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OF —— MSMA Aeinnd Mecting— Minneapolts 
MAR/13 1952 

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Volume 35 FEBRUARY, 1952 Number 2 

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Winnesola Medicine 

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

Volume 35 

February, 1952 

Number 2 



C. J. Watson, M.D., Minneapolis, Minnesota 


Joe R. Brown, M.D., Rochester, Minnesota 


Gordon R. Kamman, M.D., Saint Paul, Minnesota 141 

Harold H. Joffe, M.D., and Donald J. Van 
Ryzin, M.D., Duluth, Minnesota 

R. J. Dittrich, M.D., Duluth, Minnesota 


Ralph L. West, D.V.M., Saint Paul, Minnesota... 152 


Through Organization to Service 


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: 
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Medical Care 

Medical, Surgical Insurance Still Grows 

Renewal of Health Plan Fight Re-emphasizes 
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REPORTS AND ANNOUNCEMENTS..........ceceeceeee 162 
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AREA eee eee Lenn any eee Te Geach 176 

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Fepruary, 1952 



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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 



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 





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 
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) 


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 


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.***° 



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- 


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- 



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 


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 



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 
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- 

Our policy for some time has been to subject 


useful in differential diagnosis. The alkaline phos- 


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. 


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 



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 

Octe of observation 0 



4 }o| " pehalielishieliz }18}19|20) 2:[22lesjealesiecle7[eelea|so] 3 




TC,mg.% 200 48 
CE,% = 100 24 


— © 


TSP, gm.% 8.0F +. 




16.0 800 
UU, mg./d. UU UCP 
UCP, g/d. 8.0 400 


1600 60 

Cal. /d. Cal. Pra 
Pro. /d. 800 30 


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. 





Chronic alcoholism with cirrho- 

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 



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 

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 


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 


a ee ee ee ee ee ee 


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- 

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 


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- 

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 



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- 

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. 


. Ahrens, E. H., Jr.; Payne, M. A.; Kunkel, H. G.; 
Eisenmenger, W. J., and Blondheim, S. H.: Pri- 
mary biliary cirrhosis. Medicine, 29 :299, 1950. 

. Axenfeld, H.,.and Brass, K.; Klinische and biop- 
tische Untersuchuugen iiber den sogenannten Icterus 
catarrhalis. Frankfurt. Ztschr. f. Path. 57:147- 
236, 1942. 

Baillie, M.: The Morbid Anatomy of Some of the 
Most Important Parts of the Human Body. Ed. 5, 
pp. 118-228. London: W. Bulmer and Co., 1818. 

. Balfour, W. M.; Hahn, P. F.; Bale, W. F.; Pom- 
merenke, W. T., and Whipple, G. H.; Radioactive 
iron absorption in clinical conditions: normal, preg- 
nancy, anemia, and hemocromatosis. J. Exper. Med., 
76:15, 1942. 

. Baltz, J. I.; Steele, H. H., and Hartman, F. W.: 
The gradual evolution of acute infectious (epidemic) 
hepatitis into post-hepatic cirrhosis. Gastroenterol- 
ogy, 13:589, 1949. 

. Bergstrand, H.: Ueber die akute und chronische 
gelbe Leberatrophie. Leipzig: Georg Thieme, 1930. 

. Best, S. H.; Stanley, H. W.; Lucas, C. C., and 
Ridout, J. H.: Liver damage produced by feeding 
alcohol or sugar and its prevention by choline. Brit. 
M. J., no. 4635, p. 1001, 1949. 

. Bjornboe, M., and Raaschou, F.: Pathology of 
subchronic atrophy of liver: comparison with Laen- 
rood cirrhosis. Arch. Int. Med., 84:933 (Dec.) 

. Brown, M. R.: Alcoholic polyneuritis. J. A. M. A., 
116:1615 (April 12) 1941. 

. Chaikoff, I. L. and Connor C. L.: Production of 
cirrhosis of the liver of the normal dog by high fat 
diets. Proc. Soc. Exper. Biol. & Med., 43 :638, 1940. 

. Connor, C. L.: Fatty infiltration of the liver and 
the development of cirrhosis in diabetics and chron- 
ic alcoholism. Am. J. Path., 14:347-363 (May) 1948. 

. Connor, C. L., and Chaikoff, I. L.: Production of 
cirrhosis in fatty livers with alcohol. Proc. Soc. 
Exper. Biol. & Med., 39:356, 1938. 

. Davis, W. D., Jr., ‘and Arrowsmith, W. R.: The 
effect of repeated bleeding i in hemocromatosis. Proc. 
Cent. Soc. Clin. Research, 23:26, 1950. 

. Davis, W. D., Jr., and Culpepper, w. S.: Cirrhosis 
of the liver ‘associated with alcoholism; report of 
acute exacerbation with serial liver biopsies. Ann. 
Int. Med., 29:942 (Nov.) 1948. 


Eckhardt, R. D.; Zamcheck, N.; Sidman, R. L.; 
Gabuzda, G. J., Jr., and Davidson, C. S.: Effect of 
protein starvation and of protein feeding on the 
clinical course, liver function, and liver histology 
of three patients with active fatty alcoholic cirrhosis. 
J. Clin. Investigation, 29:227, 1950. 

. Eisenmenger, W. J.; Ahrens, E. H.; Blondheim, 

S. H., and Kunkel, H. G.: The effect of rigid sodium 
restriction in patients with cirrhosis of the liver 
ea J. Lab. & Clin. Med., 34:1029 (Aug.) 

. Faloon, W. W.; Eckhardt, R. D.; Cooper, A. M., 

and Davidson, C. S.: The effect of human serum 
albumin, mercurial diuretics and a low sodium diet 
on sodium excretion in patients with cirrhosis of the 
liver. J. Clin. Investigation, 28:595, 1949. 

. Faloon, W. W.: Eckhart, R. D.; Murphy, : oe 

Cooper, G. M., and Davidson, C. 'S.: An evaluation 
of human serum albumin in the treatment of cirrho- 
sis of the liver.. J. Clin. Investigation, 28:583, 1949. 

4 ae ee G. J., Jr.; Phillips, G. B., and Davidson, 

: Neurological complications in patients with 

cirrhosis of the liver_given cation exchange resins. 
(To be published). 

. Greenberg, A.: Unpublished observations. 
. Gyorgy, P.: Experimental hepatic injury. Am. J. 

Clin. Path., 14:67, 1944 

. Hanot, V.: Sur une Forme de Cirrhose hypertrophi- 

que. Thése de Paris, 1876. 

. Havens, W. P., Jr., and Bluemle, L. W.; The effect 

of human serum albumin and mercurial diuretics 
on ascites in patients with hepatic cirrhosis. Gastro- 
enterology, 16:455-465 (Oct.) 1950. 

. Hoffbauer, F. W.: Studies of urinary and fecal 

coproporphyrin excretion in rats, II. Experimental 
liver injury. (To be published.) 

. Howard, R., and Watson, C. J.: Antecedent jaundice 

in cirrhosis of the liver. Arch. Int. Med., 80:1-10 
(July) 1947. 

. Howard, R.; Balfour, W. M., and Cullen, R.: 

Extreme hyperferremia in hemochromatosis with a 
note on the treatment of one case by means of bleed- 
ing over a period of three years. (To be published). 

. Karsner, H. T.: Morphology and pathogenesis of 

hepatic cirrhosis. Am. J. Clin. Path., 14:569, 1944. 

. Katzin, H. M.: Waller, J. V., and Blumgart, H.: 

“Cardiac cirrhosis” of | the liver. A clinical and 
pathologic study. Arch. Int. Med., 64:457, 1939. 

. Keil, P. G., and Landis, S.: Peritoneoscopic cholangi- 

ography. Arch. Int. Med., 88:36, 1951 

. Klatskin, G., and Yesner, R.: Factors in the treat- 

ment of Laennec’s cirrhosis. 1. Clinical and histo- 
logical changes observed during a control period of 
bed rest, alcohol withdrawal, and a minimal basic 
diet. J. Clin. Investigation, 28:723 (July) 1949. 

. Klatskin, G.: Gewin, H. M., and Krehl, W 

Effects of prolonged alcohol ingestion on the liver 
of the rat under conditions of controlled adequate 
dietary intake. Yale J. Biol. & Med., 23:317, 1951. 

. Kotin, P., and Hall, E. M.: “Cardiac” or congestive 

cirrhosis of the liver. Am. J. Path., 27 :561, 1951. 

. Krarup, N. B., and Roholm, K.: The development 

of cirrhosis of the liver after acute hepatitis, eluci- 
dated by aspiration biopsy. Acta med. Scandinav., 
108 :306, 1941. 

. Kunkel, H. G., and Labby, D. N.; Chronic liver 

disease following infectious hepatitis. II. Cirrhosis 
of the liver. Ann. Int. Med., 32 :433, 1950. 

. Kunkel, N. G.; Good, R. A., and Ahrens, E. H.: 

An unusual form of chronic liver disease in young 
women associated with marked hyperglobulinemia. 
(To be published) Personal communication from 

. Kunkel, H. G.; Labby, D. H.; fem, eH. js; 

Shank, R. E., and Hoaglund, C. L.: The use of 
concentrated human serum albumin in the treatment 
of cirrhosis of the liver. J. Clin. Investigation, 

27.305, 1948 



. Laennec, R.T.: Traite’ de l’Auscultation mediate, 
et des Maladies des Poumons et du Coeur. 4th ed. 
Brussels: Wahlen and Co., 1837. 

. Layne, J. A., and Schemm, F. R.: The use of a 
high fluid intake and a low sodium acid-ash diet 
in the management of portal cirrhosis with ascites. 
Gastroenterology, 9:705 (Dec.) 1947. 

. Leibowitz, S., and Brody, H.: Cirrhosis of the liver 
following infectious mononucleosis. Am. J. } 
8:675 (May) 1950. 

. Lichtman, S. S.: Diseases of the Liver, Gall Blad- 
der and Bile Ducts, 2nd ed. p. 828. Philadelphia: 
Lea and Febiger, 1949. 

. Mallory, F. B.; Cirrhosis of the liver; five differ- 
ent types of lesions from which it may arise. Bull. 
Johns Hopkins Hosp., 22:69-75, 1911. 

. Mallory, T.: The pathology of epidemic hepatitis. 
J.A.M.A., 134:655 (June 21) 1947. 

. Martz, B. L.; Kohlstaedt, K. G., and Helmer, O. 
M.: Use of ion exchange resins in the manage- 
ment of congestive heart failure and cirrhosis of the 
liver. Proc. Cent. Soc. Clin. Research, 23:70, 1950. 

. Matteini, M., and Marabini, B.: Sulla frequenza 
di alterazioni cliniche e funzionale cel fegato in 
donne, affete da irregolar:ta mestruali. Riv. Crit. di 
Clin. Med., 51:74, 1951. 

. McCartney, J. S.: Cardiac cirrhosis. Bull. Univ. 
Minn. Hosp. Minn. Med. Found., 20:93, 1948. 

. McMahon, H. E., and Thannhauser, S. J.: Xantho- 
matous biliary cirrhosis (a clinical syndrome), Ann. 
Int. Med., 30:121 (Jan.) 1949. 

: Moschowitz, E: Laennec cirrhosis: its histogenesis, 
with special reference to role of angiogenesis. Arch. 
Path., 45 :187, 1948. 

. Moser, R. H.; Rosenak, B. D.; Pickett, R. D., and 
Fisch, C.: The role of resins in the treatment of 
water retention associated with cirrhosis of the liver. 
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. Oliver-Pascule, E.; Galan, J., and Oliver, A.; Liver 
cirrhosis following hepato-enteropathy of infectious 
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50. Patek, A. J.: Relation of acute hepatitis to cirrhosis 
of the liver. Am. J. Med., 8:267 (March) 1950. 

. Patek, A. J., Jr., and Post, J.: Treatment of cirrho- 
sis of the liver by nutritious diet and supplements 
tich in vitamin B  — J. Clin. Investigation, 
20:481 (Sept.) 1941 

. Patek, A. J.: Post, J.; Ratnoff, O. D.; Mankin, 
H., and Hillman, R. W.: Dietary treatment of 
cirrhosis of the liver. J.A.M.A., 138:543, 1948. 

53. Phillips, G. B.; Gabuzda, G. J., and Davidson, C. 
S.: Comparative effects of a purified and an 

adequate diet on the course of fatty cirrhosis in the 
alcoholic. (To ke published). 

Post, J.; Gellis, S., and Lindenauer, H. J.: Studies 
on the sequelae of acute infectious hepatitis. Ann. 
Int. Med., 33:1378, 1950. 

. Ralli, E. P.; Leslies, S. H.; Stueck, G. H.; Shorr, 
H. E; Robson, J. S.; Clarke, D. H.; and Laken, 
B.: The course of cirrhosis of the liver in patients 
treated with large doses of liver extract intraven- 
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Rossle, R.: Entziindung der Leber. In Henke, F., 
and Lubarsch, O.: Handbuch der speziellen path- 
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J. Springer, 1930. 

Royer, M.; Mazure, P., and Kohan, S.: Biliary 
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. Sherlock, S.: Post-hepatitis cirrhosis. Lancet, p. 
817, 1948. 

Sherlock, S.: The liver in heart failure: relation 
of anatomical, functional, and circulatory changes. 
Brit. Heart J., 13:273, 1951. 

. Sutherland, D., and Watson, C. J.: Studies of the 
coproporphyrins. VI. The effect of alcohol on the 
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urinary coproporphyrins. J. Lab. & Clin. Med., 37 :29, 

. Watson, C. J.: The prognosis and treatment of 
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. Watson, C. J., and Hoffbauer, F. W.: Liver func- 
tion in hepatitis. Ann. Int. Med., 26:813 (June) 

. 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. 
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. Zieve, L.; Hill, E.; Hanson, M. C. L.; Falcone, 
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and Clin. Med., 38 :446, 1951. 


“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. 

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. 


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.” 


— er. 7 ee ee 




. 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- 

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 



Climb bus steps 

Climb curb 

Climb steps without hand rail 

Discard wheelchair 

Distances (feet) 50 75 100 
48 feet—seconds 80 75 70 


Distances (feet) 200 300 400 
48 feet—seconds........ 60 50 45 
Distances (feet) 600 700 800 
48 feet—seconds 35 30 25 


*From Leemhuis and Brown by permission of the Journal- 

of various sorts may well develop and require 
considerable individualization of the program of 

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 



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 

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 


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 



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 

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 



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 


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 


- 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) 




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 

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 

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: 


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 



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- 


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 


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- 



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 

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 

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- 

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- 

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) 


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. 


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- 

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 

Death was due to traumatic shock. 


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 

(a) Direct and indirect trauma. 

(b) Pendulous abdomen. 

2. Those with disease or attenuation of mus- 



(a) During pregnancy, labor or puerperium. 

(b) Debilitating diseases such as: typhoid and 
typhus fever, influenza, tetanus and blood 

(c) Vascular disease. 

Taferior ps stric 

hitea, . 

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 


5S ermatic Cord 

terfoveolar biqament 

Lnqinal Aponevrotic 
¥ Folk 

Lxternal Obhgve 
Internal Ob que 
Trans versalis 


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 


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- 


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 

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 
- The incidence of a correct preoperative diag- 
nosis is relatively low. In a combined review, 



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 


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." 


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. 


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) 



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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 

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 

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 



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- 


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. 


the pa 
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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 

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 

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. 


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 



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 


syndrome cases—complete 

Midlumbar syndrome—one case—complete re- 


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. 


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. 


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. 


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 

The physiologic disturbances which result from 
these lesions consist of referred phenomena—pain 
and tenderness. Knowledge of the mechanism of 


of th 

in wl 

the s 
are h 


eee SO eet OOO Oe 

— tt , 

ry is 

n of 


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. 



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) 

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. 


(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. 

1. There is no clear-cut dividing line between 

“functional” and nervous diseases. 

2. However, most disorders are either pre- 
dominantly “functional” or predominantly “or- 

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. 


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 



(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.) 

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) 



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. 


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- 



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 

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 



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 



President’s Letter 


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 

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 

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 



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 

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 


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 


| 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 

In view of the drawbacks possessed by both 
these methods, it is not surprising that a third 


by tl 
As a 
the } 
of ag 

as d 


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- 

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 



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 

Science Service is located at 1719 N Street 
N. W., Washington 6, D. C. 


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. 


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. 
The Northwestern Pediatric Society has approved the 
study and appointed: 
Dr. F. H. Adams, Dr. E. S. Platou, and Dr. L. F. 
The Minneapolis Health Department has appointed: 
Dr. Evelyn Hartman. 
The Minneapolis Hospital Council has appointed: 
Mr. Russell Nye, Superintendent, Northwestern Hos- 
And from the Medical School, University of Minne- 
Dr. Irvine McQuarrie, Head, Department of Pediat- 
Dr. James R. Dawson, Jr., Head, Department of 
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- 
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- 
(a) At Medical Society ‘meetings. 
(b) At hospital staff meetings 
(c) Through medical bulletins and journals 
(d) Through other educational approaches. 



eight « 
to the 
28 cot 
top 0 
the at 
To m 
to pl 
to th 


to t 
of « 





- of 




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 

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- 

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. 


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 


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. 


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.® 


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. 


Medical Economics 

Edited by the Committee on Medical Economics 
of the 
Minnesota State Medical Association 
George Earl, M.D., Chairman 


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. 


“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 

Explaining the changes further, the report 

“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 

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 


the f 


“ I n 
are d 
cent < 

pay f 
of th 

it ne 


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. 


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. 


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.” 


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 +¢ 


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 


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 

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. 


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. 



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 


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. 


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) 




Fepruary, 1952 

now in parenteral form... 


Brand of Methantheline Bromide 



~ * 



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. 





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 

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 

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 


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. 


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 




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ICINE Fepruary, 1952 165 

In Memoriam 


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. 


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- 


neapolis; Mrs. Don O. Lampland and Mrs. David Paul 
Keefe of St. Paul. 


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 

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. 


Dr. Russell W. Morse, well-known radiologist of Min- 
neapolis, died December 29, 1951, in Panama City, 

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 

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) 




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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 

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. 


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 

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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* 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- 


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. 


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- 




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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, 

* * * 

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, 
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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. 


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) 


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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- 

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 


of ap 
of 16 






North Shore 
Health Resort 

Winnetka, Illinois 

rvice . on the Shores of 
con Lake Michigan 
} Fe 
riods A completely equipped sanitarium for the care of 
nervous and mental disorders, alcoholism and drug addiction 

for 225 Sheridan Road Medical Director Phone Winnetka 6-0211 

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 


ICINE Fepruary, 1952 

offering all forms of treatment, including electric shock. 




Now Has 

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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 compounded semi-annually . . 
March 31 and September 30. 



Bremer Arcade Robert at 7th CE 6666 
Member Federal Deposit Insurance Corporation 

. payable 

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 @ 

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. 

* * * 

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. 

* * * 

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. 

* * * 

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 


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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. 



Bilhuber-Knoll Corp. Orange, N. Ap. 

action, diminishes dyspnea and reduces edema. 


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. 

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. 

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. 



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(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.” 


(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, 

. 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 


10-14 Arcade, Medical Arts Building 
825 Nicollet Avenue—Two Entrances—78 South Ninth Street WEEK DAYS—8 to 7? 








103 East Fifth St., St. Paul 1, Minn. 

Cedar 1781-82-83 




the L 

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Miller Vocational High School. 
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who direct the treatment. 

5511 Lyndale Ave. So. 

Certificate from 


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 

(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 


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. 


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. 


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