Minnesota Medicine 1940-01: Vol 23 Iss 1

MINNESOTA MEDICINE

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

Owned and Published by
THE MINNESOTA STATE MEDICAL ASSOCIATION
Under the Direction of Its

EDITING AND PUBLISHING COMMITTEE
E. M. Hammes, M.D., Chairman, St. Paul 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

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

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

VOLUME 23

JANUARY TO DECEMBER, 1940

EDITORIAL AND BUSINESS OFFICES

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

imtere

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

MINNESOTA MEDICINE

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

PUBLISHED MONTHLY BY THE MINNESOTA STATE MEDICAL ASSOCIATION

JANUARY, 1940

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

Contents

Tue CARE OF AUTOMOBILE INJURIES INVOLVING THE PHotTocRAPH—Bertram S. Adams, M.D., President,
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

EDITORIAL :
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

THE TREATMENT OF ATOPIC DERMATITIS. / ins
E. M. Rusten, M.D., Minneapolis, Minnesota..... 16 The Bach Tradition... .............-.-+-sseeeeee 58

Preseriptioms Boaived.. ...... «x... 6.3566s0005% sacews 58
THE Symptom oF HEADACHE AND SOME CONDITIONS ‘i
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
RIAL ENDOCARDITIS. 4 :
| 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

LOWING PROSTATIC SURGERY.

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
Bone. TRANSACTIONS OF THE MINNEAPOLIS SURGICAL
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.

ST. CROIXDALE ON LAKE ST. CROIX

PRESCOTT, WISCONSIN

MAIN BUILDING—ONE OF THE 5 UNITS IN “COTTAGE PLAN”

A Modern Private Sanitarium for the Diagnosis, Care and Treatment of Nervous, Mental and Medical Cases
Located on beautiful Lake St. Croix, eighteen miles from the Twin Cities, it has the advantages of both
City and Country. Every facility for treatment provided, including recreational activities and occupational-
therapy under trained_personnel. Milk, cream and butter from our own herd of Tuberculin-tested

Registered Guernsey Cows. Inspection and codperation by reputable physicians invited. Rates very
reasonable. Illustrated folder on request.

CONSULTING NEURO-PSYCHIATRISTS

RESIDENT PHYSICIAN Hewitt B. Hannah, M.D. SUPERINTENDENT
Howard J. Laney, M.D. Joel C. Hultkrans, M.D. Williametta G. Avery
Prescott, Wisconsin 511 Medical Arts Building Prescott, Wisconsin
Tel. 39 Minneapolis, Minnesota Tel. 69
Tel. MAin 4672

Radiation Therapy Institute

of Saint Paul

Housed in a special new addition to the

GHARLES T. MILLER HOSPITAL

Facilities for Radium and Roentgen Therapy. Including 1,200,000
Volt Constant Potential Installation of Most Advanced Design.

Edward Schons, M.D., Director J.P.Medelman, M.D., Associate Director

MINNESOTA

MEDICINE

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

Volume 23

JANUARY, 1940

No. 1

THE CARE OF AUTOMOBILE INJURIES INVOLVING THE FACE*

GORDON B. NEW, M.D., and JOHN B. ERICH, MLD.
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

vy

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
inviting.

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

1

AUTOMOBILE INJURIES—NEW AND ERICH

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

2

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-
toma.

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

MINNESOTA MEDICINE

AUTOMOBILE INJURIES—NEW AND ERICH

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

3

AUTOMOBILE INJURIES—NEW AND ERICH

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
treatment.

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,

4

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

MINNESOTA MEDICINE

eae

ee ares

hae Gmsets

ame

AUTOMOBILE INJURIES—NEW AND ERICH

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

5

AUTOMOBILE INJURIES—NEW AND ERICH

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

6

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

MINNESOTA MEDICINE

1
1
I
(
|

@ .

* rE SE

AUTOMOBILE INJURIES—NEW AND ERICH

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-

4

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
patient.

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

7

EYE INJURIES—TILDERQUIST

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.

References

. 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.

EYE INJURIES DUE TO MECHANICAL CAUSES*

D. L. TILDERQUIST, M.D.
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.

8

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

MINNESOTA MEDICINE

oF

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

EYE INJURIES—TILDERQUIST

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

9

EYE INJURIES—TILDERQUIST

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
enumerated.

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

10

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

MINNESOTA MEDICINE

EYE INJURIES—TILDERQUIST

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
enucleated.

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

11

EYE INJURIES—TILDERQUIST

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-
sible.

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
vitreous.

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

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
hope.

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
healing.

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

12

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-
ing.

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.

Summary
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.

MINNESOTA MEDICINE

ROR OT agen

ETT ST

a

PR

DYSPHAGIA*

N. LOGAN LEVEN, M.D.

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
wrong.

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-
ach.

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

13

DYSPHAGIA—LEVEN

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

14

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
esophagus.

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
bifurcation.

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
pneumonia.

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
lung.

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-

MINNESOTA MEDICINE

DYSPHAGIA—LEVEN

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-
tion.

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

15

ATOPIC DERMATITIS—RUSTEN

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.

Bibliography

. 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,
1938.

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.,
1934

Cambridge

the esophagus, Jour.

origin.

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,
1922.

. 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

THE TREATMENT OF ATOPIC DERMATITIS*

E. M. RUSTEN, M.D.
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.

16

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

MINNESOTA MEDICINE

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-
mitted.

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

ATOPIC DERMATITIS—RUSTEN

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-

17

ATOPIC DERMATITIS—RUSTEN

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-
tization.

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

18

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-
tion.

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

MINNESOTA MEDICINE

SS aS

HEADACHE—WOLTMAN

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-
portance.

Summary

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.

References

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)

THE SYMPTOM OF HEADACHE AND SOME CONDITIONS
SUGGESTED BY IT*

HENRY W. WOLTMAN, M.D.

Rochester,

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,
1939.

January, 1940

Minnesota

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,

19

HEADACHE—WOLTMAN

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
Pressure

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-

20

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-
sclerosis.

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
blood.

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.

MINNESOTA MEDICINE

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-
astolic.

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

HEADACHE—WOLTMAN

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

21

HEADACHE—WOLTMAN

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.

22

Headaches Related to Endocrine
Dysfunction

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-
ties.

Migraine

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*’

MINNESOTA MEDICINE

HEADACHE—WOLTMAN

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
vessels.*

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

23

HEADACHE—WOLTMAN

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

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-
ologically.*°

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

24

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-
regarded.

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
disease.

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.

References

. Alvarez, W. C.:
Staff Meet.,
. Brewer, E.
currence and si
raphy. Bull.
1937.
. 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,
May
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,

aine
eurol.

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

MINNESOTA MEDICINE

BACTERIAL ENDOCARDITIS—HOFF

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.)
1937.

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.:

1938.
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.

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

1]

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-

1936.

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-

Lancet,

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

SOME CLINICAL VAGARIES ASSOCIATED WITH BACTERIAL
ENDOCARDITIS*

ALFRED HOFF, M.D.
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
necropsy.

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.
939.

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

25

BACTERIAL ENDOCARDITIS—HOFF

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
hospital.

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-
tysis.

2. Those with neurological manifestations

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

26

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
present.

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

MINNESOTA MEDICINE

BACTERIAL ENDOCARDITIS—HOFF

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.

CHART I. CASES OF SUBACUTE BACTERIAL ENDOCARDITIS WITH PROGRESSIVE
CONGESTIVE HEART FAILURE.
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
Hosp
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
infarct.

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

27

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.
Noble:

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

28

BACTERIAL ENDOCARDITIS—HOFF

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.

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

MINNESOTA MEDICINE

BACTERIAL ENDOCARDITIS—HOFF

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-

CHART II. CASES OF BACTERIAL ENDOCARDITIS—-ACUTE SEPTIC ONSET, WITH
SYMPTOMS OF PNEUMONIA AND MENINGITIS.
\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

29

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
clonus.

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-

30

BACTERIAL ENDOCARDITIS—HOFF

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
before.

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
emboli.

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

MINNESOTA MEDICINE

BACTERIAL ENDOCARDITIS—HOFF

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

CHART III. CASES OF SUBACUTE BACTERIAL ENDOCARDITIS.
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
good
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
entry.

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
artery.”

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-

31

BACTERIAL ENDOCARDITIS—HOFF

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
condition.

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

32

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

MINNESOTA MEDICINE

BACTERIAL ENDOCARDITIS—HOFF

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

33

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.

Summary

1. This paper is a clinical review, including

MEDICAL BIBLIOGRAPHY—KEYS

necropsy findings in thirteen cases of bacterial
endocarditis.

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
patients.

Bibliography

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

FUNDAMENTAL CONCEPTS OF
THOMAS E.

MEDICAL BIBLIOGRAPHY

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-
sota.

34

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-

MINNESOTA MEDICINE

MEDICAL BIBLIOGRAPHY—KEYS

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-
deavor.”

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
him.

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

35

MEDICAL BIBLIOGRAPHY—KEYS

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

36

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
references.

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

MINNESOTA MEDICINE

MEDICAL BIBLIOGRAPHY—KEYS

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-
tionary.*

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
sufficient.

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.
37

MEDICAL BIBLIOGRAPHY—KEYS

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-
italized.*

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
(Chicago).

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
letters.

tIncluded in Morris Fishbein’s book (op. cit.).
38

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

MINNESOTA MEDICINE

MEDICAL BIBLIOGRAPHY—KEYS

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”
article.

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

39

CYSTOGRAPHY—SWEETSER

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
source.

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-
essary.”

References

- Bulloch, William: Medical wy literature. Reviewed
935.

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 Med.cal 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.

Parasitology,

. Whit New England Jour.
Med..

CYSTOGRAPHY IN THE STUDY OF DIFFICULTIES FOLLOWING
PROSTATIC SURGERY*

THEODORE H. SWEETSER, M.D.
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-
ings.

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

40

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

MINNESOTA MEDICINE

CYSTOGRAPHY—SWEETSER

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;
stones
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
prostatectomy.

and hyper-

many
cystoscopic

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.

ing;
operation.

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
cystography
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.

several

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,

41

CYSTOGRAPHY—SWEETSER

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

4a

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

7b

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.

8a
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

42

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,

MINNESOTA MEDICINE

CYSTOGRAPHY—SWEETSER

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
radiograph).

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.

Reference

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

especially

neumocystog-
"vesical neck

esions. Jour.

BALANCING THE HEALTH BUDGET

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

* CASE REPORT o

PERFORATION OF MECKEL’S DIVERTICULUM BY FISH BONE*

Report of Case

R. V. WILLIAMS, M.D.
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
possibility.”

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
carrier.

*Read before the meetin
Association, New Ulm,

Ay

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)

MINNESOTA MEDICINE

HISTORY OF MEDICINE IN MINNESOTA

HISTORY OF MEDICINE IN HENNEPIN COUNTY
BY A. S. HAMILTON, M.D.
(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
duties.”

January, 1940

HISTORY OF MEDICINE IN MINNESOTA

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,
Secretary.”

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
article.

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.

MINNESOTA MEDICINE

HISTORY OF MEDICINE IN 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
given.

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.
Ames.

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

HISTORY OF MEDICINE IN MINNESOTA

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.

Membership—Linn,
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

MINNESOTA MEDICINE

January, 1940

HISTORY OF MEDICINE IN MINNESOTA

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

HISTORY OF MEDICINE IN MINNESOTA

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.

MINNESOTA MEDICINE

HISTORY OF MEDICINE IN MINNESOTA

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

HISTORY OF MEDICINE IN MINNESOTA

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

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:

MINNESOTA MEDICINE

HISTORY OF MEDICINE IN MINNESOTA

“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)

ARITHMETIC PROBLEM

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-
mission.

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
considered.

January, 1940

3ERTRAM S. ApAMs, M.D.
President, Minnesota State Medical Association

MINNESOTA MEDICINE

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

EDITORIAL

MINNESOTA MEDICINE

OrriciaL JourRNAL oF THE MinNESOTA STATE MEDICAL
ASSOCIATION

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

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

Duluth

EDITORIAL STAFF
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.

BUSINESS MANAGER
J. R. Bruce

Volume 23 JANUARY, 1940 Number 1

19359-1940

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.

56

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

MINNESOTA MEDICINE

EDITORIAL

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
Year.

CENTER FOR CONTINUATION STUDY

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-
passed.

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.

THE MINNESOTA MEDICAL FOUNDATION

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-
tivities.

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,
Minneapolis.

CONSULTANTS

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
patients.

More mistakes are made by the referring phys-

57

EDITORIAL

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.

THE BACH TRADITION

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

58

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
children.

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.

PRESCRIPTIONS REQUIRED

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
self-medication.

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-
scription.

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

auf;

MINNESOTA MEDICINE

MEDICAL ECONOMICS

Edited by the Committee on Medical Economics

of the

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

OFF TO A GOOD START

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-
tives.

January, 1940

MINNESOTA BRANCH

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

59

MEDICAL ECONOMICS

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.

THE COUNCIL MEETS

Marked expansion in the public health educa-
tion program of the Minnesota State Medical
Association will begin in several directions in
1940.

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

60

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

MINNESOTA MEDICINE

MEDICAL ECONOMICS

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-
sociation.”

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
February.

New Committees

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

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

61

MEDICAL ECONOMICS

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-
mittee.

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
chairman.

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.

ON MEDICAL ECONOMICS

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-
periments.

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

62

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

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
care.

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-

MINNESOTA MEDICINE

MEDICAL ECONOMICS

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
MINNESOTA MEDICINE.

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.

INSURANCE PITFALLS FOR PATIENTS

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.

63

MEDICAL ECONOMICS

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
services.

“WHY THE MEDICAL ADVISORY
COMMITTEE”
{Monthly Editorial Prepared by the Medical Advisory
Committee]

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.

ot

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.

TAKE YOUR CHOICE

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.”

MINNESOTA MEDICINE

OF GENERAL INTEREST

MINNESOTA STATE BOARD OF MEDICAL
EXAMINERS

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

OF GENERAL INTEREST

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
practice.

* * *

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
medicine.

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
1933.

***¢

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.

65

IN MEMORIAM

In Memoriam

Charles E. Fawcett
(1869-1939)

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-
ville.

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
Stewartville.

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.

66

PERFORATION OF MECKEL’S DIVERT! <u.
LUM BY FISH BONE

(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
severity.

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.

MINNESOTA MEDICINE

The
weekly
Statior
meters
(760 }

Spe
fessor
Schoo

The

Jan

Jani
Jan
Jan
No’
Minn

STA’

A
Annu
socia
will
Roch

A
the |
four
pects

from
Post
Brez
_M
mem
the
the
Exh
men
A
alre
Mos

* REPORTS and ANNOUNCEMENTS °

ae

MEDICAL BROADCAST FOR JANUARY

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.

STATE MEETING

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
functions.

January, 1940

WASHINGTON COUNTY SOCIETY

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.

MIDWESTERN FORUM ON ALLERGY

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
attend.

E. STARR JUDD LECTURE

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
death.

MINNESOTA RADIOLOGICAL SOCIETY

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.”

67

President, Dr. Willard White, in the Chair
Secretary: Dr.

CHRONIC DUODENAL STASIS

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
outlined.

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
stomach.

Acquired obstruction secondary to tumor growths
or adhesions or kinks can produce similar clinical
‘findings.

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
stasis.

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
attachment.

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.

68

TRANSACTIONS OF THE MINNEAPOLIS SURGICAL SOCIETY

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

MINNESOTA MEDICINE

duode
as th
Fre
can
t.
throu
will |
conti
2.
num
of
with
naus
3
dilat
vom
It is
is it
D
chre
frot
the
inat
nati
7
of
strt
car
of
qué
the
so
wil

aS:
th
fe

lie

TRANSACTIONS OF THE MINNEAPOLIS SURGICAL SOCIETY

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-
nations.

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-
terostomy.

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

69

BOOK REVIEWS

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
off.

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.

70

BOOK REVIEWS

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.

DIAGNOSIS AND TREATMENT OF DISEASES
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.

AN INTRODUCTION TO MEDICAL MYCOLOGY.
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.

ACCEPTED FOODS, AND THEIR NUTRITIONAL
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
foods.

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.

MINNESOTA MEDICINE

deser
work
Th
collec
the ¢
gyne
kind
of tk

BOOK REVIEWS

ENDOCRINE GYNECOLOGY. E. C. Hamblen, B.S.,
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-

SILVER PICRATE Ofycth’

has shown a

*“Treatment of
Acute Anterior
Urethritis with
Silver Picrate,”
Knight and She-
lanski, AMERICAN
JOURNAL OF
Sypui.is, Gon-
ORRHEA AND VE-
NEREAL DISEASES,
Vol. 23, No. 2,
pages 201-206,
March, 1939.

JOHN

Tanuary, 1940

WYETH AND BROTHER, INC. °¢

CONVINCING RECORD OF EFFECTIVENESS
in ACUTE ANTERIOR URETHRITIS

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.

PHILADELPHIA, PA.

BOOK REVIEWS

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.

ANNUAL REPRINT OF THE REPORTS OF THE
COUNCIL ON PHARMACY AND CHEMISTRY
OF THE AMERICAN MEDICAL ASSOCIATION
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-
ation.

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

72

“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.

TEXTBOOK OF NERVOUS DISEASES. Robert”

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.

A TOPOGRAPHIC ATLAS FOR X-RAY THERA-

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
anatomy.

Oscar LipscuHuttz, M.D.

MINNESOTA MEDICINE

Journ
Minne

Volu:

Some ¢
FRAC

eB. S.

TUMOR:
FT.

PERIOD!
GER, |
E. M

CARCIN
ENCI
Hart

INHIBI
E. 4

ne

Episio
Johi

OcuLs
Joh

sc

Convi
AN
O.

INFLA
Th

n

Nasa
)
Hist
Hi

t

A.
CASE
Su

J

||

Entered