty and their bond was fixed in the sum 
of $5,000.00 each. Brown’s trial commenced in the 
District Court on November 16, 1939, and ended with 
the jury returning a verdict of guilty on November 22, 
1939. Brown did not take the witness stand in his own 
behalf. The defendant Schmidt was named by the de- 
ceased girl as having recommended that she go to 
Brown, and as having furnished her with the $25.00, 
which it is alleged was paid to Brown for his services. 

The defendant Brown was born in Lincoln, Nebraska, 
January 17, 1893, and graduated from the University of 
Minnesota June 17, 1920, with the degree of Bachelor 
of Medicine. He was licensed in June, 1920, by the 
Minnesota State Board of Medical Examiners by ex- 
amination. According to the records at the University 
of Minnesota, Brown never completed his internship 
and the degree of Doctor of Medicine was never con- 
ferred upon him. Judge Selover granted Brown a stay 
of execution of sentence until December 30, 1939, to 
permit the defendant to make a motion for a new trial. 

A real campaign against tuberculosis demands a genu- 
ine investigation carried out with general practitioners 
looking for patients in the community, in industry and 
in home-making. We are finding an appreciable amount 
of tuberculosis through testing campaigns in schools 
but it is not one-quarter of what we would find if the 
campaign were extended to the groups where tubercu- 
losis is more prevalent—Lonc, Esmonp R., Phila. 
Tuber, Conf., 1939. 

January, 1940 


Dr. John Arthur Williams, who for the past four 
months has been associated with his uncle, Dr. L. A. 
Williams, in the practice of medicine in Slayton and 
vicinity, has accepted a position as surgeon in Gillette 
Hospital, Saint Paul. 

* * * 

Dr. John W. Johnson, son of Dr. and Mrs. Hans 
Johnson of Kerkhoven, who has just completed a year 
as resident physician at the Wyandotte General Hospi- 
tal, Wyandotte, Michigan, has returned to Kerkhoven, 
where he will be associated with his father in general 

* * * 

Dr. Milo H. Larson, formerly of Nicollet, is now lo- 
cated at Norwood, Minnesota. 

* * * 

Dr. L. R. Parson, formerly of Fergus Falls, is now 
practicing medicine in Elbow Lake, Minnesota. 

* * * 

Dr. Norman Sather, who recently completed a resi- 
dency at Ancker Hospital, Saint Paul, has established 
offices in McIntosh, Minnesota, for the practice of 

ee& 2 

Dr. A. F. Adair has recently completed his residency 
in the Eye, Ear, Nose and Throat department at the 
Ancker Hospital, Saint Paul, and is now associated in 
the practice of this specialty with Dr. Carl L. Larsen, 
1027 Lowry Medical Arts Building, Saint Paul. 

* * * 

Dr. William C. Bernstein of New Richland has sold 
his practice and will enter the Graduate School of 
Medicine at the University of Minnesota, where he will 
specialize in proctology. 

Dr. Russell O. Spittler of Livingston, Montana, took 
over Dr. Bernstein’s practice January 1. Dr. Spittler is 
a graduate of the University of Minnesota, 1932, and 
has practiced medicine and surgery at Livingston since 


Dr. Richard Cranmer and Dr. Leo W. Fink of Min- 
neapolis addressed the Scott-Carver Medical Society at 
New Prague December 12. They spoke on “Acute Con- 
ditions of the Abdomen” and “The Important Functions 
of the Nose,” respectively. 

* * * 

Dr. Frank E. Burch, Saint Paul, sailed December 15 
from San Francisco for Peiping, China, where he will 
spend four months as visiting professor of Peiping 
Union Medical College. He is being sent to China un- 
der the auspices of the Rockefeller Foundation. Mrs. 
Burch accompanied him. 



In Memoriam 

Charles E. Fawcett 

Dr. Charles E. Fawcett of Stewartville, Minnesota, 
passed away at his home Friday, December 8, 1939, 
at the age of seventy. 

Born in Marion, Minnesota, October 13, 1869, Dr. 
Fawcett attended rural schools and later went to Wi- 
nona normal school and to Darling’s business college 
in Rochester. After teaching several years he decided 
to study medicine and he completed his course at 
Northwestern University in Chicago in 1893. 

Upon receiving his M.D. degree, Dr. Fawcett began 
practice in Austin, Minnesota, but after three months, 
he moved to Stewartville and practiced there contin- 
uously until his death. 

On November 28, 1894, Dr. Fawcett married Myrta 
A. Phelps. Three daughters, Gale C., Lois M., and 
Frances, and one son, Donald N., were born of this 
union. Mrs. Fawcett died in 1910. In 1913, Dr. Faw- 
cett married Mabel Bates Slater. 

Dr. Fawcett was active in his community. He gave 
much of his time toward bettering the local schools 
and is credited with having been responsible for the 
fine local school system. 

He was an active Mason and was Worshipful Master 
of the local lodge for four years. He was also a mem- 
ber of the Modern Woodmen of America. Although 
beyond the draft age, Dr. Fawcett volunteered during 
the World War and served as Captain in the Infirmary 
at Alexandria, Louisiana. A charter member of the 
Ivan Stringer post of the American Legion, Dr. Faw- 
cett served for many years as Chaplain, the post he 
held at the time of his death. It was fitting, therefore, 
that the Captain be given a full military funeral at 
Woodlawn Cemetery. 

A Methodist from childhood, Dr. Fawcett transferred 
his membership from the Marion church and served 
on the Church Board for forty-four years at Stewart- 

Since 1907, Dr. Fawcett had been president of the 
National Bank at Stewartville, where his keen knowl- 
edge of financial affairs served his community well. 
Six years ago tribute was tendered him for this phase 
of his community activity by men and women of 

Dr. Fawcett had long been a member of the Olm- 
sted-Houston-Fillmore-Dodge County Society, and the 
Minnesota State and American Medical Associations. 

I used to wonder why people should be so fond of 
the company of their physician ’til I recollected that 
he is the only person with whom one dares to talk con- 
tinually of oneself, without interruption, contradiction 
or censure —HANNAH More. 



(Continued from Page 44) 

through the present opening so this was closed and 
a right rectus incision was made. A Meckel’s diver- 
ticulum about 2.5 inches long then came into view, a 
little more than 1 inch in width at the widest point 
and at the base about 0.5 inch. In sponging out the 
fluid the gauze sponge caught on something sharp and 
with the aid of an artery forceps this sharp for: ign 
body was pulled out of the side of the appendage about 
one-half inch from the tip. This proved to be a fish 
bone about an inch in length. The diverticulum was 
tied off and removed, the stump inverted and covered 
over as in the usual appendectomy operation. Drains 
were put into the pelvis and after a few stormy days 
following the operation the patient made an uneventful 
recovery, and in five weeks was back on his rural mail 
delivery job. 

In questioning the patient he said that he not eaten 
any fish since last February or the first part of March 
and the fish bone must have been in the diverticulum 
at least since this time. 

Summary and Conclusions 

1. A short anatomical description of the anomaly 
of a Meckel’s diverticulum has been given. 

2. The patient had had typical symptoms of appen- 
dicitis ever since he was fourteen years old, but un- 
doubtedly had a recurrent diverticulitis until a fish bone 
found its way into the diverticulum and burrowed 
its way through the various coats. 

3. The fish bone must have been lodged in the 
diverticulum for at least six or eight weks and during 
that time he had had no symptoms of it until the 
typical pain which he had had so many times during 
the past forty-eight years recurred with increased 

4. Although the incidence of Meckel’s diverticulum 
is 2 per cent, and the percentage of those which cause 
trouble is very small, it is well to keep this condition 
in mind especially in cases in which there is a long 
history of repeated symptoms resembling those of 
appendicitis. Furthermore if such cases come to opera- 
tion and the appendix is found not to be sufficiently 
diseased to explain the symptoms, exploration should 
be performed in order to eliminate the presence of a 
Meckel’s diverticulum. 

5. A fish bone perforation of a Meckel’s diver- 
ticulum is rare; at least I have not been able to find 
the history of such a case in medical literature. 

The State of Massachusetts has recently passed leg- 
islation which makes it possible to protect its citizens 
in medical affairs. Hitherto there has been no provi- 
sion for examining candidates for licenses to practice 
medicine except by a written test—a method of deter- 
mining competence considered inadequate by all other 
states. Now Massachusetts is requiring that those who 
take the licensing examination must be graduated from 
approved medical schools. 

A board, which has the authority to formulate stand- 
ards in medical education, has been organized and will 
pass on the qualifications of schools of medicine. Mas- 
sachusetts is to be congratulated upon this step which 
raises the qualifications of its medical practitioners to 
the general level prevailing throughout the United 
States.—Editorial, Jour. A.M.A. 


(760 } 







the | 





The Minnesota State Medical Association Morning 
Health Service 

The Minnesota State Medical Association broadcasts 
weekly at 11:00 o’clock every Saturday morning over 
Station WCCO, Minneapolis (810 kilocycles or 370.2 
meters), and Station WLB, University of Minnesota 
(760 kilocycles or 395 meters). 

Speaker: William A. O’Brien, M.D., Associate Pro- 
fessor of Pathology and Preventive Medicine, Medical 
School, University of Minnesota. 

The program for the month will be as follows: 

January 6—Diphtheria and Smallpox. 

January 13—Whooping Cough and Scarlet Fever. 

January 20—Measles and Chickenpox. 

January 27—Orthodontia. 

Nore: The last talk each month is sponsored by the 
Minnesota State Dental Association. 


A new program plan will be followed for the next 
Annual Meeting of the Minnesota State Medical As- 
sociation, 87th in the history of the association, which 
will be held at the new Mayo Civic Auditorium at 
Rochester, April 22, 23 and 24. 

A group of special subjects has been chosen for 
the Tuesday and Wednesday programs and three or 
four speakers will be invited to talk on various as- 
pects of each one. Among the subjects to be discussed 
from various points of view are Pre-Operative and 
Post-Operative Care; Coronary Disease; Cancer of the 
Breast; Progressive Loss of Vision; Fractures. 

Monday’s program will be given over entirely to 

‘members of the Mayo Clinic and at the conclusion of 

the day’s proceedings there will be an open house with 
the clinic members as hosts in the Auditorium Arena. 
Exhibits will be open on this occasion and entertain- 
ment and refreshments provided. 

Among distinguished out-of-state speakers who have 
already accepted invitations to speak are Drs. Harry E. 
Mock and Fred L. Adair of Chicago; and Dr. John O. 
Bower of Philadelphia. 

The round table luncheons which proved a pop- 
ular feature of the Minneapolis meeting, will be con- 
tinued this year with ten luncheons scheduled for 
each day of the meeting in Rochester hotels and din- 
ing rooms. Tours will also be arranged during the 
three days in groups of twenty for those who want 
to visit the Institute of Research. The annual ban- 
quet will be held at the Rochester State Hospital, 
Tuesday evening. 

Special entertainment will be provided also for the 
Women’s Auxiliary of the association, which will hold 
its annual gathering during the three days of the meet- 
ing. All wives of physicians will be invited to these 

January, 1940 


The Washington County Medical Society held its an- 
nual meeting on Tuesday, December 12. The following 
officers were elected by acclamation: President, D. 
Kalinoff; first vice president, Ray G. Johnson; second 
vice president, George McC. Ruggles; secretary-treasur- 
er, E. Sydney Boleyn; delegate, E. Sydney Boleyn; al- 
ternate, Wade R. Humphrey. 

Dr. Everett K. Geer of Saint Paul and Pokegama 
interpreted thirty-three chest radiographs from positive 
Mantoux reactors at the Stillwater High School. No 
lesions were demonstrable. Dr. Geer opined that pos- 
itive reactors to the Mantoux test showing no demon- 
strable lung lesions should be referred to the family 
physician for very thorough general examination as 
tuberculosis may be present in some other part of 
the body. He cited several cases which proved such 
procedure would be very desirable. 


The second annual conference of the Midwestern 
Forum on Allergy will be held at the Palmer House, 
Chicago, Saturday and Sunday, January 13 and 14, 1940. 

The meeting opens Saturday evening, January 13, 
with the annual get-together at 7 P. M. Saturday eve- 
ning, Sunday morning and Sunday afternoon will be 
devoted to the scientific program covering numerous 
phases of allergy. 

The profession of Minnesota is cordially invited to 


Dr. Edward D. Churchill of Boston, Massachusetts, 
John Homans, Professor of Surgery at the Harvard 
Medical School, and Chief of the West Surgical Serv- 
ice at the Massachusetts General Hospital, will give 
the seventh E. Starr Judd lecture at the University of 
Minnesota in the Medical Science Amphitheater on 
Thursday, March 14, 1940, at 8:15 P. M. The subject 
of Dr. Churchill’s lecture is “Surgery of the Lungs.” 

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 


The fall meeting of the Minnesota Radiological 
Society was held in Rochester, Minnesota, December 
2, 1939. The scientific program was given at the 
Assembly Room of the Mayo Clinic in the afternoon. 
Following dinner at the Hotel Kahler, the members 
were addressed by Dr. H. M. Worth on the subject 
“Radiology in England,” and Dr. Shao-hsun Wang on 
“The Practice of Medicine in China.” 


President, Dr. Willard White, in the Chair 
Secretary: Dr. 


ArtHurR Metz, M.D. 
Chicago, Illinois. 

Chronic duodenal stasis is a condition characterized 
by the delay in passage of food through the duodenum. 
It has long been recognized but the condition is fre- 
quently overlooked in routine examinations. During 
the past twenty years, articles have appeared from 
time to time describing the condition and treatment 

Etiology.—The etiology of duodenal stasis may be 
due to either a congenital anomaly with a resulting 
pressure on the duodenum where it passes over the 
spine, causing an incomplete obstruction, or it may be 
secondary to some mechanical obstruction such as tumor 
growths or adhesions. 

The most common cause of stasis in our experience 
has been pressure on the duodenum where it passes 
over the spine by the mesentery attachment. It is 
usually associated with a ptosis of the abdominal vis- 
cera. In all of our cases we could account for the 
symptoms as being directly due to this cause. 

Devine has described a type of duodenal stasis 
which he considers due to an abnormal action of the 
sympathetic nerves, for which he has devised a special 
operation consisting of a resection of a portion of the 

Acquired obstruction secondary to tumor growths 
or adhesions or kinks can produce similar clinical 

It is difficult to estimate the frequency of chronic 
duodenal stasis secondary to congenital anomalies, for 
unless the clinician and roentgenologist make a careful 
search, many of the milder cases are overlooked. It 
has been estimated that about one-half of one per 
cent of all routine gastro-intestinal examinations ir 
the x-ray department will show evidence of duodenal 

Discussion of this paper will be limited to thirteen 
operative cases where the obstruction was found to 
be due to pressure on the duodenum by the mesentery 

The age of the patients in this group was from 
fourteen to sixty years, the average being thirty-one. 
There were six males and seven females, all of whom 
were of the slender, undernourished type. 

Symptoms.—The symptoms of duodenal stasis depend 
upon the degree of obstruction. When the obstruc- 
tion is slight, symptoms vary from time to time and 
consist chiefly of recurrent attacks of nausea associated 
with a loss of weight and inability to carry on usual 
activities secondary to weakness occasioned by restric- 
tion of ‘food. 



Stated Meeting, Thursday, October 5, 1939 

Harvey Nelson 

In the more advanced cases, there is, in addition 
to the attacks of nausea, vomiting and a fullness in 
the right upper abdomen which comes on immediately 
after starting to eat. The patient as a rule does 
not describe the sensation as pain but complains of a 
fullness which develops in the right upper abdomen 
soon after starting to eat, associated with the loss 
of appetite and inability to continue eating. These 
symptoms may become so pronounced during the first 
five or ten minutes that the patient is forced to end 
the meal for fear of vomiting. Pain may be present 
and inasmuch as it is localized in the right upper 
abdomen may suggest the presence of a gallbladder 
attack, but on examination there will be an absence 
of definite tenderness and rigidity which is characteris- 
tic of gallbladder disease. 

In the more advanced cases the symptoms as above 
described increase in severity, so that the patient will 
avoid food, as there is the repeated feeling of nausea 
and vomiting when taking small amounts. In some 
cases the patient will attempt to eat frequent small 
meals so as to avoid distressing symptoms of repeated 
vomiting attacks. 

Inasmuch as the patient shows no evidence of tem- 
perature, and blood and other laboratory findings are 
negative, the condition is sometimes looked upon as 
an hysterical vomiting, and as result the patient may 
receive very little sympathy or attention. This was 
true of one case that came under our care of a young 
boy, fourteen years old, where the attending physicians 
along with the parents had labeled the patient’s symp- 
toms as hysterical in character although the patient 
was extremely emaciated and exhausted before his true 
condition was recognized. 

The diagnosis of chronic duodenal stasis is made 
by the history of recurring attacks of vomiting, which 
vary with the degree of obstruction, with the absence 
of other clinical findings suggesting an inflammatory 
lesion in the upper abdomen. 

A positive diagnosis has to be made by careful 
fluoroscopic examination. The stomach will be ob- 
served as a long, vertical, J-shaped type, with a low 
placed outlet, and on watching the barium pass through 
the outlet, it will be found to remain in the duodenum 
to the right of the spine. The most striking finding 
is that of a duodenal shadow which is two to three 
times its usual diameter, and vigorous peristaltic waves 
are observed. The peristaltic waves may even assume 
the reverse type and the barium can be observed to 
return into the stomach. In some cases the barium 
will pass to the left of the spine after the peristaltic 
waves have been observed for five to ten minutes. The 
patient can definitely locate the area of fullness in 
the right upper abdomen at a point over the distended 


as th 
will | 
It is 
is it 




duodenum and may even complain of the discomfort 
as that of a definite pain. 

From fluoroscopic examination alone, duodenal stasis 
can be roughly placed into one of three classes: 

1. Where there is a slight delay in barium passing 
through the duodenum, and after a minute or two it 
will pass to the left of the spine and the stomach will 
continue to empty itself. 

2. Where there is a definite dilatation of the duode- 
num to at least twice its normal diameter and a delay 
of barium may be of five to ten minutes duration 
with evidence of reversed peristalsis associated with 
nausea and vomiting at the time of examination. 

3. Where the obstruction is practically complete and 
dilatation is greater with pronounced regurgitation and 
vomiting and the patient shows marked emaciation. 
It is in this third group that prompt surgical treatment 
is indicated. 

Differential diagnosis will have to be made from 
chronic gallbladder disease, duodenal ulcer and also 
from other anomalies such as diverticuli and cysts in 
the right upper abdomen, which should be easily elim- 
inated by two or three repeated fluoroscopic exami- 

Treatment.—The treatment depends upon the degree 
of obstruction present. In the first stage where ob- 
struction is only slight and the symptoms come and go, 
careful medical management by regulating the intake 
of food associated with rest at meal-time will fre- 
quently produce the desired results. The object of 
the treatment is to increase the weight of the patient 
so as to increase the amount of fat in the abdomen 
with the hope that the pressure on the duodenum will 
be reduced and in this way relieve the mechanical nar- 
rowing of the lumen. 

In the second stage where the symptoms of fullness 
associated with nausea and vomiting are persistent, 
the patient should be kept in bed and given frequent 
feedings of nourishing food. Various positions should 
be tried during and after eating with the hope of re- 
lieving pressure and aid in the passing of food over 
the spine. Sometimes lying on the left side or with 
face downward will give relief and even the knee- 
chest position has in some cases given very satisfac- 
tory temporary results. 

If the patient does not make satisfactory progress 
in one or two months after careful medical manage- 
ment, surgical treatment is indicated. 

In the third stage where there is a high-grade ob- 
struction due to pressure, a course of medical manage- 
ment might be tried, but with pronounced symptoms 
of vomiting and loss of weight the patient should be 
given prompt relief by surgical treatment. 

Surgical Treatment—The most common surgical 
treatment recommended for chronic duodenal stasis 
is duojejunostomy. This operation when properly per- 
formed will give very good results. In making the 
enterostomy, care should be observed to make the 
opening large so as to give prompt emptying of the 
distended duodenum. 

The duodenum to the right of the spine is located 

January, 1940 

retroperitoneal, which places it deep in the abdomen and 
makes the operation difficult, as extra dissection is re- 
quired to mobilize the intestines enough to do an en- 

A second surgical procedure can be considered in 
giving relief which consists of a regular posterior 
gastroenterostomy accompanied by the placing of a 
silk ligature firmly about the pylorus. In these patients 
where the stomach is large, a posterior gastroenteros- 
tomy is much easier to perform than a duojejunostomy. 
The placing of a heavy silk ligature about the pylorus, 
tying it just tight enough to obstruct the lumen and 
not tight enough to produce a necrosis, will prevent 
gastric contents from entering the duodenum, thus 
making the food enter the duodenum to the left of 
the spine, after which it has no obstruction to its 
course through the intestinal canal. In our experience 
this has been a very satisfactory surgical procedure. 

In our series of thirteen cases, ten were relieved by 
the use of gastroenterostomies and placing of silk liga- 
ture about the outlet. All ten patients made unevent- 
ful and good recoveries and have been able to con- 
tinue their normal activities. 

The first and the most severe case was a patient 
fourteen years of age, who was operated upon twelve 
years ago. He was almost moribund at the time due 
to dehydration, so that he was a poor surgical risk. 
Owing to his weak condition, it was decided to do the 
simplest operation possible in order to get food into 
his small intestines. To accomplish this it was decided 
to do a gastroenterostomy and tie off the pylorus, as 
this seemed easier to do than a duojejunostomy. 

Inasmuch as this patient made a very prompt and 
good recovery, it was decided to use a similar opera- 
tive procedure on subsequent cases as they occurred, 
averaging about one a year. This accounts for the 
large proportion of gastroenterostomies as compared 
with duojejunostomies. 

The most recent case was a duojejunostomy where a 
generous opening was made and the patient made a 
good clinical recovery. 

Our first operative experience with this condition 
dates back to 1927 where a patient was diagnosed 
acute duodenal regurgitation in which a duojejunostomy 
was done but apparently in this patient the opening 
was not large enough so that although the patient 
got some relief, she never was completely well. 

A second patient a year later was operated upon, 
at which time a duojejunostomy was performed and 
apparently in this patient the opening was not large 
enough, as the symptoms persisted. The patient was 
operated upon a second time and a gastroenterostomy 
was performed, the pylorus being ligated. This gave 
the patient better results, but here again after the 
second operation the patient never got entirely well 
as she was constantly complaining of fullness and occa- 
sional vomiting and regurgitation of food. When the 
patient was observed under the fluoroscope, the barium 
passed out of the stomach into the small intestines 
through the gastroenterostomy opening and was ob- 
served to go in both directions. In order to keep 



barium out of the proximal loop, it was decided to do 
a third operation which consisted of placing a silk 
ligature just proximal to the gastroenterostomy open- 
ing. In this way all food was kept out of the duode- 
num for she then had a silk ligature at the pylorus 
and one proximal to the gastroenterostomy. The 
duodenum was then used only as a duct for the bile 
which mixed with the food stream through the former 
duojejunostomy opening. 

At the time of the third operation, an opportunity 
was had to inspect the silk ligature that had been 
placed about the pylorus some seven months previous 
and it was found to be in good condition and walled 

We have a series of fifty-one patients in which the 
pylorus has been ligated with silk for either duodenal 
regurgitation or duodenal ulcer and in no case have 
we had any evidence of bad effect. 

Our operative experience on fifteen cases of duode- 
nal regurgitation during the past twelve years has 
recalled to our mind at least two cases that were not 
recognized some twenty to twenty-two years ago. 
One of our prominent clinicians used to repeatedly 
state “how nice it would be if our foresight could 
be as good as our hindsight.” We can recall two 
young women who were under the care of two of our 
leading clinicians with a pernicious type of vomiting 
and at that time we were unable to locate the cause. 
As a result of our later experience, beginning twelve 
years ago, in recognizing a duodenal regurgitation, it 
is evident that if the first two cases had been recog- 
nized, surgical treatment could have been employed 
and relief obtained. Both patients had been fed for 
months through a duodenal tube but gradually pro- 
gressed to exhaustion and death. 

Conclusions —It is important to recognize the condi- 
tion of chronic duodenal stasis which is characterized 
by recurring attacks of vomiting associated with loss 
of weight and that the diagnosis depends essentially 
on a careful fluoroscopic examination. It is impor- 
tant that the roentgenologist always be on the alert to 
follow the barium through the duodenum and be on 
the lookout for a dilated duodenum and peristaltic 
waves with delay of the passing of barium through 
the duodenum. 

When the condition is recognized and it is not too 
advanced, medical management should first be used, 
but if satisfactory results are not obtained, surgical 
treatment should be resorted to. 

The surgical treatment is optional and may consist 
in either a duojejunostomy, making sure that the en- 
terostomy is made large, or a posterior gastroenteros- 
tomy and tying a silk ligature about the pylorus just 
tight enough to obstruct the lumen and not tight enough 
to produce a necrosis. 

Motion pictures of an African big game hunt were 
shown by Dr. Metz, who had been a member of the 
hunting party which took a trip to the Tanganyika 
Territory in Africa. The pictures were taken by a 
professional photographer. 



Books listed here become the property of the Ramse 
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. 

OF THE ESOPHAGUS. Porter P. Vinson, BS., 
M.A., M.D., D.Sc., F.A.C.P. Professor of Bron. 
choscopy, Esophagoscopy and Gastroscopy, Medical 
College of Virginia. 224 pages. Illus. Price, $4.00, 
cloth. Springfield, Ill.: Charles C. Thomas, 1940. 

George M. Lewis, M.D., and Mary E. Hopper, M.S. 
315 pages. Illus. Price, $5.50. Chicago: Year Book 
Publishers, 1939. 

This monograph of approximately 300 pages, should 
be of great interest to both practitioners and students. 
The subject matter is handled deftly and completely, 
yet brevity is the keynote throughout the entire work so 
that reading is not tiresome. There is ample practical 
information concerning the diagnosis and therapy of 
the various mycoses, discussions pertaining to immu- 
nity and sensitization to the fungi, as well as sections 
devoted to their microscopic and cultural characteristics, 
The book is printed on high grade paper, the type is 
unusually good, and the numerous photographs are ex- 
cellent. In my opinion, it is a worthwhile text and can 
be highly recommended.—Cart W. Laymon, M.D. 

SIGNIFICANCE, a publication of the Council on 
Foods of the American Medical Association. Cloth, 
Price, $2.00 postpaid. Pp. 512. Chicago: American 
Medical Association, 1939. 

Accepted Foods, and Their Nutritional Significance 
contains descriptions and detailed information regard- 
ing the chemical composition of more than 3,800 ac- 
cepted products, together with a discussion of the nu- 
tritional significance of each class of foods. The book 
provides also the Council’s opinion on many topics 
in nutrition, dietetics and the proper advertising of 

This book will be a welcome reference book for all 
persons interested in securing authoritative informa- 
tion about foods, especially the processed and fabri- 
cated foods which are widely advertised. The accepted 
products are classified in various categories; fats and 
oils; fruit juices including tomato juice; canned and 
dried fruit products; grain products; preparations used 
in the feeding of infants; meats, fish and sea foods; 
milk and milk products other than butter; foods for 
special dietetic purposes; sugars and syrups; vegetables 
and mushrooms; and unclassified and miscellaneous 
foods, including gelatin, iodized salt, coffee, tea, choco- 
late, cocoa, chocolate flavored beverage bases, flavoring 
extracts, dessert products, baking powder, cream of 
tartar, baking soda, cottonseed flour. There is a suitable 
subject index as well as an index of all the manufac- 
turers and distributors of food products that stand ac- 
cepted by the Council on Foods. 

Accepted Foods is indispensable for the library of 
every physician concerned with foods and nutrition. 


the ¢ 
of tk 


M.D., F.A.C.S. 453 pages. Illus. $4.95. Springfield, 
Ill.: Charles C. Thomas, 1939 

Dr. Collip, in his foreword, pays Dr. Hamblen a very 
deserving thank you for his admirable handling of this 
work prepared for the general practitioner. 

The author’s preface states his original purpose in 
collecting the material presented in his monograph was 
the organization of a series of lectures on endocrine 
gynecology for his classes of medical students, but their 
kind reception of his efforts prompted the preparation 
of these lectures for publication. 

The author’s expressed hope that the physician doing 
general practice, who does not have the time to review 
the various reports on endocrine subjects as they ap- 
pear in the many diverse journals and yet who is in- 
terested keenly in the endocrine physiology and patho- 
logy of women, will find this volume helpful has been 
magnificently granted. 

The pharmacology and chemistry sections of the sex- 
endocrine principles will be welcome to the reader. The 
illustrative material, hand drawn and otherwise pre- 
sented, is truly a work of art. 

You will all welcome this first edition, so characteris- 
tic of the Charles C. Thomas books and of Duke Uni- 
versity School of Medicine productions. It is the ex- 
pressed wish of the reviewer that the author will pre- 
sent revisions as often as new material is timely. The 
book is a treasury of references and a storehouse of 

information, clearly and understandingly presented for 
the general practitioner, gynecologist and pediatrician.— 
Littian L. Nye, M.D. 

VARICOSE VEINS, Alton M. Ochsner, M.D., and 
Howard Mahorner, M.D. 147 pp. Illus. Price, $3.00. 
St. Louis: C. V. Mosby Company, 1939. 

This book although of only 147 pages, including the 
references and index, is of nice width and breadth, 
measuring 7x10 inches. It is well bound, and the print- 
ing and the illustrations are excellent. 

The book is dedicated to Rudolph Matas and the 
Foreword is written by Doctor Matas. It is made up of 
ten chapters, including the history, anatomy, pathology, 
physiology, etiology, clinical aspects, examination of 
the varicose vein patient, the treatment, and the final 
chapter devoted to treatment of varicose ulcers. 

The history of the treatment of varicose veins is 
well written and is interesting. The chapters on 
anatomy, pathology, physiology and etiology are what 
one might expect. The chapter on the examination of 
the varicose vein patient consists largely of the various 
tests for evaluating the circulation in the venous system 
of the lower extremities. The comparative tourniquet 
test devised by the authors is particularly stressed. 
Under the chapter entitled “Treatment,” the injection 
treatment and the operative treatment are fully de- 


has shown a 

*“Treatment of 
Acute Anterior 
Urethritis with 
Silver Picrate,” 
Knight and She- 
lanski, AMERICAN 
Vol. 23, No. 2, 
pages 201-206, 
March, 1939. 


Tanuary, 1940 



due to Neisseria gonorrheae 

The record is based on rigid clinical and laboratory signs before 
and after treatment.* 
1. Fresh smear 3. Acid formation in maltose 
2. Fermentation of dextrose 4. Agglutination test 
5. Alkali solubility test 

Silver Picrate is a crystalline compound of silver in definite 
chemical combination with picric acid. Dosage form for use in 
Anterior Urethritis: Wyeth’s Silver Picrate Crystals used in an 
aqueous solution of 0.5 percent. 

Supplied at all pharmacies in vials of 2 grams 

Complete literature on Silver Picrate as used in genito-urinary and gyneco- 
logical practice will be mailed on request. 



scribed, especially the latter, which to my mind is the 
most important. 

Altogether the book is a very desirable one to have 
for any one interested particularly in this subject. 

M. G. Giutespre, M.D. 

FOR 1938. Cloth. Price, $1.00. Pp. 120. Chicago: 
American Medical Association, 1939. 

This volume as usual contains noteworthy exam- 
ples of the various kinds of reports made by the 
Council on Pharmacy and Chemistry: (1) prelimi- 
nary reports; (2) supplemental reports on therapeutic 
or pharmacologic problems; (3) reports on the rejec- 
tion of preparations offered for the Council’s consider- 

Among the preliminary reports in this volume that 
on Sulfapyridine, which carries a special article by 
Dr. A. Perrin H. Long, a Council member who has 
been much concerned with the work on this drug, is 
perhaps of greatest interest. After the Food and Drug 
Administration had released the drug for the use of 
physicians early in 1939, the Council accepted various 
brands for inclusion in N.N.R. and in connection with 
the published descriptions issued another status report 
(J.A.M.A. 112:1830, May 6, 1939) based on a ques- 
tionnaire sent to men who had been prominent in the 
experimental use of the drug. This report, no doubt, 
will appear in the next volume of reprinted Council 
reports. Other preliminary reports are the following: 
Allantoin, a preparation of glyoxyldiureid purposed to 
supersede the use of surgical maggots; and Sulfapyri- 
dine, published shortly before the Council acceptance of 
this new chemotherapeutic drug. 

Among the supplemental (or status) reports are 
those on Colloidal Sulfur in the Treatment of Chronic 
Arthritis, showing that much confirmatory evidence is 
needed to establish the value of this therapy; on 
Ergonovine, a careful study of the relation of this 
newly discovered principle to ergot therapy in general; 
and on Picrotoxin in Poisoning by the Barbiturates, 
showing the promise and the present limitations of 
this antidotal therapy. 

Among the reports of rejection the following are 
noteworthy: Collodaurum, a “colloidal gold” prepara- 
tion, promoted with unwarranted, exaggerated and 
misleading claims for its use in the treatment of can- 
cer; Dermo-G, stated to be a mixture of Spermaceti, 
White Wax, Oil of Sweet Almonds, Sodium Borate, 
Precipitated Sulphur and Water, an unscientific and 
superfluous mixture marketed under a therapeutically 
suggestive name with exaggerated, unwarranted claims; 
Fru-T-Lax, a needlessly complex and unscientific mix- 
ture advertised to the public under a misleading and 
inadequately descriptive name with claims which are 
unwarranted; and Hyposols Sulisocol, claimed to be 


“Sulphur Colloid” in 2 cc. of “Autoisotonized Solu- 
tion,” exploited for use in arthritis with inadequate 
evidence to its therapeutic value. Other rejections are 
explained in the reports on Map and Myoston, Nuper- 
cainal—“Ciba,” Pulvoids Sulfanilamide and Sodium 
bicarbonate (The Drug Products Co., Inc.), Quinoliv, 
Sedormid, and Tri-Costivin. 


Bing, Professor of Neurology, University of Basel, 
Switzerland. Translated by Webb Haymaker, Asst. 
Clinical Professor of Neurology, University of 
California. 838 pages. Illus, Price, $10.00. St. Louis: 
C. V. Mosby Co., 1939. 

After an examination of this book, the reviewer is 
much impressed by the imposing structure of modern 
neurology which is here set forth. The author succeeds 
admirably in condensing a massive amount of material, 
and his attempt “at the exposition and interpretation of 
facts rather than of devious hypotheses,” a feat briefly 
and modestly indicated in his foreword to the Ameri- 
can Edition, will indeed “be found profitable.” The lat- 
est advances in neurology in Europe and America are 
clearly and concisely presented; where there is more 
than one opinion on important matters, the conflicting 
opinions are presented with sufficient collateral evidence 
to enable the reader to form an intelligent judgment. 
The style is lucid and there is never any doubt as to 
what the author intended the reader to understand. This 
book should be of great value to the medical student as 
as source of information for his daily studies, and to 
the busy doctor as a convenient, concise and complete 
reference for aid in the solution of his clinical problems. 

Benj. F. Davis, M.D. 


Y. Ira I. Kaplan, B.S., M.D., and Sidney Ruben- 

feld, B.S., M.D. Price $4.00. Chicago: Year Book 
Publishers, Inc., 1939, 

The authors have provided the profession with an 
atlas which is most practical in its application. It is 
their answer to the general lack of precise knowledge 
as to the proper setting of patients for the adminis- 
tration of x-ray therapy. There are fifty-five full page 
plates showing the anatomy of the internal organs from 
the head down through the perineum. Since a correct 
knowledge of anatomy is needed in proper treatment, 
the location of the organs of the body was arrived at 
by using an average based on data obtained from 
standard works on anatomy and from clinical, surgi- 
cal and autopsy material. Each plate shows the visible 
anatomic landmarks, palpable internal landmarks, the 
internal parts to be irradiated, and the exact placement 
of the treatment cone. 

This atlas is a valuable adjunct to those practicing 
x-ray therapy. It is most handy and useful as a refer- 
ence and guide to proper localization of the x-ray 
beam. It is not intended to supplant the more extensive 
books which deal with cross section and topographic 

Oscar LipscuHuttz, M.D. 




Some ¢ 

eB. S. 


GER, | 
E. M 


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