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Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesota
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 35
February, 1952
Number 2
Contents
SoME OBSERVATIONS ON THE RECOGNITION AND
TREATMENT OF THE
HEPATIC CIRRHOSIS.
C. J. Watson, M.D., Minneapolis, Minnesota
COMMONER FoRMS OF
REHABILITATION OF THE HEMIPLEGIC PATIENT.
Joe R. Brown, M.D., Rochester, Minnesota
PosITIvE FINDINGS IN FUNCTIONAL NEUROPSY-
CHIATRIC DISORDERS.
Gordon R. Kamman, M.D., Saint Paul, Minnesota 141
HEMORRHAGE IN THE Rectus MUSCLE.
Harold H. Joffe, M.D., and Donald J. Van
Ryzin, M.D., Duluth, Minnesota
THe LuMpo-porsAL FasciA AND CHRONIC BACKACHE.
R. J. Dittrich, M.D., Duluth, Minnesota
THE MINNESOTA PROGRAM FOR THE CONTROL OF
BRUCELLOSIS.
Ralph L. West, D.V.M., Saint Paul, Minnesota... 152
PRESIDENT’S LETTER:
Through Organization to Service
EDITORIAL :
Narcotic Addiction on the Increase
A New Technique for Artificial Respiration
Science Talent Search
Hennepin County Neonatal Mortality Study
The Journal of the SAMA
MEeEpIcAL EconoMIcs:
Americans Continue to Get More and Better
Medical Care
Medical, Surgical Insurance Still Grows
Renewal of Health Plan Fight Re-emphasizes
NN FEN oa ood ca don eee tnna peeaeeteeeesees 161
Journal Urges More Improvement of Voluntary
Health Plans
REPORTS AND ANNOUNCEMENTS..........ceceeceeee 162
WomMan’s AUXILIARY
Tat TIN os iivitdvcimenanewedreceenednes~aes
Or GENERAL INTEREST
AREA eee eee Lenn any eee Te Geach 176
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Fepruary, 1952
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MINNESOTA MEDICINE
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Minnesota Medicine
Journal of the Minnesota State Medical Association, Southern Minnesota Medical Association, Northern Minnesote
Medical Association, Minnesota Academy of Medicine and Minneapolis Surgical Society
Volume 35
February, 1952
Number 2
SOME OBSERVATIONS ON THE RECOGNITION AND TREATMENT OF THE
COMMONER FORMS OF HEPATIC CIRRHOSIS
C. J. WATSON, M.D.
Minneapolis, Minnesota
FEEL gratified and deeply honored to have
been invited to give the Henry Sewall Lecture
for 1951. This has afforded a rewarding oppor-
tunity to gain some insight into the life work and
character of a genuine scientist and teacher who
played such an outstanding role in elevating the
plane of medical education and research in Colo-
rado. I am indebted to Dr. Waring for provid-
ing me with reminiscences and biographical infor-
mation about Dr. Sewall. Not being well versed
in the history of immunology, I was not previous-
ly aware that his discovery of antitoxin against
snake venom antedated v. Behring’s report of the
preparation of diphtheria antitoxin. Recognition
of this pioneer work was both inadequate and
tardy, but in 1931 Dr. Sewall was awarded the
Trudeau Medal of the National Tuberculosis As-
sociation, and in the same year the Kober Medal
of the Association of American Physicians.
The recipients of this lectureship in previous
years have set a high standard, and I feel genuine
trepidation in seeking to follow them, and es-
pecially in attempting to do so through the medium
of a topic as confusing as cirrhosis of the liver.
There is little uniformity or general understand-
ing as to the terminology and classification of
the various forms of hepatic cirrhosis. This can
be ascribed at least in part to two factors: (1)
the loose and variable manner in which the term
From the Department of Medicine, University of
Minnesota Medical School and Hospitals. Aided by a
contract from the Surgeon General’s Office, U. S. Army,
under sponsorship of the Commission on Liver Disease,
Armed Forces Epidemiological Board.
The Henry Sewall Lecture presented on February 6,
1951, at the University of Colorado Medical School, Den-
ver, Colorado.
Fesruary, 1952
Laennec’s cirrhosis is employed, and (2) the
oft expressed concept that “there is but one cir-
rhosis.” Many employ the term Laennec’s cirrhosis
interchangeably with portal cirrhosis, whether the
liver be large or small, fatty or nonfatty and re-
gardless of other characteristics. Laennec*’ real-
ly gave us little to go on except the bare state-
ment that the liver is small and yellow. A more
detailed description of what was undoubtedly the
same disease had been given earlier by Matthew
Baillie,? but unfortunately he used the poor and
confusing name of “common tubercle.” Despite
the extensive studies of the cirrhosis problem by
Mallory*? and his emphasis on the fundamental
distinction of certain forms, the idea of an essen-
tial unity of the cirrhoses gained many adherents.
Only in the past decade has the pendulum been
swinging in the opposite direction. One of the
most important factors in this change was the
study by many investigators of the transition of
fatty liver to fatty cirrhosis,?%%"""*?**7 both in
man and animals. It has now become reasonably
clear that the various forms of cirrhosis of the
liver are perhaps the best divided into two main
groups: those in which a fatty liver is an impor-
tant primary feature of the disease, and those in
which the cirrhotic liver is not fatty at any stage
in its development. A suggested classification of
cirrhosis along these two lines is given in Table I.
Several comments are needed with respect to the
classification suggested in Table I. In certain in-
stances it is not possible at the time of biopsy
or necropsy to be certain that the cirrhosis was
primarily fatty even though the history may
strongly suggest this. The fat may have been
125
HEPATIC CIRRHOSIS—WATSON
TABLE [. SUGGESTED CLASSIFICATION OF HEPATIC
CIRRHOSIS
I, Primarily fatty in pathovenesis
A ietary deficiency (“‘Kwashiorkor”’)
B. Chronic alcoholism and dietary deficiency—Laennec type
C. Toxic fatty liver (arsenic, CCls, phosphorus, certain
systemic infections) —~
D. Diabetic fatty liver
II. Primarily non-fatty in pathogenesis
A. Viral or idiopathic
1. Post-necrotic (toxic or coarsely nodular; healed acute
atrophy)
2. Diffuse portal (chronic hepatitis with fibrosis, mainly
portal) :
a. With hepatocellular impairment
h. Cholangiolitic (primary biliary; Hanot)
3. Transitions and mixtures
. Parasitic—Schistosomiasis
. Svphilitic—prohably only hepar lobatum
. Brucellosis (?)
. Obstructive biliary (cholostatic and cholangitic)
*. Metabolic error
1, Hemochromatosis (“pigmentary” cirrhosis)
2. Wilson’s disease
3. Fanconi’s syndrome
4. Porphyria hepatica
. Cardiac (central necrosis and fibrosis resulting from long
standing chronic passive congestion)
amino-aciduria
largely removed by lipotropic substances, either a
high protein diet or lipotropic substances such
as choline, or methionine given over a consider-
able period prior to the histological study.
As noted in Table I, the relation of brucellosis
to hepatic cirrhosis is questionable. There is much
reason to believe it is at times causative.
The existence of a true cardiac cirrhosis is con-
troversial.*® In the autopsy material at the Uni-
versity of Minnesota, McCartney*® was unable to
find a single instance that met the criteria for a
central, cardiac cirrhosis. A number of other
investigators, however, have emphasized the oc-
currence of a central fibrosis in cases of long-
standing passive congestion.?* 3/59
I wish to consider certain of the more important
clinical and laboratory features as well as the
problems of treatment of the two forms of cir-
rhosis which are by far the most significant in
the United States. The first and undoubtedly the
most common is that for which, if it is to be
used at all, the designation of Laennec’s cirrhosis
ought to be reserved. This is the primarily fatty
cirrhosis most commonly encountered in the
chronic alcoholic. The other type which I wish
to consider is the primarily non-fatty cirrhosis
which occurs as an idiopathic disease or as a
sequel to infectious (viral) hepatitis.
At the present time at least, the distinction of
these two most common forms is of considerable
importance from the standpoint of prognosis and
treatment. It may be emphasized that they are
not observed in a constant ratio from one hospital
to the next. In the large municipal hospitals in
this country where the problem of alcoholism is
126
encountered with the greatest frequency, the pro-
portion of cases of so-called “alcoholic” (Laen-
nec’s) cirrhosis is much higher than in hospitals
drawing material on a referral basis from a rural
population.2®> In the material of this latter type
which is characteristic of what we have at the
University of Minnesota Hospital, cirrhosis in
non-alcoholic individuals is relatively much more
common, and in this group the incidence of pre-
vious jaundice and the history of infectious hep-
atitis has been significantly higher than in the
control group.*®> The cirrhosis in these cases was
consistently non-fatty, both early and late. In
many instances the onset of the disease appeared
to be of the nature of a sporadic hepatitis. This
has been distinctly more common in women, and
we have seen as many or more cases in young
women as in those at or beyond the menopause.
Ahrens and co-workers** have recently studied a
group of cases in young women, characterized
by arthralgia and hyperglobulinemia, in addition
to other, ordinary characteristics of cirrhosis. In
our own experience these features do not ade-
quately delineate an independent form of the dis-
ease, as arthralgia is encountered with a fair
degree of frequency in acute and chronic hepati-
tis as well as cirrhosis ; and hyperglobulinemia of
marked degree may be encountered in men and in
older as well as younger women. We have been
impressed, however, with the frequency of oc-
currence of non-fatty cirrhosis in young women.
In a number of instances endocrine disturbances,
either menstrual or secondary sexual, have been
present for considerable periods prior to the first
episode of apparent hepatitis. This, together with
the sex incidence, suggests that endocrine disturb-
ances may make the liver more vulnerable to
attack. Matteini** has recently called attention to
the high incidence of clinical and functional he-
patic disturbances in women with menstrual ir-
regularities and believes that the latter precede,
rather than follow, the former.
In some of our cases the manifestations of
cirrhosis have first appeared at varying intervals
after an attack of epidemic hepatitis. Homologous
serum jaundice was believed to be the start-
ing point in a number of instances. In quite a
few the onset was insidious without clear-cut evi-
dence of an acute hepatitis. We have not seen
any case of cirrhosis in which it appeared that
infectious mononucleosis was causal, though re-
cent reports have indicated this possibility.***°
MINNESOTA MEDICINE
HEPATIC CIRRHOSIS—WATSON
The question of relationship of viral hepatitis to
diffuse cirrhosis is controversial, and it would
lead me too far astray to consider the matter in
any detail. It is my opinion, based on personal
experience and various studies reported in the
literature, that the relationship is reasonably well
established, but it is quite clear that such a de-
velopment is limited to a vary small fraction of
the entire mass of cases of infectious hepatitis.
One gains the impression from much of the
literature on cirrhosis** that the distinction be-
tween the so-called “post-necrotic” (“healed acute
atrophy” or “toxic nodular”) cirrhosis on the
one hand and diffuse,portal cirrhosis on the other
is always. sharp and distinct. While it is un-
doubtedly true that the extremes are usually dis-
tinguished accurately, it has been our experience
that the border line between the forms included in
the viral or idiopathic, non-fatty category of the
above classification is often not clear-cut, and, as
_ indicated, mixtures and transitions are ob-
served. This is not surprising when one
reflects that there are two important factors
influencing the develogitent-oF a more diffe
rather than a more irregular coarsely nodu-
lar type. These are (1) the occurrence in
many, if not all, cases of infectious hepatitis, of
small foci of necrosis, widely disseminated
throughout the liver parenchyma, **? and (2)
the occurrence of chronic hepatitis, characterized
by a persistent or recurrent inflammatory process
throughout the liver with particular involvement
of the portal spaces. °3%345+458,.63 Qur own experi-
ence indicates that while there are many clear-
cut examples of coarsely nodular (“post-necro-
tic’) as contrasted with a diffuse and more
finely nodular cirrhosis, at the extremes of this
large group, there are many and various instances
between these extremes representing the interplay
and persistence of these factors in varying de-
gree. The earlier, excellent monograph of Berg-
strand® clearly illustrates transitions between
these infectious cirrhoses.
The more diffuse and the more prominent the
portal Osis, the more likely that the term Laen-
nec will be used in designation, even though it
may be clear that the cirrhosis was primarily non-
fatty, non-alcoholic and non-dietary in character.
This is exemplified in a report by Bjorneboe and
Raaschou® relating to the distinction of post-
necrotic and “Laennec’s cirrhosis.” -Here it is in-
teresting to note that but 8 per cent of the latter
Feeruary, 1952
were classified as alcoholics, that the cirrhosis was
usually not fatty in type, and that difficulty was
encountered in distinguishing post-necrotic from
diffuse cirrhosis in some instances. One in par-
ticular was coarsely nodular in one area and
finely nodular (diffuse portal fibrosis) in an-
other. The great majority of cases included in
this study followed upon an attack of hepatitis of
unknown etiology.
There is a further important point indicating
that some cases designated as “post-necrotic” rep-
resent more than a single attack of limited dur-
ation followed by a relatively static condition in
which the necrotic areas are represented by large
scars and regenerative nodules. This is the fact
that the disease may be quite obviously progressive
in character after a relatively mild initial attack,
i.e., One without coma or the usual signs of acute
or subacute atrophy.
The “cholangiolitic” type is one in which there
is no CHWIGHCEOF necrcets, relatively little or no
evidence of hepatocellular functional impairment
for long periods, but only a chronic inflammatory
process restricted to the portal areas and exhibit-.
ing the development of pericholangiolar fibro-
sis.*°°* The clinical picture of this disease is
identical with that described by Hanot.?* The
term “primary biliary cirrhosis” is often em-
ployed." The designation “cholangiolitic” was first
suggested by the pathologist Réssle,** and
as indicated elsewhere®** we have used the
term more in a functional than in a_ his-
puncuions
tological sense, to represent the physiglogic
evidence of cholangiolar injury and segurgi-
tation of elements Of-the bile into the blood
The term is also useful in indicating the prob-
able restriction of the injury, at least during
a certain stage in any given case, to the cholangi-
olar or intrahepatic bile canalicular system, with
relative normality of the polygonal cells them-
selves. There is little doubt that cholangiolar in-
jury is often just as severe or even more severe
in many cases of hepatitis or cirrhosis in which
liver cell function is also seriously impaired, Fur-
thermore, there are many cases which, over a con-
siderable period of time, exhibit only cholangiolitic
phenomena, but after months or years gradually
develop more and more hepatocellular functional
impairment. This transition, in cases which for
long periods have presented as a pure cholan-
giolitic cirrhosis, to one of more ordinary type
with severe hepatic insufficiency, has been ob-
127
HEPATIC CIRRHOSIS—WATSON
served in a number of instances. Nevertheless,
there are a significant number of cases of the
cholangiolitic type in which liver cell function re-
mains relatively undisturbed for long periods of
time. It is particularly in this group that great
difficulty is encountered in diagnosis, since lab-
oratory aids in the distinction of extrahepatic
from intrahepatic causes of jaundice depend
mainly on tests of hepatocellular function. This
difficulty will be considered again in the following.
Ahrens and co-workers’ have recently stated
that none of their cases of primary biliary cirrho-
sis appeared to be related causally to infectious
hepatitis. Yet one of the most remarkable of our
own cases in this group gave a history of attacks
of jaundice in the family and amongst the neigh-
bors, thirty-three years earlier. At that time both
the patient and her sister were in bed with fever
and jaundice. The sister recovered completely,
but the patient persisted in having intermittent or
recurrent jaundice, at times with fever and ab-
dominal pain, up to the period of her study here
at age forty-eight. Because of fever, occasional
chills and pain simulating gallstone colic, she had
been operated on nine years earlier at which time
a normal common duct was found. Liver biopsy
then revealed a chronic hepatitis with mild portal
fibrosis. Nine years later portal cirrhosis was
well established, and the patient died of hematem-
esis from esophageal varices. This case has been
reported in detail elsewhere.®* :
‘Gertainii rtant clinical features may now
be considered with relation to the two principal
forms: (1) the primarily fatty “alcoholic” or
Laennec cirrhosis, and (2) the non-fatty viral or
idiopathic cirrhosis.
In this country the history of outspoken alco-
holism is usually evident in the Laennec or pri-
marily fatty type. A history of viral hepatitis
or of circumstances suggestive of it may be
elicited in the primarily non-fatty group. It is
important to seek carefully for an attack of
jaundice coming on from two to four months
after parenteral injection of any material that
might conceivably contain or be contaminated with
human blood serum; or, in fact, of needle punc-
ture for blood tests of one type or another. In
some instances the story of subacute diffuse necro-
sis of the liver with a very severe illness, and
perhaps with a period of coma, is easy to elicit.
After this attack the patient may have a rel-
atively static hepatic insufficiency which permits
128
some degree of activity but is easily demon-
strable by physical and laboratory methods. In
others the initial attack may be relatively mild
without indication of any considerable degree of
necrosis. The history of appearance of jaundice
from two to four months after cholecystectomy
or common duct surgery should lead one to in-
quire carefully as to the possibility of homologous
serum hepatitis-cirrhosis. The natural assump-
tion in such cases 18 that of a common duct stone
or stricture, and if operation is carried out when
the patient in reality is suffering from a diffuse
hepatitis or cirrhosis, the result may be_disas-
trous.*! — —
“Physical findings alone are often inadequate to
separate the two common forms of hepatic cirrho-
sis which we are considering. Jaundice and as-
cites are encountered singly or in varying com-
bination in either form. In general, it may be
said that the emphasis is on ascites in the alcoholic
or primarily fatty cirrhosis, and on jaurdice m the
viral or non-fatty cirrhosis.
It should be emphasized that advanced cirrhosis
with hepatic insufficiency may be encountered
without jaundice.** I have repeatedly seen cases
of fatal hepatic coma due to cirrhosis, exhibiting
fetor hepaticus and other evidence’ of failure of
liver function, without visible jaundice. This com-
bination has been most common following a sud-
den large hematemesis. The latter is undoubtedly
responsible for further deterioration of liver func-
tion, but quite probably, also, a throttling of he-
moglobin destruction so that bilirubin formation is
at a, minimum.
In the, cholangiolitic or Hanot type, it is char-
acteristic, of course, to nite Wileete jaundice,
hepatomegaly and splenomegaly, without ascites.
The pruritus which is so often observed in this
type is quite rare in association with fatty cirrho-
sis. The majority of these cases eventually ex-
hibit xanthelasma or xanthomata. The bulk of
evidence indicates that in the so-called “xanthom-
atous biliary cirrhosis” the xanthomata are sec-
ondary, rather than a primar¥Cause of the disease.
In our experience such manifestations as spider
nevi, loss of hair, especially from the axillae, and
fetor hepaticus are about equally frequent in the
two groups. The occurrence and degree of the
latter phenomenon in particular is of no little aid
in assaying the severity of the hepatic insufficien-
cy. Pigmentation or melanosis of the skin dis-
tinct from jaundice or hemosiderosis, is much
MINNESOTA MEDICINE
HEPATIC CIRRHOSIS—WATSON
more commonly encountered in the primarily non-
fatty group. It is, of course, even more frequent
in cases of hemochromatosis. Pigmentation not
due to iron is at times associated with pruritus in
cases of cirrhosis without jaundice and without
elevation of the serum bile acids. The significance
of this association is unknown.
Certain laboratory data deserve special com-
ment. ‘Pht-tenkocyte formula is of some sig-
nificance in separating the two main forms. Thus,
in the sever€fatty.cirrhosis of the chronic alco-
holic it is not uncommon to observe a rather mark-
ed neutrophilic leukocytosis in association with
even considerable fever, and, although this find-
ing should induce a careful search for intercurrent
infection, it is often not found, even at necropsy
In some of these cases a polymorphonuclear
leukocytic exudate may be quite prominent in the
cirrhotic liver,* but in others with the same
degree of peripheral leukocytosis and fever we
have failed to see this, Leukocytosis is much less
frequently observed in the primarily non-fatty
group. In fact in our own experience it has been
associated only with intercurrent infection in
these cases.
In cirrhosis the fractional serum bilirubin de-
termination is of value under two circumstances:
(1) When the prompt (1’) fraction is significantly
increased ( >0.25 mg. per 100 cc.), within a nor-
mal value for total bilirubin (<1.5 mg. per 100
cc.), in the non-jaundiced case. This, of course, is
non-specific for cirrhosis and is often observed in
other hepatobiliary disease. (2) When the bili-
rubin ratio
Prompt direct or 1’ x 100
Total
is less than 30 in a patient with jaundice or with
a total serum bilirubin above 2.0 mg. per 100 cc.,
and when the condition at hand is not a primary
or uncomplicated hemolytic anemia. As a matter
of fact, this combination is most often encountered
in patients with cirrhosis and with a hemolytic
component or outspoken hemolytic anemia.
From the laboratory standpoint, cirrhosis, of
course, enters prominently into the problem of
differential diagnosis of jaundice. The laboratory
procedures of aid in this respect depend in the
main on alterations of hepatocellular function. In
extrahepatic obstructive jaundice such alterations
commonly are slight or absent, while in the usual
case of parenchymal or hepatic jaundice, including
cirrhosis, the alterations are sufficiently marked to
Fepruary, 1952
indicate with a fair degree of certainty that the
jaundice is due to a diffuse disease of the liver,
rather than a mechanical obstruction in the biliary
tract. The distinction is perhaps of chief im-
portance with respect to the question of whether
an operation is indicated. There is perhaps no
area in medicine in which it is more desirable to
avoid a mistake in this regard. _General anesthesia
anf-a torial operation on a patient with a pri-
mary diffuse disease of the liver may be followed
shortly by profound hepatic insufficiency, coma,
and death. On the other hand, an equally great
injustice may be done by failure to operate on a
patient with a common duct stone or even a
carcinoma of the biliary tract. In the ordinary
case of cirrhosis a careful history and physical ex-
amination with attention to some of the above de-
tails, considered together with a reasonable num-
ber of well-chosen laboratory procedures, will
very often provide the right diagnosis. Mistakes
+
are most likely to be made in that groffp of cases
in which hepatocellular function is relatively less
and cholangiolar function relatively more impaired,
as in the “pure” type of cholangidlitic cirrhosis.
Here the Tests which we ordinarily Tely upon to
indicate a diffuse hepatocellular functional impair-
ment may be entirely normal or only slightly dis-
turbed. The cgphalin cholesterol flocculation test
is often negative. The thymol turbidity test may
be increased even considéfably, but since in these
cases there is frequently a hypercholesterolemia,
and since the thymol tubidity test is much more
positive under these circumstances, it becomes less
phatase is commonly elevated to a marked degree
along with the hypercholesterolemia, and the ser-
um bile acid level is usually elevated. There may
be relatively little urobilinogen in the urine. Thus,
one is left with the problem of relatively painless
jaundice, an enlarged liver, and sometimes a palp-
able spleen and a liver function profile quitecom-
patible with an extrahepatic biliary obstruction. In
some cases there may be mild evidence of hepa-
tocellular functional impairment but not suffici-
ently outspoken to enable one to make the distinc-
tion on this basis alone. Another confusing fea-
ture in this particular variety of cirrhosis is the
occurence of the pseudo-gallstone colic with or
without fever and chills.*** ‘This may simulate
cholelithiasis so exactly that a distinction is im-
possible.
Our policy for some time has been to subject
129
useful in differential diagnosis. The alkaline phos-
HEPATIC CIRRHOSIS—WATSON
doubtful cases to a small laparotomy under local
anesthesia in the region of the gall . bladder.
Neither opiates nor barbiturates should be given.
The gross appearance of the liver is noted and a
Fig. 1. Case E. N., a woman, aged forty-eight.
Cholangiolitic cirrhosis. Cholangiogram through gall
bladder under local anesthesia. No evidence of bile duct
obstruction or abnormality.
liver biopsy is taken under direct vision, If the
cystic duct is patent, cholangiography is then car-
ried out through the gall bladder, while the patient
is on the table. If the common duct is visualized
and not dilated, and if the contrast medium flows
readily into the duodenum, nothing more is done
If the common duct is dilated and there ap-
pears to be obstruction at the ampulla, the incision
may be extended and a more formal exploration
of the duct may be carried out under general
anesthesia. We are increasingly convinced that
this method has a great deal of merit in avoiding
*Study in progress with Dr. Richard Varco, professor
of surgery, University of Minnesota. Peritoneoscopic
cholangiography, as recommended by Royer and
others,?%57 has been demonstrated to be equally useful
for this purpose.
130
jeopardy to the patient whose jaundice is due to
hepatitis or cirrhosis.* Figure 1 shows a cholangio-
gram obtained in this way in a case of cholangio-
litic cirrhosis. The common duct is not dilated, and
the contrast medium flows readily into the duo-
denum. Prior to this study and a liver biopsy car-
ried out at the same time, there was a serious
question in this case as to the possibility of an
extra hepatic obstruction.
Considerations of Treatment
We must readily admit that we lack any very
specific therapy for hepatic cirrhosis. Neverthe-
less, it has become increasingly apparent in recent
years that, of the two main forms of the disease
which we have been considering, the results of
certain general measures are often remarkably
good in the primarily fatty group, while in the
viral or non-fatty group there has been but little
evidence that any of the measures thus far em-
ployed have been beneficial. The important con-
tribution and subsequent experience of Patek
and his co-workers*'*’ with a diet plentiful in
protein and vitamins undoubtedly has led to a
much more favorable attitude generally as to the
prognosis of patients with cirrhosis. It appears
however, that the good results which they are
now able to report after a period of more than
ten years® are limited to alcoholic fatty cirrhosis
and that their statistical evidence of improvement
and indeed of survival in these would be still
better if the relatively small number of cases of
post-hepatitis cirrhosis were omitted from their
calculations. Patek®® has evidently made no at-
tempt to divide his material along the lines of the
present classification, and he uses the term Laen-
nec’s cirrhosis in a much broader sense, and, it is
believed, for a much more heterogeneous group.
In cases of Laennec’s cirrhosis, using the term
only as presently defined, it is quite clear that
bed rest, abstinence and a good diet are often fol-
lowed by dramatic improvement. Patients who are
able to eat and whose livers are still enlarged have
by far the best prognosis.**? Those with small
livers or with persistent and marked anorexia may
fail to show any significant improvement, even
with parenteral nutrition and various supplements.
Nevertheless, we have found it difficult to deter-
mine any definite borderline, clinically, beyond
which a patient is unable to recover, at least to a
point compatible with comfort and a reasonable
existence. In some of our cases liver biopsy at
MINNESOTA MEDICINE
HEPATIC CIRRHOSIS—WATSON
the outset has shown the most striking degree of
fatty cirrhosis and disorganization®™ in spite of
which after a variable period of time and follow-
ing many and various therapeutic measures, re-
lowed by improvement even though the liver be-
comes considerably smaller. * It is not unlikely that
the determining factor in the prognosis is the mass
of relatively normal liver cells still present, both
Improvement in hepatic cirrhosis with low protein, low caloric intake
L.M.,,%, 0ge 35 yr. No. 8263/6
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sis, jaundice and ascites.
Riboflavin phosphate
40 mg. daily, 1.V.
Fig. 2. Case L. M., a woman, aged thirty-five.
Improvement with low protein, low caloric intake.
‘
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,
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,
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Chronic alcoholism with cirrho-
Ribo-
flavin phosphate was given in relation to a study of porphrin metabolism, but it
is probable that improvement had commenced before it was started.
covery to a relatively normal state has been ob-
served. In some instances even, in which jaundice
ascites and somnolence were prominent at the
outset, this recovery has been so complete that the
physical examination and many of the liver func-
tion tests have returned entirely to normal, and
only with a battery of tests has it been possible to
detect some residual impairment of liver func-
tion.** Such individuals undoubtedly could pass a
life insurance examination except for the history
of their illness. Unfortunately, a reversion to
their alcoholism all too often results in renewed
progress of the cirrhosis. There are, of course
cases of severe “alcoholic” fatty or Laennec’s
cirrhosis that fail to respond to therapy and suc-
cumb, either to hepatic insufficiency, blood loss, or
intercurrent disease, or a combination, As men-
tioned earlier, the fat may be removed from the
liver, at times quite completely, due to the lipo-
tropic substances, but this is not necessarily fol-
Fepruary, 1952
to resume an improved function and for normal
(not adenomatous) regenerative activiiy.
It has not been possible to determine what meas-
ures are of greatest significance in promoting re-
covery. The production of fatty cirrhosis in ani-
mals as a result of choline deficiency and its occur-
rence in human dietary deficiency without alcohol ;
also the improvement reported by Patek and
others, following a liberal intake of protein and
vitamins argue in favor of dietary factors as being
of principal significance. Nevertheless, it is now
clear that with rest and abstinence, striking im-
provement will often occur on diets relatively low
in protein*® Eckhart and co-workers! observed
improvement in cases of “alcoholic” cirrhosis re-
ceiving a diet of carbohydrate almost devoid of
protein but containing small amounts of choline
and Vitamin B complex. In Figure 2 data are
shown from a case of “alcoholic” fatty cirrhosis
in which marked improvement occurred on a
131
HEPATIC CIRRHOSIS—WATSON
relatively low calorie and protein intake. Re-
cent studies indicate, however, that no improve-
ment occurs if calories are supplied as glucose
alone, without choline or protein.** This is in
accord with the observation of Best and co-work-
ers’ that fatty liver is promoted in the rat by
feeding glucose, or alcohol, without choline. Nev-
ertheless, these observations do not exclude the
possibility that alcohol increases the requirement
of choline, perhaps by interfering with its func-
tion in the liver. This, in fact, has been sug-
gested by certain recent experiments of Klatskin.**
If this were true, it would readily explain the
occurrence of outspoken fatty cirrhosis in some
individuals who have been drinking excessively
for years but give histories of an adequate protein
intake and are fully supported in this story by
members of their families. A critical experiment
that is much needed, but for obvious reasons dif-
ficult to carry out, is that of continuing cases of
“alcoholic” fatty cirrhosis on alcohol, under con-
trolled conditions in the hospital. A similar study
has been carried out with respect to alcoholic poly-
neuritis, and this yielded the interesting informa-
tion that the controlled cases not receiving alcohol
responded more quickly to dietary and vitamin
therapy.®
It appears inéscapable that striking individual
differences exist as to the ease of development of
cirrhosis in chronic alcoholics, some with long his-
tories of severe alcoholism and poor diet neverthe-
less failing to show the least evidence of cirrhosis ;
others, as already mentioned, with outspoken fatty
cirrhosis but without any history of dietary de-
ficiency. It cannot be denied that there may be
important constitutional variance in the tendency
to cirrhosis, and that this might be ascribed to the
relative efficiency of utilization of lipotropic fact-
ors, especially choline. There are certainly dif-
ferences between species in respect to the effect
of alcohol on porphyrin metabolism, the disturb-
ance of which in cases of human cirrhosis is prob-
ably a reflection of a disturbed cellular metabolism
in the liver. An increased excretion of type III
coproporphyrin characterizes acute alcoholisim in
humans and is found in human alcoholics with
cirrhosis, for variable periods after cessation of
alcohol.®**> In rats?* and dogs,?° however, these
increases have not been observed, either in relation
to acute alcoholism or dietary fatty cirrhosis,
either with or without alcohol.
It is doubtful that the addition of choline or
132
methionine provides any benefit for the patient
with “alcoholic” cirrhosis, beyond that to be ex-
pected from a normal intake of protein. Pre-
liminary studies with large amounts of vitamin
B,., which has also been shown to be lipotropic
and choline sparing, lead to the same conclusion.
A good deal has been written about the value of
crude liver extract in the treatment of cirrhosis
of the liver. Ralli and co-workers® have recently
reported a difference in survival rates in patients
receiving crude liver extract (“intraheptol”) in-
travenously, as compared with those not so treat-
ed. In this report, however, it was not stated
whether the controls returned at as regular and
frequent intervals to receive a placebo instead of
liver extract, and, since’ the entire group consisted
in the main of alcoholics, this would seem to be an
important requirement. We have not been able
to convince ourselves of the beneficial effect of
crude liver extract. We have often seen patients
who were receiving it improve, but only after a
long period of time during which other measures
were employed, so that the improvement could
scarcely be ascribed to the extract. Actually, a
controlled study of the effect of any given sub-
stance in the treatment of hepatic cirrhosis is
attended by unusually great difficulty. Such a
study requires hospitalization and a base line
period of observation, and, as already noted
marked improvement may occur during the con-
trol period. On the other hand if the patient is
very ill, one does not feel justified in attempting
a controlled experiment with one substance since
a number of days would be required, during
which he would be denied the possible benefit of
other measures.
It was generally hoped that salt-poor human
albumin (prepared by Cohn’s method) might be
of great value in the treatment of hepatic cirrho-
sis. Its value, however, appears to be limited
largely to certain patients with ascites, if given
shortly after the abdomen has been tapped rela-
tively dry’*** and particularly if used in conjunc-
tion with mercurial diuretics and a very low
sodium intake.17?* Some caution is required in
the administration of albumin, as pulmonary ede-
ma and fever have repeatedly been observed after
large amounts.** It appears, too, that the likeli-
hood of hematemesis from esophageal varices is
distinctly increased by administration of albumin
in an amount sufficient to have any effect on
acites,1*-?5
MINNESOTA MEDICINE
a ee ee ee ee ee ee
anna
ee es i
The appreciation of the great significance of
sodium for the accumulation of ascitic fluid is one
of the more important recent advances in the
treatment of cirrhosis.**'"** Various studies have
shown that if a low salt diet is to be effective,
it must contain less than 1 gram of sodium chloride
(0.4 gm. sodium) in twenty-four hours and pre-
ferably not more than half of this amount. *%?"
The use of an ion exchange resin to permit a
more liberal intake of sodium, without absorp-
tion from the intestine, has proven of some value.
but has distinct danger.’®
I have striven thus far to focus your interest
principally upon the two forms of hepatic cirrho-
sis most common in this country. It may be well
in closing to give brief attention to another
member of the primarily non-fatty group, name-
ly, hemochromatosis. This is the most important
representative of the metabolic subdivision given
in Table I. It is invariably a hypertrophic cirrho-
sis, in the broad sense, and the size of the
liver may attain unusual proportions. It should
be emphasized that while the disease is commonly
termed “bronze diabetes” the evidence of cirrhosis
and the pigmentation of the skin may appear well
in advance of the glycosuria and in some instances
enlargement of the liver due to iron deposition
may be present without diabetes and with very
little pigmentation of the skin. Liver biopsy is
of the utmost value in the diagnosis of such
cases, indeed of the disease quite generally. The
skin biopsy may be negative for iron, even in
the presence of considerable degrees of pigmenta-
tion.
An intriguing method of treatment of this form
of cirrhosis has recently been suggested.*** This
depends upon the concept that the primary dis-
turbance in hemochromatosis is one of abnormal
iron absorption and storage and that the cirrho-
sis is secondary to the extensive deposits of iron
The method consists of repeated bleeding, over
long periods of time, to force utilization of the
iron stored in the liver and perhaps in this way
to bring about improvement of the cirrhosis.
Davis'® has reported cases in which it appears
that this may have been achieved to some extent.
Howard and associates in this clinic have been
following the case of a surgeon with hemochro-
matosis who has been unusually co-operative in
permitting repeated blood letting over a three-
year period.”* In this span of time approximately
100 liters of blood have been removed. The
Fepruary, 1952
HEPATIC CIRRHOSIS—WATSON
liver is still enlarged, but it appears to be dis-
tinctly smaller than at the outset. The only evi-
dence of improvement of liver function has been
a slight increase in the serum albumin, and an in-
crease of the cholesterol ester percentage. The
pigmentation of the skin has clearly diminished.
With this there has been an improvement in the
patient’s general status, his feeling of well-being
and his ability to work. Only time will tell whether
the disease can be held in abeyance permanently or
whether even an outspoken remission can be
brought about in this way. Of course, as time
goes on a major difficulty is that the veins become
increasingly less available to phlebotomy. In this
connection one is reminded that a deliberate hook- |
worm infestation has been employed by French
clinicians in the treatment of some cases of poly-
cythemia vera. Actually, this method would ap-
pear to be even more logical for hemochromatosis,
though just as repugnant.
Summary and Conclusions
1. Hepatic cirrhosis is not regarded as a single
disease with variations but rather as a group of
diseases of widely varying etiology in which chem-
ical, dietary, infectious, and metabolic factors are
all of importance, either individually or in com-
bination.
2. It is useful and logical and in accordance
with present available knowledge to divide the
cirrhosis into two main groups, those that are
primarily fatty in pathogenesis and those that are
primarily non-fatty. The principal representative
of the former group in this country is the fatty
(Laennec) cirrhosis of the chronic alcoholic,
while the non-fatty group is represented mainly
by the cirrhoses, either post-necrotic, diffuse port-
al, or transitions, following upon an attack of in-
fectious hepatitis or occurring without known
etiology. Cases which are indistinguishable from
those following hepatitis, but which may have a
differing etiology either develop insidiously or fol-
low immediately upon an attack which may repre-
sent a sporadic infectious hepatitis. This form
is more often observed in women. A special va-
riety or stage in the large group of primarily non-
fatty cirrhosis is the relatively pure cholangiolitic
or primary biliary cirrhosis which undoubtedly
corresponds with what Hanot originally described.
This variety is of particular importance be-
cause of the ease with which it is confused clin-
ically with extrahepatic biliary obstruction. In
133
HEPATIC CIRRHOSIS—WATSON
this respect the value of cholangiography under
local anesthesia is discussed.
3. The results of treatment of cirrhosis are
much better than was formerly believed, but it is
emphasized that the good results are limited
largely to the primarily fatty group (in this coun-
try mainly in chronic alcoholics). The relative
importance of various factors responsible for
these good results is not yet clear, but it appears
that the value of rest and complete abstinence may
have been underestimated. The possibility is con-
sidered that alcohol may increase the choline re-
quirement.
4. The treatment of ascites is centered upon
the importance of a low sodium intake and of pro-
moting sodium excretion, once due attention has
been given to the simple factors just referred to.
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1949.
. Watson, C. J., and Hoffbauer, F. W.: Liver func-
tion in hepatitis. Ann. Int. Med., 26:813 (June)
1947.
. Watson, C. J., and Hoffbauer, F. W.: The problem
of prolonged hepatitis with particular reference to
the cholangiolitic type and to the development of
cholangiolitic cirrhosis of the liver. Ann. Int. Med.,
25:195 (Aug.) 1946.
Watson, C. J., and Greenberg, A.: Certain effects
of salt poor human albumin in cases of hepatic
disease. Am. J. M. Sc., 217:651-657 (June) 1949.
Watson, C. J.; Sutherland, D., and Hawkinson, V.:
Studies of the coproporphyrins. V. The isomer dis-
tribution and per diem excretion of the urinary
coproporphyrin in cases of cirrhosis of the liver.
J. Lab. & Clin. Med., 37:8, 1951.
. Zieve, L.; Hill, E.; Hanson, M. C. L.; Falcone,
A. B., and Watson, C. J.; Normal and abormal
variations and clinical significance of the one minute
and total serum bilirubin determinations. J. Lab.
and Clin. Med., 38 :446, 1951.
MORE AUTOPSIES NEEDED
“An increase in the proportion of autopsies . . . would
lead to more accurate diagnosis” in infants’ deaths, says
Mr. J. W. Brower, acting director of the Division of
Vital Statistics, Minnesota Department of Health. A
teport recently issued by that division states that autop-
sies are not common in the smaller cities and rural areas
of the state. For the first part of 1951, Duluth reported
the largest proportion of autopsies, followed by Minneap-
ol's and Saint Paul.
The Divisions of Vital Statistics and Maternal and
Child Health are making a statistical analysis of infant
Ferruary, 1952
deaths from birth and death records of Minnesota in-
fants. This study indicates that 806 infant deaths oc-
curred in the state during the first five months of 1951,
and that 53.6 rer cent of the infants who died weighed
less than 5 pounds 9 ounces at birth. These infants were
premature according to the widely accepted definition of
the term. Fewer than 11 per cent of the deaths due to
premature birth were autopsied. Congenital malformation
was the second highest cause of death among the 806
infants, accounting for 171 deaths—Minnesota Health,
January, 1952.
REHABILITATION OF THE HEMIPLEGIC PATIENT
JOE R. BROWN, M.D.
Rochester, Minnesota
D URING the past few years increasing atten-
tion has been paid to the retraining of pa-
tients who have hemiplegia. With the increasing
aging of our population this problem promises
to be of even greater importance in the future
than in the past. The fact that satisfactory re-
sults can be obtained is indicated by the experi-
ence of Leemhuis and Brown, who have report-
ed that at least 85 per cent of 105 hospitalized
hemiplegic patients treated showed significant im-
provement under an integrated program of ther-
apy. Such a program can be adapted for the
treatment of patients in the home or as out-
patients. In the management of a patient who
has had a stroke it is necessary to take many
factors into consideration. The more one can
learn about his total situation, the more readily
can one deal with specific problems as they arise.
It is possible to describe the management pro-
gram according to the stage of the illness of the
patient. The care of the patient during the acute
illness is beyond the scope of this paper. Ordi-
narily one can consider this stage to be termi-
nated when the major immediate threat to life
seems to have subsided. In general, the acute
stage lasts from two to ten days and merges
into the subacute stage. At this point it is im-
portant to evaluate the extent of the disability.
There may be severe weakness in the arm, the
leg or both. There may be associated hemianes-
thesia and hemianopsia. The patient and his
family should be gently but confidently introd-
duced to the idea that measures are being started
for the purpose of aiding him to walk again.
Early in the subacute stage the paretic extrem-
ity is frequently flaccid but later it becomes
spastic. Because of immobility and spasticity,
contractures are prone to occur and may make
their appearance within ten days. Common sites -
of early contractures are the shoulder, hip and
knees. Spastic contractures of distal joints may
develop later. Prevention of contractures de-
pends on the early institution of passive motion
From the Department of Neurology and Psychiatry,
Mayo Clinic, Rochester, Minnesota.
kKead at the fourth annual Clinical Session of the
American Medical Association, Cleveland, Ohio, De-
cember 5 to 8, 1950.
136
daily through the full joint range. Proper posi-
tioning in bed will help avoid flexion at the hip
and knee, as well as inversion of the foot. The
correct position can be maintained by the use
of sandbags, footboards, and so forth. If trained
therapists are not available, nurses or responsi-
ble relatives can be instructed in the penpes use
of passive motion.
The duration of the subacute stage will gen-
erally vary from three to six weeks, depending
on the cause, severity and location of the brain
lesion. In general, a cerebral hemorrhage re-
quires a longer period of rest in bed than does
a cerebral infarct. The presence of a complicat-
ing medical condition may also prolong this pe-
riod. During the subacute stage the patient is
encouraged to move and use the affected extremi-
ties. At the same time he is stimulated to assist
with his daily self-care needs' (Table I). By
the end of the subacute stage he should be capable
of the first eight self-care activities listed.
The early convalescent stage begins when the
patient is permitted out of bed. At this time he
is instructed progressively in the next seven self-
care activities and the beginning ambulation ac-
tivities (Table Il). At this point the patient
should be protected against possible falls.” Care
should be taken to attain full extension of the
knee of the paretic leg. A solid table, posts of
a bed, and so forth, may be used to substitute for
parallel bars. The exercises at this time should
be taken over by the patient as much as possible.
Passive motion can be obtained by the use of
pulley assistance. Muscle power in paretic mus-
cles can be increased by utilizing the—pririciple
of progressive resistance exercises.> At the start
the patient should be expected to lift ten times
successively an amount which is one half of his
maximal capacity for a single lift through the
range of that particular joint. If he is unable
to move the extremity through full range against
gravity, the final few degrees he lacks may be
completed by a therapist or by a properly instruct-
ed relative (active assistive exercises). Re-educa-
tion exercises for the development of finer skills
will probably require the supervision of a trained
therapist. For details of the use of specific exer-
cises, a standard text on the subject is suggested.”
MINNESOTA MEDICINE
— er. 7 ee ee
REHABILITATION OF THE HEMIPLEGIC PATIENT—BROWN
TABLE I.—SELF-CARE*
TABLE II.—AMBULATION*
. Change position in bed
. Feed self
. Wash hands and face
Arise and stand with aid in parallel bars
Arise and stand without aid in parallel bars
Shift weight from foot to foot in parallel bars
Brush teeth and comb hair
Write name and address
Use telephone
Sit up for six hours
Get from lying to sitting position
Walk in parallel bars with assistance
Walk in parallel bars without assistance
Walk with assistance of instructor
Walk without assistance, instructor by side
Arise to stand from wheelchair without aid
. From sit on bed to stand
. Tie pajama bottoms
Put on and take off shoes
From bed to wheelchair to bed
Sit and arise from armless chair
Put on and take off pajama bottoms
Put on and take off pajama tops
In and out of chair at table
Shave self
Pick object off floor
Use toilet without assistance
In and out of car
Tie shoes
Put on and take off braces
Clothe self completely
Take bath without assistance
Get from floor to stand
+:
>
*From Leemhuis and Brown by permission of the Journal-
Lancet.
During the later convalescent stage the remain- ,
der of the self-care and ambulation activities are
added to the patient’s program. He is expected
to take the initiative for continuing to utilize
each new accomplishment in his daily activities.‘
The patient at this point is encouraged to take an
increasing part in family affairs and household
tasks. The development of hobbies, social events
‘and group contact are all a part of his retraining
program. The convalescent stage may be expect-
ed to last in the neighborhood of three months.
The stage of social and vocational readjustment
follows the convalescent period. At the present
time, many of the older patients with hemiplegia,
particularly those with complicating medical dis-
orders, must be satisfied with a goal of self-care,
moderate ambulation and avocational pursuits at
home. Others, especially in the younger age
group, can achieve economic independence. Be-
cause of the disability it may be necessary for the
person to learn a new vocation. The resources
of such agencies and facilities as the state voca-
tional rehabilitation units and local social workers
can be utilized.
So far we have been discussing the relatively
uncomplicated physical portion of a program of
rehabilitation. Such measures are subject to con-
siderable standardization. In the course of re-
training patients with hemiplegia, complications
Fepruary, 1952
Walk alone, using crutch
Climb stairs with railing
. Climb stairs with rail backwards
Walk sidewards and backwards
Walk alone using cane
Walk on ground and carpeting (rugs)
Open and close door from stand
e+
%09°%EE
Climb bus steps
Climb curb
Climb steps without hand rail
Discard wheelchair
Distances (feet) 50 75 100
48 feet—seconds 80 75 70
e+
%8-%19
Distances (feet) 200 300 400
48 feet—seconds........ 60 50 45
Distances (feet) 600 700 800
48 feet—seconds 35 30 25
b+
%001-%S8
*From Leemhuis and Brown by permission of the Journal-
Lancet.
of various sorts may well develop and require
considerable individualization of the program of
therapy.
Perhaps the most common medical complica-
tion is the presence of heart disease. This is fol-
lowed in frequency by urinary difficulties and or-
thopedic disabilities. The development of thala-
mic pain or an aphasia from involvement of the
major cerebral hemisphere will present perplex-
ing treatment problems. Any detailed discussion
of the management of these problems is beyond
the scope of this paper.
The emotional readjustment of the patient is
an ever-present problem in the management of
these patients. The occurrence of a stroke with
all of its actual and implied significance—physical,
intellectual, emotional, financial and social—is ac-
tually a catastrophic blow to the patient and to
his family. The patient is faced with physical
disability which may well seem overwhelming.
He has available to meet this a damaged nervous
system with reduced capacity for adjustment.
In the presence of brain damage psychologic
and intellectual capacities may be reduced to vary-
ing degrees, a process which Hughlings Jackson
named dissolution. Affected in this process are
the abilities to abstract, to integrate, to modulate
emotions, and to select adaptive responses. The
damaged nervous system is left shallower, the top
137
REHABILITATION OF THE HEMIPLEGIC PATIENT—BROWN
is lower, there is less of the person. The effects
of this process will appear even though the pa-
tient’s memory and conversation show no appar-
ent deficit. With reduced ability to abstract, the
patient misses fine transitional distinctions, is
slow to grasp the essential features of a given
experience and has difficulty in keeping in mind
simultaneously two or more factors.. Because
he does not understand fully the implications
of a situation, his ability to integrate information
and form judgments is poor. He has a predeter-
mined bias which interferes with his ability to
relearn and interpret. There may be limited abil-
ity to modulate emotional responses, leading to
unwarranted outbursts of irritability, crying or
laughing. Behavior tends to become stereo-
typed, compulsive and concrete because of the
loss of the most highly flexible, complex and
voluntary mechanisms. The patient with brain
damage has lost some of his capacity for free
voluntary selection of behavior and must act in
a more automatic manner.? Simple tests for the
estimation of the amount of brain damage are
available.**
Psychotherapy in the management of patients
who have hemiplegia is an essential part of the
treatment regimen. The physical disability im-
poses limitations on the patient’s personal, voca-
tional and social activities and threatens his posi-
tion within his family or group. The psychologic
effect of brain damage may significantly repair his
capacity for adaptation. These two factors in-
teract with the basic personality structure of
the individual. This constellation of forces may
well have an effect which is catastrophic. Sug-
gestion, reassurance and support by the physician
can be potent forces in preventing or ameliorat-
ing a catastrophic, effect. Many patients will
respond with hope to a well-planned, active thera-
peutic program which says in effect, “You will be
able to walk.” Appropriate measures must be
taken to bring the family into the therapeutic
regimen, to help educate them in their role and
to deal with situational problems within the fam-
ily group.
In directing an integrated treatment program, it
is possible to approach directly by symptomatic
management various problems as they arise.*
Confusion is a constant finding during the
acute stage of a stroke. The duration of the
confusion will depend largely on the extent and
location of the brain lesion. It is important to
138
protect the patient against self-harm during this
stage. Particular attention must be paid to fluid
and electrolyte balance, as well as caloric and vita-
min intake. As soon as possible a simple daily
schedule should be started. Regularly scheduled
attention to the bowels and bladder will reduce
soiling. Gradual habit training in the simple
self-care activities of personal hygiene, turning
in bed, feeding, and so forth, is gradually added.
Social contacts are kept at a very simple level.
Apprehension and fear are generally disguised
or kept suppressed by various defenses. They
may appear during the acute stages as delirium,
which is actually fear mixed with confusion. The
patient’s fears under such circumstances become
his reality. He must -be protected against self-
harm and should be encouraged to accept reas-
surance and support from someone he trusts.
Properly chosen sedative and narcotic drugs are
of distinct value. They should be quick-acting
drugs that are rapidly metabolized. Slow-acting,
slowly excreted drugs often produce a prolonged
twilight state of consciousness that makes un-
manageable an otherwise mild delirium.
Anxiety and tension reactions are particularly
common in the early stages of retraining. They
tend to reappear when new experiences are antici-
pated, for example, when the patient first is per-
mitted to stand or walk, when he goes outdoors
for the first time, or when a return to work is
planned. The capacity to adapt is limited by the
physical disability, by the psychologic effects of
brain damage, and by long-standing personality
characteristics. On approaching a new problem
the hemiplegic patient tends to feel insecure,
anxious and fearful, and because of the total cata-
strophic effect of the “stroke” he is less able to
tolerate anxiety. To defend himself against this
anxiety he may be forced to resort to compulsive-
ness, irritability, depression, or indifference and
apathy. When possible, such reactions should be
foreseen and avoided. Encouragement, reassur-
ance and support will help considerably in allay-
ing the feelings of anxiety. The activity pro-
gram should be of progressive difficulty but should
be undertaken in easy steps. It is particularly
‘important to avoid tasks which are overwhelming
to the patient.
Compulsiveness, stercotyped behavior, per-
severation and rigidity result directly as con-
comitants of brain damage, and they may also
occur as an adaptation to any stress situation. The
MINNESOTA MEDICINE
REHABILITATION OF THE HEMIPLEGIC PATIENT—BROWN
marked limitation of flexibility will delay a re-
training process and requires an attitude of
increased patience on the part of the physician
and family. Retraining should begin early because
it is difficult to change unfavorable habits which
have become rigidly fixed. Sudden changes or
complicated situations are likely to produce con-
fusion and return the patient to increased rigidity
of response. It is important to utilize the com-
pulsiveness of the patient by developing a
schedule of daily activities, utilizing the patient’s
natural needs and rhythm. A simple schedule
would include daily self-care activities of toilet,
dressing and eating. Ambulation, recreation,
handcraft and social activities are gradually added
to the daily routine. Family responsibilities and
vocational readjustment are later steps which can
be gradually assumed by some patients.
Irritability, impatience and stubbornness are
characteristic of many patients with brain dam-
age, particularly patients whose pre-illness per-
sonality showed evidences of this mood. Fortu-
nately the outbursts of irritability are generally
short-lived and there are times when the patient
is more amenable. It is generally wiser to be
permissive when the patient is obstinate and then
induce him to accept a suggestion when he is more
tractable. On rare occasions it may be wise to
establish by an interested, calm, firm approach that
the physician is boss, but it is ordinarily wise
to avoid such a showdown. Frequently the irrita-
bility will be most marked in relation to other
members of the family. Consequently an in-
quiry into the attitudes and behavior of the fam-
ily group is indicated. As soon as practicable the
patient is permitted to take on responsibility for
his daily activities to reduce the frustrations of
inactivity. Competition with other patients, hob-
bies, diversions and social contacts all combat
irritability by fostering the independence of the
patient.
Depression is a common response to serious ill-
ness and may be particularly persistent in patients
with generalized brain damage. It appears to be
most common in individuals whose pre-illness per-
sonality has shown moderaie aggressiveness cou-
pled with moderate needs for dependency and
support. Such a person feels guilty and self-
accusatory about giving in to his dependency
needs. In setting up a treatment program it is
important to avoid assigning a task at which the
patient will fail, since any failure tends to pro-
Fepeuary, 1952
duce self-accusation and increase the depression.
To prevent rut formation, the program should be
started early with simple activities. A period of
lightened depression commonly occurs in the late
afternoon, a time which can be used to begin ac-
tivities. Early, the activities should be simple and
should require little effort. Recreation, physical ac-
tivities and social contacts are gradually added
within the patient’s tolerance. The load should be
progressive but should never exceed his capacity
at the time. Responsibilities must be avoided until
the patient is well recovered. A depressed patient
may feel the obligation to take on responsibilities
before he is actually prepared to cope with them.
Somatic complaints, fatigability, hypochondri-
acal attitudes and conversion symptoms may be
unconsciously utilized to avoid the tension and
anxiety of facing new situations. Such attitudes
occur particularly in individuals who have a life-
long history of passive dependent relationships
with other people. Such patients unconsciously
utilize a serious or disabling illness to maintain
the dependent relationship by conversion symp-
toms, fatigability and somatic complaints. In the
treatment of a patient with such findings it is im-
portant to recognize that the symptoms are serv-
ing a useful purpose in fulfilling his dependency
needs. Any sudden opportunity to get well is
also a threat to the need for dependence and
is likely to exacerbate the symptoms. An in-
quiry into life situations, previous personality and
family attitudes is important. It is often helpful
to foster in the patient a reaction of dependence
on the physician and the therapeutic measures.
It is important to see that early the patient gets
adequate “tender loving care” to avoid forcing
him to wheedle attention by somatic complaints.
As the treatment schedule is established the phy-
sician is able to withdraw his support gradually
and encourage the transfer of the dependence to
the routine of daily activities. Prolonged symp-
tomatic therapy in which the patient does not ac-
tively participate should be avoided.
Indifference, apathy and withdrawal may be
the more or less direct result of brain damage but
are usually conditioned by the basic personality
inake-up of the individual. They represent the
ultimate in defense against feelings of anxiety,
resentment, pain and depression. Goldstein spoke
of this as a catastrophic reaction to. a situation
which overwhelms the adaptive capacities of the
person. A patient who has developed or has the
139
REHABILITATION OF THE HEMIPLEGIC PATIENT—BROWN
capacity for developing a catastrophic reaction
must be handled with great care. Approaches
must be gentle, reassuring and tentative. At-
tempts must be made to learn of factors which
arouse in the patient a spark of interest. The
therapist must woo the confidence of the patient.
Very slowly the retraining procedures may be be-
gun. Extreme caution must be observed to avoid
new frustrations which might again threaten the
defenses of the patient.
The concept of body image plays an important
role in the readjustment of a hemiplegic patient.
There are numerous hypotheses and observations
related to the neurologic, psychologic and psychiat-
ric aspects of the body image (Kolb). For the
purposes of the present discussion a few observa-
tions may suffice. A concept of the body image
is essential in the daily activities of every human
being. The infant begins to develop the concept
with his early exploratory movements of his
arms, legs, body, mouth, eyes, and so forth.
These exploratory movements gradually develop
from impressions of isolated parts into a concept
of an integrated whole. As the child grows in
stature, there is a continual changing of the body
image. The body image concept is a fluid one
even in adult life. It must be different when one
is wearing glasses than when one is not wearing
them. The purchase of a new hat necessitates
some reorientation of body image. While one
is driving, the automobile becomes in essence an
extension of one’s own body image. As we begin
to develop the middle age spread, we readjust
our concept of our body image to match.
The stroke, with its sudden hemiplegia, vio-
lently disrupts the patient’s concept of his body
image. Without attempting to cite the reasons
and hypotheses which explain the phenomena, I
should like to describe some of the phenomena
observed. Most patients will early consider their
involved side as paralyzed and useless. They
tend to look at the loss of function rather than
at what function is remaining. An occasional
patient will deny the existence of an obvious hemi-
plegia or will fail to recognize the paralyzed ex-
tremities as his own.®
During the convalescent stage the patients be-
gin to reorient their concept of body scheme.
There is generally a tendency for persistence of
the negative concept, that is, loss of function.
Patients may have a tendency to look on them-
selves as crippled. There may even be continuing
140
imperception. for the extremity or a portion of it.
The patient who is adapting more successfully
will gradually begin to develop a concept of body
image based on positive concepts. He will be-
gin to recognize the remaining usefulness of his
extremities and integrate the useful although
impaired extremity into his ordinary daily activi-
ties. Continuing studies on the role of body
image promise to give increasing information on
the problem of retraining patients.
This attempt to survey quickly the principles of
rehabilitation of patients who have hemiplegia
has of necessity been superficial. The purpose is
to give a blueprint of a flexible program of ther-
apy. Details of the physical measures and ad-
ditional bibliography will be found in the standard
texts on physical medicine.*7? A careful study
of the patient, his family and his social situation
will give added information. Age of the patient,
duration of disability and complicating medical
conditions will influence the course of treatment
but do not contraindicate instituting retraining
therapy.
References
- Baker, A. B., and Brown, J. R.: Rehabilitation of
the Chronic Neurologic Patient. V. A. Pamphlet
10-29, p. 9, Veterans Administration. Washington,
a U. S. Government Printing Office, (May)
. Brown, J. R.: Retraining patients with brain dam-
age. Journal-Lancet, 70:455-458 (Dec.) 1950.
3 Brown, J. R.: The holistic treatment of neurologic
disease. M. Clin. North America, 34:1019-1028
(July) 1950.
. Deaver, G. G,, and: Brown, Mary E.: Physical
Demands of Daily Life: An Objective Scale for
Rating the Orthopedicaliy Exceptional. Studies in
Rehabilitation. No. 1, 1-35. New York: Institute
for the Crippled and Disabled, 1945.
. DeLorme, T. L., and Watkins, A. L.: Technics of
progressive resistance exercise. Arch, Phys. Med.
29 :263-273 (May) 1948.
. Gerstman, Josef: Problem of imperception of dis-
ease and of impaired body territories with organic
lesions; relation to body scheme and its disorders.
Arch. Neurol. & Psychiat., 48 :890-913 (Dec.) 1942.
. Goldstein, Kurt: Aftereffects of Brain Injuries
in War, Their Evaluation and Treatment; the Appli-
cation of Psychologic Methods in the Clinic. New
York: Grune & Stratton, 1942.
. Halstead, W. C.: Brain and Intelligence; a Quanti-
tative Study of the Frontal Lobes. Chicago: Univer-
sity of Chicago Press, 1947.
. Jackson, J. H.: Selected Writings of John Hugh-
lings Jackson. Evolution and Dissolution of the
Nervous System—Speech—Various Papers, Address-
es and Lectures. Vol. 2, pp. 3-118. London: Hodder
and Stoughton, Limited, 1932.
. Kolb, L. C.: Psychiatric aspects of treatment for
intractable pain in the phantom limb. M. Clin. North
America, 34:1029-1041 (July) 1950.
(Continued on Page 178)
MINNESOTA MEDICINE
POSITIVE FINDINGS IN FUNCTIONAL NEUROPSYCHIATRIC DISORDERS
GORDON R. KAMMAN, M.D.
Saint Paul, Minnesota
ib-ssinignsaguia to the belief of some physicians,
there is no clear-cut dividing line between
“functional” and “organic” nervous disorders.
Formerly it was the custom to make the diag-
nosis of a “functional” disorder by exclusion, i.e.,
when the symptoms presented by the patient
failed qualitatively or quantitatively to correspond
to objective findings or to meet known diagnostic
criteria. Physicians adhered to the two-valued
“either-or’” orientation and-assumed that a given
nosological entity had to be either “functional” or
“organic.”
Stanley Cobb’ has pointed out that neuropsychi-
atric disturbances are the result of an interplay
of four main categories of events: (1) genogenic
or hereditary causes, (2) histogenic causes or
those related to visible lesions of the tissues, (3)
chemogenic causes due to ultramicroscopic
(molecular) changes in tissue function and struc-
ture, and (4) psychogenic causes due to malad-
justments in personal relations. To quote Cobb:
“T would insist that the old dichotomies ‘functional
or organic,’ ‘mental or physical’ are not only
wrong but lead to bad habits of thinking because
they lead to static and obsolete ideas and do not
allow for modern pluralistic and dynamic ideas
of matter and structure. Physiology is the basis
of clinical diagnosis, and no physiologist would
accept for a moment the clinical jargon that uses
the. word ‘functional’ to denote .‘psychogenic.’
Anybody who stops to think, realizes that no
function is possible without an organ that is
functioning and, therefore, no function takes
place without structural change. Every symptom
is both functional and organic. It is never a
question of ‘either-or’.”
Lester S. King* considers diagnosis to be extra-
polation, and he says that the process of making
a diagnosis may be compared to looking at a
moving picture. A motion picture reveals a defi-
nite sequence of events in which one part has some
definable relation to the other parts. In making
a diagnosis the physician may be compared to a
movie spectator who, viewing a segment of film
tries to guess the plot, predict the outcome, and
_Read before the Ramsey County Medical Society,
Saint Paul, Minnesota, November 26, 1951.
Fepruary, 1952
name the category to which it belongs. Since
diseases, like movies, fall into certain general
groups, the process often is not too difficult. A
veteran movie fan, seeing the middle of a picture,
and seeing a cowboy, horse, some Indians and a
tough looking hombre with a moustache, can
usually make a pretty good guess as to the be-
ginning of the picture which he hasn’t seen and
also a good guess as to the outcome which he
also has not seen. In the same way, many diseases
are so characteristic that the experienced physi-
cian, by observing only a brief span of its natural
history, can predict the outcome as well as identify
the villain.
On the other hand, some movies, like many
diseases, are subtle, and the viewer must see a
considerable part of it before he can hypothecate
the beginning and the ending. By the same token,
the physician, before he can fit a disease into a
known category, must similarly have a period of
observation fortified by special tests and diagnostic
procedures.
In spite of the fact that there are no absolutes
in the order of purely “functional” or purely
“organic” diseases, there is a certain degree of
polarity in the field of morbidity in general. Most
diseases tend to be predominantly “functional” or
predominantly “organic.” As before stated, in
many instances the diagnosis of a predominantly
functional disorder is made on. the absence of
positive findings which fit into the known diag-
nostic categories. However, after having ex-
amined many hundreds of patients suffering from
symptoms not related to any demonstrable organic
lesion, I am impressed by the number of positive
objective findings which emerge during the course
of a neurological examination. Some of these
are as follows:
Station
Although swaying or falling in the Romberg
position occurs in cerebellar disease and in dis-
orders which produce degeneration of the dorsal
columns of the spinal cord (tabes dorsalis, com-
bined sclerosis, et cetera), swaying can also occur
in functional nervous disorders. However, there
is a difference between the type of swaying seen
141
FUNCTIONAL NEUROPSYCHIATRIC DISORDERS—KAMMAN
in organic disease and that seen in the psycho-
neuroses. In organic conditions the patient will
actually fall unless he is supported by the ex-
aminer. In functional states, the patient never
falls, even if he is not caught or if he is unable
to reach something to steady himself. Moreover,
im functional nervous disorders the swaying is of
a much more bizarre and dramatic nature than it
is when the manifestation is due to organic dis-
ease,
Gait
The hysterical gaits, and the gaits shown by
malingerers are entirely different from those seen
in organic disorders. Halting gaits, steppage
gaits, grotesque limping, and bizarre and un-
physiologic associated movements characterize
the gait of a patient suffering from a functional
nervous disorder.
Flinching and Startle Reactions
These are seen in connection with a variety of
tests. When the pupillary reactions are tested
with a light of moderate intensity, in many in-
stances the patient with a functional nervous dis-
order will pull his head back and squeeze his eyes
shut. Similarly, when the tuning fork is held
close to either ear, the patient with a functional
nervous disorder will pull away from it and
flinch as if the sound were painful to him. These
reactions are always very conspicuous by reason
of théir bizarre and unphysiologic nature.
An eighteen-year-old girl while playing basket-
ball in her school gymnasium was thrown against
a piece of equipment, slightly injuring her lower
back. She continued to play for another fifteen
or twenty minutes experiencing only slight dis-
comfort in the back. Several hours later she re-
ported to the school nurse that the backache was
worse and that there was pain down the back of
the left thigh, extending into the left calf. The
pain was not aggravated by coughing, sneezing,
or straining. The examination by the school physi-
cian was negative but the girl was hospitalized
for physical therapy. When I saw her two weeks
after the accident, she stili was complaining of
pain in the lower lumbar region radiating into
the left calf. The neurological examination was
entirely negative for organic signs. However,
when the ears were tested with a tuning fork (c
128) there was a marked flinch reaction... More-
over, the gait was peculiar and grotesque. The
142
patient walked on the tips of the left toes, held
the left knee slightly flexed, and the knee was
xept in adduction in such a manner as to produce
almost a scissors gait. When pain sensation was
tested with a pin, there was extreme hyperesthesia
over a stocking distribution in the left lower ex-
tremity from midthigh down.
Because of these objective findings, which |
consider pathognomonic of hysteria, the patient’s
psychic life was explored, and it was found that
she was in a severe emotional conflict revolving
around an adolescent love affair amid strong
parental objections. She was given sodium amytal
intravenously, and under its effect she abreacted
and ventilated a great deal of hostility toward her
parents. Physiotherapy -was discontinued and the
patient was given insight therapy and within two
days was completely free of symptoms, and she
now is in school, doing very satisfactory work.
Functional Reduplication of Deep Reflexes
This phenomenon is almost pathognomonic of a
functional disorder, and I think that it relates
to the startle reaction. It is difficult to describe,
but, once seen, it never will be forgotten. It usual-
ly is seen when the knee jerk is elicited. Instead
of a single contraction of the quadriceps femoris
which appears when the patellar tendon is tapped,
the patient produces a series of knee jerks in rapid
succession. The reaction is totaily unlike the
exaggerated knee jerk seen in pyramidal tract
involvement, for instead of eliciting a single re-
action whose amplitude and speed are greater than
those seen in normal knee jerks, the stimulus
elicits a series of jerks. There also is what has
been referred to as the “anticipatory knee jerk.”
A normal or organically abnormal knee jerk can
be purely reflex and can be elicited in the spinal
animal which has neither psyche nor conscious-
ness. At the same time it is possible for a nervous
patient to have a knee jerk just before the patellar
tendon is tapped with the percussion hammer.
This relates to what I have referred to as “func-
tional reduplication” of the knee jerk, which
merely indicates that the patient has anticipated
the stimulus and has jerked his knee. It is the
difference between the knee jerk of physiology and
the “person jerking the knee” of psychobiology.
It is quite clear that such a performance must
necessarily be the result of a previous experience
with the test, coupled with certain personal emo-
tional attitudes and relations to it as represent-
MINNESOTA MEDICINE
FUNCTIONAL NEUROPSYCHIATRIC DISORDERS—KAMMAN
ing general tension and fear of the examination.
Sometimes responses are accompanied by jump-
ing of the entire body. The same thing often
happens when the Achilles reflex is tested. It
also may occur with the testing of other deep
reflexes.
Incomplete Reactions
These are best destribed as more or less half-
hearted attempts to carry out the commands of
the examiner. For instance, when the patient is
told to close his eyes tightly, he does not close them
tightly. He closes them only partly, and he then
opens them after having kept them partly closed
for only a second or two. Another incomplete
reaction is failure on the part of the patient to
follow the examiner’s finger when the extra-ocular
movements are being tested. While the test is
being performed, the patient will keep his eyes
on the examiner rather than follow the examiner’s
finger. If he does follow the examiner’s finger,
he does not keep watching it but will follow the
finger only part way and then return his gaze to
the face of the examiner or to some other point.
Rough testing of the visual fields often elicits
signs that are characteristic of a functional ner-
vous disorder. In the first place, during the con-
frontation test the patient will not keep his gaze
fixed on the stationary reference point (usually
the examiner’s nose). He will watch the exami-
ner’s fingers, and sometimes it is impossible to get
him to avoid doing this. Secondly, the field pat-
terns themselves may show the typical “gun
barrel” or “tubular” configuration characteristic
of hysteria. If the fields are mapped on a tangent
screen and then on an ordinary perimeter, in
hysterical patients they will be the same size on
the screen as they are on the perimeter card. This
is a demonstrably objective sign of hysteria—a
purely functional nervous disorder.
Another incomplete reaction is in the finger-
nose test. When the patient is asked to extend
his arms in the horizontal position, close his eyes,
and then, touch his nose, he does so in an incom-
plete and half-hearted manner. Furthermore, the
patient frequently will display an ataxia which is
all out of proportion to any known organic con-
dition, i.e., he will touch his forehead with his
index finger, or he will miss his head completely
and point way past the ear opposite the hand
which he is using. Furthermore, he usually will
hit the same spot on successive attempts, while the
Frsruary, 1952
patient with an organic ataxia will hit different
areas. It will be noted that the past-pointing al-
ways occurs on the side of the head opposite from
the hand which is being used in the test. Similar
incomplete reactions are found in the heel-to-knee
test.
Functional Sensory Patterns
The well-known glove and stocking anesthesia
need not be discussed here. The “yes” and “no”
test for sensation are well-known evidences of a
hysterical disturbance. Shifting areas of anes-
thesia, areas of anesthesia that correspond to
psychological boundaries rather than to anatomical
boundaries, peculiar dissociations which are ana-
tomically and physiologically impossible, and a
variety of other sensory responses are character-
istic of the functional nervous disorders.
Therefore, it is readily seen that the diagnosis
of certain functional nervous disorders can be
made upon positive neurological findings, and the
examiner will not have to rely upon the exclusion
of findings suggesting organic neurological dis-
ease.
It is interesting to speculate as to the dynamics
of these positive findings exhibited by patients
suffering from functional nervous disorders. I
believe that the most important factor is anxiety.
We know that anxiety is present in all the psycho-
neuroses, although it need not always be mani-
fest. Witness the “belle indifference” of the
hysteric. Here the anxiety is not overt, but it
plays its part in the unconscious life of the pa-
tient.
It is not difficult to see how overt anxiety ac-
counts for flinching and startle reactions, and
how it produces the functional reduplication of
deep tendon reflexes as well as the anticipatory
knee jerk. However, when the anxiety is latent,
one must delve into the psychodynamics of the
process in order to understand the mechanism.
Grinker® concluded that “repression and inhibi-
tion, which are basic principles in psychoanalysis
and neurology, respectively, are dynamically
identical.” Both repression and inhibition indicate
a negative factor, in that a certain level of activity
is abandoned, and a positive factor, which results
from or is permitted by the shift of activity from
one portion of the nervous system to another.
“In the evolutionary (phylogenetic) process and
(Continued on Page 151)
143
HEMORRHAGE IN THE RECTUS MUSCLE
HAROLD H. JOFFE, M.D., and DONALD J. VAN RYZIN, M.D.
Duluth, Minnesota
JEMORRHAGE into the rectus muscle and/
or sheath is an established clinical entity
with a definite symptomatology and physical find-
ings. Its chief significance lies in that it is most
often indistinguishable from an acute intra-ab-
dominal condition.s?*®101%14'7
At this institution, two such cases were recently
encountered. A summary of the cases and a re-
view of the literature on the subject is presented.
Case Reports
Case 1.—A_ sixty-two-year-old machinist, one week
prior to admission, experienced the gradual onset of a
constant dragging pain in the right lower quadrant.
The pain was occasionally sharp in character with no
relation to food or exercise and remained localized.
There was no fever, chills, diarrhea, constipation, food
intolerance, back pain or dysuria. The stools and urine
were normal in color.
On the evening of May 26, 1951, he was seen at
home because the pain became more intense. The fol-
lowing morning the pain had not subsided and the patient
was admitted to the hospital.
Physical examination revealed a well developed and
well nourished male in no acute distress. The chest
was clear to auscultation and percussion. The respira-
tions were 16 and the pulse 80 per minute. The tem-
perature was 98.6 degrees. The heart was not enlarged,
the tones and rhythm were good, and no murmurs were
heard. The blood pressure was 140/90. There was
tenderness, rebound tenderness, rigidity and guarding
in the lower portion of the right rectus muscle. Rectal
examination revealed right-sided tenderness.
The red blood cell count was 4,660,000 with 13.5
grams of hemoglobin. The white blood cell count was
8,200 with 76 per cent segmented neutrophiles. The plate-
let count was 234,000 with a normal clotting and bleeding
time. The prothrombin activity was likewise normal.
An exploratory laparotomy was performed, using a
right rectus incision. A hematoma was found, which
dissected up and down the rectus sheath on the right
side. A visible bleeding vessel was clamped and tied.
The amount of blood was neither measured nor esti-
mated. The peritoneal cavity was entered and found
to be normal, but an appendectomy was performed.
Histopathologic studies revealed complete obliteration
of the appendiceal lumen by old fibrous tissue with no
evidence of an inflammatory process. The material from
the rectus muscle was made up entirely of blood clot
with no evidence of muscle tissue.
The patient made an uneventful recovery.
From the Department of Pathology, Saint Luke’s
Hospital, Duluth, Minnesota.
144
Case 2.—A _ sixty-nine-year-old male had apparently
fallen at home and sustained multiple bruises of the
face, left elbow and right chest and was admitted to
the hospital on August 2, 1949. The patient had had
no complaints a few days before when he visited his
physician for parenteral liver which he had been taking
since June of 1948 when a diagnosis of pernicious anemia
was made. '
On admission, the abdomen was tense but no bowel
sounds were audible. There was generalized abdominal
tenderness and rigidity, most marked in the right lower
quadrant. The hands and feet were pale and cold.
The rectal temperature was 102 degrees. The pulse
was rapid and feeble with a blood pressure of 100/70.
The chest was clear and the neurological examination
was negative. An electrocardiogram showed a right
ventricular strain with right axis deviation. A_port-
able flat plate of the abdomen was not too satisfactory
but did reveal dilatation of the colon and questionable
dilatation of a few loops of small bowel in the central
portion of the abdomen. No fractures could be dem-
onstrated.
The hemoglobin was 14 grams. The white blood cell
count was 4,600 with 70 per cent neutrophiles. The
urine showed a trace of albumin and a 4-plus sugar.
An exploratory laparotomy was performed approxi-
mately five hours after admission. A large extra-
peritoneal hematoma was found with a hemorrhage
in the rectus muscle estimated at about 750 cc. There
was no intraperitoneal bleeding.
In spite of a transfusion and adequate intravenous
fluids, the patient went rapidly downhill with a shock-
like picture and expired the following morning.
A necropsy examination revealed the following es-
sential findings :
1. Diffuse infiltration of the abdominal wall with
approximately 500 cc. of clotted blood in the right
lower quadrant.
2. Extensive atelectasis of both lungs.
3. Severe mesenteric, mediastinal and retroperitoneal
edema.
Death was due to traumatic shock.
Etiology
There is no single specific etiologic factor in
this condition. The following general classifica-
tion is widely accepted :*%5.6-12,13,16,17,20
1. Those with normal musculature and blood
vessels.
(a) Direct and indirect trauma.
(b) Pendulous abdomen.
2. Those with disease or attenuation of mus-
cles.
MINNESOTA MEDICINE
HEMORRHAGE IN THE RECTUS MUSCLE—JOFFE AND VAN RYZIN
(a) During pregnancy, labor or puerperium.
(b) Debilitating diseases such as: typhoid and
typhus fever, influenza, tetanus and blood
dyscrasias.
(c) Vascular disease.
Taferior ps stric
hitea, .
Semjcircularis
Taferioy —
literature up to 1923 disclosed that 107 (84.2 per
cent) occurred in young males following exercise
jn whom the musculature and vascular system
were normal. In a review’ of fourteen cases
occurring in women, the majority were multipara
Laternal Oblique
Transversalis
5S ermatic Cord
1
terfoveolar biqament
Lnqinal Aponevrotic
¥ Folk
Lxternal Obhgve
Internal Ob que
Trans versalis
Peritoneum
Fig. 2. Diagrammatic sketch of transverse section through anterior abdominal
wall below linea semicircularis.
The effect of direct trauma such as a blow or
fall is easily understood. Spontaneous or idio-
pathic hemorrhage has been reported to occur as
the result of light exercise, jumping, riding, turn-
ing in bed, lifting, sneezing, coughing, vomiting
and obstipation. ':7*5:1013)17,19
In a collective review’ of 100 cases in the lit-
erature, only 4 per cent occurred in the colored
race. The ratio of women to men was 3:1.
The ages ranged from seventeen to eighty-three
with an average age of 46.8 years. The decades
ten to thirty accounted for 14 per cent; thirty to
fifty for 37 per cent; fifty to seventy for 32 per
cent; seventy to ninety for 7 per cent, and in
ten cases the age was not stated. In the same
review, direct trauma accounted for 19 per cent
and those associated with pregnancy for 22 per
cent. Six cases occurred during the course of
such diseases as influenza, typhoid fever and
blood dyscrasia. Spontaneous or idiopathic hem-
orrhage accounted for 53 per cent of cases. A
collective series’? of 127 cases appearing in the
Frpruary, 1952
and all but one were over thirty-five years of
age.
Pathogenesis
The anatomical differences of the rectus
muscle and aponeurotic sheaths in the lower
half of the abdominal wall account for the
greater incidence of vascular rupture and hem-
orrhage in this location.?**11161718 The low-
er third of the muscle is the most powerful por-
tion and undegoes greater changes in length. The
extramuscular branches of the vessels are likewise
longer to compensate for the excessive change in
length.t The sheath of the rectus, formed by the
aponeuroses of the obliqui and transversalis mus-
cles, passes in front of the muscle below the level
of the semilunar line of Douglas. The muscle is
thus separated from the peritoneum only by the
thin transversalis fascia on which lies the inferior
epigastric artery and its anastomoses with the
descending branch of the superior epigastric ar-
tery (Figs. 1 and 2). The bleeding thus primar-
145
ily occurs between the muscle and posterior
sheath above the semilunar line of Douglas
and between the muscle and peritoneum be-
low this fold. The hemorrhage is usually uni-
lateral and below the level of the umbilicus.”’”
In a collective review of 100 cases’’ the hemor-
rhage occurred in the right lower quadrant in
forty-seven and on the left side in twenty-two
cases. The right upper quadrant was the site
of predilection in nine and the left upper in seven
cases.
Symptoms and Diagnosis
The symptoms are essentially those of an intra-
abdominal condition with abdominal pain, tender-
ness, rigidity, nausea, vomiting, fever, leukocyto-
sis, ecchymosis and a palpable mass.*?%:1416,17
The most common and earliest symptom is pain
which is usually severe and sudden in onset
but may be mild for several days. In a review™’
of 100 cases in the literature, abdominal pain was
present in all but three and those patients were
comatosed from the onset. Tenderness is usually
quite marked and was either localized or general-
ized in 71 per cent of cases. Abdominal rigidity,
either localized or diffuse, was recorded in 59
per cent. Nausea and vomiting occurred in 23
and 15 per cent respectively. The temperature
ranged from 97 to 102 degrees with an average
99.5 degrees. The white blood cell count aver-
aged 11,600 with a high of 18,600 and predomi-
nance of neutrophils. Ecchymosis is usually a
late sign and occurred in 21 per cent of cases.
A palpable mass occurred in 78 per cent of cases.
In no case was there an abnormal platelet count,
bleeding or coagulation time.
The symptoms so closely simulate an intra-
abdominal process that an incorrect diagnosis
will invariably be made if this condition is not
kept in mind. A careful history is essential and
the onset of abdominal pain following injury or
exertion, no matter how slight, should make one
suspicious of a hematoma.’* The presence of
ecchymosis is of diagnostic importance but is
usually a late manifestation. The two pathog-
nomonic signs of considerable diagnostic value
are: (1) a non-movable palpable mass when
strain is placed on the abdominal musculature,”*1"
and (2) the absence of rigidity and tenderness in
the abdominal wall adjacent to the palpable
mass,****6
- The incidence of a correct preoperative diag-
nosis is relatively low. In a combined review,
146
HEMORRHAGE IN THE RECTUS MUSCLE—JOFFE AND VAN RYZIN
totaling 187 cases**1* 1" in which a diagnosis was
stated, a correct diagnosis was made in only twen-
ty-one (10.7 per cent) of the cases. This condi-
tion is confused with a wide variety of both intra-
and extraperitoneal processes, such as appendi-
citis, ovarian cyst and tumor, ectopic pregnancy,
hernias of various sorts, mesenteric thrombosis,
intestinal obstruction, gall-bladder disease, leio-
myoma of the uterus, hydronephrosis, ruptured
viscus, tumor of the abdominal wall, tetanus and
the more rare conditions of gumma, actinomyoco-
sis and tuberculosis.**%17
Treatment
Spontaneous recovery undoubtedly occurs.’
The symptoms are so often indistinguishable from
that of an intra-abdominal condition and the fact
that bleeding tends to recur, makes an exploratory
laparotomy the procedure of choice.?"7_ The prog-
nosis in general is favorable but carries a certain
mortality in elderly and debilitated individuals
with an over-all mortality of 4 per cent in a col-
lective review of 100 cases."
Conclusions
1. The symptoms in both cases simulated a
intra-abdominal condition.
2. The etiology in the first case was repeated
trauma to the lower abdominal wall from the
operation of a lathe. An uneventful recovery fol-
lowed an exploratory laparotomy with ligation
of a bleeding vessel.
3. The fall in the second case was undoubtedly
the etiologic factor. Death in this case was the
result of traumatic shock. The exploratory lapa-
rotomy added insult to injury and there was
apparently a recurrence of bleeding.
4. A review of the literature is presented.
References
1. Ashkar, P. A.: Spontaneous rupture of right rectus
— in pregnancy. Lancet, 2:934-935 (Oct. 28)
2. Block, B. M., and Stalker, L. K.: Spontaneous
hemorrhage into the sheath ‘of the rectus abdominis
muscle. Proc. Staff Meet. Mayo Clin., 206-208
(Mar. 27) 1940.
3. Broady, H.: Spontaneous hematoma of the rectus
abdominis muscle simulating twisted ovarian cyst
ae hernia. Meridan Hosp. Bull., 21-23 (Apr.)
4. Bredel M.: Lesions of the rectus abdominis mus-
cle simulating an acute intra-abdominal condition.
mn Johns Hopkins Hosp., 61:295-315 (Nov.)
Browers, W. F., and Richards, N. F.: Rectus
muscle strain simulating acute appendicitis. Mil.
Surgeon, 92 :645-648 (June) 1943.
(Continued on Page 151)
ul
MINNESOTA MEDICINE
: Et
R,
the lv
disabi
fascia
the re
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tures
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clinic:
body.
THE LUMBO-DORSAL FASCIA AND CHRONIC BACKACHE
R. J. DITTRICH, M.D.
Duluth, Minnesota
ECENT clinical observations have revealed
additional information on abnormalities of
the lumbo-dorsal fascia in individuals with back
disability. The anatomical derangements of the
fascia and contiguous structures, combined with
the resulting physiologic disorders, appear to pro-
vide a relationship which clarifies the clinical fea-
tures and simplifies treatment. In addition, an
explanation has become available for a variety of
clinical pictures affecting upper portions of the
body.
Anatomical Considerations
In the lumbar region, the lumbo-dorsal fascia
consists of a dorsal and a ventral layer, enclosing
the sacrospinalis muscle. The dorsal layer is at-
tached to the spinous processes and the ventral
layer to the transverse processes of the vertebrae.
In the sacral region, only the dorsal layer is
present, attached medially to the spinous proc-
esses of the vertebrae and laterally to the sacrum.
In the angle formed by the dorsal and ventral
layers of the fascia, fat tissue is located, overlying
the lateral portion of the sacrospinalis muscle. In
the sacral region a similar relationship is pro-
vided in that the fat lobules are situated between
the fascia dorsally and the sacrospinalis muscle
ventrally. The fat tissue at these sites represents
portions of the “basic fat pattern” described by
Copeman and Ackerman.’ Although the basic
fat pattern is said to be a constant feature, in two
instances no fat tissue was found in the lumbar
region.
The latissimus dorsi muscle is of importance for
the reason that a portion of its aponeurosis of
origin is attached to the lumbo-dorsal fascia.®
It is also stated that ‘“‘although the fascia becomes
considerably thinner after it ceases to be the
aponeurosis of the latissimus, it usually still con-
tains distinct tendinous slips.”’ There is reason
to believe that these tendinous prolongations ex-
tend over the dorsal surface of the lumbo-dorsal
fascia throughout the lumbar and sacral regions.
Whereas earlier reports”** have considered the
entire extent of the basic fat pattern as sources of
painful impulses, more recent studies on struc-
tural abnormalities have revealed a marked pre-
Fenruary, 1952
dilection for injuries of the fascia at two sites:
the midsacral paraspinal region, and the mid-
lumbar region over the lateral portion of the
sacrospinalis muscle. The vulnerability of the
former site is explainable by the attachment of a
portion of the gluteus maximus, the latter by the
origin of a portion of the latissimus dorsi muscle.
For practical clinical purposes, these two sites of
the fascia merit most attention.
The principal pathologic changes seen at opera-
tion consist of scar formation between the lumbo-
dorsal fascia and the subfascial fat. The fascia,
at the site of injury, may be thickened but is more
often thin and distended. In three instances, a
complete defect was present in the fascia, about
4 to 5 millimeters in diameter but not occupied
by protruding fat tissue as described by Cope-
man and Ackerman. In two cases in which the
injury was three to four weeks old; the fascia
was dark red in color and irregularly torn.
Under normal conditions, the subfascial fat is
free from the fascia and presents the character-
istic yellowish color of fat tissue elsewhere. After
the fascia has been traumatized by partial or com-
plete tears, with subsequent healing the subfascial
tissue shows a grayish-white color and is fre-
quently attached to the ventral aspect of the fas-
cia. Microscopically, prolongations of fibrous tis-
sue can be seen extending for a considerable depth
from the fascia into the fat tissue layer which
has become extensively fibrosed.
With recognition of this form of abnormality,
it becomes necessary to modify earlier descrip-
tions of pathologic change, consisting of hernia-
tion and edema of subfascial fat. The impression
is gained that edema of fat lobules is a secondary
effect produced reflexly by the pain impulses aris-
ing elsewhere. Nevertheless, removal of such tis-
sues, as it was carried out in the earlier stages of
this investigation, has provided significant and
lasting relief of pain. Complete herniations, as
described by Copeman and Ackerman, have been
found in only one case.
The mechanism of pain production is explained
by the anatomic changes. The subfascial fat, evi-
dently arising from the sacrospinalis muscle,
seems to serve the same purpose as bursae in
147
LUMBO-DORSAL FASCIA—DITTRICH
other locations. Traction on the fat lobules, which
are well supplied with nerves and blood vessels,
causes pain, as has been repeatedly demonstrated
at operation. When the fat tissue becomes fi-
brosed and attached to the ventral aspect of the
lumbo-dorsal fascia, traction on the fat lobules is
more or less continuous. Both the traction and
the resulting pain are aggravated by motion of
the body.
Physiologic Aspects
Telalgic phenomena (referred pain and re-
ferred tenderness) are noted in practically all
cases of injury to deep somatic structures. Al-
though our knowledge of these effects is incom-
plete, a few well-defined principles have been es-
tablished and found to be of practical importance
in the evaluation of painful syndromes.
Referred pain is considered as misinterpreta-
tion by the central nervous system. It is initiated
and abolished almost simultaneously with the
onset and elimination of pain impulses at the pri-
mary source of the pain, or trigger-point. Re-
ferred tenderness is believed to be due to deposit
of metabolites in the affected tissues. This proc-
ess requires a longer period of time, usually a
matter of several hours, for development after
the onset of noxious stimuli and also for subsi-
dence after cessation of the irritation. Both of
these phenomena may occur in any portion of the
sclerotome—a term used by Inman and Saunders®
to denote the distribution of sensation from a
spinal nerve root to deep somatic structures.
Likewise both are limited to the extent of the
sclerotome in which the impulses arise, although
contralateral reference is a common observation,
the distribution corresponding approximately to
that found on the injured side of the body.
The skin is less frequently involved in cases of
injury to skeletal structures. The dermatomic
supply varies considerably from the sclerotomic
distribution. When sensory disorders of the
skin develop, they present varying degrees of
hypoesthesia, even anesthesia, of the annular or
“glove and stocking” type. Sensory disorders of
this kind are not uncommon although they are
rarely mentioned by the patient unless they be-
come marked in degree.
When a painful lesion occurs in the lumbo-
dorsal fascia in the midsacral paraspinal region,
it lies within the sclerotome of the first sacral
nerve. When the midlumbar region over the lat-
148
eral portion of the sacrospinalis muscle is the site
of an injury, the pain is experienced within the
sclerotome of the second lumbar nerve or, rarely,
the third lumbar. Identification of the sclerotomes
related to these sites was made from the pain
charts of Inman and Saunders.*®
Following observations in two patients’ in
whom pain in the upper portions of the back
was relieved by correction of the disability in the
lower part of the back, it was subsequently estab-
lished that this is a very common association.
The mechanism involves the latissimus dorsi mus-
cle which is in close anatomical relationship with
the lumbo-dorsal fascia, particularly in the mid-
lumbar region. With irritation of the tendinous
prolongations of the aponeurosis of origin of this
muscle, referred phenomena are transmitted up-
ward within the sclerotomes of the sixth, seventh
and eighth cervical nerves which supply numer-
ous structures in the upper part of the body.
Clinical Features
With knowledge of the anatomic lesions of fat,
fascia and muscle, together with application of
accepted principles of referred phenomena, it is
considered possible to evaluate the majority of
cases of back disability quickly and accurately.
The diagnosis is made from the usual history
given by the patient, the description and location
of the-pain by the patient and the areas of hyper-
algesia determined by palpation. Verification of
the trigger-point is then obtained by injection of
local anesthetic. Roentgenographic examination is
necessary for identification or exclusion of or-
ganic disease of the bones and joints.
Classification of the various pain complexes
affecting the back and the extremities can be made
most clearly on an anatomical basis—the site of
origin of the pain together with identification of
the afferent nerve supply to the structures from
which the pain arises.
The Midsacral (First Sacral Nerve) Syndrome.—
When this is found in isolated form, the complaint
of the patient is pain in the lower part of the back,
the buttock and the lateral and posterior aspects of
the thigh. Sometimes the pain is also noted in
the outer part of the leg and foot. On examina-
tion, the chief finding is a diffuse tenderness in
the lower two-thirds of the buttock. The trigger-
point is almost invariably to be found in the
paraspinal region of the third sacral vertebra.
MINNESOTA MEDICINE
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DICINE
LUMBO-DORSAL FASCIA—DITTRICH
Tenderness at the latter point may be moderate or
marked in intensity, with or without radiation of
the pain to other portions of the sclerotome. It
may on the other hand, be elicited only on heavy
pressure. Frequently a nodular mass of soft tis-
sue can be palpated and identified as the source
of the pain. The suspected lesion is verified by
diagnostic injection of a local anesthetic.
The midsacral paraspinal region is apparently
also the location from which pain may be re-
ferred to the coccyx, to produce the clinical pic-
ture of coccygodynia.*
The Midlumbar (Second Lumbar Nerve) Syn-
drome.—In this the chief complaint is pain in
the lower part of the back, located in the lower
lumbar, the upper sacral and the sacroiliac re-
gions. Referred pain to the lower extremity,
when present, is located in the groin and the ad-
ductor region of the thigh. Tenderness may be
elicited at either of these areas, more commonly
in the lumbar and sacral regions. The trigger-
point is to be found in the midlumbar region
over the lateral portion of the sacrospinalis mus-
cle. This is substantiated by injection of local
anesthetic into the subfascial tissues at the latter
point.
The Latissimus Dorsi (Sixth, Seventh and
Eighth Cervical Nerve) Syndrome.—Attention
was called to this structure by statements of pa-
tients that they were relieved of pain in the up-
per portions of the body following operations in
the lumbar and sacral regions.2, The symptom-
complex, developing apparently from painful irri-
tation of the tendinous slips of origin from the
lumbodorsal fascia, may present a wide variety of
manifestations, subjective and objective, through-
out the entire extent of the latissimus dorsi, the
scapular region, shoulder, upper extremity, neck
and chest. The more common complaints of the
patient are pain and weakness in the scapular
region and the shoulder. Tenderness is found
frequently in those locations. The trigger-point
is located at the site of injury of the lumbo-
dorsal fascia in the lumbar and sacral regions.
Anesthetization of this must be carried out in the
superfical layers of the fascia, by interruption of
the painful impulses arising in those portions of
the latissimus dorsi muscle.
Headache as a symptom related to low back
pain has been described in a group of seven
Fepruary, 1952
cases.’ Since then it has been found to occur as a
common manifestation associated with disabilities
due to fat and fascial lesions in the lower part of
the back. The impulses arising in the tendinous
fibers of origin of the latissimus dorsi muscle
produce referred pain and referred tenderness in
those portions of the paraspinal muscles which
are innervated by the sixth, seventh and eighth
cervical nerves. If it is accepted that pain and
spasm of those muscles at the base of the neck are
capable of producing the pain which is interpreted
as headache, then it is explainable as a referred
pain.
Combined Syndromes.—While each one of the
individual syndromes may occur in the isolated
and uncomplicated form, in many instances vari-
ous combinations are found in the same patient.
This is readily understandable when‘it is con-
sidered that the tendinous prolongations of the
aponeurosis of the latissimus dorsi muscle may
extend distally over the entire lumbodorsal fascia.
Any injury of the fascia would be likely to include
also some damage to the fibers of the tendon at-
tached to it. Under those conditions two different
streams of impulses are set up as referred phe-
nomena: one to the second lumbar or first sacral
nerve field, the other to the sclerotomes of the
sixth, seventh and eighth cervical nerves. When
the combination consists of the first sacral and the
latissimus dorsi syndromes, the manifestations in
the upper parts of the body are relatively mild in
degree. The more serious types of clinical pic-
tures are derived from a combination of the sec-
ond lumbar and the latissimus dorsi syndromes.
Finally, the three syndromes may be combined
in the same patient.
Treatment
The indications for treatment were clarified
with the discovery of the more definite patho-
logic changes. Recognition of the predilection for
two sites of injury simplified the problem. It be-
came obvious that only surgical measures could
be employed with expectation of relief.
The technique is similar for the sacral and the
lumbar regions. Under local anesthesia of the
skin, a transverse incision is made over the
trigger-point. The lumbo-dorsal fascia is exposed
by freeing the subcutaneous fat. The fascia is
incised vertically. The subfascial tissues, if ad-
herent, are dissected from the ventral aspect of
149
LUMBO-DORSAL FASCIA—DITTRICH
the fascia and removed. It is difficult to formulate
any rule regarding the extent of resection of the
fat tissues. It has become the practice to remove
the layer of subfascial tissue which is obviously
fibrosed, and to leave the normal fat tissue intact.
Caution is necessary to avoid injury to the sacro-
spinalis muscle. The fascia is usually approxi-
mated with sutures, leaving an adequate opening
for a soft rubber drain to be inserted into the op-
erative field. The drain is left in place for five to
seven days. Discharge of sero-sanguinous fluid
continues usually for three to four weeks until
the sinus is healed. If drainage is inadequate, the
accumulation of bloody fluid becomes troublesome
and will require evacuation.
In some cases the fascia is too thin to permit
suturing; the results appear to be fully as satis-
factory as in the cases in which suturing can be
successfully carried out.
In cases of isolated latissimus dorsi syndrome,
the incision is carried down to the fascia, the
tendinous fibers of the aponeurosis are resected
transversely, bleeding points are ligated and the
incision is closed. A small drain is inserted for
a period of twenty-four to forty-eight hours.
When the latissimus dorsi syndrome occurs in
combination with either or both of the other syn-
dromes, it requires no special attention. It ap-
pears, from the clinical results, that these fibers
form part of the anatomical derangement of the
fascia and any abnormality which involves these
elements is simultaneously corrected.
Depending on the nature and the extent of the
operative procedure, patients may leave the hospi-
ital one to three days after the operation.
Since the previous report on ten cases,” opera-
tions have been performed on fourteen additional
patients. The type of disorder and the results in
these may be classified as follows:
Midsacral three
relief.
syndrome cases—complete
Midlumbar syndrome—one case—complete re-
lief.
Latissimus dorsi syndrome—two cases—com-
plete relief.
Midsacral and latissimus dorsi syndromes—two
cases—complete relief in one; in the other, in-
complete relief due to adherent, painful scar.
Midlumbar and latissimus dorsi syndromes—
one case—complete relief.
150
Three syndromes combined—five cases. In
three of these, operation was carried out in the
midsacral and midlumbar regions at the same time,
with complete relief in all; in one, complete relief
was obtained by two separate operations ; in one,
partial relief was obtained, but patient refused
further treatment; result is considered a failure.
Comments
From an analysis of this group of patients, sev-
eral features are of sufficient importance to re-
quire emphasis. In all cases the operation was
performed at one or both sites of the lower part
of the back which are considered particularly vul-
nerable to injury. In four cases, operation was
performed at both sites; in one of the latter it
was bilateral. Distinct pathologic changes were
found in the lumbo-dorsal fascia and the sub-
fascial tissues in all instances except those in
which the clinical picture was that of the latissimus
dorsi syndrome. Clinical manifestations in the
upper portions of the body, representing the latis-
simus dorsi syndrome, were present in ten of the
fourteen patients. These were relieved in all in-
stances except one in which additional treatment
could not be carried out. Chronic head pain in six
cases and attacks of dizziness in two were elimi-
nated. Relief of disability is usually prompt so
that the outcome can be determined with reason-
able accuracy within a few days. Depending on
the nature of the work, patients may resume such
activity in one to six weeks after operation.
“Complete relief” as used here, enabled the pa-
tient to return to his former, or similar, types of
work, with little or no handicap.
Summary
A review is made of fourteen cases of low back
pain treated surgically.
The anatomical lesions consisted of scar forma-
tion between the lumbo-dorsal fascia and sub-
fascial fat at one, or both, of two sites in the lower
part of the back: the midsacral paraspinal region
and the midlumbar region over the lateral portion
of the sacrospinalis muscle. The initial injury 1s
probably a tear of the fascia produced by muscle
action.
The physiologic disturbances which result from
these lesions consist of referred phenomena—pain
and tenderness. Knowledge of the mechanism of
MINNESOTA MEDICINE
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these processes is essential for proper evaluation
of the clinical manifestations.
Clinically, three different syndromes can be
recognized: the midsacral or first sacral nerve,
syndrome; the midlumbar, or second lumbar
nerve, syndrome; the latissimus dorsi syndrome,
in which the clinical picture is dominated by mani-
festations within the sclerotomes of the sixth,
seventh and eighth cervical nerves. Each of these
syndromes may appear in isolated form. Com-
binations of two, or all three, syndromes in the
same patient are more common.
Surgical treatment, consisting of correction of
the structural changes, has yielded results which
are highly satisfactory.
LUMBO-DORSAL FASCIA—DITTRICH
References
1. Copeman, W. S. C., and Ackerman, W. L.: Edema
or herniations of fat lobules as a cause of lumbar
and gluteal “fibrositis.” Arch. Int. Med., 79:22-35
(Jan.) 1947.
2. Dittrich, R. J.: Subfascial fat abnormalities and
low back pain. Minnesota Med., 33 :593-596 (June)
1950.
3. Dittrich, R. J.: Headache related to low back pain.
Journal-Lancet, 71:47-48 (Feb.) 1951.
4. Dittrich, R. J.: Coccygodynia as referred pain. J.
Bone & Joint Surg., 33-A: 715-718 (July) 1951.
5. Grant, J. C. B.: The musculature. In Morris’ Hu-
man Anatomy, ed. 10, edited by J. Parsons Schaeffer.
Philadelphia: Blakiston Co., 1942.
6. Inman, V. T., and Saunders, J. B. de C. M.: Re-
ferred pain from skeletal structures. J. Nerv. &
Ment. Dis., 99 :660-667 (May) 1944.
7. Sobotta, J.. and McMurrich, J. P.: Atlas and Text-
book of Human Anatomy. Vol. 1. Philadelphia:
W. B. Saunders Co., 1906.
FUNCTIONAL NEUROPSYCHIATRIC DISORDERS
(Continued from Page 143)
in biological learning (ontogenetic) the shift is
upward. In the devolutionary process of disease
either functional or morphological, the shift is
downward and is termed regressive.” Therefore,
when we are psychologically repressed, we are
neurologically inhibited. Psychological repression
can be and probably always is accompanied by
neurological inhibition.
I believe that the “incomplete” reactions which
have been described are due to repression and in-
hibition, which are the result of either overt or
latent anxiety.
Conclusion
1. There is no clear-cut dividing line between
“organic”
“functional” and nervous diseases.
2. However, most disorders are either pre-
dominantly “functional” or predominantly “or-
ganic.”
3. The diagnosis of a predominantly functional
nervous disorder can be made on the presence of
objective signs.
4. Some of these signs are described.
References
1. Cobb, Stanley: Borderlands of Psychiatry.
bridge: Harvard University Press, 1944
2. Grinker, Roy R.: A comparison of psychological
“repression” and neurological “inhibition.” J. Nerv.
& Ment. Dis., 89:765-781, 1939.
3. King, Lester $.: The meaning of medical diagnosis.
Etc., A review of general semantics, 8 :202-211, 1951.
1044 Lowry Medical Arts Building
Cam-
HEMORRHAGE IN THE RECTUS MUSCLE
(Continued from Page 146)
6. Coleman, E. P., and Bennett, D. A.: Spontaneous
hemorrhage into the sheath aot the rectus abdomi-
nis muscle. Illinois M. J., 292-295 (Oct.) 1941.
7. Culbertson, C.: Hematoma probes spontaneously
in sheath of rectus abdominis muscle. J.A.M.A
85 :1955-1958 (Dec. 19) 1925.
8. Fothergill, W. E Hematoma in abdominal wall
simulating pelvic new growth. Brit. M. J., 1:941-
943, 1926.
9. Halperin, G.:
dominal wall.
(Dec.) 1928.
10. Hobbs, F. B.: Fatal hemorrhage into rectus abdcem-
inis muscle during pregnancy. Brit. M. J., 1:895-
8% (Apr. 23) 1938.
ll. McCarty, R. B.: Spontaneous hematoma of the
rectus abdominis muscle. Am. J. Surg., 23:480-
483 (Mar.) 1934.
12. Mailes, R.: Spontaneous hematoma of abdominal
wall. Brit. M. J., 1:637-639 (Mar. 28) 1936.
13. Maxwell, A. F.: Spontaneous hematoma of the
abdominal wall in women. California & West. Med.,
30 :407-410 (June) 1929.
Fepruary, 1952
Spontaneous hematoma of the ab-
Surg., Gynec. & Obst., 47 :861-863
14. Payne, R. L.: Spontaneous rupture of the superior
and inferior epigastric arteries within the rectus
abdominis sheath. Ann. Surg., 108:757-767 (Oct.)
1938.
15. Perman, E.: Hematoma in the sheath of the mus-
culus rectus abdo~inis. Acta chir. Scandinav.,
54 :434-454 (Apr.) 1922.
16. Strenger, G.: Spontaneous hemorrhage into the
rectus abdominis muscle simulating acute intra-
abdominal conditions. Am. J. Surg., 55:594-596
(Mar.) 1942.
17. Teske, J. M.: Hematoma of the rectus abdominis
muscle. Am. J. Surg., 71:689-695 (May) 1946.
18. Ward, C. F.: Rupture of rectus abdominis muscle.
U. S. Nav. M. Bull., 44:515-518 (Mar.) 1945.
19. Wohlgemuth, K.: Uber de subcutane Rupture des
M. rectus abdominis und der Art. epigastrica. Arch.
f. klin. Chir., 122 :649-659, 1923.
20. Zohman, B. L.: Spontaneous hematoma of the rec-
tus muscle, = a case of acute alcoholism and acute
nephritis. . J. & Rec. 137:232-234 (Mar. 15)
1933.
151
THE MINNESOTA PROGRAM FOR THE-CONTROL OF BRUCELLOSIS
RALPH L. WEST, D.V.M.
Saint Paul, Minnesota
HE control of brucellosis in domestic animals
has been of major concern to the State Live
Stock Sanitary Board for more than thirty years.
Progress at first was slow, but with the increas-
ing realization by the livestock industry of the
tremendous economic loss caused by this disease,
and with the knowledge that the disease is trans-
missible to human beings and is now a public
health problem, it has been possible to steadily in-
crease the tempo of the eradication program.
Popular demand for the eradication.of this disease
was particularly stimulated by action taken in re-
cent years by the health departments in certain
municipalities, serving notice on producers of
dairy products, that after a certain date, milk and
cream products, to be sold within their respective
municipalities, must originate from herds free
from brucellosis. In order to maintain their
market, dairymen now realize they must get their
house in order and are demanding that brucellosis
of cattle be eradicated as rapidly as possible.
and livestock sanitarians
realize that it is impossible to eradicate brucellosis
from dairy herds unless it is eradicated from all
cattle, including beef herds in the areas where
dairy herds are maintained. Because of the tre-
mendous movement of cattle in the United States
from areas where beef cattle are raised, to the
middle west where they are finished for beef, and
because these feeding areas are usually in close
proximity and often on the same farms where
dairy herds are maintained, it is very necessary
that the disease control officials of all states where
dairying is a large project require that importation
of livestock into their respective states be free
from this disease. This in turn has resulted in a
demand by breeders in the beef-raising states, for
the elimination of bovine brucellosis, not only to
reduce direct financial losses caused by the disease
in their own herds, but to protect the market for
feeding cattle in the midwest farming states.
There has thus developed a nationwide movement
Livestock owners
Read at the Minnesota Public Health Conference,
Minneapolis, Minnesota, September 28, 1951.
Dr. West is secretary and executive officer of the
Minnesota Live Stock Sanitary Board.
152
for the eradication of brucellosis from the do-
mestic animals of this country.
Minnesota has been in the forefront in this
effort to eradicate this serious disease of do-
mestic animals and human beings for many years,
In 1939, the State Legislature enacted a law to
provide for the eradication of brucellosis from
cattle under the Area Plan, based on a similar
plan which had proven so successful in the eradi-
cation of bovine tuberculosis. A number of states
have enacted similar laws. The Minnesota law
has been amended slightly since its original enact-
ment, and it is believed that at the present time
it provides for the most practical, orderly and
systematic plan for the eradication of brucellosis
of any such law in the United States. The amend-
ments since the original law was passed have
been made to adapt the law to the peculiarities of
brucellosis which naturally differ in some respects
from tuberculosis,
Excellent progress was made in extending the
Area Plan of control after it was enacted until
the advent of World War II. During the war
and the unsettled conditions which followed and
still exist, numerous factors, including the tre-
mendous increase in the value of livestock and
the shortage of veterinarians, have tended to delay
the eradication program.
Another factor also entered the picture in 1942
which has actually delayed the eradication pro-
gram, although, if properly interpreted and used,
it can be of great value. I am referring to the
vaccination of cattle against brucellosis, which
was recommended as an adjunct to other control
measures by the Bureau of Animal Industry
of the United States Department of Agriculture
in December of 1941. The Bureau of Animal In-
dustry, which had developed the vaccine recom-
mended and still in use, has emphasized at all
times that this product was to be used as a
supplementary procedure only, and could not in
itself bring about satisfactory eradication. Never-
theless, advantage was taken of the announcement
of a successful vaccine by commercial interests
producing and selling the product, as well as by
some segmients of the livestock industry and cer-
MINNESOTA MEDICINE
CONTROL OF BRUCELLOSIS—WEST
tain veterinarians seeking an easy and painless
method of eradicating the disease. The farm jour-
nals for several years carried misleading adver-
tisements and article after article by uninformed
persons making unjustified claims as to the value
of the vaccine and the unreasonableness of the
regulations requiring restraint or disposal of in-
fected animals. Much confusion ensued and for
some ten years has resulted in a definite setback
to the nationwide efforts to eradicate this disease.
Only during the last few years has it become
generally recognized that the recommendations
of the Bureau of Animal Industry, when the vac-
cine was first introduced, were sound and that
the use of vaccination was an adjunct to
other control measures. If used in this manner,
it can be and is of great value, and is used ex-
tensively in the program in this state.
During the period of confusion above men-
tioned, there was a definite loss of ground in
some states in the control of brucellosis. I am
proud to report that the program in Minnesota has
progressed steadily although rather slowly during
the war years. Furthermore, we are today in a
position to increase the program for eradication
as rapidly as funds are provided by the legislature
without materially changing our laws, regulations
or procedures.
As above stated, the eradication of brucellosis
is the goal in this state, and our program is based
primarily on the Area Plan. Briefly, this plan
consists in applying the agglutination blood test
to all cattle in a county; the proper disposal of
reactors, the quarantine of infected herds, the
prevention of the importation of infected animals,
and the systematic retesting until the disease has
been eradicated.
The Uniform Methods and Rules of the Bureau
of Animal Industry, United States Department
af Agriculture, and the rules and regulations of
the Live Stock Sanitary Board provide that when
atest of all cattle in a county reveals the incidence
of infection to be less than 1 per cent and the in-
fected animals are found in less than 5 per cent of
the herds, the county may be declared a Modified
Certified Brucellosis-Free Area for a period of
three years. Such declaration, however, does not
complete the program. All infected and suspect
herds must be retested at frequent intervals until
all infected herds have passed three consecutive
hegative tests and until any herds in which infec-
Fepruary, 1952
tion is disclosed or suspected because of clinical
evidence have been tested and the status of such
herds determined. At the end of the three-year
period of certification, the entire county is again
retested and if the incidence is found sufficiently
low, the county is recertified.
In order to put this plan into effect, it is nec-
essary under the law for 67 per cent of the cattle
owners to petition the Live Stock Sanitary Board.
There are now thirty-six of the eighty-seven coun-
ties which have adopted the plan, and twenty-
three of those counties have been declared Modi-
fied Certified Bang’s Disease-Free Areas.
Progress in the area control of Bang’s disease
has been accelerated during the last three years
by the adoption of the so-called ABR or ring test
of milk and cream. This test is again a measure
to supplement other procedures, and with our
present knowledge cannot be satisfactorily used
as a substitute. Here, again, there is grave danger
that confusion may develop due to placing un-
justified reliance on this measure to the exclu-
sion of other methods of diagnosis which have
proved so satisfactory in the control program to
date. Where properly used, it not only allows
sanitary officials to do a better and quicker job
of eradication, but reduces the cost of such pro-
cedures to some extent. The role the ring test
should play, in my opinion, is to discover new
centers of infection which may occur from time
to time in any area where the control program
is in progress, due to various causes, more often
than not to violations of quarantines or illegal
importations. The test is not sufficiently accurate
to constitute a means of officially determining the
status of a herd or an individual animal, and if
used in such a manner, only disappointment will
result and consequently delay in the eradication
procedure.
The State of Minnesota has not confined its ef-
forts in the control of brucellosis to the eradica-
tion program under the Area Plan. Provisions
have been made whereby any cattle owner may
receive credit through certification of his herd,
if at his own expense he eradicates and main-
tains his herd free from brucellosis. Also regu-
lations have been in effect for many years re-
quiring that cattle imported into the state must
be tested and found free from the disease.
In 1945 the State Legislature enacted a law
whereby all cattle over six months of age, except
153
CONTROL OF BRUCELLOSIS—WEST
steers, before being sold or offered for sale for
any purpose excepting for immediate slaughter
or consignment to a public stockyards, must be
tested and found free from Bang’s disease, with
two exceptions. These exceptions were cattle
located in Modified Certified Bang’s Disease-Free
areas and cattle owned by the seller since birth.
The theory on which these exceptions were based
was, first, that all infected herds in counties
which have adopted the Area Plan are presumed
to be under quarantine, and no cattle can legally
be removed therefrom except under permit from
the Live Stock Sanitary Board, and, second, that
cattle raisers should not be required to conduct the
test before selling such cattle provided they could
not be resold by dealers and traders after pur-
chase, except for immediate slaughter. These
exceptions were, however, abused in many in-
stances, and the 1951 Legislature amended the
law to delete these two exceptions and also to
provide means whereby cattle legally and officially
vaccinated might be sold in accordance with the
rules and regulations of the Live Stock Sanitary
Board without a Bang’s disease test. The 1951
law is now in effect. Rules and regulations have
been adopted by the Board and it is hoped that
the provisions providing for the sale of vaccinates
will be practical. It surely will be, if we have the
co-operation of the livestock industry and the
practicing veterinarians of the state on whom
we must depend for its efficient operation.
Because of the warning given by certain munic-
ipalities, particularly the City of Chicago, that
after a specified date only milk and milk prod-
ucts produced by brucellosis-free cattle may be
sold within the municipality, the Minnesota Live
Stock Breeders Association and the Minnesota
Farm Bureau conferred with Governor Young-
dahl in regard to the urgent need of expediting
the eradication program in Minnesota. Governor
Youngdahl appointed an advisory committee on
brucellosis. This committee included representa-
tives from all producing agencies and others in-
terested in the eradication of the disease, includ-
ing representatives of the State Department of
Health and the State Live Stock Sanitary Board.
A legislative program was prepared by this com-
mittee. One of the principal recommendations
was an increased appropriation for the purpose
of extending the area program to the entire state
-
within the next few years. The Live Stock Sani-
tary Board prepared an estimate of the funds
needed for the next biennium to carry out the
first two years of this program. A special ap-
propriation bill was introduced in both the House
and Senate. The State Senate passed the bill
unanimously, but it failed of passage in the Ap-
propriations Committee of the House. It was
killed in that committee. It is evident that sat-
isfactory progress towards this statewide pro-
gram cannot be made during the present biennium.
Every effort will be made to use the funds now
available to the best advantage and to extend the
work as rapidly as possible, but if the entire state
is to be placed under an eradication program with-
in the deadline set by the City of Chicago and
some other municipalities, it will be essential that
the next legislature take action to materially in-
crease the funds available. Their failure to do so
in the 1951 session, while a serious setback to the
program, need not be fatal if the legislature in
1953 will provide sufficient funds. Veterinary
personnel is steadily increasing, the demand of
the livestock producers is insistent, and it is be-
lieved fully possible to extend the work if only
funds are made available.
Records of the State Department of Health in-
dicate that approximately 85 to 95 per cent of
the cases of brucellosis in human beings in Min-
nesota are caused by brucella abortus or the type
of brucella organisms derived from cattle. There
is, however, a material number of cases caused
by brucella suis and brucella melitensis, both of
which in Minnesota are caused by exposure to
infected swine. Our organized control program
at the present is confined to cattle. The Live
Stock Sanitary Board has now under consider-
ation the adoption of regulations for the control
of brucellosis in swine based on recommendations
of the United States Livestock Sanitary Associa-
tion. It is not believed that brucellosis in swine is
now as prevalent as the disease in cattle, nor is it
as difficult to eradicate. It is possible that in the
near future some additional legislation may be re-
quired, but it does not seem advisable to request
such legislation until initial steps are taken through
regulations to provide for certified brucellosis-free
herds of breeding swine. It is hoped that this
program will be in effect within a very short
time.
MINNESOTA MEDICINE
a
President’s Letter
THROUGH ORGANIZATION TO SERVICE
A very significant indentification card has undoubtedly been delivered to you
by this time—your membership certificate from the Minnesota State Medical
Association, which also indicates your inclusion in the ranks of your local medical
society.
In recent years there have been varying evaluations of organized medicine,
appraisals so heated that oftentimes we have used substitute phraseology for
“organized medicine,” to blunt the criticism directed against us on that basis.
The term organized medicine, twisted into a definition of bigotry, self-interest,
and monopoly, by the proponents of government health insurance, nearly met
the fate of permanent identification with this description.
However, through the national education campaign, the campaigns conducted
by state and county medical societies and a doctor-to-patient informational ex-
change, the public has been swerved from a hasty acceptance of the propaganda
against the organizations of the medical profession.
In justifying organized medicine to the public, we have, ourselves, come to
a clearer understanding of the purposes and ideals of the three-level organizational
structure of medicine and a greater appreciation of the facilities it affords for
furthering medical standards and protecting public and profession alike from
health-profiteers.
Each level of membership—county, state and national—as you know, offers
unique advantages to the physician: not only is his position with the public
enhanced by the profession’s official symbol of approval, but he is afforded a
myriad of opportunities to become better able to serve his patients. Through
his medical affiliation he is offered post-graduate education, the opportunity
to work, with other physicians, on the scores of committees that are striving
in a practical, yet progressive, fashion to solve the problems that impede the way
toward increasingly better public health records. He has available, in central
locations, information and literature of subjects ranging from flat feet to voluntary
health insurance. He can check the efficacy of a new drug, obtain a speaker for
a medical meeting, order a packet of material to help him in writing a scientific
paper, sign up for an insurance policy at lower-than-individual rates, obtain assist-
ance in legal difficulties, book an education film, receive a list of available
physicians from which to choose a partner or an associate. But all these ad-
vantages and many more are familiar to you, as a member of organized medicine.
In recounting the purposes and merits of these organizations, however, we
must continually bear in mind that none of the three, neither the county, nor
the state, nor the American Medical Association exists as an entity unto itself.
The organizations are interwoven and, although autonomous, are interdependent
and, more particularly, they are dependent for their continued successful record
of service upon active participation, utilization, and endorsement by every mem-
ber. We cannot content ourselves with mere acceptance of the functions of medical
societies—we must vigorously and consistently support and implement those func-
tions, helping to adapt them to each new turn of events, each new challenge and
demand upon the profession. You have only begun to assume your rightful
reponsibilities when you pay your dues and accept the certificate of membership.
<P rned,
President, Minnesota State Medical Association
Fepruary, 1952
- Editorial .
Cart B. Drake, M.D., Editor; Georce Eart, M.D., Henry L. Utricu, M.D., Associate Editors
NARCOTIC ADDICTION ON
THE INCREASE
HE ALARMING INCREASE in narcotic
addictions, particularly in the youth of our
larger cities, should be emphasized and exposed
to the full glare of publicity.
Certain facts about drug addition should be
given to the public in order to know how best to
attack the problem. It is perhaps not widely
recognized by the profession that the smoking of
marihuana cigarettes provides the start for most
narcotic addicts. With youthful recklessness and
the mistaken idea that to smoke this weed is smart,
the misstep is taken that leads to more serious
and irretrievable addiction. While the smoking
of marihuana causes a form of intoxication that
is harmful, discontinuance of its use is not accom-
panied by serious withdrawal symptoms. The
most serious aspect of its use is that it so often
leads to the use of heroin or morphine. In the
search for new thrills (so-called), the youngster
tries the sniffing of heroin and for further, more
effective use, tries the intravenous administration
of small doses of heroin. Habitual use leads to
the requirement of larger and larger doses of
this expensive narcotic which is no longer sold
by druggists or prescribed by physicians but is
bartered entirely by members of the underworld
at exorbitant prices. The habit gets such a hold
on the addict that he will do anything to obtain
the drug or obtain the cash needful to buy his
supply. The addict, as is well known, loses his
moral sense of right and wrong, and will lie or
steal or resort, in the case of the lesser per-
centage of girls who constitute the unfortunate
group, to prostitution in order to obtain necessary
funds.
According to Taday’s Health for October, 1951,
in Chicago alone the State Attorney’s office
processed 3,126 addicts in six months. On one
day recently, one-fourth of the prisoners in Cook
County jail in Chicago were addicts, ninety-two
under twenty-one, 108 between twenty-one and
twenty-five and ninety-five over twenty-five. Ad-
missions to the two Federal hospitals for addicts
156
rose from 2,700 in 1949 to 4,500 in 1950. The
addicts in these hospitals under twenty-one
jumped from twenty-two in 1947 to 440 in 1950.
Boys outnumber girls six to one.
The hold that narcotics get on their victims is
difficult to imagine, and perhaps impossible to
imagine for anyone not an addict. Release of
the addict from the bonds of the habit is the ex-
ception rather than the rule. For this reason,
prevention of the commerce in narcotics except for
medicinal purposes, and of heroin for all pur-
poses, lies in the field of national control.
Physicians must aid Uncle Sam’s preventive
activities to the utmost. How insidious and
powerful drug addiction can be is evidenced by
the regrettable fact that many physicians allow
themselves to become addicted to one narcotic or
another, and demerol seems to be a favorite.
Punishment is and should be severe for those
convicted of underground traffic in narcotics. The
exposure being made in the public press of the
insidious dangers accompanying the trifling with
narcotics should be of value in a preventative
campaign.
A NEW TECHNIQUE FOR
ARTIFICIAL RESPIRATION
| THE September 1951 number, we mentioned
the undesirable features of the Schaefer and
Sylvester methods of artificial respiration. With
the former method, the air is forced out of the
lungs and the entirely passive recoil of the chest on
the relief of the pressure results in a small amount
of air being inspired, while the inhalation of air,
with the Sylvester method, is an active process as
well as the exhalation. The disadvantage of the
latter method is that the tongue has to be seized by
a forceps or a safety pin and pulled forward to
avoid the swallowing of the tongue. Most of us do
not carry a forceps or safety-pin with us, and time
is of the essence when artificial respiration is
needed.
In view of the drawbacks possessed by both
these methods, it is not surprising that a third
MINNESOTA MEDICINE
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EDITORIAL
method has been devised and adopted, largely
through the efforts of the American Red Cross.
In 1947, the American Red Cross requested the
Council of Physical Medicine of the AMA to
review the problem. A committee of the Council
reported that the Schaefer method taught for years
by the Red Cross was inferior to other methods.
As a result, the Red Cross made grants during
1948 and 1949 to evaluate various methods. After
studying air exchange induced by artificial respira-
tion in animals and human beings, it was decided
that the back pressure—arm lift method used for
many years in Europe, especially in Denmark and
Norway, was comparatively easy to learn and
perform and produced a satisfactory volume of
tidal air. The military consultants in June, 1951,
recommended to the armed forces that they adopt
this method. In October, 1951, at a meeting of
the National Research Council, at which a number
of agencies such as the Red Cross, the AMA, the
Army, Navy and Air Force were represented, the
back pressure-arm lift method originally de-
scribed by Holzer Nielsen was decided upon as
being the preferable one. The standard technique,
as described by the Red Cross, is as follows:
Standard Technique for the Back Pressure-Arm
Lift Method of Artificial Respiration
The Standard Technique, agreed upon by a committee
appointed at the meeting of agency representatives on
October 2, is as follows:
(Position of the Subject)
1. Place the subject in the face down, prone position.
Bend his elbows and place the hands one upon the
other. Turn his face to one side, placing the cheek
upon his hands.
(Position of the Operator)
2. Kneel on either the right or left knee at the head
of the subject, facing him. Place the knee at the
side of the subject’s head close to the forearm. Place
the opposite foot near the elbow. If it is more
comfortable, kneel on both knees, one on either side
of the subject’s head.. Place your hands upon the
flat of the subject’s back in such a way that the
heels lie just below a line running between the arm-
pits. With the tips of the thumbs just touching,
spread the fingers downward and outward.
(Compression Phase)
3. Rock forward until the arms are approximately
vertical and allow the weight of the upper part of
your body to exert slow, steady, even pressure
downward upon the hands. This forces air out of
the lungs. Your elbows should be kept straight and
the pressure exerted almost directly downward on
the back.
(Expansion Phase)
4. Release the pressure avoiding a final thrust, and
commence to rock slowly backward. Place your
Fepruary, 1952
hands upon the subject’s arms just above his elbows,
and draw his arms upward and toward you. Apply
just enough lift to feel resistance and tension at
the subject’s shoulders. Do not bend your elbows,
and as you rock backward the subject’s arms will be
drawn toward you. Then drop the arms to the
ground. This completes the full cycle. The arm
lift expands the chest by pulling on the chest mus-
cles, arching the back, and relieving the weight on
the chest.
The cycle should be repeated“12 times per minute
at a steady uniform rate. The compression and ex-
pansion phases should occupy about equal time, the
release periods being of minimum duration.
Additional Related Directions
It is all-important that artificial respiration, when
needed, be started quickly. There should be a slight
inclination of the body in such way that fluid drains
better from the respiratory passage. The head of the
subject should be extended, not flexed forward, and
the chin should not sag lest obstruction of the respiratory
passages occur. A check should be made to ascertain
that the tongue or foreign objects are not obstructing
the passages. These aspects can be cared for when
placing the subject into position or shortly thereafter,
between cycles. A smooth rhythm in performing arti-
ficial respiration is desirable, but split-second timing is
not essential. Shock should receive adequate attention,
and the subject should remain recumbent after resuscita-
tion until seen by a physician or until recovery seems as-
sured.
SCIENCE TALENT SEARCH
OO OFTEN youthful talent is not dis-
covered, and because of a lack of financial
backing the high school boy or girl with excep-
tional natural ability in the field of science is
never able to develop his God-given gifts.
In order to discover the talented boys and girls
of high school age, Science Service, a non-profit
institution for popularization of science, has been
established. Its trustees are nominated by the
National Academy of Sciences, the National Re-
search Council, the American Association for the
Advancement of Science, the E. W. Scripps
Estate and the journalistic profession. Financed
by the Westinghouse Educational Foundation, it
forms Science Clubs in the high schools all over
the country. Through these clubs, students are
urged to undertake research problems in the field
of science. Each year, examinations are held and
from the 300 top-ranking contestants forty are
awarded trips (all expenses paid) to Washington,
D. C., to take part in a five-day Science Talent
Institute. They visit places of scientific interest
in our capital, meet prominent scientists, and
compete for scholarships awarded by the West-
inghouse Educational Foundation. Although the
scholarships total but $11,000, nearly half going
to the winner and runner-up in the contest, to be
157
EDITORIAL
among the 300 top-ranking contestants serves as
a recommendation for admission to a college.
The record shows that of 400 chosen during the
past ten years, 178 have earned undergraduate
degrees, forty-seven Masters and twenty-three
M.D., Ph.D., or D.Sc. degrees. At least eighty
have full-time positions as astronomers, mathe-
maticians, chemists, engineers, physicists or phy-
sicians in research centers or nationally known
industries.
Science Service is located at 1719 N Street
N. W., Washington 6, D. C.
HENNEPIN COUNTY NEONATAL
MORTALITY STUDY
During 1950, in Minnesota, 1,874 infant deaths
occurred. On the basis of provisional figures, 1,893
infant deaths occurred in 1951. There are as many
deaths during the first year of life as there are in the
total of the next consecutive 39 years. In other words,
as many babies die before reaching their first birthday
as the total number of deaths that occur between the
ages of one and 40 years. More than one-third of
these babies die during their first day of life; more
than two-thirds die during the first week of life; and
three-fourths of all the deaths during the first year of
life occur within the first month after birth. Less than
25 per cent of infant deaths occur between the first and
twelfth month of life. Thus, any significant reduction
in infant mortality must depend on a decrease in deaths
during the first month of life, the so-called neonatal
period. While many of these deaths are non-preventable
at the present state of our medical knowledge, there are
many that are considered preventable and hence the
special interest in neonatal mortality.
A study of maternal deaths by the Minnesota State
Medical Association in co-operation with the Depart-
ment of Obstetrics of the University and the State
Department of Health, was first carried out in 1941-42.
It was reactivated in 1950 and is now in its second
consecutive year. In 1941-42 the maternal mortality
rate was 1.6 per 1,000 live births with 94 maternal deaths.
On the basis of 1951 provisional statistics, the rate has
dropped to 0.4 per 1,000 live births with only 32 deaths,
a decrease of 75 per cent in the rate in a decade. The
effectiveness of the maternal mortality study and its
general acceptance is furthér evidenced by the fact that
the Council of the State Medical Association has re-
quested the State Health Department to continue to
underwrite the study indefinitely. It is generally felt
that a similar study of neonatal deaths should produce
equally effective results. A state-wide neonatal study,
however, presents a much more formidable problem, as
almost 1,500 neonatal deaths occur annually in Minne-
sota. Furthermore, many clinical records in rural hos-
pitals are scanty, laboratory facilities may be limited,
and autopsies are infrequent. A state-wide study was
therefore considered impractical and it was deemed ad-
visable to establish a pilot study in one metropolitan area.
158
After the pilot study demonstrates its value, it is planned
to extend the study to Ramsey, St. Louis, and other
counties and possibly to eventually make it state-wide
in scope.
Hennepin County was selected for the pilot study be-
cause it is a convenient and easily accessible area, has
a limited number of neonatal deaths, with fairly com-
plete records, and has a reasonably high percentage of
autopsies. Of a total of 500 annual infant deaths occur-
ring in 15 Minneapolis hospitals, there are approximately
385 neonatal deaths or 32 per month; 43 per cent have
autopsies, a total of 165 per year or 14 per month,
The Board of Directors of the Hennepin County
Medical Society has approved the study and appointed
the following committee:
Dr. A. Friedell, Dr. E. C. Maeder, and Dr. H. R.
Ransom.
The Northwestern Pediatric Society has approved the
study and appointed:
Dr. F. H. Adams, Dr. E. S. Platou, and Dr. L. F.
Richdorf.
The Minneapolis Health Department has appointed:
Dr. Evelyn Hartman.
The Minneapolis Hospital Council has appointed:
Mr. Russell Nye, Superintendent, Northwestern Hos-
pital.
And from the Medical School, University of Minne-
sota:
Dr. Irvine McQuarrie, Head, Department of Pediat-
rics.
Dr. James R. Dawson, Jr., Head, Department of
Pathology.
The Committee elected Dr. L. F. Richdorf as Chair-
man and Dr. A. B. Rosenfield as Secretary.
The objective of the study, in general, is to reduce
the preventable causes of neonatal mortality by a de-
tailed study of each neonatal death, including manage-
ment af the newborn, nursery procedures, and the ade-
quacy of autopsies.
More specifically, the committee will:
Consider the clinical history, physical findings, and
diagnosis in relation to autopsy findings.
Rate responsibility—
Was it a pediatric or obstetric death?
Was it preventable or non-preventable, or unclassi-
fiable?
Was there adequate prenatal care?
Were there adequate hospital facilities?
Was family, physician, or hospital at fault?
(a) Error in judgment or technique?
(b) Intercurrent disease?
(c) Unavoidable disaster?
Judge adequacy of records, autopsies, et cetera.
Point out inadequacies and make suggestions for re-
ducing preventable factors by an educational pro-
gram—
(a) At Medical Society ‘meetings.
(b) At hospital staff meetings
(c) Through medical bulletins and journals
(d) Through other educational approaches.
MINNESOTA MEDICINE
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The study will limit itself to all deaths under twenty-
eight days of life with autopsies, in accordance with the
generally accepted definition of “neonatal,” which relates
to the period of life, following delivery, of less than
28 completed days. The study will be carried out by
means of specially prepared questionnaires that will be
completed by the hospital librarian at the time the
clinical record is compiled. A detachable tab at the
top of the form will contain the name of the patient,
the attending physician, and the hospital and patient code
numbers so that death certificates may be cross matched.
To maintain anonymity of patient, physician and hospital,
however, this tab will be removed by the Minnesota
Department of Health before referring the completed
report to the Study Committee, leaving only a hospital
code number and a patient code number on the study
form.
Each hospital staff has been requested to appoint a
hospital committee consisting of a pediatrician, an ob-
stetrician, and the pathologist to supervise the comple-
tion of the study form, to return the form to the study
committee, and to act as a liaison group between the
hospital librarian and the Neonatal Study Committee.
The possibility of employing a pediatrician-investigator
to prepare the questionnaires and a summary of each
death, similar to the method used in the maternal mor-
tality study, will be considered by the committee. A
member of the state-wide maternal mortality study com-
mittee, Dr. C. J. Ehrenberg, will serve as liaison member
to the Hennepin County Neonatal Mortality Study Com-
mittee,
The study will begin as of January 1, 1952, and will
continue during the current year. At the end of one
year’s study, the committee will evaluate the benefits
and accomplishments of the study and will determine
the future course of the study.
THE JOURNAL OF THE SAMA
For several years, there has been some talk of the
desirability and need for a Students’ American Medical
Association. This culminated in a resolution passed by
the AMA House of Delegates assembled in San Fran-
cisco in June, 1950, approving the formation: of a
Students’ AMA and pledging the support of the AMA
to the new organization. On December 28, 1950, delegates
from forty-eight medical schools met at the Sheraton
Hotel in Chicago in response to letters sent to the Deans
of every medical school by Dr. George F. Lull, Secretary
of the AMA. On the following day, December 29,
1950, the Students’ AMA was launched.
The first officers elected at this Chicago meeting were:
Warren R. Mullen, University of Michigan Medical
School, president; Harry W. Sandberg, University of
Illinois College of Medicine, vice president; David
Buchanan, University of South Dakota School of
Medical Sciences, treasurer. A constitution was drawn
up which by March, 1951, had been ratified by forty-one
component student medical societies which became
charter chapters in the new organization. From the
Start it was evident that the AMA had no desire to
dictate to the students’ organization. However, three
Fesruary, 1952
EDITORIAL
Senior Councilors to the Students’ AMA, Drs. Ernest
E. Irons, G. Lombard Kelly and Thomas P. Murdock,
were appointed by the AMA Trustees, to serve in ad-
visory capacities.
Last July, the Council of the SAMA decided to
publish a journal for the membership of the SAMA to
be known as The Journal of the Students’ American
Medical Association. The first issue appeared in January
and nine issues will appear each year during the school
months. Subscriptions are free to all medical students
who are members of the SAMA. Efforts were made to
reach every medical student in the country. If any
medical student or intern has failed to receive his
journal, he may fill out the form that appears on page 6
of the January issue of the Students’ JAMA (or a
similar certificate), have it countersigned either by the
SAMA chapter advisor or the dean of the medical
school, and send it to Students’ AMA headquarters at
535 North Dearborn Street, Chicago 10, Illinois.
There is undoubtedly a need for a Students’ AMA.
Canada has had an active student intern organization
for more than ten years. Similar organizations exist
in Austria, Denmark, France, Germany, Italy, India,
Netherlands, Sweden and Switzerland. It is also
generally felt that there is a definite need for a SAMA
journal which will contain articles of scientific and
public relations value for the doctors of tomorrow.
MINNESOTA MEDICINE extends its best wishes for the
success of this youngest journal of them all—The
Journal of the Students’ American Medical Association.
The January issue is a credit to the students’ organization.
ANTABUSE® AND BARBITURATES
Care should be taken in the administration of a bar-
biturate to ‘one who is being treated with Antabuse.®
While no clinical cases have been reported, in animals
the effect of certain barbiturates is magnified many times
by the pre-administration of Antabuse.®
HEALTH PROBLEMS IN INDIA
Communicable diseases are a major feature of health
conditions in India. Smallpox, plague, cholera, typhoid,
and dysentery still claim an enormous number of victims
every year. Malaria is rampant throughout the region
and claims over 100 million cases, with more than one
million deaths every year. Tuberculosis is extremely
common. While no reliable statistics are available, it
has been estimated that in India alone there are two and
one-half million cases, with half a million deaths every
year. Another three-fourths of a million cases are esti-
mated for Java and Madura, and so on—for other
countries. The quantitative aspect of the health prob-
lems therefore presents a staggering picture. Poverty,
hunger, and disease are arrayed in force against the
people. In the field of tuberculosis, international assist-
ance of WHO is being directed primarily to providing
training facilities in modern methods of diagnosis and
prevention. In Southeast Asia, an army of tuberculosis
workers is needed, not a platoon. New training and
demonstration centers, at present being opened with
WHO assistance in almost all the countries of the re-
gion, are intended to point the way and to stimulate
governments to concrete action on an adequate scale.—
CHANDRA Mant, M.D., American Journal of Public
Health, December, 1951.
159
Medical Economics
Edited by the Committee on Medical Economics
of the
Minnesota State Medical Association
George Earl, M.D., Chairman
AMERICANS CONTINUE TO GET MORE
AND BETTER MEDICAL CARE
The latest report of the AMA’s Bureau of
Medical Economic Research shows conclusively
that, on the whole, the American people in 1950
received relatively more medical care for their
money than they did in 1935-39. Dr. Frank ©
Dickinson, director of the bureau, felt, however,
that such a quantitative analysis could not possibly
reveal the great improvements in the quality of
medical care. He states : “Such tremendous strides
in our health progress as the sharp reduction in the
number of maternal deaths per 1,000 live births
from about 5.0 in 1935-39 to less than 1.0 in 1950
and the jump in life expectancy at birth from
59.5 years in 1930 to more than 68 years in 1950
are not measured by indices of the quantity of
medical care.”
During the past twenty years, according to this
report, the American people have spent a constant
proportion of their consumer budget, roughly 4
per cent, for medical care. Dr, Dickinson ex-
plains this comparatively small proportion in this
way: “The demand for medical care has been
small in comparison to the demand for other
consumer items. It has been small, not because
people could not afford more, but because they
preferred to spend their budgets in this manner.
In the past one could say that the irregularity
and unpredictability of medical expenses were
greater deterrents to the purchase of medical
care than the actual amount of expenses. Today,
however, the widespread availability of hospital
and medical insurance makes medical care a readi-
ly marketable item.”
Medical Insurance Readily Available
The report states that the availability of hos-
pital and medical insurance enables any particular
family to approach this 4 per cent rate—the aver-
age for all families.
160
“A family can purchase a typical Blue Cross-Blue
Shield membership, which will pay the bulk of hospital
and in-hospital medical bills for roughly 25 cents a day
—the price of a package of cigarettes . . . With over
half the population carrying some form of medical or
hospital insurance, the small demand for medical care
certainly does not mean that people do not have the
money for medical care, but that they are purchasing
the amount they desire.”
Get More for the Money
Thus, the report continues, “with the index
of the prices of medical care, including the high
hospital rates, lagging behind the index of all
consumer prices, they are receiving much more
medical care for their money. In fact, average
weekly earnings have risen so much more rapidly
than the cost of medical service, that a produc-
tion worker today can buy almost twice as much
medical care with a week’s wages as he could in
1935-39. And health progress has given him an-
other dividend—more and better years in which to
earn. Today, in a period of general inflation, the
consumer is getting more and better medical care
for the same proportion of his personal consumer
expenditures.”
Explaining the changes further, the report
says:
“The rise between 1945 and 1950 largely reflects
wartime conditions in 1945, the tremendous increase in
the number of births in the postwar years, the rapid
rise in hospital room rates and the increased use of
hospitals.”
The report also pointed out that during the
last twenty years, the physicians’ share of the
medical dollar dropped 12 per cent, from 318
cents to 28.1 cents, while the hospitals’ share rose
66 per cent, from 13.9 cents to 23.1 cents. The
report stressed the fact that the amount of serv-
ices rendered by the average doctor was from
one-third to one-half times greater in 1950 than
during 1935-1939. Introduction of wonder drugs,
improved transportation, increasing proportion
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of patients seen in the hospital and office, and
other increases in technological efficiency have all
contributed to this change in the over-all situation.
MEDICAL, SURGICAL INSURANCE
STILL GROWS
A recent report of the Research Council for
Economic Security has announced “an unprece-
dented growth in the activity of the commercial
insurance companies in the hospital field during
the past few years.”
The report presents the following figures for
comparison :
“In 1939, some 1,260,000 persons were protected by
group hospital insurance. By 1944, that number had
grown to 8,400,000 and as of 1950 it was estimated to
be 22,600,000. This is 15.1 per cent of our 1950 popu-
lation. Some 75 million persons either have policies or
are dependents of policy-holders who were covered by
hospital insurance in 1950. Therefore, roughly 50 per
cent of the population, excluding the armed forces, are
estimated to have some measure of hospital insurance
protection. It is estimated that the insurance companies
pay from 45 to 50 per cent of the total hospital costs
of their policy holders.”
In the medical-surgical field, the report states
that, in 1939, about 630,000 persons had cash in-
demnity coverage providing for medical and sur-
gical costs. By 1944, the number had passed 5%
million and at the close of 1950, estimates placed
it near 21,500,000. About 46 per cent of the total
surgical and medical charges of group and indi-
vidual policyholders are paid.
RENEWAL OF HEALTH PLAN FIGHT
RE-EMPHASIZES HUGE COST
New agitation for enactment of compulsory
federal health insurance has brought a renewed
effort on the part of the medical profession and
other groups to defeat any such legislation even
before it gets started. A recent statement quoted
in the Christian Science Monitor stresses the pro-
posed program’s huge cost: “Adoption by the
United States of an all-inclusive national medical
service like that in Britain would cost the federal
government at least $18 billion a year, perhaps
more, according to Miss Elizabeth W. Wilson,
actuary and economist who has specialized in
government health insurance.” She reports:
“Americans now spend approximately $10 billion year-
y on both private and government medical care .. . the
British health service is presently costing approximately
Fepruary, 1952
three times the amount originally named by advocates,
. the costs of any such system rise with the rise of
salaries and the cost of materials. Inflation has boosted
the cost of the British health service, and would boost
the comparably sized American health service in the
same way.”
Compulsory Insurance Inflationary
Miss Wilson’s estimate of the amount of the
rise in cost over the $18 billion now forecasted by
advocates of the system, is $3 billion more than a
similar estimate made three years ago. That
means a 20 per cent increase, she stated. “The
introduction of socialized medicine would be in-
flationary in itself in tendency because $18 billion
is approximately $8 billion more than is being
spent in the United States for medical care at
the present time. Unless such an added expendi-
ture would result in the production of $8 billion
more goods, the net result would be inflationary.”
Miss Wilson concludes:
“The figure of $18,000,000,000 represents about 7.5 per
cent of the total annual income, whereas today the
average American worker pays only about 4 per cent
of his wages to medical care. Would the average
workman—if he knew the actual figures—wish to
nearly double his expenditure to obtain the benefits of
government medicine? The Truman administration and
the Federal Security Agency advocate introduction of
a compulsory health insurance system which they say
would be less inclusive than the British. It would cover
somewhat more than 85 per cent of the population and
would not include complete hospital or dental care.
Certain drugs would not be free. But, experience has
shown that once such a system is inaugurated, coverage
is expanded to include all types of care for everyone.”
JOURNAL URGES MORE IMPROVEMENT
OF VOLUNTARY HEALTH PLANS
Asking the question, “what is the purpose of
the medical profession, of our hospitals, and of
our health insurance plans?”, a recent editorial in
the JIlinois Medical Journal states that the answer
is as plain as the question: “the provision of the
best possible medical care to the greatest number
of people.” The Journal states:
“In any consideration of their activities this funda-
mental ‘Purpose must never be lost sight of. Whenever
other aims, other purposes are allowed to assume greater
importance than the provision of the best possible
medical care, we invite just criticism and, still more
seriously, we invite failure. In spite of the fact that
health insurance plans deal primarily with economic prob-
lems, we must always organize and develop, criticize, re-
examine and reorganize these plans in answer to the
question—-‘Do they help to assure the best possible med-
ical care?’”
(Continued on Page 178)
¢ Reports’and Announcements +¢
AMERICAN ACADEMY OF GENERAL PRACTICE
The American Academy of General Practice will hold
its fourth Annual Assembly at Atlantic City, March
24-27, 1952.
The scientific program has keen carefully planned so
that the Scientific Exhibits will be an integral part of
the formal teaching program. An array of outstanding
teachers will take part in the program.
All AMA members are invited to attend. A registra-
tion fee of $5.00 will be required from non-members.
Hotel reservations may be made through the A.A.G.P.
Housing Bureau, 16 Central Pier, Atlantic City, New
Jersey.
AMERICAN COLLEGE OF CHEST PHYSICIANS
The eighteenth annual meeting of the American
College of Chest Physicians will be held at the Con-
gress Hotel, Chicago, Illinois, June 5 through 8. A
scientific program covering all recent developments
in the treatment of heart and lung diseases is being
arranged.
The Board of Examiners of the American College
of Chest Physicians announces that the next oral
and written examinations for fellowship will be held
in Chicago on June 5. Candidates for fellowship in
the College who wish to take the examinations should
contact the Executive Secretary, American College of
Chest Physicians, 112 East Chestnut Street, Chicago
11, Illinois.
Dr. John F. Briggs, Saint Paul, is regent of the
College for the district, and Dr. Herman J. Moersch,
Rochester, serves as governor of the College for
Minnesota. Officers of the Minnesota Chapter are
Dr. Gustaf A. Hedberg, Nopeming, president, and Dr.
Arthur M. Olsen, Rochester, secretary-treasurer. Dr.
Jay Arthur Myers Minneapolis, is editor-in-chief of
the College journal, Diseases of the Chest.
AMERICAN CONGRESS OF PHYSICAL MEDICINE
The thirtieth annual scientific and clinical session
of the American Congress of Physical Medicine will
be held on August 25, 26, 27, 28 and 29 at the Roose-
velt Hotel, New York, N. Y. Scientific and clinical
sessions will be given on the days of August 25, 26,
27, 28 and 29. All sessions will be open to members
of the medical profession in good standing with the
American Medical Association. In addition to the
scientific sessions, annual instruction seminars will be
held. These lectures will be open to physicians as
well as to therapists who are registered with the
American Registry of Physical Therapists or the
American Occupational Therapy Association. Full
information may be obtained by writing to the Amer-
ican Congress of Physical Medicine, 30 North Michi-
gan Avenue, Chicago 2, Illinois.
162
MINNESOTA SOCIETY OF
NEUROLOGY AND PSYCHIATRY
A special meeting of the Minnesota Society of
Neurology and Psychiatry was held at the Town and
Country Club in Saint Paul on February 5. Dr. H.
Houston Merritt, Professor of neurology, Columbia
University, was the guest speaker. Dr. Merritt’s sub-
ject was “Epilepsy: Its Physiological Basis and
‘Treatment.”
PHYSICIANS ART ASSOCIATION EXHIBIT
The Physicians Art Association will have an exhibit
at the Minnesota State meeting this year. Ample space
and arrangements are being made, thanks to the spon-
sorship of the State Association and the Hennepin Coun-
ty Medical Society. The committee urges physicians to
exhibit paintings, photography, sculpture, metal work
and any other art project in this great exhibit. Be sure
to enter your work out of your own interest and to en-
courage others in this excellent type of hobby.
Write to Dr. F. A. Zinter, 600 Physicians and Sur-
geons Building, Minneapolis, Minnesota, for entry blanks.
CONTINUATION COURSES
Otolaryngology—The University of Minnesota an-
nounces the eighth biennial continuation course in
otolaryngology to be held June 23 through 27. This
course, designed to bring to the practicing oto-
laryngologist the newer concepts and developments in the
specialty, will be under the direction of Dr. Lawrence
R. Boies and associates of the University Medical
School. Dr. Fred A. Figi, Dr. Henry L. Williams
and others of the Graduate School faculty will partic-
ipate in the instruction. Guest lecturers will include
Dr. Louis Clerf, Philadelphia; Dr. Leland Hunnicutt,
Pasadena; Dr. William McNally, Montreal, and Dr.
W. Wallace Morrison, New York.
The fee for this course is $50. The enrollment is
limited. Application should be made at an early date
to the Director, Center for Continuation Study, Uni-
versity of Minnesota, Minneapolis 14, Minnesota.
Proctology.—The University of Minnesota will
present a continuation course in proctology at the
Center for Continuation Study on April 14 to 19.
The course is intended primarily for physicians en-
gaged in general practice. All aspects of ano-rectal
disease will be covered, and two half days will be de-
voted to operative clinics in which registrants will
take an active part. The visiting faculty member of
the course will be Dr. Garnet W. Ault, professor,
Department of Proctology, Georgetown University
School of Medicine, Washington, D. C., and the
course will be presented under the direction of Dr.
O. H. Wangensteen, professor and chairman, De-
partment of Surgery, and Dr. Walter A. Fansler,
clinical professor, Department of Surgery, and di-
(Continued on Page 179)
MINNESOTA MEDICINE
FE
nks.
Fepruary, 1952
now in parenteral form...
BANTHINE’ ~~
Brand of Methantheline Bromide
Bromide
\
~ *
ee
~—_~,
for use when oral administration is difficult or impractical ~~
—when more prompt action is desired
Banthine—a true anticholinergic drug with
an adequate range of safety—is now made
available to the medical profession in par-
enteral form, for use intravenously or in-
tramuscularly in those conditions charac-
terized by nausea and vomiting, when oral
medication cannot be retained and when a
prompt action is desirable.
Through its anticholinergic effects, Ban-
thine inhibits excess vagal stimulation and
controls hypermotility.
In Peptic Ulcer —the value of the oral form of
Banthine is now well established. However,
edema in the ulcer area may indicate parenteral
Banthine until the healing processes have re-
duced the edema.
In Pancreatitis —it has been found that par-
enteral Banthine relieves pain, effects a fall in
blood amylase and produces a general improve-
ment in the patient’s condition.
In Visceral Spasm — it inhibits motility of the
gastrointestinal and urinary tracts.
Parenteral BANTHINE is supplied in serum-
type ampuls containing 50 mg. of Banthine powder.
Adult dosage is generally the same as with Ban-
thine tablets.
RESEARCH IN THE SERVICE OF MEDICINE SEARLE
Woman’s
Auxiliary
AUXILIARY PRAISED BY
PRESIDENT KENNEDY |
State board members of the Woman’s Auxiliary were
urged to continue assisting democracy to “keep its house
in order,” at the annual mid-winter board meeting, held
January 16 at the Curtis Hotel in Minneapolis.
Dr. R. L. J. Kennedy, president of the Minnesota
State Medical Association, asked auxiliary members to
help with “washing out the dirty linen created by politi-
cal propaganda-rakers, sweeping out of office the bureau-
crats unqualified to conduct this country’s affairs, and
dusting off our cherished ideals of freedom and personal
initiative.”
Dr. Kennedy praised the auxiliary for its excellent co-
operation and aid to the medical profession and called
for continued efforts to keep the issue of socialized
medicine from gaining a foothold in America. There
is to be no slackening of individual effort in the national
education campaign being conducted by the American
Medical Association and by state and county medical
societies, Dr. Kennedy pointed out.
Speaking at the luncheon, Dr. Kennedy cited Presi-
dent Truman’s recent appointment of a commission to
study health needs and a proposal to provide free hos-
pitalization for all persons over sixty-five, regardless of
their ability to pay, as examples of devious means of
obtaining government control of the nation’s health.
“As long as the public knows the value of its liberty,
rights and responsibilities, we need never fear that
socialism will gain entry,” he said. “Protecting our own
threshold—the right of the individual to choose the
medical care he wants—is vital, but we must continue to
interpret this right and this freedom in its context of
all American freedoms. We know that when the public
loses control over its health care, then it has begun to
lose control over every other field of human thought
and endeavor. We can’t let that happen here and we
won't.”
Countering the charge that doctors are against every-
thing and for nothing except the status quo, Dr. Kennedy
said: “We are for the status quo, insofar as that is
interpreted to mean the present framework for medical
practice, research and education. .. .” He noted that
that framework cannot work except by a constant
changing and state of flux.
Regarding medicine’s so-called “negative attitude,”
Dr. Kennedy said:
“We are hard at work at far more progressive pro-
grams than the socializers, with all their Utopian dream-
ing, ever visualized. We are, for example, working very
hard on a problem that medical science, through its prog-
ress, has created for itself: geriatrics, the problem of an
aging population in a world that is not yet geared to
making the most of the 20 bonus years that medical
advancements have added to the average life span. We
164
are concerned with the correlated problem of proper
care of the chronically ill. We're troubled over civil
defense and trying, through leadership in our ranks, to
help awaken a tragically dormant populace. We're in-
terested in improving and enlarging medical schools,
without sacrificing the excellence we have strived so
hard to gain.”
Auxiliary President Reports
Beginning the morning Board meeting, Mrs. F. P.
Moersch, president of the State Auxiliary, reported on
the Conference of State Presidents and Presidents-Elect
which was held in Chicago last November, stating that
“all but three states and territorial auxiliaries were
represented,” and with nearly 130 women attending.
Mrs. Moersch summarized for auxiliary members
each of the important panel discussions which were pre-
sented at the meeting, including which states were rep-
resented on each panel, what topics were discussed, and
what conclusions were drawn. Mrs. Moersch represent-
ed the Minnesota Auxiliary on the panel on Health
Days, speaking on “The Meaning and Objectives of
Health Days.”
The excellent attendance at this meeting, Mrs. Moersch
felt, proves the familiar saying that “coming together is
a beginning; working together is growth; staying to-
gether is progress.” She quoted Mrs. Eusden, national
president-elect, who stated: “Today, state presidents
and presidents-elect believe attendance at this con-
ference is one of the duties that they assume when
taking office.”
Board Hears Reports
Also during the morning Board meeting, reports of
various committee chairmen and county representatives
present were heard. Members were urged to subscribe
to the Bulletin, and Today's Health, and to work to
collect surplus medical supplies, to be informed about
legislative matters, to promote Health Days, to continue
to plan interesting and informative programs. County
presidents, or a representative from the county, reported
on activities of their auxiliaries since the fall conference,
revealing much progress and continued hard work on
the part of medical auxiliaries throughout the state.
LEGISLATIVE REPORT
SENT TO COUNTIES
Mrs. H. F. R. Plass
A summary of the medical profession’s official position
on all important national legislative matters has been
sent to all county auxiliary presidents and legislative
chairmen.
MINNESOTA MEDICINE
FEp
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to Bismarck...
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te REPOUd ( now 1803
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A clinical record stretching over 17 years of use in a wide variety of procedures . . .
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about complete surgical amnesia. The patient usually awakens without nausea. With PenrorHat,
itinue the explosion hazard is eliminated, the equipment simple and easily stored.
ounty {=a— + When individual requirement warrants, PENTOTHAL may be combined with any
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TUBOCURARINE Chloride, Abbott Cum,
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lative
ICINE Fepruary, 1952 165
In Memoriam
E. SYDNEY BOLEYN
Dr. E. Sydney Boleyn, for over fifty years a practi-
tioner at Stillwater before his retirement five years ago,
died on December 23, 1951, at the age of 87. For years
he had been active in the affairs of Washington County
Medical Society and of the Minnesota State Medical
Association. He was secretary-treasurer of his county
society for about 40 years and served as vice president
of the state association at one time.
Born on shipboard under the British flag, May 1, 1864,
Dr. Boleyn was educated in England before coming to
this country in 1886. He obtained his medical degree
at the University of Minnesota in 1894. After interning
three years at St. Barnabas Hospital, Minneapolis, he
spent 15 months more in medical training at the State
Penitentiary in Stillwater before locating in Stillwater
for private practice.
On December 2, 1907, he was married to Helen Bus-
inger who survives him.
Even after his retirement from practice, Dr. Boleyn
maintained his interest in medical affairs and was a reg-
ular attendant at state and county medical meetings as
long as his health permitted.
At a County Officers Medical Conference held in St.
Paul in 1940, Dr. Boleyn remarked on the longevity
which had characterized his family and stated that his
mother was living at the age of 104 at that time and
his father was about 10 years older. Both were re-
siding in India at that time, his father being a retired
civil service employe of the British Government. The
oldest relatives he knew of were an uncle who had
lived to be 127 and an aunt 124.
AXEL E. HEDBACK
Dr. Axel E. Hedback, on the editorial board of the
Journal Lancet beginning in 1920, the editor of Modern
Medicine from 1933 to 1939 and lately editor of Ger-
tatrics, died December 31, 1951.
He was born at Karlstad, Sweden, April 21, 1874. His
preliminary education was obtained at New Richmond,
Wisconsin, and he received his M.D. at the University
of Minnesota in 1897. A year’s internship was spent at
the State Penitentiary in Stillwater. Postgraduate study
was taken at Harvard, Johns Hopkins and the Univer-
sity of Vienna.
Dr. Hedback was active in civic affairs and took part
in raising funds for the new central YMCA building
in Minneapolis. He was a onetime member of the Min-
neapolis charter commission and was a member of the
Minnesota State Board of Health from 1919 to 1923.
He was president of the Hennepin County Medical
Society in 1928.
Dr. Hedback is survived by his wife, Gladys W.
Hedback, a son, John William Hedback of Chicago
and three daughters, Mrs. Dwaine Lindberg of Min-
166
neapolis; Mrs. Don O. Lampland and Mrs. David Paul
Keefe of St. Paul.
JOHN H. MILLS
Word has been received of the death of Dr. John
M. Mills on October 14, 1951, in Portland, Oregon;
he was formerly a fellow in medicine of the Mayo
Foundation.
Dr. Mills was born May 19, 1902, at Liverpool,
England. He received the degree of M.D. in 1933
from the University of Chicago and interned at the
Presbyterian Hospital, Chicago, from May, 1932, to
October, 1933. .
Dr. Mills entered the Mayo Foundation as a fellow
in medicine on January 1, 1934; he received the degree
of M.S. in Medicine in 1936 from the University of
Minnesota and left the Foundation on January 1, 1937,
at which time he went to Tacoma, Washington, to
practice general medicine. During the next several years
he practiced general medicine at - Lakeland, Florida;
was instructor in medicine at the University of Mary-
land; practiced general medicine at Chicago and was
instructor in medicine at Northwestern University. He
joined the staff of the Rockwood Clinic in Spokane,
Washington, in June, 1941, and more recently was chief
of medicine of the Veterans Administration Hospital
at Marquam Hill, Portland, Oregon. He became a
lieutenant colonel while on active service, A.U.S., and
served successively at Letterman General Hospital, San
Francisco, Kennedy General Hospital, Memphis, Ten-
nessee, and Cushing General Hospital, Framingham,
Massachusetts. After his separation from the service
he resumed his work at the Veterans Administration
Hospital at Marquam Hill, Portland, Oregon.
Dr. Mills was a fellow of the American College of
Physicians, and a member of the American Medical
Association, Alphi Chi Sigma, Sigma Xi, Phi Rho
Sigma and Alpha Omega Alpha.
RUSSELL WRIGHT MORSE
Dr. Russell W. Morse, well-known radiologist of Min-
neapolis, died December 29, 1951, in Panama City,
Florida.
He was born in Minneapolis May 24, 1894, and at-
tended Minneapolis Central High School. He received
the degrees of B.S. and B.M. from the University of
Minnesota in 1917 and M.D. in 1920. He interned the
following year at the University Hospital from 1920 to
1924.
Dr. Morse practiced in Minneapolis from 1920 to 1924
when he moved to New York. In 1932 he returned to
Minneapolis where he practiced until his death. He
was roentgenologist at St. Barnabas Hospital and clinical
(Continued on Page 168)
MINNESOTA MEDICINE
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RUSSELL WRIGHT MORSE
(Continued from Page 166)
assistant professor of radiology at the University of
Minnesota School of Medicine.
Dr. Morse was a past president of the Minneapolis
Academy of Medicine, a member of the Hennepin Coun-
ty Medical Society of which he was president in 1940,
a member of the New York Academy of Medicine, the
Radiological Society of North America, the American
College of Radiology and the Minnesota Radiological
Society.
Surviving are his wife, Elizabeth, a daughter, Melva;
and a son Russell, both of Bozeman, Montana. Two
stepsons, Lyman and Robert Tifft both of Edina also
survive him.
Dr. Morse was a member of the Minneapolis Club
and for many years was active in musical organizations
in Minneapolis. An aecomplished cellist he eften ap-
peared in concerts with amateur musical groups. His
untimely death was the result of an anemia incurred
by exposure to X-ray radiation.
J. SPENCE REID
Word has been received of the death of Dr. J. Spence
Reid, former fellow im surgery of the Mayo Founda-
tion, on November 29, 1951, at Toronto, Ontario.
Dr. Reid was born December 26, 1893, at Tillson-
burg, Ontario, and received the degree of M.B. in 1920
from the University of Toronto after which he prac-
ticed medicine at Tillsonburg for one year. He entered
the Mayo Foundation as a fellow in surgery on Jan-
uary 1, 1922. From October 1, 1924, to January 1, 1926,
he was first assistant in surgery and he left the Mayo
Foundation on April 1, 1926, to practice surgery in
Toronto.
Dr. Reid was a fellow of the Royal College of Sur-
geons of Canada and a member of the Toronto Acad-
emy of Medicine, the Ontario Medical Association,
Alpha Kappa Kappa, and Alpha Omega Alpha.
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Fepruary, 1952
169
* Of General Interest +
Grants of $90,776 for seven cancer research and
education projects have been made to the University
of Minnesota by the Minnesota Division of the
American Cancer Society, it was announced on Jan-
uary 5 by Dr. C. G. Uhley, Crookston, president of
the state organization.
The projects include the following: investigations
on mammary cancer in mice and observation:; on lung
and liver cancer, a special research fund to support
new ideas in cancer research, a special fund for fu-
ture development of the staff and program of the
division of cancer biology at the medical school, sup-
port of a professorship in cancer biology, continuance
of the cancer detection center, support for “second
look” operations for patients with gastrointestinal
cancer, and cancer education for graduate and under-
graduate nurses.
* * *
Dr. Roger L. J. Kennedy, Rochester, president of
the Minnesota State Medical Association, was the
principal speaker at the annual mid-winter board
meeting of the medical association’s Woman’s Aux-
iliary in Minneapolis on January 16.
* * *
It was announced on January 10 that Dr. R. L.
Baird had become associated in practice with Dr.
F. W. Franchere at Lake Crystal. Dr. Baird, a grad-
uate of the University of Colorado School of Medi-
cine, was a resident physician at St. Luke’s Hospital,
Saint Paul, prior to joining Dr. Franchere.
* * *
Dr. David S. Thorsen, Saint Paul, was guest speak-
er at a meeting of the Saint Paul Association for
Mentally Retarded Children on January 9.
* *k *
Among those attending a continuation course in
pediatrics at the University of Minnesota early in
January was Dr. Clayton E, J. Nelson of Albert Lea.
* * x
Dr. Henry E. Michelson, Minneapolis, was recently
elected an honorary member of the Austrian Der-
matological Society.
* * *
At the annual meeting of the Itasca County Board
on January 8, Dr. M. J. McKenna of Grand Rapids
was named county health officer.
x * *
Dr. Gaylord W. Anderson, director of the Univer-
sity of Minnesota Schoo! of Public Health, has been
appointed to the board of editors of the newly re-
vised magazine, Public Health Reports. The magazine
is an expanded version of the weekly journal of the
same name which has been published since 1878 by
the Public Health Service.
* * *
Among the featured speakers at a meeting of the
Probate Judges’ Association at Minneapolis on Jan-
170
uary 9 and 10 were Dr. Ralph Rossen, Minnesota
mental health commissioner, and Dr. Nelson Brad-
ley, superintendent of the Willmar State Hospital.
a /
Dr, W. L. Benedict, Rochester, attended the Pan-
American Ophthalmology Conference in Mexico City
early in January. Dr. Benedict is the executive sec-
retary-treasurer of the American Academy of Opthal-
mology and Otolaryngology.
ees
Dr. Clarence Siegel, Saint Paul, presented a review
of tuberculosis cases at the Ramsey County Chil-
dren’s Preventorium during a meeting of the Minne-
sota Tuberculosis Nurses Council at the preventorium
on January 15.
* = 6
Lt. Col. Thomas E. Dredge, Minneapolis, is now
serving in Korea as senior advisor to the South
Korean army medical service. He is helping to build
a medical corps modeled along American lines.
When the war started, many Korean medical stu-
dents were unable to complete their education, so an
army medical school was established. Thus far it
has graduated 130 students. A similar training pro-
gram for nurses was also set up.
Dr. Dredge, a son of Dr, and Mrs. H. P. Dredge of
Sandstone, is a graduate of the University of Minne-
sota Medical School. During World War II he was
chief of medicine at Air Force hospitals at Miami,
Florida, and at Veterans Administration Hospital,
Brecksville, Ohio. He joined the United States mili-
tary advisory group to the Republic of Korea in
November, 1950.
* * *
Dr. J. Paul Person, Albert Lea, was a guest speak-
er at a meeting at Albert Lea on January 10 of the
Freeborn County Relatives and Friends of the Men-
tally Retarded. Dr. Person’s topic was “Physiological
Aspects of Retardations.”
* * *
Dr. George E. Moore, of the Department of Sur-
gery at the University of Minnesota, was the guest
speaker at a meeting of the Woman’s Club at Hutch-
inson on January 10. Dr. Moore, who has been
recognized for his work with fluorescine dye and
radioactive substances in the detection of brain
tumors, presented a discussion of cancer.
* * *
Dr, Nels M. Strandjord, Virginia, was awarded a
certificate of merit for community service at the an-
nual banquet of the Virginia Junior ‘Chamber of
Commerce on January 15.
* * *
Dr. Joseph W. Goldsmith and Dr. Thomas K. Kre-
zowski have moved their offices to 1154 Lowry Med-
MINNESOTA MEDICINE
OF GENERAL INTEREST
MUNICIPAL BONDS
are secure investments. Next to United States Government
Bonds they have proved themselves over many years to be
the safest form of investment.
MUNICIPAL BONDS “e @ marketable investment. There are more municipal
bonds bought and sold every day than the average daily
sales of corporate bonds on the New York Stock Exchange.
MUNICIPAL BONDS provide a unique income. No investor has ever paid Fed-
eral Income Taxes on income from Municipal Bonds—and
tax-exempt income is especially advantageous for the pro-
fessional man.
SECURITY — MARKETABILITY — TAX-EXEMPT INCOME
These advantages have been received by the Municipal Bond Investor
Write us or telephone for complete information
JURAN & MOODY
MUNICIPAL SECURITIES EXCLUSIVELY
TELEPHONES
St. Paul: Cedar 8407
Minneapolis: Nestor 6886
GROUND FLOOR
Minnesota Mutual Life Bldg.
St. Paul 1, Minnesota
ical Arts Building, Saint Paul, where they are limit-
ing their practices to obstetrics and gynecology.
* * *
The eighth annual J. B. Johnston lecture was pre-
sented at the University of Minnesota on January 30
by Dr. Harold G. Wolff, professor of medicine and
psychiatry’ at Cornell University Medical College,
New York. The title of Dr. Wolff’s lecture was “The
Nature of Pain.” The meeting was open to the public.
* * *
Dr. Spencer F. Brown, of the Department of Pedi-
atrics of Minneapolis General Hospital, has been
awarded a scholarship for advanced study in cerebral
palsy from the National Society for Crippled Chil-
Fepruary, 1952
dren and Adults and Alpha Chi Omega, international
women’s collegiate fraternity. Dr. Brown will study
this summer with Dr. Meyer A. Perlstein, chief of the
children’s neurology clinic, Cook County Hospital,
Chicago.
* * *
The volume of services handled by the Minne-
apolis War Memorial Blood Bank has increased so
much since the bank was opened three years ago that
it now faces a serious shortage of space. During the
1951 fiscal year, 17,699 units of blood were drawn
from donors—an increase of nearly 50 per cent over
the 1950 total and 100 per cent more than in 1949,
The blood bank also provides the technical services
171
OF GENERAL INTEREST
Laboratories in
Minneapolis and
Principal Cities of
Upper Midwest
Since 1913
ACCIDENT + HOSPITAL - SICKNESS
INSURANCE
FOR PHYSICIANS, SURGEONS, DENTISTS EXCLUSIVELY
PHYSICIANS
SURGEONS
DENTISTS
———
$5,000.00 accidental death............---- $8.00
$25.00 weekly indemnity, accident Quarterly
and sickness
$10,000.00 accidental death
$50.00 weekly a accident
sickness
$15,000.00 accidental death
£75.00 weekly indemnity, accident
and sickness
$20,000.00 accidental death
$100.00 weekly indemnity, accident
and sickness
Cost has never exceeded amounts shown.
ALSO OSPITAL POLICIES FOR MEMBERS
WIVES AND CHILDREN AT SMALL
ODITIONAL Cost
85c out of each 7 gross income used for
members’ benefits
$4,000,000.00 $18,300,000.00
INVESTED ASSETS PAID FOR CLAIMS —
$200,000.00 deposited with State of Nebraska for protection of our members.
Disability need met be incurred in line of duty—benefits from
he beginning day of disability
eunamneeen CASUALTY ASSOCIATION
PHYSICIANS UFALTE ACEOCTATION
50 years unuer tne seme maweagem<xt
400 First National Bas Bldg.. Omaha 2, Nebr.
COME FROM
Quarterly
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17?
for the Defense Blood Center in Minneapolis, with
the Red ‘Cross in charge of donor recruiting. Since
last July more than 10,000 units of blood have been
drawn there for the Armed Forces.
* * *
Dr. O. F. Mellby, Thief River Falls, was re-elected
president of the Oakland Park Sanatorium Commis-
sion at its annual meeting on January 11. Dr. Mellby
is now serving his thirty-fifth consecutive year as
president of the commission. Ex officio secretary is
Dr. Baldwin Borreson, Thief River Falls, superin-
tendent of the institution.
* * *
On January 18 Dr. George D. Haggard, Minne-
apolis, celebrated his ninety-sixth birthday anniver-
sary. During the past year he has virtually given
up all active practice and has been confined to his
home because of illness.
* * O*
Dr. Norman J. Lee, formerly of Saint Paul, is now
associated in practice with the Hoidale-Workman
Clinic at Tracy. sone
A one-day conference on criminal psychiatry for
state hospital employes and law enforcement officials
was held at the Hastings State Hospital on January
30. The conference was conducted by Dr. William H.
Haines, psychiatrist at the Cook County Behavior
Clinic, Chicago.
HOSPITAL NEWS
The following are the results of staff elections held
recently at several Minnesota hospitals:
Glencoe Municipal Hospital, Glencoe.—Dr. H. H.
Holm, president; Dr. H. C. Goss, secretary-treasurer.
Swedish Hospital, Minneapolis—Dr. Arthur N. Rus-
seth, chief of staff; Dr. Nordahl Peterson, vice chief
of staff; Dr. Delph T. Stromgren, secretary-treasurer.
Lutheran Hospital, Bemidji—Dr. T. P. Groschupf,
president; Dr. Charles Vandersluis, vice president;
Dr. Harry A. Palmer, secretary-treasurer.
St. Joseph’s Hospital, Brainerd—Dr. John A.
Thabes, Jr., chief of staff; Dr. R. A. Beise, vice chief
of staff; Dr. A. M. Mulligan, secretary-treasurer.
Eitel Hospital, Minneapolis—Dr. A. C. Olson,
president; Dr. R. D. Thielen, vice president; Dr. Al-
lan J. Blake, secretary-treasurer.
* * *
Le Sueur County became associated with nine other
counties in the ownership of the Southwestern Min-
nesota Sanatorium at Worthington early in January
when the board of commissioners paid almost $8,000
as a first half installment on a one-tenth equity in the
institution. Increased cost of patient care and in-
creased numbers of tuberculosis patients were given
as reasons for the step. The cost of maintaining pa-
tients in state institutions had grown so much that
the county commissioners decided to join the sana-
torium group as an economy move,
Other counties who are part owners of the sana-
torium are Blue Earth, Lincoln, Murray, Pipestone,
Watonwan, Jackson, ‘Cottonwood, Lyons and Nobles.
(Continued on Page 174)
MINNESOTA MEDICINE
Entirely chrome plated
WASTE RECEPTACLES
with porcelain enamel re-
movable Inner Pail, 12
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C. F. ANDERSON CO., Inc.
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MINNESOTA
ZEnith 2055
Cook County Graduate School of Medicine
ANNOUNCES CONTINUOUS COURSES
SURGERY—Intensive Course in Surgical Technic, two
weeks, starting February 4, February 18, March
3.
Surgical Technic, Surgical Anatomy and Clinical
Surgery, four weeks, starting March 3 June 2.
Surgical Anatomy and Clinical Surgery, two weeks,
starting March 17, June 16.
Surgery of Colom and Rectum, one week, starting
March 3, April 7.
Gallbladder Surgery, ten hours, starting April 21.
Basic Principles in General Surgery, two weeks,
starting March 31.
a and Thyroid Surgery, one week, starting June
3
Esophageal Surgery, one week, starting June 23.
Thoracic Surgery, one week, starting June 2.
Fractures and Traumatic Surgery, two weeks, start-
ing February 4.
GYNECOLOGY—Intensive Course, two weeks, starting
February 18, March 17.
Vaginal .Approach to Pelvic Surgery, one week,
starting March 3, March 31.
OBSTETRICS—Intensive Course, two weeks, starting
March 3, March 31.
MEDICINE—Intensive General Course, two weeks,
starting May 5.
Micstwoceseequeony and Heart Disease, two weeks,
Starting March 17.
Gastroenterology, two weeks, starting May 19.
Hematology, one week, starting June 16.
URCLOGT—Iatensive Course, two weeks, starting April
Ten-Day Practical Course in Cystoscopy starting
February ag, March 3, and every two weeks.
ROENTGENOLOGY—Two-week Lecture and Clinical
Courses each month.
General, Intensive and Special Courses in All Branches of
Medicine, Surgery and the Specialties
TEACHING FACULTY—ATTENDING
STAFF OF COOK COUNTY HOSPITAL
ADDRESS: REGISTRAR, 707 South Wood Street
Chicago 12, Illinois
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Clinical Biochemistry
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Interpretation of YOUR E.K.G. records
Toxicological Examinations
MURPHY LABORATORIES
—Est. 1919
Minneapolis: 612 Wesley Temple Bldg., At. 4786
St. Paul: 348 Hamm Bldg., Ce. 7125
If no answer call: 222 Exeter Pl., Ne. 1291
———
Fepruary, 1952
OF GENERAL INTEREST
AT YOUR CONVENIENCE,
DOCTOR...
you are cordially invited to visit our new
and modern prescription pharmacy located on
the street floor of the Foshay Tower, 100 South
Ninth Street.
With our expanded facilities we will be able
to increase and extend the service we have
been privileged to perform for the medical pro-
fession over the past years.
Exclusive Prescription Pharmacy
Biologicals Pharmaceuticals Dressings
Surgical Instruments Rubber Sundries
JOSEPH E. DAHL CO.
(Two Locations)
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T
MEDICAL PROTECTIVE
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MINNEAPOLIS Office:
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(If no answer, call Fillmore 1411)
(Continued from Page 172)
BLUE CROSS-BLUE SHIELD PLANS
In administering the Blue Shield Claims Department,
rejection of claims involving previously known condi-
tions has been the most difficult single feature. Claims
rejected as previously known conditions require that
questionnaires be sent to both the attending physician
and the subscriber. Relationships with subscribers and
doctors are not infrequently disturbed by the rejection of
such claims. For these reasons, the previously known
condition clauses of sixty Blue Shield plans in con-
tinental United States have been reviewed, and the
results of this study appear to be of importance in any
future consideration of this general problem.
Of the contracts examined, forty-one were service
and nineteen were indemnity. Among the sixty con-
tracts reviewed, four made no mention of pre-existing
conditions and sixteen had no restrictions or limita-
tions regarding such conditions. Further analysis re-
vealed that of the ten largest plans in the country, three
have indemnity contracts, and six have waiting periods
for pre-existing conditions, while 4 place no limitation
on such diseases.
Of the forty plans which limit benefits for previously
existing conditions, thirteen exclude such benefits per-
manently—that is, they never pay benefits for conditions
which antedated the effective date of the contract. The
remaining twenty-seven contracts exclude benefits for
pre-existing conditions for periods varying from six
to eighteen months. Ejighteen of these plans have a
waiting period of eleven to eighteen months, four have a
waiting period of ten months, and only five have a wait-
ing period of six to nine months. Minnesota Blue
Shield with its 10-month waiting period is more liberal
or has a shorter waiting period than the majority of the
plans in this survey which have some restrictions regard-
ing pre-exitsing conditions.
As a result of this review, Minnesota Blue Shield has
revised its subscriber and physician foreknowledge let-
ters, this being the third revision during the past year.
The entire system of informing both the physician and
the subscriber of the rejection of claims has also been
remodeled. In the newly adopted method, one letter is
used for the six reasons for rejection which means “no
contract is in effect” with the specific reason checked.
Each of the remaining causes for rejection has a special
letter to both the subscriber and doctor, each using as
much as possible the exact language of the contract
pertaining to that reason for rejection. This new method
has been so fashioned as to save employees’ time, in-
form both subscriber and physician regarding the con-
tract, and improve subscriber and physician relation-
ship.
During December, 1951, 7,279 claims were paid by
Blue Shield and these claims costs amounted to $254,
812.95. Minnesota Medical Service Inc. during this year
1951 provided medical-surgical-obstetrical care to ap-
proximately 88,000 Blue Shield subscribers. Payments
to doctors during 1951 for their services amounted to
approximately $3,095,000.
Since Blue Shield was incorporated. four years ago,
approximately 182,000 claims have been paid for Blue
MINNESOTA MEDICINE
Shielc
imatel
Blue
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throu;
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of ap
pende:
sevent
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scribe
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for
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OF GENERAL INTEREST
North Shore
Health Resort
Winnetka, Illinois
rvice . on the Shores of
con Lake Michigan
sting
nita-
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three
riods A completely equipped sanitarium for the care of
ation
nervous and mental disorders, alcoholism and drug addiction
usly
per-
tions
The SAMUEL LIEBMAN, M.S., M.D.
for 225 Sheridan Road Medical Director Phone Winnetka 6-0211
six
ve a
ve a
wait- Shield subscribers and doctors have received approx-
Blue imately $6,662,000 for their services rendered to these
beral Blue Shield subscribers.
. the During the third quarter of 1951, Blue Shield Plans
ard- throughout the nation gained a total of 1,403,063 new
members. The increase in membership was comprised
| has of approximately 423,725 subscribers and 979,338 de-
let- pendents. As of September 30, 1951 membership in the
year. seventy-seven approved Blue Shield plans totaled 20,-
and 279,725 and consisted of approximately 8,416,086 sub-
been scribers and 11,863,639 dependents.
er is Approximately 166,500 Blue Cross subscribers re- ST,
0 ceived hospital care during 1951 totaling approximately or
eked. $12,500,000.
ecial Since Blue Cross was organized in Minnesota in 1933, : LS. f
ig as approximately 1,230,000 subscribers received hospital Professiona upp Les
tract care with benefits totaling approximately $63,800,000.
thod During the third quarter of 1951, Blue Cross Plans d
. in- throughout the nation gained .a total of 468,918 new an
con- members. The increase in membership was comprised
tion- of 167,427 subscribers and 301,491 dependents. As of & .
September 30, 1951, membership in the 88 approved ervice
d by Blue Cross plans totaled 40,888,535 and consisted of
254,- 17,126,007 subscribers and 23,762,528 dependents.
year Non-Group Enrollment Opens
, ap- As of Friday, January 11, on the Blue Cross-Blue
nents Shield “Dinner at the Adams” radio show via WCCO, *
xd to Cedric Adams again began a series of direct appeals BROWN & DAY, INC.
lor non-group enrollment. In other words, NON- St. Paul 1, Minnesota
ago, GROUP ENROLLMENT IS AGAIN OPEN UNTIL
Blue FURTHER NOTICE!
ICINE Fepruary, 1952
offering all forms of treatment, including electric shock.
BOOK REVIEWS
Important
News!
GLENWOOD
INGLEWOOD
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Other Glenwood-Inglewood Waters:
Glenwood-Inglewood Natural Spring Water
Glenwood-Inglewood Distilled Spring Water
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GLENWOOD AT THOMAS’ CALL GENEVA 4351
BOOK REVIEWS
Books listed here become the property of the Ramsey,
Hennepin and St. Louis County Medical Libraries when
reviewed. Members, however, are urged to write re-
views of any or every recent book which may be of
interest to physicians.
INTEREST
GUARANTEED
O ON
SAVINGS
Interest compounded semi-annually . .
March 31 and September 30.
THE AMERICAN NATIONAL BANK
OF SAINT PAUL
Bremer Arcade Robert at 7th CE 6666
Member Federal Deposit Insurance Corporation
. payable
ROENTGENOLOGIC DIAGNOSIS OF DISEASES
OF BONES. David G. Pugh, Assistant Professor of
Radiology, Mayo Foundation, Graduate School, Uni-
versity of Minnesota; Consultant, Section on Roent-
genology, Mayo Clinic. 316 pages. Illus. Price $5.00,
cloth. New York: Thomas Nelson and Sons, 1952.
eo @
CALCULATION OF INDUSTRIAL DISABILITIES
OF THE EXTREMITIES. Carl O. Rice, MD,
M.S., Ph.D., F.A.C.S. Clinical Associate Professor
of Surgery, University of Minnesota Medical School;
Surgical Staff, St. Barnabas Hospital, Minneapolis,
Minnesota. 289 pages. Illus. Price $10.50, cloth,
Springfield, Illinois:-Charles C Thomas, 1952.
* * *
STANDARD NOMENCLATURE OF DISEASES
AND OPERATIONS. Fourth Edition. Richard J.
Plunkett, M.D., Editor, and Adaline C. Hayden,
R.R.L., Associate Editor. 1034 pages. Price $8.00,
cloth. Philadelphia: The Blakiston Co., 1952.
* * *
DIAGNOSTIC BACTERIOLOGY. A Textbook for
the Isolation and Identification of Pathogenic Bac-
teria. Fourth Edition. Isabelle Gilbert Schaub, A.B,
Technical Director Clinical Bacteriology Laboratories,
Johns Hopkins Hospital; Instructor in Bacteriology,
Johns Hopkins University School of Medicine, and
Nurses Training Schools, Johns Hopkins Hospital and
Sinai Hospital; and M. Kathleen Foley, M.A., In-
structor in Bacteriology, Department of Biological
Sciences, College of Notre Dame of Maryland; for-
merly Bacteriologist i in Charge of the Diagnostic Bac-
teriological Laboratory of the Medical Clinic, Johns
Hopkins Hospital. 356 pages. Price $4.50, cloth. St.
Louis: C. V. Mosby Co., 1952.
* * *
DYNAMIC PSYCHIATRY—Basic Principles. Volume
1. Louis S. London, M.D. Diplomate, American
Board of Psychiatry and Neurology, member American
Psychiatric Association, etc. 98 pages. Price $2.00,
cloth. New York: Corinthian Publications, Inc., 1952.
* * *
ENDOCRINE FUNCTIONS OF THE PANCREAS.
Bernard Zimmermann, M.D. Department of Surgery,
University of Minnesota, Minneapolis, Minnesota.
pages. Illus. Price $2.50, flexible binding. Springfield,
Illinois: Charles C Thomas, 1952.
OMEWOOD HOSPITAL is one of the
Northwest's outstanding hospitals for the
treatment of Nervous Disorders—equipped
with all the essentials for rendering high-grade
service to patient and physician.
Operated in Connection with
Glenwood Hills Hospitals
HOMEWOOD HOSPITAL
Corner Penn and Plymouth Avenues North
Minneapolis Minnesota
MINNESOTA MEDICINE
BOOK REVIEWS
For the Failing Heart of Middle Life
Prescribe 2 or 3 tablets of Theocalcin, t. i. d. After
relief is obtained, continue with smaller doses to keep
the patient comfortable. Theocalcin strengthens heart
Brand of theobromine-calcium salicylate,
Trade Mark reg. U. S. Pat. Off.
RE Le A OER
Pail.
Bilhuber-Knoll Corp. Orange, N. Ap.
action, diminishes dyspnea and reduces edema.
™
:
SPATIAL VECTOR ELECTROCARDIOGRAPHY ;
CLINICAL ELECTROCARDIOGRAPHIC IN-
TERPRETATION. By Robert P. Grant, M.D.,
National Heart Institute, Bethesda, Md., and E.
Harvey Estes, Jr., M.D., U. S. Naval Hospital,
Bethesda, Md. 149 pages. Illus. Price $4.50. Phila-
delphia: Blakiston, 1951.
Spatial vector electrocardiography is assuming im-
portance in bringing precision into the study of elec-
trocardiography. The vector method of interpretation
supersedes the empirical method of such an inter-
pretation in a great many ways. We have, as a re-
sult, better criteria for differentiating the normal
from the abnormal record, These criteria are precise
and more rational. Although this volume makes no
effort to be comprehensive it is an excellent and
readily understandable exposition of a difficult sub-
ject. This volume will be valued by anyone in-
terested in electrocardiography.
Joun F. Briccs, M.D.
ROSENAU PREVENTIVE MEDICINE AND HY-
GIENE. Kenneth F. Maxcy, ed. Seventh edition,
New York; Appleton Century, Inc., 1951.
The first edition of this authoritative work was pub-
lished in 1913 by Dr. Milton Y. Roseman, Professor of
Preventive Medicine and Hygiene at the Harvard Med-
ical School. In five subsequent editions, the work was
brought up to date in a field that has been making rapid
Progress during the years. His sixth edition was pub-
lished in 1935.
The task of bringing out a seventh edition was ac-
cepted in 1942 by Dr. Kenneth F, Maxcy, Professor of
Fepruary, 1952
Epidemiology, the Johns Hopkins School of Hygiene
and Public Health. The war interfered with progress
in the compilation of a work which necessarily required
the cooperation of many specialists in the various phases
of Preventive Medicine. This seventh edition will
continue the publication as a valuable and authoritative
source of reference.
C. B. Drake, M.D.
SURGERY OF THE OBLIQUE MUSCLES OF THE
EYE. By Walter H. Fink, M.D. 350 pages with 93
illustrations. Price $8.75. St. Louis: C. V. Mosby
Company, 1951.
This isan excellent book by one of our Minnesota
authors. The volume is well illustrated with numerous
anatomical photographs and line drawings.
Part I goes into great detail on embryology, compara-
tive anatomy, developmental anomalies, and microscopic
and gross anatomy of the superior oblique muscles. The
author has made a successful attempt to be very inclusive
in his coverage of the subjec{: matter. The illustrations
are particularly helpful.
Part II covers the Management of Oblique Muscle
Defects. The chapter on Diagnosis contains seventy-
three pages giving a very comprehensive coverage of the
many tests that may be applied. To one who is less
conversant with the field than the author, it is perhaps
confusing to be forced to choose from so many different
tests. The chapter on Surgical Technique is very lucidly
illustrated and is a pleasure to read. An appended chap-
ter on Anatomical Considerations in Operation for Ret-
inal Detachment is well illustrated and very helpful.
M. F. Fettows, M.D.
177
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For years we have maintained the
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JOURNAL URGES MORE IMPROVEMENT
OF VOLUNTARY HEALTH PLANS
(Continued from Page 161)
Warns Against Negative Approach
“A negative approach to these problems is not
enough,” according to the Journal. “We cannot
merely find fault with and oppose those plans
of which we do not approve. We must continue
to improve, expand and extend the voluntary in-
surance programs along with other plans to
achieve the best possible medical care. Each plan
each program, each extension, and each limitation
must be examined in that light.”
The Journal emphasizes that the voluntary in-
surance plans are mutual efforts:
“They are no more a way of obtaining something for
nothing than is aid from the Federal Government.
Every service provided through these insurance plans
has to be paid for by ‘the members of the plans, by the
recipients of the services. These plans are merely
means of avoiding large, unexpected, unplanned, ex-
penses at one time and of spreading this expense over
a larger number of people, for the time being, and over
a number of years.”
REHABILITATION OF THE
HEMIPLEGIC PATIENT
(Continued from Page 140)
. Kraus, Hans:
peutic Exercises.
Thomas, 1949.
. Krusen, F. H.: Physical Medicine; the Employment
of Physical Agents for Diagnosis and Therapy. Pp.
517-629. Philadelphia: W. B. Saunders Company,
1941.
. Leemhuis, A. J., and Brown, J. R.: Treatment of
the hemiplegic patient. Journal- Lancet, 70 :90-93
(Mar.) 1950.
4 Wells, F. L., and Ruesch, Jurgen: Mental Exam-
iners’ Handbook. Ed. 2, pp. 33-46. New York:
Psychological Corporation, 1945.
Principles and Practice of Thera-
Springfield, Illinois: Charles C
DANIELSON MEDICAL ARTS PHARMACY,
10-14 Arcade, Medical Arts Building
825 Nicollet Avenue—Two Entrances—78 South Ninth Street WEEK DAYS—8 to 7?
PHONES:
ATLANTIC 3317
ATLANTIC 3318
MINNEAPOLIS
INC.
HOURS:
SUN. AND HOL.—10 TO!
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PATTERSON SURGICAL SUPPLY COMPANY
103 East Fifth St., St. Paul 1, Minn.
HOSPITAL AND PHYSICIANS SUPPLIES AND EQUIPMENT
Cedar 1781-82-83
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MINNESOTA - MEDICINE
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REPORTS AND ANNOUNCEMENTS
THE VOCATIONAL HOSPITAL
TRAINS PRACTICAL NURSES
Nine months Residence course, Registered Nurses and
Dietitian as Teachers and Supervisors.
Miller Vocational High School.
always in demand.
EXCELLENT CARE TO CONVALESCENT AND
Rates Reasonable.
who direct the treatment.
5511 Lyndale Ave. So.
Certificate from
VOCATIONAL NURSES
CHRONIC PATIENTS
Patients under the care of their own physicians,
LO. 0773 Minneapolis, Minn.
The Birches Sanitarium, Ine.
A hospital for the care and treatment of.
Nervous and Mental disorders.
ful environment.
Recreational and occupational therapy.
2391 Woodland Avenue
Duluth 3, Minnesota
Quiet, cheer-
Specially trained personnel.
Dr. L. R. Gowan, M.D., M.S., Medical Director
CONTINUATION COURSES
(Continued from Page 162)
rector, Division of Proctology. The remainder of the
faculty will include members of the clinical staff of
the University of Minnesota Medical School and the
Mayo Foundation.
Surgery —The University of Minnesota will present
a continuation course in surgery on April 7 to 9.
The course will be held at the Center for Continua-
tion Study and is primarily intended for physicians
engaged in general practice. The course will be con-
cerned primarily, but not exclusively, with pediatric
surgery. The guest speaker for the course will be
Dr. Robert E. Gross, Ladd Professor of Children’s
Surgery, Harvard Medical School, and surgeon-in-
chief, Children’s Hospital, Boston, Massachusetts,
who will also deliver the annual George E. Fahr Lec-
ture on April 8 at 8:00 pm. The subject of the
Fahr Lecture will be “Coarctation of the Aorta.” In
conjunction with the continuation course, Dr. Gross
will also discuss “Surgery in the Early Months of
Life” and “Treatment of ‘Certain Tumors in Child-
hood.” The course will be under the direction of
Dr. Owen H. Wangensteen, professor and head of
the Department of Surgery, and he will be joined by
clinical and full-time members of the staff of the
University of Minnesota and the Mayo Foundation.
Fepruary, 1952
McLEOD COUNTY SOCIETY
Dr. Joseph Selmo, Norwood, was elected president
of the McLeod County Medical Society at its annual
meeting at Glencoe on January 17. Named as secre-
tary of the organization was Dr. Kenneth H. Peter-
son, Hutchinson.
WASECA COUNTY SOCIETY
At the annual meeting of the Waseca County Med-
ical Society at Waseca on January 7, Dr. S. C. G.
Oeljen was elected president and Dr. S. T. Normann,
vice president, both of Waseca; and Dr. George H.
Olds, New Richland, secretary-treasurer.
RADIUM & RADIUM D+E
(Including Radium Applicators)
FOR ALL MEDICAL PURPOSES
Est. 1919
Quincy X-Ray and Radium Laboratories
(Owned and Directed by a Physician-
Radiologist)
Harold Swanberg, B.S., M.D., Director
W.C.U. Bldg. Quincy, Illinois
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