<1U JOURNAL

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Iowa State Medical Society

Vol. XXXVIII Des Moines, Iowa, January, 1948 No. 1

OBSTETRICS YESTERDAY AND TODAY Ralph Luikart, M.D., Omaha, Neb.

This year the American Medical Association, as you know, is celebrating the one hundredth anniversary of its organization. This year, by a coincidence, also marks a milestone in obstetrics which is far more dramatic than the organization of American physicians into an association. It was in 1847 that a 29 year old physician, by the name Ignaz Philipp Semmelwies, threw a bomb- shell into the camp of his learned Viennese col- leagues in the form of an unorthodox theory re- garding the etiology of puerperal sepsis.

With youthful abandon, as though he were actu- ally in possession of experimental proof, he de- clared that the staggering mortality from puer- peral fever was not a matter of ill-humor or bad luck, but that the angel of death was guided to the bedside of unsuspecting mothers by doctors, nurses and hospital attendants who were carrying “decomposed, organic material’’ on their hands and their fingers into the delivery room. We, in Amer- ica, accept freedom of thought and expression as an incontestable human right. It is not easy for us to believe that a doctor who propounds a new viewpoint on a menacing disease would suffer ridi- cule and contempt as a consequence. Indeed on our own shores, at the time Semmelweis was being denounced for his ideas on puerperal sepsis, Dr. Oliver Wendell Holmes on his own initiative ad- vanced an essentially similar theory regarding the cause of the disease. There were many who re- jected his philosophy, but Dr. Holmes’ status as a great clinician remained unaltered. Semmelweis succumbed to the humiliation. It may be said that he died a martyr, if not to science itself, to a principle which ultimately proved his greatness. For, with acceptance of the cause of puerperal sep- sis, we see the dawn of a new era in obstetrics. From an appalling mortality rate, due to infection in childbed prior to 1847, today we consider even a single death from this source as a most un- fortunate phenomenon. We not only explain and

Presented at Ninety-sixth Annual Session, Iowa State Medical Society, Des Moines, April 16, 17, and 18, 1947.

apologize, but indeed we make a most thorough effort to determine if and how we were amiss in our aseptic technic. Add to this the modern use of antibiotic and chemotherapeutic agents and you arrive at the conclusion that child bearing from the infectious viewpoint has become safe indeed.

Analgesia and Anesthesia

1 here is a biblical exhortation in Genesis 3 which for centuries kept women in terror at the prospect of childbirth. “Unto the woman He (The Lord) said ‘I will multiply thy pain and thy travail : in pain thou shalt bring forth children’ ...” Without in any manner contesting the word of the Good Book, we are nevertheless faced with a body of knowledge which progressively tends to reduce the punitive measures originated through Mother Eve for her indulgence in the Forbidden Fruit. Or shall we say that in the eons of our past, sufficient penance had been done by her descendants to atone for the original sin, and therefore the woman of today is entitled to pain- less childbirth? I suggest that we assign such judgment to the theologist and the philosopher. As physicians we are more concerned with the comfort of our patients than the fundamentalist concepts of biblical interpretations.

So far as we know Sir James Simpson was the first practitioner to use ether in obstetrics. To what extent or to what degree the anesthetic was employed is not too clear, but Simpson advised ether for the relief of pain soon after the anes- thetic came into use in surgery. Incidentally, he was also the first to establish and become the head of the Department of Midwifery at the University of Edinburgh.1 It was not the coveted post it is considered today, for, as you know, most of the physicians of that era looked upon this field of practice rather disdainfully.

In discussing analgesia and anesthesia in ob- stetrics, I hasten to endorse the general belief among my colleagues that the ideal agent in this field has not yet been discovered. To meet opti- mum requirements such a drug must be safe for both mother and baby ; it should do no harm to

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Journal of Iowa State Medical Society

January, 1948

either, should be prompt in its action, and should not require time-consuming attention of a trained staff for its administration. In the present state of our knowledge we should not promise total relief from pain in childbirth. All a conscientious obstetrician can do is repeatedly reassure the patient during her prenatal visits that everything possible will be done to carry her through labor with a maximum of comfort to herself and the highest degree of safety to her baby. It is a sad reflection on female psychology to find so many women who have borne children thrive on uncer- tainties and anxieties they impart to their younger and less experienced friends and relatives as a result of thoughtlessness as well as groundless remarks concerning pregnancy and delivery. Once the doctor, through frank and honest discussion, has gained the confidence of his patient, he will have no difficulty in obtaining the cooperation necessary to success.

The subject of analgesia makes one of the most interesting chapters in the history of obstetrics. The most spectacular phase to my mind was the old “Twilight sleep.” I feel certain that many of us can recall the dramatic performance of our patients under the influence of scopolamine, the “battle royal” in which we participated until we finally got the excited patient under ether, and following a wild delivery, the heroic effort it took to resuscitate the blue baby. In the light of what we know today about anoxia we cannot es- cape the conclusion that twilight sleep as an anal- gesic was as unsafe as it was ineffective. What little alleviation there was from pain during labor was the result of the morphine which accompanied the scopolamine, and morphine in doses given under the old procedure is now considered un- thinkable from the standpoint of safety to the infant and the mother. The present use of scopo- lamine combined with barbiturates is an improve- ment over the previous method, but the danger of asphyxia to the baby remains.

Rectal anesthesia2 is preferred by some, but the results lack uniformity. In some cases it fails because of improper administration of the drug, in others because the rate and speed of absorption is difficult to predict. Paraldehyde has recently gained popularity. Given by mouth it has a most disagreeable taste and odor. Admin- istered by rectum it is subject to the uncertain- ties I have just mentioned.

Intravenous analgesia, using such barbiturates as pentothal sodium, thus far has not proved suc- cessful. Its action is too short to be satisfactory in labor. Inhalation anesthesia as now used dur- ing first and second stages of labor has its dis-

advantages. It requires prolonged services of an experienced anesthetist. It is also an expensive method. Saddle block anesthesia has a wide range of safety when properly administered in the latter part of the second stage, but it requires a trained anesthetist, and is therefore not universally adaptable. Caudal anesthesia has been revived since the improved, continuous method has come into vogue. This method of relieving pain has a definite place in obstetrics, but good results de- pend upon a trained staff. Here, too, the re- sults are not uniform. Hingson and Edwards,3 who have reported the largest number of cases in this category, report a maternal mortality of 1 in 1400. Cook County Hospital4 discontinued caudal anesthesia because of a maternal death in their nine hundred sixty-fourth patient. And this occurred under caudal anesthesia adminis- tered by experts !

From what has been said it should be evident that in spite of periodic ballyhoo in the lay press and the honest but at times over-enthusiastic opin- ions in the medical literature, each method of pro- ducing analgesia, anesthesia or amnesia has failed thus far to meet the requirements of an ideal agent. In my opinion today (and I reserve the right to change it if something better appears on the horizon) a combination of demerol with sco- polamine comes closest to the desired amnesic and analgesic goal in this field. It is simple to admin- ister, it is safe for the mother and the babv and it controls pain without delaying progress. There are no deaths reported from its use.

The technic is as follows : When labor pains have become established with discomfort from which the patient asks to be relieved, 50 mg. of demerol and 1/150 gr. of scopolamine are slowly (2-3 minutes) injected intravenously and 50 mg. of demerol is given intramuscularly. Analgesia and amnesia follow almost instantly. Additional demerol is given if the patient becomes wakeful between pains and talks coherently. When dilata- tion of the cervix is complete and the presenting part is on the perineum, ether or cyclopropane is used to complete the second stage. If the in- halation anesthesia is not prolonged, there is very little or no asphyxia of the infant and the cry is spontaneous. I have used this method for two years and the results have been uniformly good.

Although we are far from the millenium on this problem of analgesia, we can point with justifiable pride and a mild satisfaction to our ability to re- duce pain to a considerable degree, a degree to which the terror formerly associated with child- birth has been largely eliminated.

There are other spheres in which obstetrics of

Vol. XXXVIII, No. 1 Journal of Iowa State Medical Society

today differs favorably from that of yesterday. One of the outstanding, though because of its evolutionary aspects, less noticeable phases is the constant improvement in our mechanical skills which have contributed to the material reduction of maternal and infant mortality and even moie so to the lessening of morbidity.

I am not blind to the fact that even with or in spite of our better understanding of the physiol- ogy and mechanics of labor poor obstetric results may be found in every community. It is my sincere conviction, however, that the careful ac- coucheur can cut those unfortunate accidents down to a minimum. It is my firm belief that no physician should assume the responsibility of obstetric care without a thorough knowledge of the use of oxytocics, nor should he allow a patient with a perineal or cervical tear to leave the de- livery table without a repair. If the patient’s condition at the time of delivery does not permit immediate repair, secondary repair should be done later, preferably before she leaves the hospital.

I cannot dismiss our mechanical progress with- out a brief discussion of the important role of the obstetric forceps. During the seventeenth cen- tury and the early part of the eighteenth cen- tury the Chamberlen family designed and first made use of obstetric forceps. This step marks one of the great mechanical advances in obstet- rics. The Chamberlens asserted that with their newly discovered instrument they could deliver any pregnant woman. Their optimism was only paralleled by their lack of modesty. During the next century and up to the present time obstetric forceps have been modified and improved from time to time. The forceps with the fixed lock and open fenestra had definite shortcomings. The newest obstetric forceps6 which has become avail- able the past few years has a sliding lock, and the fenestra is closed on the maternal side of the blade. It has an easily attachable axis trac- tion bar. These are safety factors which also facilitate the ease in application and removal of the forceps.

Along with this advance in the mechanics of obstetrics came the great improvement in Cesarean technic. The greatest advance was made by Sanger,7 who in 1882 first used sutures in Cesar- ean sections. This, along with the advances in aseptic technic, brought about a great reduction in maternal mortality.

We have come a long way since the time Sem- melweis died fighting in the cause of safer ob- stetrics. With aseptic technics aided by chemo- therapeutic and antibiotic agents, puerperal sepsis has become a rarity. Pain in childbirth, though

not entirely conquered, has come under consider- able control. Improved knowledge and better un- derstanding of the physiology of pregnancy and the mechanics of labor has contributed greatly to the reduction of maternal and infant mortality. However, we must not become too smug in these achievements for there is yet much left to be de- sired. Obstetric tragedies on the maternal and fetal sides are far from eliminated. But progress, like time, is on the march, and each year brings new information, new discoveries and new con- cepts.

As I see it the most pressing need today is bridging the gap between what the doctor has to offer in the way of adequate obstetric care and the desire for the application of this care by the public. It is ironical that while in some spheres there is a persistent clamor for more and more medical care, in other spheres the public refuses to take advantage of facilities that are readily available. This anomaly stems from the fact that the people generally are aware only of those ad- vances in medicine which are dramatized in the lay press and on the radio, but remain lukewarm toward the simple but less spectacular procedures which have proven themselves of greatest benefit to their welfare. As an illustration I call your attention to the fact that while many intelligent women apply for obstetric advice early in their pregnancies, many, many more still wait until late in the last trimester to consult you.

To my way of thinking we need less ballyhoo and more down to earth public information on principles of health. And the most logical agency to advance such a program is the State Health Department under the stimulus of and in coop- eration with state medical societies. I have strong convictions that health education in all its phases should begin in the early grades of our public school and should become progressive in scope as the pupil advances in scholastic standing. Only through an appreciation of elementary principles of health can we expect full cooperation of the obstetric patient.

This brings us to the final point in this discus- sion: A woman chooses her doctor in the belief that he will give her the best care to be had in the community. She has confidence in him. It therefore becomes his duty to justify that confi- dence. This axiom applies to all branches of medicine, but it becomes especially dominant in obstetrics, because under proper care with the cooperation of the patient, tragedy involving two lives often can be averted. Therefore, the medi- cal adviser’s first duty to his patient is to enlist her cooperation in a program of optimum pre-

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Journal of Iowa State Medical Society

January, 1948

natal care. To accomplish this task effectively the doctor must himself be convinced of its full importance. A perfunctory attitude on the part of the physician is not conducive to enthusiastic acceptance of any program, and least so in the realm of prenatal care where inhibitions and self- control must be practiced by the patient.

What then is optimum obstetric care? It is more than just seeing the patient in the office and examining her urine on occasion, and when the time comes, delivering her. Prenatal visits to the office should stress the benefits of hygiene of preg- nancy and the progress of the fetus. Emphasis must be laid on the various maternal factors which aid in the development of the new organism. Good prenatal care includes a complete examina- tion of the patient with records of weight, height, blood pressure, urine and blood tests including Rh factor determination. Even a slight deviation from the normal calls for strict evaluation of cause and in any event must be considered a po- tential if not an immediate handicap to normal progress. In my practice patients in good health present themselves at monthly intervals the first seven months and from then on twice each month. I need not dwell on the quality or extent of these follow-up examinations.

Good obstetric care prior to delivery involves the elimination, insofar as they lend themselves to elimination, of all undesirable factors which potentially menace the welfare of the patient. One of the most frequent correctable defects which pregnant women present is tooth decay, and all too often abscessed teeth as well. As you know, there are many superstitions and erroneous be- liefs among lay people concerning- teeth. Unfor- tunately, too many physicians and dentists adhere to the antiquated dictum “for every child a tooth,” in spite of the fact that the calcium in the teeth is fixed and cannot be absorbed by the blood to deposit it in the tissues of the fetus. Another mistaken impression too frequently aided and en- couraged by doctors and dentists is that it is dan- gerous to have carious teeth filled or abscessed ones extracted during pregnancy. The fact is that women are too often inclined to neglect their teeth prior to and during pregnancy and then acquire marked caries as a result of this neglect.8 The ultimate effects of these foci of infection are too well known to require further elaboration.

One of the most significant advances in connec- tion with prenatal care is our improved knowledge of nutrition and the effects of overweight on preg- nancy. I have seen women who not only believe in, but diligently practice the old saying that a pregnant woman has to eat for two, and judging

from the results some of them must feel that they carry quintuplets. Only last month one of these enthusiasts who came to me during her eighth month of gestation had gained not less than 65 pounds since the discovery of her pregnancy and delivered a baby weighing 11 J4 pounds. If over- eating resulted in overweight babies alone, the problem would be only that of difficult labor. Unfortunately, there are other, and indeed, more dangerous implications.

In all of the reports of pregnancies I have ex- amined, toxemia occurred in about 4 per cent of the patients who gained 18 pounds or over. For the past several years I have been using a high protein, low calorie diet on all my patients. In 1946 I reported a series of 1,000 cases of women who followed this weight control program through- out their pregnancies. All were delivered without a death or a single instance of toxemia, pre- eclampsia or eclampsia. In no patient did the blood pressure exceed 145/85. Edema was a neg- ligible factor throughout the series. The fetal mortality in this series of diet controlled cases was just one-third of the mortality rate reported in accepted standard statistics. There were no large babies.

These results were attained through a regimen which calls for a maximum gain of a total of 16 pounds throughout the entire period of pregnancy. It calls for a high protein, low calorie diet sup- plemented by iron, calcium and a liberal allowance of vitamins. Thyroid extract is given to all pa- tients who can tolerate it. Every patient with a pulse rate below 70, regardless of the basal meta- bolic rate, is given small daily doses of dessicated thyroid. The dose is increased every fifth day until there is indication of excessive dosage, when it is discontinued for four days. On the fifth day dessicated thyroid is again started in dosage equal to the last daily dose which did not disturb the patient.

A recent case will illustrate the help that prop- erly administered thyroid may afford. A 34 year old woman weighing 185 pounds with a height of 65 inches appeared sluggish both mentally and physically. She had been married nine years and had had two pregnancies ending in spontaneous abortion. Information obtained in previous ex- aminations was practically negative. My exami- nation gave no new light except her BMR was plus seven, pulse 52. She had been given two similar reports by other doctors. Thyroid was ordered in accordance with my routine directions. She returned to the office ten weeks later, two months pregnant. She was mentally alert and in excellent physical condition. She was taking des-

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sicated thyroid, grains 7, daily. She was very happy about her pregnancy and regretted that thyroid had not been ordered by the other two doctors who saw no reason to give it because her BMR was plus 7. She carried the baby to term and had an uneventful delivery.

Now, you may ask, does this high protein-low calorie diet prevent toxemia ? According to Dieck- man10 “the albumin and globulin molecules are so large that they do not pass through the capillary wall. As a result they exert colloid osmotic or on- cotic pressure within the capillary, thus preventing edema.” Straus11 writes, “If the expectant mother does not eat enough protein food, she gains ex- cessively, but this weight consists of water or oc- cult dropsy.” Williams12 found that “The inci- dence of toxemia in pregnancy was twice as great in pregnant women whose protein intake was 60 to 70 grams daily as compared with a similar group whose protein intake ranged from 110 to 120 grams.”

There is another important factor which con- tributes greatly to the rationale of the high pro- tein diet. You are all aware of the notorious frequency with which anemia occurs in pregnancy. You are also conscious of the importance of keep- ing up the blood volume during this precarious period. The administration of iron is good prac- tice, of course. The proteins in the food, how- ever, are invaluable. Blood is made, and worn- out blood is replaced normally by protein in the diet. The chief foods from which protein is ob- tained are meat, eggs, fish and vegetables, green in color. These foods are the blood making foods. Throughout the pregnancy close watch must be kept of the blood protein. Primarily its rise and fall depends on intake of animal protein by the mother. Because of the nature of their specific dynamic actions, proteins are not fatten- ing. They are blood makers and baby builders. Nor do I need to remind you of the rationale of a low fat intake. Aside from its high caloric value and its resulting tendency to increase weight, even a slight rise in the blood cholesterol which accom- panies fat metabolism is often sufficient to raise the blood pressure during pregnancy. Hyper- cholestronemia has long been known for its tend- ency to cause arteriosclerosis.

I must warn you, however, that this is not an easy regime to carry out even if you, yourself, are fully convinced of its benefits. If you accept it lukewarmly you will waste your time in trying to put it into effect. In order to be successful the calorie reduction must be maintained through- out the period of pregnancy. It cannot be con- sidered a free diet because it is definitely restricted quantitatively and to some extent qualitatively.

The caloric intake has to be low, the protein high. Women will argue, haggle with you, and at times change doctors because of your insistence on die- tary limitations, but the results are worth all the effort you will make. Your task will be easier if you will take the time and patience to explain the why of the strict program. At least you will have carried out your side of the unwritten con- tract.

Our experience of yesterday and today, speak- ing figuratively, would be entirely worthless if we failed to put these experiences to useful pur- poses. I am fully confident that in the scientific sphere developments will come which will add greatly to our understanding of the problems which today appear inscrutable. I have no doubt, for example, that as we progress the primary tox- emias of pregnancy, now far better understood than they were a decade ago, will some day come under adequate control and thus further reduce the maternal and infant mortality. Similarly, our improved understanding of the nature and signifi- cance of a good many other conditions, which are now unexplainable, will in time lessen the mortality and morbidity for both the mother and her off- spring. Better teaching of obstetrics in the medi- cal colleges and ample provision for postgraduate and refresher courses for practicing physicians will bring greater knowledge and result in better tech- nique, which will reflect themselves in the doctor’s office and in the delivery room.

BIBLIOGRAPHY

1. Findley, P. : Priests of Lucina : The Story of Obstetrics.

Little, Brown & Co., 1939, pp. 234-244.

2. Gwathmey, J. T.t and McCormick, C. O. : Ether-oil rectal analgesia in obstetrics: modified technic. J.A.M.A., cv:2044 (De- cember 21) 1935.

3 Fitzgerald, J. E. : Report on caudal analgesia at Central States Meeting, Chicago, Sept. 19, 1946.

4. Ibid.

5. Aveling, J. H. : Chamberlens and the midwifery forceps : memorials of family and essay on invention of instrument. Lon- don, J & A Churchill, 1882.

6. Luikart, R. : New forceps possessing sliding lock, modified fenestra with improved handle and axis traction attachment. Am. J. Obst. & Gynec., xl:1058-1060 (December) 1940.

7. Sanger, M. : Zur Rehabilitirung des clasischen Kaiser-

schnittes. Nebst einem Anhange: Nachtrage zur Geschicts der Uterus, naht beim Kaiserschnitte, Arch. f. Gynak., xix:370, 1882.

8. Luikart, R. : Pregnancy does not cause dental caries. Bull. Creighton Univ. Sch. Med., 76-77 (May 3) 1946.

9. Luikart, R. : High protein, low caloric diet for prevention of toxemia of pregnancy. Am. J. Obst. & Gyn., lii :428-434 (September) 1946.

10. Dieckmann, W. J. : Toxemias of pregnancy. St. Louis, C. V. Mosby Co., 1947, p. 75.

11. Strauss, M. B. : Observations on etiology of toxemias of

pregnancy ; relationship of nutritional deficiency, hypoprotein- emia, and elevated venous pressure to water retention in preg- nancy. Am. J. M. Sc., cxc:811-824 (December) 1935.

12. Williams, P. F. : Importance of adequate protein nutrition in pregnancy. J.A.M.A., cxxvii :1052-1055 (April 21) 1945.

CHANGE OF ADDRESS Help your central office to maintain an accurate mailing list. Send your change of address promptly to the Journal, 505 Bankers Trust Bldg., Des Moines 9, Iowa.

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Journal of Iowa State Medical Society

January, 1948

NONSPECIFIC GRANULOMA OF THE COLON

Louis T. Palumbo, M.D., Des Moines

A great number of articles appear in the medi- cal journals concerning the entity granuloma of the colon. However, the occurrence of a solitary nonspecific lesion in the large bowel is rare.1, 3- 8

The granulomas represent a chronic inflamma- tory disease involving a portion or local segment of the colon. These are classified as follows:

I. Specific

A. Tuberculosis

1. Hyperplastic

2. Ulcerative

B. Fungi

1. Actinomycosis

2. Blastomycosis

C. Amebiasis (Ameboma)

II. Nonspecific

A. Benign solitary cecal ulcer

B. Segmental ulcerative colitis

C. Foreign body

Since in the discussion of this disease the vari- ous lesions of the colon must be considered, a brief review and resume of the above listed conditions will be discussed.

Hyperplastic tuberculous granuloma is a very rare disease as a single tuberculoma of the cecum or ascending colon. It is often primary, and only in about one-third of the cases is pulmonary in- fection found.1 It is rare, particularly after the age of 40 years, for Crohn and Yaries4 report only four cases in 4,800 autopsies, and onlv three cases of tuberculoma at the Graduate Hospital in Philadelphia.2

The ulcerative form is usually secondary to active pulmonary tuberculosis, and the mode is usually enterogenous. It ordinarilv begins in the terminal ileum but may be located solely in the cecum.

Actinomycosis of the bowel has been reported in 62 cases ; 77 per cent of the cases were in the cecum and terminal ileum, the etiologic agent being actinomyces bovis or ray fungus. However, only one case has been reported of blastomycosis in- volving the cecum alone. The case was cured by resection of the terminal ileum and ascending colon.10

Amebic granuloma occurs frequently in patients with amebiasis. The early lesions are confined to the mucosa, give a lacey appearance to the x-ray silhouette, and later there is coning with incom- plete filling of the cecum. A persistent deformity of the cecum should always suggest amebiasis in

From the Department of Surgery, Veterans Hospital, Des Moines, Iowa.

patients with obscure hepatitis and diarrhea. These lesions usually disappear under specific antiamebic therapy.11

Benign solitary ulcer or penetrating ulcer of the cecum are rare and have been reported by Cromar, Caravati, Dixon and McMillan.1, 5> 6’ 8 Cromar collected a series of 68 cases in the litera- ture. The lesion occurs more commonly in males between the ages of 25 and 50. The etiology is obscure. The lesion penetrates the bowel wall in 6.5 per cent of the cases. The symptoms usually suggest acute appendicitis or penetrating malignant lesion of the ascending colon.

Occasionally a localized idiopathic ulcerative colitis has been reported involving the cecum or ascending colon. The etiology is unknown, but evidence suggests an obstructive lymphadenitis as a contributory factor.

Foreign bodies of any type, such as instru- ments. sponges, and ingested objects which per- forate the intestine, may cause a localized inflam- matory reaction, with resulting chronic granu- lomas.

Report of Case

Case No. 1 :

This white male patient was admitted for the first time in this hospital in November, 1938, for treatment of hemorrhoids. A hemorrhoidectomy was performed. He was not in this hospital again until the present admission on Jan. 29, 1947. He stated at the time of admission that he had been en- tirely well until approximately one year ago, at which time he noticed that his stools were no longer formed. He stated that throughout his life he had had a slight tendency towards constipation, but in the last year this had disappeared. For the last six or eight months he had felt lethargic and had lost his appetite, and also during the same period he had had three to four spells of diarrhea, each lasting from one to three days with two to three bowel movements of watery stools each day. On frequent occasions he stated that he had passed bright red blood in his stools in quantities up to one-half ounce. He had had no symptoms from hemorrhoids since he had a hemorrhoidectomy as stated above. »

Approximately eight to nine days before ad- mission he noticed that his bowel movements be- came smaller in quantity and that he began hav- ing a burning in his stomach with occasional gen- eralized abdominal cramps. At 5 p. m. one dav later, he began having severe abdominal cramps which were located primarily in the right lower quadrant of the abdomen. His temperature be- came elevated, and from that time to the time of admission he perspired a great deal, particularly

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at night. He was seen by his local doctor one day after the onset of the severe cramps and was told that he probably didn’t have appendicitis and was also told to take frequent enemas. He had three enemas that day, four the following day and three days later he had four more. The first enema gave quite satisfactory results with the passage of a few hard, small chunks of stool and a large amount of gas. Three days before ad- mission he took an oil enema and took some min- eral oil by mouth, following which he had the sen- sation that “something gave” in the right lower quadrant of his abdomen. The day following this he had a spontaneous bowel movement — the first for a period of 7 to 8 days.

The patient stated that he had lost weight in the last few months, and although he did not know just how much, he estimated that it was about 15 lbs.

Positive Findings:

Partial, bilateral deafness of the perception type was found to be present. There was generalized lymphadenopathy present, including the anterior and posterior cervical, axillary, and inguinal glands. The glands were nontender and were enlarged up to the size of a pea. They did not appear to be fixed to surrounding tissue and were relatively freely movable.

Physical Examination : ,

The patient was a rather thin, 51 year old, white male, who was lying quietly in bed and who did not appear to be in any acute distress. Oral hygiene was poor. On examination of the abdo- men the solid organs were not palpable. There was slight rigidity in the lateral, right lower quad- rant, and a mass, which was rather sausage shaped and which extended in an oblique direction, could be felt just superior and medial to the right anter- ior superior spine of the iliac bone. It measured approximately 3 inches in length by 1 inch in width. It was rounded on top and was fairly well fixed. It was quite tender to palpation. Peristaltic sounds could be heard, and the abdo- men was not distended.

At the time of admission, the patient’s tem- perature was 98.8 F. His pulse was 94 and his respirations were 18. On the second day follow- ing admission his temperature was 102 F., his pulse 96 and his respirations 20.

At the time of admission it was felt that the patient had an abscess in the right, lower abdo- men and conservative therapy, consisting of hot stupes to the abdomen, penicillin, intravenous feed- ing with nothing by mouth, semi-Fowler’s posi- tion, was instituted. By Feb. 7, 1947, the mass was still present but was much smaller and was nontender.

During the work-up of the patient, three stool examinations were taken while he was on a meat free diet, one of which was reported as negative, one as 2-f- occult blood and the other as 3-j- oc- cult blood. At the time of admission his blood sodium chlorides were 500, total proteins were 6 and his NPN was 65. His urinalysis was nega- tive. His red blood count was 4,920,000 with 14 grams of hemoglobin, and his white blood count was 20,000 with 81 per cent polymorphonuclears, 17 per cent lymphocytes, 2 per cent eosinophils, with a shift to the left. Two days later his white blood count was reported as 10,600 and the day following this it was reported as 15,400.

On Feb. 4, 1947, "a barium enema revealed a deformity with narrowing of the lumen of the proximal portion of the ascending colon (fig. 1),

Fig:. 1. Barium enema, filling; defect, lateral wall of ascending colon.

This irregularity was more marked on the lateral aspect of the colon than on the medial. Films made before and after evacuation and by air con- trast method (fig. 2) did not show the deformity as marked as when compression was used. The conclusion was that there was a definite patho- logic lesion, and the suspicion was that it was probably neoplastic, if not inflammatory.

On February 6 a proctoscopy was performed,

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Journal of Iowa State Medical Society

January, 1948

and no pathology was noted. Also on that date a lymph node was removed from the left posterior cervical region. Pathologic examination of this lymph node showed hyperplasia. “The picture presented was very suggestive, but was not con- sidered diagnostic of a lymphoma.”

On February 10 an intravenous pyelogram was performed and the right kidney was reported as revealing a double pelvis with a fork shaped ureter

Fig. 2. CQntrast enema of colon, persistent filling defect, lat- eral wall of ascending colon.

extending to the third lumbar vertebra. The lower pelvis and calices were reported as normal after the upper pelvis and calyx were visualized but not completely filled. No abnormalities could be seen in either calyx or in the left kidney.

On February 13 a roentgenogram of the chest revealed no abnormalities. The next day an ex- ploratory laparotomy was performed, at which time a firm, circumscribed mass was found on the posterior-lateral wall of the ascending colon just above the cecum. There were many adhe- sions in this area and the appendix was rotated upon itself, and it was found that the tip of the appendix was protruding through the center of the mass described above and was plugging the hole that had existed in the mass and bowel wall. The appendix was freed and removed. A biopsy was taken of the mass and was reported as in- flammatory tissue. The defect in the colon was sutured and the wound closed. The patient’s postoperative course was uneventful; wound healed by primary intention.

Pathologic examination of the biopsy of the colon was reported as acute, nonspecific colitis or granuloma ; that of the appendix was reported as periappendicitis, subacute, and that of the lymph nodes was reported as hyperplastic lymphadenitis.

The patient complained of a recurrence of pain in the right lower quadrant. On February 27 a resection of the terminal six inches of the ileum, cecum, and ascending colon was carried out, and a side to side transverse ileocolostomy was per- formed. Again, the postoperative course was uneventful.

Due to the fact that the result of the previous biopsy of the cervical lymph node was unsatisfac- tory, a lymph node from the right axilla was re- moved on March 12. This was reported as show- ing severe hyperplasia, consistent with but not diagnostic of an early lymphomatous change.

Blood smear taken six days later was reported as showing mild anisocytosis, with 58 per cent polys, 34 per cent lymphocytes, 7 per cent mono- cytes and 1 per cent eosinophils.

The pathologic report of the resected specimen dated March 11, 1947, revealed a large, firm, nod- ular, irregular mass of the upper cecum, meas- uring approximately 3 cm. in thickness. 5 cm. in width, and completely circumscribing the cecum. The cut section was yellow with small areas of hemorrhage. The section, when cut. was a pearly- gray color and had small layers of red. In the mass was a large hemorrhagic cystic area, ap- proximately 1.5 cm. in diameter, which was well circumscribed by this grayish cartilagenous-like tissue.

The submucosal tissue was greatly thickened, whitish in color, and rubbery hard in consistency.

Microscopic examination revealed a complete loss of mucosa at the base of the depressed scarred area of the ulcer. The base of the ulcer was co’ posed of a thick layer of chronic granulation tis- sue. The wall of the bowel was greatly thickened and the submucosa and muscularis throughout had been largely replaced by a few acute and many chronic inflammatory cells, hyperplastic connective tissue cells, occasional foci of hemorrhage and multinucleated giant cells. The other cells pres- ent were large mononuclears, lymphocytes, plasma cells, vacuolated cells, areas of pigment and hem- orrhage. There were areas of relatively acellular necrosis.

Summary

Although this is a rare condition, nonspecific granulomas of the intestinal tract should be con- sidered in patients presenting a palpable mass in the right lower quadrant, associated with pain, change in howel habits, and low grade fever.

X-rays revealing a filling defect or deformity in this area of the colon should bring to mind, in addition to carcinoma, sarcoma, specific and nonspecific granulomas.

The specific etiologic agent has not been dis-

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covered, despite careful and persistent effort. A low grade infection is thought to be the cause of the condition.

It is generally accepted that this nonspecific lesion should be treated by surgery consisting of resection or some type of side-tracking operation for relief of symptoms. If the mass appears irremovable, biopsy should always be made, since even at operation it is impossible to differentiate this type lesion from carcinoma.

bibliography

1. Caravati, C. M. : Cecal granulomas. North Carolina Med. J., vii :633-636 (December ) 1946.

2. Bockus, H. L. : Gastro-enterology. Philadelphia, W. B.

Saunders Co., 1944. Vol. II, p. 211.

3. Colp, R. : Nonspecific granulomata of intestine. Ann.

Surg., cvii :74-8 1 (January) 1938.

4. Crohn, B. B., and Yaries, H. : Primary ileocecal tubercu-

losis. New York State J. Med., xl :158-166 (February 1) 1940.

5. Cromar, C. D. L. : Benign ulcer of cecum. Am. J. Digest. Dis., xiii :230-232 (July) 1946.

6. Dixon, C. F., and Deuterman, J. L. : Nonspecific granu-

loma of intestine. Inter-State Postgraduate Med. Assn. N. Am., 1937-1938.

7. Golob, M. : Infectious granuloma of intestines, with special reference to difficulty of preoperative differential diagnosis. M. J. & Rec., cxxxv :390-393 (April 20) 1932.

8. McMillan, F. L. : Ileocecal granulomas. Illinois M. J.,

lxxxi:15-21 (January) 1942.

9. Ralphs, F. G. : Chronic inflammatory tumors of intestinal tract. Medical Press, ccxvii :48-52 (January 15,) 1947.

10. Thompson, G. F. ; Sullivan, M. J. ; and Fox, P. F. : Blasto- mycosis of cecum; case report. Am. J. Surg., lvii:369-372 (Au- gust) 1942.

11. Wilbur, D., and Camp, J. : Amebiasis. Read Before Am. Gastro Assn., Atlantic City, N. J., 1946.

Published with permission of the Chief Medical Director, De- partment of Medicine and Surgery, Veterans Administration, who assumes no responsibility for the opinions expressed or conclu- sions drawn by the author.

THORACOPLASTY IN PULMONARY TUBERCULOSIS Leon J. Galinsky, M.D., Des Moines

It is the purpose of this presentation to pro- vide a reorientation concerning collapse therapy in pulmonary tuberculosis.

In general, it is the family physician who estab- lishes the diagnosis of the disease. Even though he may require special medical assistance in the procedure, it is to him that the patient turns for advice and reassurance. We could not hope for a better source for such information. Much of what we have to tell a patient must be given on faith — for we are dealing with laboratory reports that tell of acid fast organisms which we may not actually have seen, and we speak of x-ray shad- ows which are only interpreted to mean pulmonary tuberculosis. Similarly, the patient must accept “on faith” the diagnosis of pulmonary tubercu- losis and the instructions for his future conduct and management. His physician, whom he has voluntarily sought when symptoms presented, has the patient’s confidence and should be qualified to present a modern concept of treatment. If that physician can give the patient some adequate ideas

Presented at the preconvention clinical sessions, Broadlawns Hospital, Des Moines, Iowa, April 16. 1947.

concerning the medical problem of tuberculosis, much will be gained. If, on his entrance to the sanatorium, the patient meets the same views, in slightly different form, he is already prepared to accept treatment ; his confidence in his own physi- cian is strengthened ; and his introduction to the sanatorium regimen is facilitated.

Our concepts concerning collapse therapy are still changing. We believe that this development is sound and based upon factors supported both in the experimental laboratory and by careful clini- cal observation. In the term collapse therapy we include any procedure which has for its purpose the diminution of lung volume for control of an active tuberculous process. The objective, as is true of all therapy of tuberculosis, is to render the sputum free of tubercle bacilli and to arrest the activity of the process.

The primary indications for such treatment are the concurrence of both sputum containing tu- bercle bacilli and a demonstrable pulmonary cav- ity. It is true, however, that there are instances where collapse therapy is employed in cavitating tuberculosis when all the evidence favors a diag- nosis of tuberculosis, but sputum examinations do not reveal tubercle bacilli. On the other hand, we have advised certain collapse measures for patients who have positive sputum but in whom pulmonary cavity is not revealed by the usual methods of examination. Finally, there is a third important exception : the patient who, in spite of carefully controlled rest routine, has an unstable, slowly progressive lesion, disclosed by serial x-ray studies and a persistently negative sputum. The outlook is less favorable in such an individual unless he is supported by certain collapse measures.

Assuming that the patient has the prime requi- sites for collapse therapy, we must then suggest the procedure most suitable for his recovery. Not long ago, it was accepted that we try the mildest type. If it were unsuccessful, we would attempt the next more serious measure, and so on until we were driven to suggest a procedure which at one time was considered very hazardous. Our present approach is rather different. Three chief factors must be evaluated and interrelated before we can reach a suitable estimate.

First, there is the patient. We must still bear in mind that we are treating an individual with pulmonary tuberculosis. We are not caring for pulmonary tuberculosis per se, nor are we try- ing to cure a chest x-ray film of an abnormal shadow. The general condition and age of the patient as well as his home environment and eco- nomic status must influence our decision. We must determine how closely we can approximate the ideal of sputum conversion and arrest of dis-

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ease, yet allow the patient to lead a useful exist- ence.

What have we gained, if by our technical dex- terity we accomplish the first portion of our ob- jective only to find a dyspneic, helpless patient who cannot care for himself and who, because of limited respiratory capacity is destined to an in- stitutional existence for custodial care? What have we achieved if we control the disease so as to lengthen the patient’s life, if, by so doing, we overburden the cardiac mechanism and cause it to fail years before that event would normally take place ? Can we justify collapse therapy in a patient with emphysema whose respiratory reserve is already taxed ? Shall we attempt to close the cavity in patients in the older age groups — the late 60’s and the 70’ s — who have lived almost a normal life span and have achieved a biologic balance with the tuberculous disease? And what of the increased technical difficulties among such patients whose friable arteries may bleed freely — and where vascular channels close to a cavitv may be broken if the size and contour of the cav- ity are suddenly altered? The patient is the focal point of our discussion in selecting the appro- priate procedure.

Closely allied to this is the pulmonary status of the patient. Dyspnea is not necessarily a contra- indication to collapse therapy. Important studies in the realm of individual bronchospirometry have revealed interesting data and confirmed certain clinical suspicions. A contracted partially fibrotic lung is not a valuable organ for exchange of gases in the respiratory process. In addition, it may have drawn the heart and mediastinal structures toward that side of the thorax, putting undue tension on the less involved lung. A surgical ap- proach may be distinctly beneficial to such a pa- tient, through collapse of a relatively non-respiring lung, and return of the mediastinal structures to their normal positions. The pulmonary status, in particular the effective respiratory capacity, must dictate, at least in part, the amount of collapse therapy that the patient will tolerate.

Similarly, the possible complications of any col- lapse measures may be foreseen by an evaluation of the type of tuberculous process to be dealt with. If the disease is highly active and the lung is “crumbling away” under the assault of rapidly multiplying tubercle bacilli, gross bronchial ob- struction may result. Complete atelectasis may follow and the patient may be decidedly worse off than before. Attempts to collapse such a “hot lesion” may lead to even more rapid tissue necro- sis with additional dissemination of the bacilli throughout the lungs.

We should not undertake the induction of arti- ficial pneumothorax in such patients, lest, in addi- tion to atelectasis and bronchial dissemination, there should develop pleural infection with a sub- sequent tuberculous empyema.

A third determinant in the selection of collapse therapy is the expected end result. While our primary aim is to render the patient’s sputum free of bacilli through collapse of open cavity, and at the same time to preserve an effective respiratory capacity of as high degree as possible, our decision must again rest on the type of lung that will re- sult from our effort. If an entire lung must be collapsed by artificial pneumothorax in order to control a cavity near its apex, then such a patient might be better off with thoracoplasty. If the result of artificial pneumothorax is to be a fibrotic upper lobe, which cannot be expected to re-ex- pand, our choice should be thoracoplasty. If the entire lung is extensively diseased and cannot be returned to a normally functioning organ, we may well consider a pneumonectomy.

To recapitulate, factors determining our selec- tion of therapy are chiefly ( 1 ) the status of the patient; (2) the character of the disease process; (3) the results to be expected from the particular measures under consideration.

In the evolution of the therapy of pulmonary tuberculosis, interruption of the phrenic nerve and introduction of air into the pleural space have had a prominent place. More recently, doubt has been developing concerning each of these proce- dures. We object to immobilization of the dia- phragm, except temporarily, because, although it limits pulmonary expansion, it decreases the ef- fective self-cleansing mechanism of the basal por- tion of the lung. Secretions may be retained in this area to the future detriment of pulmonary function. The mechanism of cough becomes somewhat paradoxical and is incapable of empty- ing the lung, for the abrupt diaphragmatic relaxa- tion is an important element in the expulsive phase of cough. Our present attitude toward phrenic nerve interruption is that it may be used (1) in an indolent exudative type of process which shows little tendency to improve or may even progress on a routine rest regimen, and (2) to supplement artificial pneumothorax or pneumoperitoneum.

Artificial pneumothorax in experienced hands appears to be a simple treatment that has the ad- vantage of being continued on an outpatient basis. If we are presented with a small cavity and a free pleural space unobstructed by even localized ad- hesive bands, artificial pneumothorax may well be considered. If the infection reaches the pulmon- ary periphery, we must be wary of the occurrence

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of a tuberculous empyema — a complication which may be far more serious and difficult to control than the underlying pulmonary disease. In some instances the risk must be undertaken, as when we advise establishing a protective artificial pneumo- thorax on a less involved lung, before proceeding with extensive thoracoplasty on the other side.

Pneumoperitoneum, or the introduction of large quantities of air into the abdominal cavity, is indi- cated as a temporizing measure in cases of bi- lateral disease when we wish to give support to the patient over an observation period in order to determine which lung is in greater need of per- manent collapse.

These are all medical types of collapse therapy. Thoracic surgery’s advances have brought much hope to the tuberculous patient. Three major classes of procedures are available. ( 1 ) Primar- ily, there is thoracoplasty — the partial decostaliza- tion of the hemithorax in order to decrease lung volume either locally or generally. (2) Local col- lapse by separating manually the apical pleura from the endothoracic fascia and filling the space with (a) air — extrapleural pneumothorax, (b) paraffin, oil, or wax — plombage, or (c) more re- cently lucite balls. 1'his last material is now un- der popular trial — for a nonirritating light-weight filler has been made available to maintain the apical space without irritation or producing suffi- cient pressure to cause tissue necrosis. (3) Final- ly, surgical extirpation of a lobe or an entire lung has been under extensive trial in recent years and some of the results are heartening.

Thoracoplasty is a permanent, irreversible form of collapse therapy. The lung volume is reduced by the removal of costal segments of varying lengths. In the past decade the procedure has reached a degree of standardization. Methods may differ, but the manner of performing the operation in stages allows for progressive decrease in pulmonary volume in the area of greatest destruction.

From the standpoint of therapy of major tuber- culous lesions, thoracoplasty is a procedure of great importance. It provides a permanent col- lapse of a relatively limited portion of lung. The anticipated end-result is cavity closure and con- version of sputum to negative.

It is a major surgical procedure usually in- volving a series of three or more operative stages in as rapid succession as the patient’s condition will allow. Its effectiveness in experienced hands with suitable selection of patients has been dem- onstrated repeatedly. It is not a cure-all, and is not applicable to all patients. It is gaining dis- tinct preference over artificial pneumothorax and

is now being utilized even in lesions of limited extent and with small cavities.

Patients and their advising physicians must learn that such a series of operations should be carefully planned and prepared for. Tuberculo- sis is a serious disease and its treatment may neces- sarily involve major surgery. Yet there is a ten- dency for patients to want to run away when a surgical remedy is suggested. There is an equal tendency for them to seek a less drastic way out. They must be taught that the remedies offered are the result of an appraisal of the particular condi- tion presented, evaluated along the lines that have been discussed. With this type of selection and planning, with a skillful surgical team and anes- thetist, and with meticulous preparation and post- operative care, the results should be increasingly in favor of thoracoplasty for the therapy of pul- monary tuberculosis.

Conclusions

1 . The patient’s physician should be equipped to provide presanatorium orientation.

2. Factors to be evaluated in planning collapse therapy include :

a. The general status and respiratory capacity of the patient.

b. The character of the disease process.

c. The remote effects upon the lung of each form of treatment.

3. Thoracoplasty for selected patients can pro- vide a permanent, effective collapse of the involved portion of lung.

4. Thoracoplasty should be undertaken more frequently as the initial form of collapse therapy.

CONGENITAL GASTRO ENTERIC CYSTS OF THE THORAX:

A Review and Report of a Case

Joseph H. La Tona, M.D., Des Moines and

Francis C. Coleman, M.D., Des Moines

Gastro-enteric cysts of the thorax are relatively rare. In 1944, Olken collected eighteen cases from the literature and added one of his own. Two cases have since been reported by Schwarz and Williams, one by Wyllie and Pilcher, five by Ladd and Scott, one by Laipply, one by Steele and Schmitz, and one by Valle and White.

Of the thirty cases, 70 per cent were found in the right pleural cavity, 20 per cent in the pos- terior mediastinum, and 10 per cent in the left pleural cavity. Twenty-eight of these cases were

From the Department of Pathology, Mercy Hospital, Des Moines, Iowa.

Journal of Iowa State Medical Society

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in patients under the age of 29 months. The other two were discovered at the ages of 14 years and 23 years. Neither of these had produced symptoms. The origin of such cysts has been ascribed to the pinching off of a bud or a diverti- culum of the embryonic foregut, or to a persist- ence of a portion of the vitelline duct. The fol-

Fig. 1. Gastro-enteric cyst in right pleural cavity. The medias- tinum is displaced to the left, and the liver is displaced downward.

lowing case is unusual in that the gastro-enteric cyst was present at birth.

Case Report

Baby girl N. was delivered spontaneously at full term after a normal pregnancy on Oct. 20, 1946 ; very light anesthesia was required. Cyanosis ap- peared immediately after delivery but was relieved by oxygen administration. One hour after deliv- ery cyanosis reappeared in spite of continued oxygen. On physical examination no demon- strable expansion of the chest occurred with each respiration. No breath sounds could be heard on the right side of the chest. Dullness to percus- sion was present over the entire chest posteriorly. The abdomen was distended and the liver palpable three fingers breadth below the right costal mar- gin. Cyanosis became more marked and the respirations more rapid. The baby expired six hours and twenty minutes after delivery.

Fig. 2. Gastro-enteric cyst. Many adhesions are present on the outer surface.

Autopsy (Performed 7 hours after death)

The peritoneal cavity contained approximately 25 cc. of clear straw colored fluid. The dia- phragms were pushed down so that they were at the level of the eleventh rib on each side. The liver was also pushed down and the stomach, in-

Fig. 3. Gastro-enteric cyst wall. The wall consists of mucosa, submucosa, muscularis mucosae, a longitudinal and a circular muscular layer, and a serosa. Only part of the longitudinal muscle layer is shown : x 100.

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stead of lying inferior to the liver, was posterior to the left lobe of the liver. Examination of the pleural cavities revealed a shift of the mediastinum to the left. The left pleural cavity contained approximately 35 cc. of straw colored fluid. The right pleural cavity was filled by a cystic struc- ture measuring 11 cm. x 7 cm. x 4 cm. This cyst was adherent to the diaphragm below, to the mediastinum medially, to the great vessels of the neck superiorly, and to the vertebrae posteriorly. It extended upward into the neck so that it was within 0.5 cm. of the thyroid gland. Its most firm point of attachment was to the anterior sur- faces of the cervical vertebrae. This cyst was soft and contained clear mucoid fluid. No chemi- cal analysis of the fluid was made. Incidental findings were complete atelectasis of the right lung, 90 per cent atelectasis of the left lung, and a cen- tral interventricular septal defect of the heart.

Fig. 4. Mucosa of gastro-enteric cyst. Glandular formations are lined by columnar mucous secreting epithelium. Both chief cells and parietal cells are present ; x 440.

Microscopic examination of the cyst wall re- vealed it to be covered externally with a meso- thelial lining resembling pleura. Two layers of smooth muscle were present, one layer being longi- tudinal and the other circular. A muscularis mucosa was present. The mucosa consisted of well defined glands surrounded by a delicate stroma. The glands for the most part were lined by columnar mucous secreting epithelium. Both parietal and chief cells could be identified in some of the formations.

Summary

A congenital gastro-enteric cyst occurring in the right pleural cavity of a female infant is re- ported. These cysts usually occur before the age of 29 months and 70 per cent of them occur in the right pleural cavity.

BIBLIOGRAPHY

1. Olken, H. G. : Congenital gastro-enteric cysts of mediasti- num ; review and report of case. Am. J. Path., xx:997-1009 (Sep- tember) 1944.

2. Schwarz, H., II, and Williams, C. S. : Thoracic gastric

cysts ; report of 2 cases with review of literature. J. Thoracic Surg., xii:117-130 (December) 1942.

3. Wyllie, W. G., and Pilcher, R. S. : Intrathoracic cysts of

intestinal and bronchial structure. Arch. Dis. Childhood, xviii : 34-40 (March) 1943.

4. Ladd, W. E„ and Scott, H. W., Jr.: Esophageal duplica- tions or mediastinal cysts of enteric origin. Surgery, xvi:815-835 (December) 1944.

5. Laipply, T. C. : Cysts and cystic tumors of mediastinum. Arch. Path., xxxix :153-161 (March) 1945.

6. Steele, J. D.. and Schmitz, J. : Mediastinal cyst of gastric origin. J. Thoracic Surg., xiv :403-406 (October) 1945.

7. Valle, A. R., and White. M. L., Jr. : Thoracic gastric cyst. Ann. Surg., cxxiii :377-383 (March) 1946.

8. Lewis, F. J., and Thyng, F. W. : Regular occurrence of

intestinal diverticula in embryos of pig, rabbit, and man. Am. J. Anat., vii :505, 1907-1908.

9. Fitz, R. H. : Persistent omphalo-mesenteric remains ; their importance in causation of intestinal duplication. Cyst forma- tion, and obstruction. Am. J. M. Sc., Ixxxviii :30, 1884.

10. Black, R. A., and Benjamin, E. L. : Enterogenous abnor- malities; cysts and diverticula. Am. J. Dis. Child., li : 1126-1 137 (May) 1936.

11. Poncher, H. G., and Milles, G. : Cysts and diverticula of

intestinal origin. Am. J. Dis. Child., civ :1064-1078 (May) 1933.

12 Nicholls, M. F. : Intrathoracic cyst of intestinal structure. Brit. J. Surg., xxviii :137-143 (July) 1940.

ALLERGY IN OTOLARYNGOLOGY Oral L. Thorburn, M.D., Ames

The subject of allergy as it applies to otolaryn- gology is too large for consideration in detail here. It is my purpose to consider some of the allergic conditions commonly encountered in every- day practice with views on them expressed in re- cent literature. I want also to stress the impor- tance of considering allergy in every patient.

Most of the diseases we are called on to treat fall under the headings of trauma, deformities in development, new growths, infection and allergy. These all produce disturbed physiology. It is our job to determine which of these factors is caus- ing the symptoms. In many cases allergy plays the important role or modifies the other factors, and we cannot restore normal function unless it is given special consideration.

The incidence of allergy runs high. Vaughan1 estimates that at least 10 per cent of the popu- lation exhibits a major allergic manifestation some time in life. Shambaugh2 states that 70 per cent of chronic sinusitis and 90 per cent of chronic nasal infection can be shown to have an under- lying allergic factor responsible for the chron- icity. Kern and Schenck state that polyposis is always an evidence of allergy. Arbuckle says 50 per cent of sinus patients have an allergic back- ground. Meniere’s syndrome or endolymphatic hydrops is now being explained on an allergic basis. Many cases of otitis externa, some of otitis media and some of chronic catarrhal deaf- ness are being given an allergic etiology. The dis- turbing symptom of tinnitus is being considered in many cases an allergic manifestation. Headache

Presented at the Ninety-Sixth Annual Session, Iowa State Medical Society, Des Moines. April 16, 17, and 18, 1947.

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is often relieved best when considered as an al- lergic manifestation.

The manifestations of allergy in the ear, nose and throat are probably best summarized by Han- sel3 as follows : ear — external canal by eczema, urticaria, purpura, contact dermatitis ; eustachian tube by edema ; middle ear by edema ; internal ear by deafness, vertigo, tinnitus, edema; auditory nerve, the same ; nose by perennial nasal allergy and hay fever, hyperplasia, polyposis, edema ; para- nasal sinuses by hyperplasia, polyposis, edema ; mouth by chelitis, canker sores, stomatitis, edema, ulceration, hemorrhage ; pharynx, nasopharynx, and larynx by urticaria, hemorrhage, purpura, edema and ulceration. We must always be on the lookout for these more or less characteristic manifestations.

Our understanding of the allergic reaction is very incomplete. Some conceive that the reac- tion is in a sense a protective one having features in common with immune responses. In the al- lergic individual, however, there is over reaction in response to a variety of external and internal stimuli and symptoms result. These symptoms can be attributed usually to increased capillary permeability and resulting edema or to smooth muscle spasm or to both.

The exact mechanism of the allergic reaction in terms of tissue chemistry is also a matter of spec- ulation. At present it is believed by many that the union of antigen and antibody on the cell sur- face results in release of a substance which is similar to if not identical with histamine. This has been called H substance and it is thought to be immediately responsible for allergic reactions.

It is difficult to fit some of the manifestations of allergy into a concept of altered immunity and the histamine theory to explain the mechanism of the allergic reaction also has gaps in it. At pres- ent a broad viewpoint which is simply descriptive of allergy as we see it is probably most helpful clinically. Vaughan expresses such a viewpoint when he says that allergy represents a failure in adaptation to environmental influences such as pollens, foods, contactants, physical agents and bacteria. The common denominator of this fail- ure is not known but there is reason to think that it is influenced by heredity, that it is linked with a hyperexcitable autonomic nervous system and that it is subject to psychic influences and fatigue. With such a viewpoint we are prepared to consider the patient as a whole and to assess the many factors which play a part in an indi- vidual case.

Let us now consider the patient. He comes to us with certain complaints, usually referring them

to certain areas. He says his head aches or his nose is stuffy all the time, that he has to clear his throat frequently, his throat is sore, his ears ache, or that he is dizzy or deaf. It is best then to take these areas up one at a time.

First let us consider headache. You are all familiar with migraine. Perhaps this condition does not belong in our field but we see these patients all the time and must at least recognize the condition. Typically the attack is periodic with free intervals, preceded by visual aura ; is unilateral, incapacitating, accompanied by nausea and sometimes vomiting. But many cases do not follow this pattern. Allergy may not be found as a cause in all cases but it must be considered if one is to attempt treating these patients.

In addition to this typical migraine picture Wil- liams4 speaks of a vasodilating pain syndrome ; deep, unilateral, sudden in onset and associated with dilatation of the capillaries of the skin and conjunctiva on the homolateral side with edema of the lids and lacrimation. He believes this is brought on by sudden changes in temperature and by imbibing alcohol. He explains the allergic relationship by a physical or psychic stimulus im- peding the flow of blood in the capillary loops, in- terfering with nutrition and releasing histamine in the tissues thus causing the edema and pain. He states that this condition can be relieved by the use of niacin, a vasodilator. Certainly there is nothing much to be found on physical exami- nation of these patients, and one must get most of his information from the history.

Williams5 also describes what he calls “myalgia of the head” which is referred to by his patients as “sinus headache.” He believes this pain to be due to hyperplastic sinusitis which he says indi- cates a primary nasal allergy on which is en- grafted a secondary infection. He locates tender spots in the muscles of the head and neck and describes them in detail. These symptoms usu- ally occur in the third decade of life or later after an acute infection and are precipitated by expo- sure to drafts or emotional stimuli. The pain is deep and can often be reproduced by pressure over the tender muscle area or temporarily relieved by aspirin, but he gets good results by the use of niacin over a period of time.

Next let us consider tinnitus and deafness. Meniere’s Syndrome is now spoken of more de- scriptively as endolymphatic hydrops. There is an extracellular edema in both acoustic and coch- lear end organs. Grove6 states that it occurs in patients with an allergic history such as vasomotor rhinitis, asthma, etc. ; that there is vasomotor in- stability and increased capillary permeability. It

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occurs usually in the third, fourth or fifth decade and starts with violent vertigo, though it may start with deafness or tinnitus. The vertigo gives the patient the sense of whirling or of objects whirling about him and is aggravated by move- ments of the head. In intervals between attacks the patient feels good but may complain of a headache as an extra aural symptom. Sometimes there are preliminary aura such as fullness of the head, faintness, a burning sensation in tbe throat or tingling and numbness of the fingers. Miles Atkinson7 divides the patients with Meniere’s syndrome into two groups, those sensitive to his- tamine by intradermal test which he treats by his- tamine desensitization and those due to vaso spasm which he treats with nicotinic acid. Reduc- tion of fluids is also a factor in the treatment. Lawrence Farmer8 concludes in an evaluation of the histamine intradermal test as a general indi- cator of allergy that it is not possible to differen- tiate allergic from nonallergic individuals by this test.

Tinnitus is considered by Atkinson9 as a par- asthesia of the auditory nerve, symptomatic of an active pathologic disturbance of the auditory tract, a warning of impending deafness. He makes the statement that Meniere’s syndrome is no other than chronic progressive deafness with tinnitus complicated by a vestibular disturbance, and that 85 per cent of the cases of chronic pro- gressive deafness are improved with nicotinic acid.

Chronic otorrhea is occasionally due to allergy. Noun10 gives the history of two cases which cleared when treated for a food sensitivity. Gay11 recommends the treatment of residual lymphoid tissue in the naso-pharvnx by radium in cases of deafness which may have an allergic factor. In these cases there may be evidence of blocking of the tube only at the orifice.

The throat rarely enters into the symptomatol- ogy except in cases of angioneurotic edema or as a part of the complaint of allergic rhinitis when the patient is disturbed by the profuse mucous discharge and the resultant hawking and spitting. Sometimes there is a complaint of sore throat with no evidence of inflammation on examination ; this may be an evidence of allergy. Of course the trachea and bronchi enter into allergic changes resulting in a chronic cough and asthma.

By far the greatest percentage of patients with allergy coming to our offices have symptoms refer- able to the nose. These are the cases of hay fever and perennial allergic rhinitis and sinusitis. Vari- ous terms have been used to name the condition, for example — chronic catarrh, chronic sinusitis, atopic coryza, atopic rhinitis, perennial allergic

rhinitis, perennial hay fever, nasal allergy, sea- sonal hay fever, pollinosis, nasal asthma, vasomo- tor rhinitis. Perhaps allergic rhinitis is as good as any. These patients complain of a “stuffy nose,” especially at night. On arising they have a dry mouth, bad taste and foul breath, and they hack and clear their throat, spitting up thick mucus. They sneeze and blow their nose frequently and have a dull feeling or headache. They complain of morning fatigue and often have gastrointesti- nal symptoms. There is a marked tendency to chronicity. Shambaugh2 states that there is a marked contrast in the way of normal nasal and sinus mucosa recover from severe infections as compared to the allergic nose when hyperplasia is present. On examination the nasal mucous membrane may appear pale and edematous. This would be a characteristic picture. But many cases of nasal allergy do not exhibit this pallor. There is in some only a dull red intumescence of the turbinates with strands of mucus stretching across from septum to lateral nasal wall. If mu- copus is present there may be an accompanying infection. Polypi are almost a sure indication of allergy. Pathologically, the mucosa would show desquamating epithelium with increased number of goblet cells, thickening of the basement mem- brane, edema of the subepithelial connective tis- sue which is infiltrated by eosinophils.

Now that we have the patient’s complaint and have inspected the area involved and suspect al- lergy, what next? We must prove it as far as possible by a detailed allergic history, examina- tion of nasal smears for eosinophils and detection of the specific allergen by skin tests or elimination diet, so that we may know how to proceed with treatment. This may take more time or involve more investigation than we wish to give. If so, someone specializing in allergy should go on from here. Shambaugh2 recommends that the rhinolo- gist make his own allergic studies. He says that skin tests are useful but not always reliable as a means of diagnosis, that twenty to thirty tests are sufficient for the average case after reducing the possibilities by a careful history as to the influ- ence of season, surroundings, climate, diet, etc., that an elimination diet is usually necessary for the determination of specific food allergy and that sometimes it is necessary to try a therapeutic test such as desensitization with house dust, which he finds responsible in a large percentage of nasal cases. He uses as small an amount as .05 cc. of 1 :10,000,000 dilution as the initial injection. It is his aim to keep the patient in what he calls “aller- gic balance” by continued small injections.

In taking the history one must inquire into al-

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lergic manifestations in the family, such as eczema, hay fever, asthma and migraine and into childhood manifestations such as colic and eczema. The in- fluence of season and climate, the effect of indoors or outside air, the time of day the symptoms are most pronounced, the influence of fatigue and emo- tional conflicts ; these are all very important in limiting the possibilities and pointing to probable allergens. The psychic factor may be nonspecific but is a very important one in initiating and influ- encing allergic symptoms. Cedric Swanton,12 in discussing psychologic influences in the asthmatic child, quotes Urbach as saying that there are five times as many neurotic conditions among the al- lergic as among nonallergic individuals. He states that this would seem to justify the assumption that nervous instability constitutes a predisposing factor in relation to allergic diseases. Winfred L. Post,13 in discussing nasal psychosomatic syn- dromes accompanying and following acute anxiety in soldiers, states that the functional activity within the nose is a somatic reflection of the individual’s emotional state. I am sure I observed this rela- tionship among many unhappy soldiers. The inci- dence of what might be better termed hyperesthetic rhinitis in these cases seemed far greater than in civil life. Psychotherapy may be a very impor- tant part of the management of allergic cases.

The examination of nasal smears for the pres- ence and number of eosinophils is considerable aid in the diagnosis. A negative smear does not neces- sarily rule out allergy, but a positive smear makes the diagnosis certain. Blood eosinophilia, when found, also indicates allergy.

Dutton14 emphasizes proper technic in prepar- ing and staining nasal smears. He feels that we fail to utilize them to the fullest degree because of difficulty in recognizing poorly stained eosino- phils, and suggests the following technic : nasal mucus is obtained by swab or by blowing into waxed paper, then smear is made on a clean slide and dried by air and not flame. Flood slide with thin film of eosin solution, immediately wash in tap water; alcohol and acetone decolorizing solution for 10 seconds; wash in tap water again. Cover with methyline blue and again tap water , the whole procedure taking about thirty seconds. When dry, examine first with low power then oil immersion. Repeated smears may be necessary.

Skin tests are best done intradermally using those allergens suspected from the history. They are more reliable when testing for inhalants than foods. Elimination diets are usually necessary to determine food allergy. King15 states that he commonly tests for feathers, house dust, orris root, wheat, milk, eggs, chocolate, dander, tim-

othy and ragweed and that there are very few cases where allergy is based on infection. It takes judgment and experience to interpret skin reac- tions and for that reason they are probably best made by the allergist.

Now we come to the treatment of our patient. From the foregoing it is quite obvious. Some temporary relief may be obtained by the use of antihistaminic drugs such as benadryl and pyri- benzamine. These are chiefly valuable to give the patient some relief while further investigations are made. Avoidance of guilty foods or inhalants may be successful. Hyposensitization by extracts is helpful in other cases. In all cases the man- agement of contributing factors such as sudden changes in temperature, physical and mental ex- haustion endocrine imbalances and emotional storms is very important.

Conclusions: Allergy is a frequent manifesta- tion in the practice of otolaryngology. Tt must be recognized as a possibility in every patient. By complete management we have the means of giving relief to a high percentage of patients. bibliography

1. Vaughan, W. T. : Practice of allergy. St. Louis, C. V.

Mosby Company, 1939.

2 Shambaugh, G. E., Jr. : Nalas allergy for practicing rhin-

ologist. Ann. Otol., Rhin. & Laryng., liv :43-60 (March) 1945.

3. Hansel, F. K. : Allergy in otolaryngology and its relation to other manifestations ; general considerations. Ann. Otol., Rhin. & Laryng., xlviii :54-72 (March) 1939.

4. Williams, H. L. : Syndrome of physical or intrinsic allergy of head. Proc. Staff Meet. Mayo Clin., xxi :58-64 (February 6) 1946.

5. Williams, H. L. : Syndrome of physical or intrinsic allergy of head; myalgia of head (sinus headache). Proc. Staff Meet. Mayo Clin., xx:177-183 (June 13) 1945.

6. Grove, W. E. : Evaluation of Meniere’s disease. Trans.

Am. Laryng., Rhin. & Otol. Soc., 330-346, 1941.

7. Atkinson, M. : Meniere’s syndrome: basic fault? Arch.

Otolaryng., xliv:385-391 (October) 1946.

8. Farmer, L. : Evaluation of histamine intradermal test as general indicator of allergy. J. Allergy, xvi :44-47 (January) 1945.

9. Atkinson, M. : Tinnitus aurium : observations on effect of

curare on loudness level. Ann. Otol., Rhin. & Laryng., lv:398- 405 (June) 1946.

10. Noun, L. J. : Chronic otorrhea due to food sensitivity. J. Allergy, xiv :82-86 (November) 1942.

11. Gay, L. N. : Treatment of residual lymphoid tissue in naso- pharynx by radium. J. Allergy, xvii :348-351 (November) 1946.

12. Swanton, E. : Asthma and other psychophysical inter-rela- tions. Med. J. Australia, i : 138-145 (February 1) 1947.

13. Post, W. L. : Nasal psychosomatic syndromes accompanying and following acute anxiety. Ann. Otol., Rhin. & Laryng., (December) 1946.

14. Dutton, L. O. : Nasal and sputum smears. Ann. Allergy, iv -.138-140 (March-April) 1946.

15. King, E. : Colds, sinusitis and allergy. Cincinnati J. Med., xxv:495-500 (January) 1945.

AMERICAN CONGRESS OF PHYSICAL MEDICINE MEETING

The Midwestern Section of the American Congress of Physical Medicine will hold its annual sectional meeting and seminar Feb. 26-27, 1948, at the Vet- erans Administration Hospital, Hines, 111. Registra- tion will start at 10 a. m. February 26. A seminar on spinal cord injuries will follow at 11 a. m. The program includes conducted tours of the physical medicine rehabilitation activities at the hospital. All sessions will be open to physicians, other pro- fessional personnel and their guests.

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College of Medicine State University of Iowa

CLINICOPATHOLOGIC

CONFERENCE

December 8, 1947

Summary of Clinical Record

This 58 year old man was admitted to the hos- pital on June 12, 1947. His illness began eight years previously when, after a rest period follow- ing a game of baseball, he experienced weakness of the left lower extremity. He was examined in the hospital in 1940, at which time he exhibited weakness of the left lower extremity and impair- ment of vibratory sense, two-point discrimination and position sense on both lower extremities, more severe on the left.

Gradually over the next few years he devel- oped increasing difficulty in walking, and both lower extremities felt numb. He noticed that when he immersed his left leg in tepid water, the water felt unusually hot. Six months previous to admission he began to experience a band-like sensation in his upper abdomen. This discom- fort was particularly severe on the left side. He denied backache or any aggravation of his discom- fort when he coughed or sneezed. There was slight disturbance of the function of his bladder in that he experienced difficulty in starting the urinary stream. The hearing in his left ear had been poor since an automobile wreck 34 years pre- viously, when he also experienced a paresis of the left side of the face.

He was an obese man weighing 220 pounds with normal temperature. His pupils were round and equal, and reacted well to light and accommoda- tion. His uncorrected vision was 20-40 in each eye. The ocular fundi were normal. There was a slight droop of the left side of the face, and the hearing was reduced to an estimated 80 per cent of normal in the left ear. Examination showed the tongue and palatal muscles to be nor- mal. His neck was strong, and anteflexion of the neck did not aggravate the difficulty with his lower extremities. Physical examination of the heart was not unusual ; the blood pressure was 170-110. Abdominal examination was normal. His spine was straight, flexible and nontender. Situated at the dorsolumbar junction was a sub- cutaneous nodule which measured 8x6x4 cm. There was weakness and atrophy of the small muscles of the hands. Both lower extremities

were hypertonic and ataxic, but there was no selective atrophy of the legs, and no fibrillary tremors were observed. The biceps reflexes were hyperactive, the abdominal and cremasteric reflexes were absent, knee reflexes were very hyperactive, the Achilles reflexes wrere diminished, and the response to plantar stimulation was extension. Vibratory sense was absent on both legs, the trunk and both little fingers. Pain and thermal sensations were absent on the right lower extrem- ity and impaired on the left. Impairment of pain and thermal sensations extended up as high as the second dorsal dermatome. Sensation of light touch was impaired very little over these several areas. His gait was spastic ataxic.

The urine was negative for albumin and sugar. Serologic tests on the blood were negative for syphilis. The hemoglobin was 14 gm., the leuko- cyte count 9800 per cu. mm., and the blood smear showed no unusual findings. X-ray films of the cervical, dorsal and lumbar spine were normal except for advanced hypertrophic changes in the dorsal and lumbar regions. An x-ray film of the chest revealed calcification of the pleura in the left base. A spinal puncture was performed in the lateral horizontal position. The fluid was slightly^ yellow in color, contained 3 monocytes per cu. mm., 2 plus globulin, a total protein of 102 mg. per 100 cc., and a negative Wassermann. Tbe rise and fall of the fluid in the spinal mano- meter were very slow when the jugular veins were compressed and released. On June 26, 5 cc. of lipiodol was instilled into the cisterna magna. The column of lipiodol was delayed at the fourth cer- vical level in its passage down the spinal sub- arachnoid space. Below this point the contrast medium was irregularly distributed down to a level corresponding to the first dorsal vertebral region.

On June 28 a laminectomy was performed from the third to the seventh cervical regions, inclu- sive. The bone and dura mater looked normal. On palpation, the dural sac felt tense. The dura was incised longitudinally. Many string-like ad- hesions presented between the arachnoid and dura. The arachnoid was thickened and milky. The cervical spinal cord was clearly enlarged, reducing the subarachnoid space to about a millimeter in depth. Over the surface of the spinal cord were many moderately enlarged tortuous and freely intercommunicating blood vessels, most of which appeared to be arterial in character. All aspects of the cervical canal were inspected, and extra- medullary pathologic processes were excluded. Anomalous blood vessels were seen over the an- terior as well as the lateral and posterior aspects

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of the cord. The posterior median line of the cord was incised, and a grayish, granular looking tissue was demonstrated. A tiny biopsy was taken. It was felt that the intrinsic tumor was nondemarcated and therefore inoperable. Closure was carried out.

Two days following operation a neurologic sur- vey disclosed no positive findings other than those recorded preoperatively. The patient ran an ir- regular febrile course with variation between 101 and 103 F. and corresponding increases in pulse and respiratory rate. This unstable elevation of vital signs persisted, although gradually receding, until the patient’s death sixteen days after opera- tion. The patient voided urine voluntarily on the second postoperative day. However, the same difficulty in micturition noted preoperatively pre- vailed, for which reason the patient was kept on

Fig. 1. Large vessels over cord.

“tidal drainage." A second visceral dysfunction took the form of abdominal distension. Because of the persistent febrile state, penicillin was insti- tuted on the fifth postoperative day. The opera- tive wound appeared healthy and all sutures were removed at the end of the first week. The tend- ency for tympanitic distension of the abdomen was combatted with enemas, the infra-red lamp, rectal tube and intramuscular injections of sur- gical pituitrin. Beginning on the fourth post- operative day, the patient ate well.

There was no essential change in the patient’s condition except for a gradual lysis of febrile state until midnight between the fifteenth and six- teenth postoperative days. At this time he be- came somewhat dvspneic. At 7:30 a. m. on July 14 he became apprehensive. He complained only of shortness of breath, asserting that he had no pain anywhere. He grew ashen, cyanotic, cold and clammy. The temperature at this time was 99 F., the pulse rate 88 per minute, and the respiratory rate 40 per minute. Blood pressure was 90/70. Mentally he was alert and clear.

Neurologic examination disclosed no additional findings. By percussion, the heart was found slightly enlarged to the left. The tones were weak and muffled. An occasional extra-systole was ob- served. The lungs were clear. The abdomen was somewhat distended but was soft and exhibited no masses or tenderness. The patient could ex- pel flatus. Ephedrine, gr. Y\, was given intra- muscularly, followed by morphine sulphate, gr.

A supportive glucose infusion was started. The patient expired at 8 :50 a. m.

Clinical Diagnosis

Intra-medullary cord tumor

Intrathecal hemangioma

Necropsy Findings

The principal lesions were in the cervical por- tion of the spinal cord. The cord was greatly enlarged in this area and its surface was covered by large dilated blood vessels (fig. 1). These had prominent muscular walls, and each was many times larger than the normal spinal artery. On cross section the cord substance was seen to be honeycombed with cystic spaces (fig. 2.) The surrounding cord tissue was compressed and showed gliosis in microscopic section. The cystic cavities had no definite epithelial lining, but a single cell layer could be made out in some areas. These cells resembled ependyma. The cystic spaces did not communicate with each other. There were about 6 such spaces. The remaining cord structures showed myelomalacia and atro- phy. The cord architecture was greatly distorted.

The heart was both dilated and heavy. It weighed 500 gm. (normal 360 gm.), and there was considerable hypertrophy of the myocardial fibers. The coronary arteries showed advanced sclerotic changes but no definite occlusions could be demonstrated. A large recent myocardial in- farct occupied the apex and lateral wall of the right ventricle. Masses of thrombus material were adherent to the endocardial surface in this area. Organization was proceeding at the base of the thrombus.

The bronchial tree contained bits of aspirated food material. Several large, tangled masses of old fibrin were found in the right pulmonary artery. These occluded the artery close to its origin. A previous embolus had apparently lodged in this same vessel since a large, rather old infarct was found in the posterolateral portion of the upper lobe.

The viscera were all congested. The spleen and liver were heavy as a result of this conges- tion. Incidental findings included a stone in the lumen of the gallbladder and chronic inflamma-

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tion in its wall. Extensive old fibrous adhesions between the lungs and chest wall obliterated the left pleural space.

Necropsy Diagnosis

Syringomyelia, cervical and dorsal cord with extensive myelomalacia.

Arteriosclerosis, severe, with coronary sclerosis.

Myocardial infarct with mural thrombus right ventricular wall.

Massive pulmonary embolism.

Pulmonary infarct, right lung.

Myocardial hypertrophy and dilatation.

Visceral congestion.

Chronic cholecystitis with cholecystolithiasis.

Pleural adhesions, extensive, left.

Dr. A. L. Salts (Neurology) : This patient was 50 years old when his neurologic difficulty began. His illness started after a period of exertion and was characterized by weakness of his left lower extremity. Approximately one year later he was examined in this clinic ; by that time the situation had progressed to the point where both lower ex- tremities were affected.

From the diagnostic standpoint, one might con- sider several diseases which are likely to occur at this stage of life. In the first place, syphilis could have produced this same situation. Multiple sclerosis occasionally begins at the age of 50 and is characterized by the same symptomatology. A spinal cord tumor should be considered in an individual who presents a picture of this sort. He preferred at that time not to enter the hos- pital and was not examined for a period of sev- eral years. Gradually over the period of the next few years, symptoms indicating an ascending type of sensory loss began to make their appear- ance.

When he was admitted on June 12, 1947, he was found to have a droop of the left side of the face and a reduction of the hearing. These were sequelae of an old injury, apparently. It was noted that the blood pressure was slightly elevated, but the routine physical examination of the heart was normal. The findings which were present at that time indicated spastic and ataxic lower extremities and a dissociated type of sens- ory loss. In other words, deep sensation (vibra- tion, two-point discrimination and position sense) were very severely impaired. These sensory find- ings were elicited as high as the little fingers. Pain and thermal sensations were absent on the right lower extremity and impaired on the left. Interestingly, light touch was not very much affected.

In other words, there was a very selective type of sensorv loss in this particular situation. The

urine was negative for albumin and sugar ; all tests for syphilis were negative. The x-ray ex- amination of the spine revealed nothing unusual in the plain films. The spinal puncture gave us

Fig. 2. Dorsal cord : syringomyelia.

definite evidence that a lesion in his spinal canal was blocking the flow of the spinal fluid. The fluid was slightly xanthochromic in appearance ; the total protein was elevated, and the rise and fall of the fluid in the spinal manometer was de- layed appreciably so that we felt that there was justification for the use of a contrast medium such as lipiodol (fig. 3).

Again we have the same general problem com- ing up as far as the diagnosis of this case is con- cerned. In reconsidering the differential diagno- sis, syphilis has now been practically excluded by the fact that his Wassermann tests were negative in blood and spinal fluid. Multiple sclerosis is eliminated because of the disturbance in the spinal fluid dynamics. We are left with the diagnosis of spinal cord tumor.

One’s attention is now directed to the question of intrinsic or extrinsic spinal cord compression. Clinically, it is not always an easy matter to dif- ferentiate the two. Frequently the best that one can do clinically is to make the diagnosis of a tumor and then to determine exact level of that tumor by using contrast medium. In this instance the diagnosis of spinal cord tumor of the cervical level was made, but the question as to whether this was extrinsically or intrinsically situated was not entirely settled. The results of the lipiodol examination are evident in figure 3. At operation, as indicated in the protocol, this patient exhibited a large number of dilated vessels of a racemose type situated over the surface of the cord. Dr. Meyers was kind enough to call me at the time he had this cord exposed at operation. It was our opinion that this spinal lesion was probably angio- matous in nature. Angiomatous lesions of the spinal cord may have dilated vessels over the sur-

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face, vessels which worm their way in and out of the spinal cord.

Dr. E. D. Warner (Pathology) : The other find- ings were those of generalized arteriosclerosis and congestion of all the viscera, as you would expect

Fig. 3. These two spot films demonstrate lipiodol within the spinal canal in the region of the lesion. The irregular filling de- fects are due to the dilated blood vessels over the cord. Because of this an x-ray diagnosis of hemangioma was made.

with his massive pulmonary embolus. He died of the complications of arteriosclerosis with myo- cardial infarction, with pulmonai-y infarction, and massive pulmonary embolism. As perhaps the agonal event, the tracheo-bronchial tree was full of aspirated vomitus.

Dr. Russell Meyers (Neurosurgery) : It was

the consensus that we were dealing with an intra- medullary lesion. The major reason for assuming that the patient did not have an extramedullary tumor bore reference to the fact that pain and tenderness were so inconspicuous a part of the patient’s history. The patient had no radicular pains, nor did he have any local pains in the re- gion of the cervical or upper thoracic spine. Neither did he have any intensification of discom- fort on coughing and sneezing, bending, lifting and straining. Likewise, anteflexion of the neck failed to evoke an intensification of discomfort. It ought to be emphasized, however, that none of the cri- teria which were relied upon with such confidence twenty years ago in clinical neurology can be re- liably substantiated as the means of differentiat- ing between intramedullary and extramedullary lesions. It not infrequently happens, however,

that an individual with extramedullary lesion has a good deal of pain, and on the other hand that one with a similar lesion may have had no pain or tenderness at any time in his course. Now the presence or absence of pain is generally taken to be one of the criteria by which we may infer whether a lesion is intramedullary or extramedul- lary ; that is, the absence of pain and tenderness may be taken as probably indicating the presence of an intramedullary rather than extramedullary lesion. Pain is much more likely to be inconspicu- ous when an extramedullary lesion is located in the anterolateral or anteromedial portions of the spinal canal, that is — remote from the dorsal and dorsolateral disposition of the nerve roots that convey sensory impulses into the cord.

Aside from the matter of pain and tenderness as related to the locus of the lesion, I think we can derive a second lesson from this case. This may be introduced by observing that neurologic signs and symptoms are as they are simply be- cause there has been a disturbance of a neuro- physiologic mechanism. Such a disturbance will be very much the same irrespective of the etio- logic agent which induces that disturbance. More specifically, in spinal cord problems, we encounter changes in deep and superficial sensation, deep and superficial reflexes, motor status, motor pow- er, and vegitative functions as represented by the anal and bladder sphincters. Likewise, we en- counter changes in coordination and integration of movements. These dysfunctions are all of the same clinical character whenever a given neuro- physiologic mechanism is disturbed and that irre- spective of the cause. It is on such a concept that one might postulate on clinical grounds the pres- ence of a tumor when in point of fact he is actu- ally dealing with a degenerative or dysplastic type of disease, of which syringomyelia is a prominent example. Whether we are dealing with vascular, congenital or degenerative disease, with neoplasms, infectious processes of virus, pyogenic or whatever origin, or whether we are dealing with traumatic lesions, the signs and symp- toms will be similar and one may not reliably infer from clinical considerations alone the etio- logic agent responsible for that disturbance.

There is another lesson we can derive from this case. Upon laminectomizing the cervical region, a large expanded cervical cord was encountered occupying almost all of the available canal. On the surface of the cord — laterally, dorsally and ventrally — there was a complicated snarl of cavern- ous blood vessels. These cavernous vessels sug- gested that we were dealing with an inoperable angiomatous type of lesion. Operation in such

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cases is likely to produce a complete tetraplegia, for once the operator gets into the substance of the lesion he encounters fragile vessels and pro- duces intrinsic hemorrhage in the cord at every new step of his procedure. When the patient has even a small amount of function remaining, the surgeon does wisely in exercising a policy of conservatism. This was the guiding principle em- ployed in this case once we were satisfied that we were dealing with an inoperable intrinsic lesion. As you now know, the blood vessel lesions were ultimately demonstrated to be chiefly on the surface. Such a finding is, in my expe- rience, a nonspecific process.

A third point deserves emphasis in this case. This has to do with the traditional clinical story of syringomyelia. If one were to ask the average clinician for a “trick" mnemonic device to be applied to the clinical manifestations of syringo- myelia, the response he would get would be sensory dissociation. This pathophysiologic manifestation is generally supposed to be the characteristic feature of springomyelia. It is asserted that the syringomyelic patient exhibits a dissociation of perception such that pain and thermal sensations are blotted out, whereas tactile sensation is com- monly preserved. This notion is posited on two concepts, the first of which has to do with the physiology of the spinal cord and the second of which has to do with an erroneous concept of the pathology of syringomyelia — the notion that the latter is characterized by a cavitation in the center of the cord.

The notion arises that an “enlargement” of the central canal knocks out the pain and thermal fibers which are coursing through the ventral commissure on their way to the thalamic tract. Clearly, such a lesion leaves undisturbed those tactile fibers which are disposed in the dorsal columns. The phenome- non of sensory dissociation is conceived to arise in such a fashion. The major difficulty with the con- cept as applied to the present case is that syringo- myelia is not a disease of the central canal of the spinal cord. The lesion or lesions are eccen- tric in their onset. The disorder as far as we now know begins in the glia as a degeneration. Several such vacuolized areas may approach one another and coalesce, in time encroaching upon or displacing the central canal. The rather rarely encountered condition in which there is actually a dilatation of the central canal should not be called “syringomyelia” but “hydromyelia.” Our present knowledge forces us to regard this as a quite dif- ferent pathologic process from that of syringo- myelia. The eccentric character of springomyelia is well represented in our present case.

There is one final point. The pathologic exam- ination revealed that this man had evidences of coronary and pulmonary complications. Yet no- where in his course did we encounter a full- blown clinical picture of such lesions. Even when he entered upon his pre-agonal hour he had no pain. This leads us to speculate on the reasons why this may be. He exhibited dyspnea early in the morning of the sixteenth postoperative day, and by 7 :30 a. m. he had become highly apprehensive and complained of shortness of breath. However, when inquiry was directed at the acutely developing problem he asserted that he was experiencing no pain anywhere. He grew ashen, cyanotic, cold and clammy and showed the often-encountered picture of an individual enter- ing upon his pre-agonal hour as a result of a cardiac or pulmonary catastrophe. We are led to observe that a patient may have the characteris- tic apprehension without pain being a primary factor in its production. We may speculate on whether the damage evident in the pathologic cross sections of the cord effectively interrupted the visceral ascending pathways, thus blotting out pain of either pulmonary or cardiac origin or both.

Dr. Salts: I have a few things more to add to the picture as presented to you by Dr. Meyers. First of all, I will mention the age group in which syringomyelia ordinarily is encountered. As you know, it is a disorder which generally ap- pears in young adulthood, but the fact that it does appear at the age of 45 or 50, or even be- yond that time, is not entirely surprising. I would certainly emphasize what has been said about the irregular nature of these lesions and would sub- stantiate entirely the statement that this is not primarily a lesion of the central canal of the spinal cord. In numerous sections studied one can al- most invariably find a central canal which looks quite normal, or one which is pushed to one side by the presence of these cystic areas. You may ask what causes these cysts to develop. That question is not so easily answered, but perhaps several statements about the associated lesions might give one some slight clue as to what is going on in these cases. If one looks through the literature one finds many case reports in which other lesions have been present elsewhere in the body or in the central nervous system, a few of which are asymmetrical mammary glands, pigeon breast or outwardly curving sternum, and scoliosis ( which is a very commonly associated or resultant finding). In one of our cases an Arnold-Chiari malformation was found. Other lesions which have been reported in association with syringo- myelia include cervical ribs, Sprengel’s deformity and spinal cord tumors of various types. In pub-

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lished reports of spinal cord tumors there are some instances in which spinal cord tumor had produced most of the trouble, but in the course of the investigation syringomyelia was found as well. One of our cases had multiple tumors, neurofibromata, and had rather definite syringo- myelic lesions in the spinal cord. Incidentally, these lesions may be present in the brain as well. They may sweep up through the medulla and have been reported even as far superiorally as the ven- tricular system.

Now a word or two about the typical symp- tomatology seems to be in order. Remember this is an asymmetric type lesion. The trouble gen- erally starts on one side of the body — usually in the cervical region. The lower extremities may be involved first. One of the first things an indi- vidual notices is that he will have some impair- ment of thermal and pain sensation. The history from these patients is to the effect that they will burn themselves usually on a cigarette without knowing it. That same loss of pain and sensation may be present in other portions of the body. Associated with this pain and thermal loss will be involvement of the other tracts, particularly the dorsal columns and the corticospinal pathways. One must think of this disease as groups of lesions scattered rather indiscriminately throughout the cord but involving the posterior portion of the cord first of all or most severely of all. Often these cystic lesions will be situated from the me- dulla down to the sacral region.

Dr. Warner: I would like to add one comment to this case relative to the cardiac lesion in that this again is a case of myocardial infarction which not only did not have pain but also did not have a coronary occlusion. The coronary arteries were sclerotic, they were narrowed, but they were not occluded. There was no complete obstruction of a coronary artery of sufficient size to account for this infarct, nor was there any lesion which could have acutely increased the narrowing of the ves- sel of the size that it would have to be to account for the size of the infarct.

CORRECTION

The Journal apologizes for an error in the num- bering of illustrations which appeared in the article, “One Stage Resection of the Sigmoid Colon with Primary End-to-End Anastomosis for Malignancy: Case Report” by Leonard C. Hallendorf, M.D., which was published in the December issue. What read as figure 2 should have been 3, figure 3 should have been 4, and figure 4 should have been 2.

SPECIAL ARTICLE

THE PRICE OF GOVERNMENT MEDICINE

Fred Sternagle, M.D., West Des Moines

The desire for security is a natural human instinct. Like all good things, however, security has a price. That price is work, saving, and planning for the future. Some people believe our government should relieve us of this respon- sibility. We have already delegated old age se- curity and unemployment security. Sickness security appears to be the next step.

All the security we desire may be found in Alcatraz — at the price of freedom. It follows, therefore, that if we desire government spon- sored security we must consider its character, its price in dollars, and its price in the individual rights that we must surrender to our govern- ment.

The past decade has seen much agitation for a national plan of unlimited medical care regard- less of economic status or ability to pay. To this end, numerous schemes have been proposed, some of which are vigorously promoted by a group of subordinate but powerful government employees in Washington. The price of any such scheme will he paid by the taxpayers. It behooves us, then, to count the cost and appraise the product.

1. We pay the price in losing the privilege of being treated when and as desired. The plan is to socialize medicine and place the federal gov- ernment in the position of a dispenser of medical services. This scheme will never be practical because everyone has a different idea about sick- ness and its treatment. When asked what he expects as a recipient of medical service, the average person replies, “Taking care of me when I am sick.” We accept this popular idea of medi- cal care. For administrative purposes, the gov- ernment must decide who is and who is not sick, even though sickness is not always a specific con- dition but only an opinion arrived at between pa- tient and physician after consideration of the facts. Conclusions will be as numerous and contradictory as there are people and doctors.

The definition of the word “care” would have to carry a designation of what constitutes proper treatment in a particular illness, an impossibility inasmuch as there are as many ideas as we have physicians, cults, and healers. Any attempt, therefore, on the part of our government to regulate and pay for medical services, where the

Vol. XXXVIII, No. 1

Journal of Iowa State Medical Society

23

necessity for such services is often vague and the treatment ill-defined, would invite injustice, irreg- ularity, public controversy, and dissatisfaction, no matter how sincere the effort of enforcement. The American people, unlike continental peoples, are traditionally not subservient to authority, par- ticularly when they disagree with its motives and methods.

2. We pay the price in liberal contributions to political plunder. The majority of nationalized medicine plans propose to treat everyone entitled to medical care, whether he actually requires it or not. The people reasonably anticipate a plan which would assure them adequate medical atten- tion in event of prolonged and serious illness. They do not anticipate services to victims of hys- teria or hangover. Yet this is a huge item when we consider that 80 per cent of those who come to a doctor’s office for services are suffering from minor illnesses and imagined disabilities, from which they would recover in a short time without any medical attention. I do not contend that these people should be denied medical attention at their own expense ; the cost to any patient would not be prohibitive, unless he permitted him- self to be exploited by some mercenary quack. I do contend, however, that including this group in any government plan would invite administra- tive problems beyond the ability of any civic authority to solve fairly. Consider the large number of people with questionable illnesses who spend annually about three billion dollars for med- ical service — about 60 per cent of our nation’s medical care bill. Consider further the inclusion of such groups in a nationalized medical care plan. Then imagine the possibilities of exploitation by the political combines with which nationalized medicine must necessarily be associated.

3. We pay the price in surrendering care dur- ing sickness to political opportunities. Any plan depending on a bureaucratic directive for its ad- ministration invites political intrigue, particularly when the execution of that plan involves spending huge sums of money for poorly defined purposes. The American people are known to tolerate and condone more crooked politics than any other democratic nation in the world. The deleterious effects of political cunning on medical service would filter down through the bureaus directing medical care and their subordinate offices. If the supporters of nationalized medicine realized that they were banishing the family physician into sub- serviency to a political machine and surrendering their lives and health to political opportunists, they would never favor the proposal.

4. We pay the price in sacrifice of the infor-

mal doctor-patient relationship. The distribution of medical care under a nationalized scheme would necessitate ration boards or bodies whose function would be the same under any other name. Most Americans are familiar with the operations and shortcomings of such boards. There is a difference between medical services and automo- bile tires. An applicant for help in sickness, es- pecially in an emergency, would have to estab- lish his priority over 80 per cent of other appeals for similar services by individuals whose illness may be largely imaginary. Furthermore, proof of an emergency in any illness is not always appar- ent until service by a doctor has been rendered. Even that proof is everchanging, because people often get worse or better very quickly. These are only a few of the problems a ration board must face. In such a system, imagine the plight of an individual who has used up his stamps only to find himself suddenly and seriously ill at 2 a. m. on a Sunday morning, without a red stamp, the ration board closed until Monday morning at 9 a. m. and the board itself is not meeting until the following Wednesday evening.

The use of ration boards to regulate medical services would mean that an illness which today is a private matter between the patient and the physician of his choice will become, through the ration board, public business. The physician’s responsibility would shift from the patient to the ration board, which would tell him when to treat and even how to treat. It has long been recog- nized that the introduction of a third party into the relationship between a sick patient and his physician is not good medical practice.

5. We pay the price in increased cost of medi- cal care. Proponents of socialized medicine have estimated the cost of such a program as being about six billion dollars anuallv and have recently admitted that this amount may not be sufficient. These figures are based on experience tables for the cost of medical care six years ago. It is rea- sonable to assume today that even twice this amount would not be sufficient to carry out these socialistic plans : first, because of the reputation our government has for wasteful and inefficient spending ; second, the added administrative costs attendant on such a program ; third, the increased demand for services and prolonged attention, which must be anticipated when people have the idea that it is not costing them anything; fourth, because medical men, if regimented to work on salaries, might, like other wage earners, demand an 8-hour day and a five-day week.

6. We pay the price in surrendering the priv- ilege to endure a handicap or illness in secrecy.

24

Journal of Iowa State Medical Society

January, 1948

There are many people holding responsible jobs or enjoying good reputations whose status would be jeopardized if the public were aware of their ailments. It is a heritage of the American peo- ple to be treated in secrecy if they so desire, and to iron out any difficulties arising from physical incapacity on a strictly private basis between them- selves and their physician. This right is upheld by our courts under the rules of privileged com- munications, which a physician must not divulge except in unusual circumstances. If the govern- ment is to designate the person who shall receive medical care then that patient must divulge his reasons for desiring care, and his doctor will be required to make carbon copies of the procedures and diagnoses, which will be distributed all the way from the local ration board through various other offices to Washington in full view of every inquisitive person who desires to make it his business to read them. Furthermore, the neigh- bors would be vitally interested in one’s illness, 'especially in regard to how many trips the doc- tor made, because they would share in the pro- gram and pay part of the bilk One could also anticipate being accused of receiving more at- tention than he deserved, with the result that some snooping official or unofficial investigator will be watching from behind a telephone pole or calling at the home. For alleged infractions of rules, patient and doctor would be subjected to the embarrassment of a public investigation or at least one attended by enough people to make it public.

7. We pay the price in losing the choice of a physician. Socialized medicine plans allegedly provide for a free choice of a physician. This freedom is largely illusory. There are not enough physicians to go around and half of them are supplying two-thirds of our country’s overbur- dened medical services, which will increase under the stimulus of a nationalized medical plan. It is proposed to divide this work up evenly among doctors by incorporating a quota system, with the result that there would be only half enough desirable physicians to go around. In choosing a physician, there will be a two-to-one chance that the choice must be made from a list of the more undesirable and incompetent doctors, particular- ly if the patient happens to be just a common man without influence.

8. We pay the price in losing the human ele- ment in medical services. Whenever a physician cannot adminster to his patients as conscience and circumstances dictate, but is responsible to a higher directive for all his acts, he loses his in- centive to practice humanitarian medicine. Autoc- racy does not recognize the necessity of sympathy

and measures a physician’s value only by purely scientific achievements that can be reported on a piece of paper. A medical hireling would look on his patients as he looks at a piece of machin- ery. The kindly but not necessarily scientific art of honest medicine, with its administrations of sympathy and assurance, has cured as many ills and relieved as much suffering as the laboratorv or operating room.

The art of medicine is well established as an important part of the American way of life. A subscription to political medicine would mean the consignment of body and soul for its preservation in times of illness to the type of services found in the cold corridors of a court house.

The American people desire adequate medical care in times of critical illness, not such services as are offered by schemes like the Wagner-Mur- ray-Dingell bill, which proposes to take care of everything from hangnails to dandruff. Any plan so universal that it includes free care for minor or imagined illness is a reflection on the sponsor’s knowledge of the character of medical service and the circumstances under which such service is rendered. On the other hand, if these ideolo- gists insist that they are aware of these condi- tions and persist in an all-inclusive program as proposed in these bills, it becomes our privilege to suspect them of political machinations.

Socialized medicine will require huge sums of money for the distribution of many services of a questionable value. It will offer unprecedented opportunities for the acquisition of power. Many men desirous of power have seen this opportunity and are vigorously working for the adoption of these schemes in order to advance their present position to that of commissar of our nation’s health and well being. The total regimentation of physicians and their facilities under a govern- ment controlled plan that would furnish medical care to everyone for everything is a first cousin to Communism. It is indeed deplorable that the Reds and pseudo-liberals have chosen for their approach the appeal that goes with a service dedi- cated to the preservation of life.

There are people who really need medical help and to whom our nation is trying to extend a helping hand. Under our system of free enter- prise such persons have available a variety of medical service and hospital plans which will sup- ply them with every reasonable need in times of critical illnesses. If, however, these people do not voluntarily avail themselves of one of these opportunities, then it may be necessary for our government to direct medical services in serious or prolonged illness, but not for every human ail-

(Continued on page 31)

Vol. XXXVIII, No. 1

Journal of Iowa State Medical Society

25

STATE DEPARTMENT OF HEALTH

BRUCELLOSIS OF MAN IN THE UNITED STATES AND IN IOWA

Data pertaining to the reported incidence of bru- cellosis of man or undulant (malta) fever in the United States have been made available through courtesy of state health officers of the forty-eight states and through Public Health Reports of the United States Public Health Service. Knowledge as to symptomatology, month of onset and dura- tion of illness ; residence, occupation, age and sex of patients ; history of contact with livestock, use of dairy products (whether raw or pasteurized) and probable sources of infection — these and other items of information have been generously fur- nished over a period of years by Iowa physicians and veterinarians. The fact that human illness from this cause is currently at a high level (870 cases in 1947, through December 6, compared with an annual average of 396 cases for the seven year period 1940-1946) calls for ever closer coop- eration of all agencies and individuals concerned, in the pursuance of measures for effective control and eventual eradication of brucellosis in farm animals.

Reported Occurrence in the United States

For the decade 1930-1939, reported cases of brucellosis of man in the United States, exclusive of the District of Columbia, averaged 2,386 cases per year, an annual rate of 1.99 per 100,000. Average annual reports totaled 4,078 during the period 1940-1946, or a rate of 3.11 per 100,000 population. This represents an increase of nearly 60 per cent in reported morbidity in the past seven years compared with the previous 10-year period.

The following table (Table I) presents the aver- age annual total of cases of brucellosis of man and the average annual rates per 100,000 in the vari- ous sections of the United States for the fourteen year period 1930-1943 and the seven year period 1940-1946.

While nearly all of the individual states showed an increase in reported cases of brucellosis in recent years, North Carolina, the state with the lowest morbidity rate and significantly the only

table i

BRUCELLOSIS IN THE UNITED STATES 1930-1946 Reported Morbidity Data Secured through Courtesy of State Health Officers and from Published Reports of the U. S. Public Health Service

Average

Average Annual Annual

States Annual Rate per Cases Annual

Area Cases 100.000 1940-1946 Rate

New England 175.5 2.08 274.5 3.25

Middle Atlantic 355.1 1.29 426.0 1.55

East North Central 487.7 1.83 807.0 3.03

West North Central. .. 507.6 3.76 933.3 6.90

South Atlantic 209.1 1.22 288.5 1.68

East South Central 105.6 0.98 204.7 1.89

West South Central 436.1 3.34 598.4 4.58

Mountain 82.6 1.99 142.9 3.44

Pacific 248.4 2.56 403.9 4.15

U. S. A. TOTAL 2,607.7 1.09 4.079.2 3.11

state thus far accredited in the program for eradi- cation of brucellosis in dairy cows, had a rate of 0.4 per 100,000 for the years 1930-1941 and of only 0.3 per 100,000 for the seven year period 1940-1946. Hogs apparently are but a minor source of infection in that state.

The ten states with the highest morbidity and the rates per 100,000 for the periods 1930-1946 and 1940-1946 are shown in Table II which fol- lows :

TABLE II

BRUCELLOSIS OF MAN IN THE UNITED STATES 1930-1946 Ten States with Highest Reported Morbidity for the 17-year Period 1930-1946 and the 7-year Period 1940-1946 1930-1946 1930-1946

Annual rate Annual rate

State per 100,000 State per 100,000

Vermont	T-, . . 11.7	Vermont ....	18.5
Iowa	9.4	Iowa	15.6
Oklahoma ....	7.7	Kansas	9.6
	7.0		9.5
Texas	5.8	Oregon	6.9
Minnesota ....	5.7	Texas	6.9
Arizona	4.5	Wisconsin . . .	6.5
Wisconsin ....	4.3	Connecticut .	5.4
	4.2	Utah	5.1
Oregon	4.1	Nevada	4.8
Reported Occurrence in Iowa The annual morbidity rate from	brucellosis

Iowa for the five year period 1935-1939 was 5.31 per 100,000. Due largely to increased pork and livestock production during World War II, with attendant increase in occasions for direct contact with animals, the rate rose to 15.6 per 100,000 for the seven year period 1940-1946.

The following table (Table III) contains an- nual totals of positive agglutination reactions as notified from the Iowa State Hygienic Laboratory

26

Journal of Iowa State Medical Society

January, 1948

and of case reports in this state for the period 1940-1946 and thus far in 1947.

table III

BRUCELLOSIS OF MAN IN IOWA 1949-1947 Annua] Case Reports and Positive Agglutination Findings

Positive

Reported Agglutination

Year Cases 1-80 and above

1940 250 577

1941 354 691

1942 333 834

1943 418 646

1944 295 849

1845 482 1,045

1946 638 1,981

1947 871 (12-6-1947) 2,176 (1st 9 months)

In 1946, in addition to the 1,981 agglutination reactions in titers of 1-80 and above, serum speci- mens numbering 766 showed a doubtful reaction of 1-40. For the first 9 months of 1947, besides the 2,176 positive agglutination findings (see Table III), additional specimens with a doubtful titer of 1-40 totaled 819. The marked increase in positive laboratory reports for the current year is due in large measure to pre-employment and routine agglutination tests on packing house work- ers. in view of the new occupational disease law which went into effect beginning Oct. 1, 1947.

Seasonal Distribution of Brucellosis

The State Department of Health is indebted to Iowa physicians for detailed information rela- tive to persons who have during past years suf- fered illness caused by brucellosis in animals. The distribution according to month of onset of illness

of 2,882 cases of brucellosis of man reported to the Iowa State Department of Health for the fourteen year period 1933-1946 is shown in the following table.

BRUCELLOSIS OF MAN IN IOWA 1933-1946 Distribution of 2,882 Reported Cases by Month of Onset of Symptoms

Month of	No. of Cases	Month of	No. of Cases
Onset	1933-1946	Onset	1933-1946
January	169	■July	325
February	222	August	314
March	208	September . . .	219
April	266	October	234
May	259	November ....	189
Jute	316	December ....	161
total . .

As may be observed in the above table, undu- lant fever is definitely a disease, onset of which may occur in any month of the year. More pa- tients have beginning symptoms during June, July and August than at any other similar period ol the year. About 60 per cent of the patients be- come ill during the six month period, April through September, and 40 per cent from Octo- ber through March.

Considering separately the month of onset of illness of individuals who give no history of con- tact with farm animals, the cases are distributed quite uniformly throughout the 12 months. Of a series of 509 such cases reported during the six year period 1941-1946, patients numbering 270 or 53 per cent developed illness during the warm months, April through September, while 239 (47 per cent) began to complain in the fall and winter months ( October-March ) .

MORBIDITY REPORT

Disease Diphtheria Scarlet Fever .. Tvphoid Fever	Nov. ’47 16 ..152 1 0	Oct. ’47 4 52 14 0	Nov. ’47 19 119 2 0	Most Cases Reported From Howard, Muscatine, O’Brien Polk, Story, Webster Pottawattamie
Measles	58	32	33	Lee, Muscatine, Winneshiek
Whooping Cough	79	84	76	Des Moines, Dubuque, Lee
Brucellosis	67	85	173	Black Hawk, Polk, scattered
Chickenpox	204	47	384	Black Hawk, Des Moines, Dubuque
German Measles	9	4	5	Des Moines, Johnson, Tama
Influenza	4	1	1	Mitchell
	0	4	2
Meningitis	6	4	7	Scattered
Mumps	82	52	54	Linn, Pocahontas
Pneumonia	4	4	19	Black Hawk, Ida, Tama
Poliomyelitis	18	41	96	Clay, Polk, Woodbury
Tuberculosis	58	68	63	For the State
Gonorrhea	...113	106	153	For the State
Syphilis	355	221	135	For the State

Vol. XXXVIII, No. i

Journal of Iowa State Medical Society

27

<JU JOURNAL <4 tU

Iowa State Medical Society

ISSUED MONTHLY

Everett M. George, Editor Des Moines

Viola M. Turnbr, Assistant Editor Des Moines

EDITORIAL BOARD

JOHN W. Dulin Iowa Oity

Horace M. Korns Dubuque

Ernest E. Shaw Indianola

Emil A. Futllgrabe. . Sioux Oity

PUBLICATION COMMITTEE

Everett M. George. Editor Des Moinee

John 0. Parsons, Secretary Des Moines

John I. Marker, Trustee Davenport

Walter A. Sternberg, Trustee Mount Pleasant

Lee R. Woodward, Trustee Mason City

SUBSCRIPTION $3.00 PER YEAR

Address all communications to the Editor of the Journal, 505 Bankers Trust Building, Des Moines 9

Office of Publication, Des Moinis e, Iowa

Vol. XXXVIII JANUARY, 1948 No. 1

Another Year Ahead

Again it becomes the privilege of the editorial staff of the Joltrnal to express to its readers best wishes for the coming year.

As is customary in postwar periods, 1947 was not unusual in its quota of unrest. Although no national compulsory health bill was passed by the Congress, political activity continued strong in Washington to further governmental medicine.

The year was marked by an excellent survey of the state needs as outlined in the hospital con- struction act, with definite recommendations for the building of several badly needed county hos- pitals.

A revision of the salary schedule as applied at the medical school at Iowa City is a factor which has attracted much attention. The committee on medical education and hospitals has made a report to the State Society regarding this matter.

The cancer control division of the State Depart- ment of Health has been unusually active with the establishment of clinics throughout the state for cancer control. The Department has also been active in the control of tuberculosis through the use of mobile units which are available to any county society.

The Committee on Medical Service and Public Relations has arranged for signing the contract for home town care of veterans by family physi- cians. The Speakers Bureau likewise has been busy carrying out its program of postgraduate institutes.

At this time it is considered appropriate to pre-

sent the following toast prepared by Dr. Edward A. Holyoke, the first president of the Massachu- setts Medical Society, on Aug. 13, 1928, on the occasion of his one hundredth birthday : “The State Medical Society — may it flourish and pros- per. May it continue to improve the art for which it was instituted, to the utmost of its wishes, and be the means under Providence of alleviating the pains and evils of life, and promoting the happi- ness of Society by suppressing Quackery, and rendering the business of the profession as perfect as the nature of things admits. And may each in- dividual of the Society enjoy health and prosperity in the pressing consciousness that he has con- tributed somewhat to the advancement and im- provement of the public. welfare.”

Dr. Womack Professor of Surgery

The State University of Iowa College of Medi- cine has announced the appointment of Dr. Nathan Womack of St. Louis, Mo., as professor in the Department of Surgery.

Dr. Womack, who was born in Reidsville, N. C., May 24, 1901, was graduated from the University of North Carolina in 1922 and received his M.D. degree from Washington University two years later.

Most of his training was obtained in St. Louis where he was associated with Barnes Hospital as intern and resident. In 1929 he served as a traveling European fellow following which he re- turned to the Department of Surgery at Washing- ton University School of Medicine where he has been the professor of clinical surgery.

Dr. Womack was a founder member of the American Board of Surgery in 1937 and has been a member of the examining committee since 1942. He is a member of the editorial board of the An- nals of Surgery. In addition to his usual county medical affiliation, he is a member of the Southern Medical Association, St. Louis Surgical Society, American Surgical Association, Southern Surgical Association, American Association of Pathology and Bacteriology, American Gastroenterological Association, American Association for Cancer Re- search, Society of Experimental Biology and Medicine, Society of Clinical Surgeons, Halsted Club, Central States Surgical Association, Society of University Surgeons, Fellow of the American College of Surgeons, and Societe Internationale de Chirurgie.

The Journal takes this opportunity to welcome Dr. Womack to Iowa and to extend best wishes for his success at the State University.

28

Journal of Iowa State Medical Society

Penicillin Reactions

It has been apparent ever since its use that penicillin will produce skin manifestations and other toxic reactions in certain individuals receiv- ing the drug. Another side reaction has recently made its appearance. This is a clinical toxic pic- ture resembling pyogenic infection with daily chills, septic type of temperature and malaise. These reactions have appeared in surgical patients where no evidence of wound infection was appar- ent. One patient had undergone removal of a herniated disk following which a spinal fusion was performed. Another patient had undergone a prostatectomy. A third case, a child, was given penicillin empirically for an obscure myelopathy. In all three of these patients, the fever, chills and malaise promptly subsided upon discontinuance of penicillin.

It is not unusual to see patients who have been receiving penicillin for weeks and months. In view of these side reactions, it might be well to remember that certain individuals may develop toxic manifestations from the use of penicillin.

Nurses’ Aid Training

The Rohlf Memorial Clinic at Waverly has in- stituted a definite course for training practical nurses. The state of Minnesota is conducting a similar program in several of its county units. This type of training is commendable in that it will afford some relief from the drastic need for nurses which now exists.

The program at the Rohlf Clinic consists of : ( 1 ) therapeutics, including toxicology and allied subjects, 18 hours — taught by a registered phar- macist; (2) nutrition — health and diseases, in- cluding the preparation and serving of foods, 24 hours — by M.D. ; (3) maternity and child care, 18 hours — by M.D. ; (4) postoperative care and practical surgical technic, 6 hours — by M.D. ; (5) common diseases, causes and manifestations, 12 hours — by M.D. ; (6) educational films, including nursing care, practical physiology, nutrition, etc., 24 hours — by M.D. ; (7) nursing arts, 86 hours — by R.N.; (8) ethics, 12 hours — by R.N. ; (9) rec- reational therapy, 12 hours; (10) hospital work including class work, 340 hours; (11) ward con- ferences, one per week for nine months, conducted by supervisor or head nurse in each department ; (12) hospital service, total of nine months, forty hours per week, including class work.

In addition these girls are uniformed in a dis- tinctive manner and will receive a local certificate at the time they have completed their work. Edu- cational movies rented from the extension division

January, 1948

of the State University of Iowa are used weekly in the classroom.

It will be interesting to follow the success of this particular training program in Iowa.

HOSPITAL COMMITTEE OF H.S.I.I.

The Hospital Committee of Hospital Service, Inc., of Iowa has proved to be of inestimable value in hospital relations with our Blue Cross Plan. It has been functioning since 1945.

The first Board of Directors of H.S.I.I. was com- posed of a majority of Iowa Hospital Association members with representatives of the Iowa State Medical Society. This was a natural outgrowth of the labors of these associations to set up the Blue Cross Plan and to get enabling legislation for it. Very soon after the Plan went into operation the hospitals saw the need for putting business men on the Board. These were selected from their trustees and boards, which almost without exception have attracted the civic leaders in their communities. Con- sequently, this brought the best business minds of the area to the Board of H.S.I.I.

The Board of Directors itself is made up of 15 representatives of the hospitals, Iowa State Medical Society and the public. Twelve of these are elected by the hospital corporate members and three by the Iowa State Medical Society. Of the 12, eight are representatives of the hospitals and four of the pub- lic. Two of the Medical Society members are doctors and one represents the public.

In 1944 problems arose to indicate that a closer contact with the practical operations of the hospitals themselves was desirable, and the president, Joseph F. Rosenfield, appointed the first Hospital Committee. The purpose of the committee is to interpret to the Blue Cross Plan the needs and desires of the mem- ber hospitals as far as Plan policies are reflected in their operations and to aid in reporting to the mem- ber hospitals the purposes, policies and decisions of the Board of Directors of the Plan.

This committee is chairmaned by a member of the Board of Directors, Harold A. Smith, administrator of the Atlantic Memorial hospital, Atlantic, but otherwise is composed of administrative personnel of other member hospitals. The present members of the committee in addition to Mr. Smith are: Robert A. Nettleton, former administrator of Iowa Meth- odist hospital, Des Moines; Glen E. Clasen, assistant to the administrator of University Hospitals, Iowa City; Erwin W. Wegge, business manager of Moline Public Hospital, Moline, 111.; Rubie M. Carlson, su- perintendent, Allen Memorial Hospital, Waterloo; Sister Mary Edmunda, superintendent, St. Joseph Mercy Hospital, Dubuque, and Mrs. Rose Jacobs, su- perintendent, Skiff Memorial Hospital, Newton.

Pertinent subjects discussed by the hospital com- mittee have been monthly reports of Blue Cross to the hospitals, hospital employee groups, national enrollment, methods of payment to the hospitals, reciprocity agreements, proprietary hospitals and problems and interpretation of the subsci'iber’s con- tract.

Vol. XXXVIII, No. 1

Journal of Iowa State Medical Society

29

SPEAKERS BUREAU

Herman J. Smith, M.D., Des Moines, Chairman Robert N. Larimer, M.D., Sioux City Horace M. Korns, M.D., Dubuque

Ben F. Wolverton, M.D., Cedar Rapids L. C. Hickerson, M.D., Brooklyn

SPEAKERS BUREAU SERVICES

The Speakers Bureau provides, upon request, the following:

1. Speakers to discuss suggested subjects at meetings of county or district medical societies and lay organizations.

2. Assistance in planning and conducting postgraduate courses and institutes.

3. Medical and health films for professional and lay groups.

The Bureau also sponsors a medical program broadcast weekly over radio stations WOI, Ames, and WSUI, Iowa City.

The purpose of the Speakers Bureau is to render service. Requests for help are wel- comed. Contact Speakers Bureau, 505 Bank- ers Trust Building, Des Moines 9, Iowa. Tele- phone 3-0928.

MOVING PICTURE AVAILABLE

“The Problem Child,” a 16mm. sound and moving picture film has been written and produced by the American Academy of Pediatrics for distribution, free of charge, to responsible medical and lay organ- izations. The picture requires about twenty-five minutes running time. It covers a few of the com- mon problems of growth and development and stresses some of the environmental factors, especial- ly parental attitudes, which influence mental health. Feeding schedules, food habits, toilet habits and discipline of the two year old child are discussed and portrayed in the picture.

The Speakers Bureau will make arrangements for the use of this film upon request. Please list the date you would like to show the picture and allow a month for your order to be handled.

PLANS FOR 1948

With the start of a new year, the Speakers Bu- reau is planning a continuation of its educational efforts and an expansion of services to members of the State Medical Society. We hope that 1948 will bring about a reactivation of county medical so- cieties; that they will have more meetings; and that there will be a greater participation in scien- tific and educational programs. The pressure of work has been great upon every doctor but we should realize the need for a certain amount of social contact with our colleagues as well as a brushing up on new technical advances. The Speak-

ers Bureau believes that when men sit down to- gether at dinner and later participate in a scien- tific program each individual departs a better doctor. It is because of that conviction that the Speakers Bureau is planning its postgraduate course and educational institutes for the spring months.

A pediatric and obstetric institute will be held in Fort Dodge on Thursday, March 25, and at Sioux City on Thursday, May 6. Burlington is planning a cancer institute sometime after the first of the year and also a postgraduate course to be given the nights of April 28, May 5, and May 12. A post- graduate course of five lectures will be held at Creston starting March 3. They are as follows:

POSTGRADUATE COURSE— CRESTON

James G. Macrae, M.D., Local Chairman Iowana Hotel

March 3 The Treatment of Diabetes Mellitus Henry T. Ricketts, M.D., Chicago, Associate Professor of Medicine, University of Chicago. March 10 RH Factor in Obstetrics

William C. Keettel, M.D., Iowa City, University Hospitals, Department of Obstetrics and Gyne- cology.

March 17 Gastro-intestinal Diagnosis

J. Dewey Bisgard, M.D., Omaha March 24 Heart Block and Use of Quinidine

Horace M. Korns, M.D., Dubuque March 31 Encephalitis, Cerebral and Peripheral Nerve Diagnosis

Speaker not yet scheduled.

If there are other counties desiring any type of course or institute, the Speakers Bureau will be happy to hear from them. Best results are obtained when we have two months or more in which to pro- cure speakers. Please don’t ask us to arrange a course on a month’s notice, for a good job cannot be done in that length of time.

SPEAKERS BUREAU RADIO SCHEDULE WOI — Wednesdays at 2:45 p. m.

WSUI — Thursdays at 11:45 a. m.

Jan. 7-8 Winter Illnesses — Frostbite

Donald F. Rodawig, M.D., Spirit Lake, Iowa Jan. 14-15 Winter Illnesses — Common Head Cold Elmer P. Weih, M.D., Clinton, Iowa Jan. 21-22 Winter Illnesses — Influenza

H. M. Hurevitz, M.D., Davenport, Iowa Jan. 28-29 Winter Illnesses — Pneumonia

Elmer G. Senty, M.D., Davenport, Iowa

30

Journal of Iowa State Medical Society

January, 1948

NEWS NOTES

from the

Committee on Medical Service and Public Relations

American Academy of General Practice

There are several exciting causes of the pres- ent awakening of the general practitioner from the state of lethargy which has enveloped him throughout the past and brought him at long last to the realization that unless the large number of doctors who are doing general practice (85 per cent) are brought together in an organization founded on solid unquestioned principles, the status of the general practitioner will be rele- gated to that of the various cults which attach themselves to the fringe of the medical profession.

Today the great trend in medicine is toward specialization. That trend has become so preva- lent, especially in the cities, that even the lay- man, when he meets a doctor elsewhere than in the office, immediately inquires what specialty the doctor practices.

A doctor spends ten years in premedical, medi- cal, and internship education. Some may argue that this is sufficient preparation to begin working for a specialty board membership. However, this training, regardless of how thorough, does not produce the one attribute most needed in practicing the healing art — judgment. Judgment comes only from continuous daily contact with medical, surgical, and obstetric problems which sharpen the intellect, develop the power of ob- servation, and broaden generally the young doc- tor’s understanding of human nature.

When a conscientious and honest contractor contemplates erecting a building, he begins by selecting a firm footing. On this footing he builds a foundation and puts into it every known vehicle of strength and durability. In the building of a doctor T believe his premedical and medical work represents the footing, while his internship, residency, and at least five years of general prac- tice constitute the foundation. With that on which to stand he is equipped to continue in gen- eral practice or begin intensive work for some specialty of his choice.

General practice has no grievance with spe- cialization. and I do not believe that the specialist depreciates the great need for high type, well trained doctors doing general practice. Each is

needed by the other. But when hospitals begin closing their doors to a doctor unless he is a diplomate of some specialty, and government starts the agitation for socialization of medicine, it is high time counter activities are begun.

The first attempt at general practice organiza- tion was made in Wayne County, Michigan, some fifteen years ago. The project, being then some- thing quite new, was at first frowned upon and termed bolshivistic, communistic, and ultraradi- cal ! But after many serious and unselfish con- ferences with specialist leaders in the Wayne County Medical Society, of which Detroit is the hub. all selfish interests and personalities were put aside, the general practitioners received places on the Council, and Dr. W. B. Harms became president of the Wayne County Medical Society. Incidentally, to Dr. Harms of Detroit belongs most of the credit for this early organization work. Through the efforts of Wayne County, a General Practice Section was established in the Michigan State Medical Society.

Through both of these organizations, resolu- tions were presented to the House of Delegates of the American Medical Association for five years before a Scientific Section on the General Practice of Medicine was finally established. The Section on General Practice of the American Med- ical Association is primarily a scientific section but it does have a delegate to the House of Dele- gates who can introduce any resolution to that body from the Scientific Section. At the San Francisco meeting a resolution was introduced for the recognition of general practice sections in hospitals. It failed. However, in San Fran- cisco last year the general practitioners present at the scientific session recommended that a na- tional association of general practitioners inde- pendent of the American Medical Association be formed on a basis similar to the various specialty colleges. Whether the doctors from long suffer- ing were more eager to grasp the lifeline of gen- eral practice organization at this time than at other times in the past I am not prepared to say. It seemed to click, however, and at once activi- ties throughout the country began. Independent

Vol. XXXVIII, No. 1

Journal of Iowa State Medical Society

.31

sections during the past year have been formed in San Francisco, Los Angeles, Cincinnati, Min- nesota, Louisiana, and in my own city of St. Louis.

In St. Louis great enthusiasm has been shown in establishing the Section on General Practice of Medicine of Greater St. Louis. We have at present more than 200 paid members and I am sure we will add another 100 during the coming year. My reasons for such optimism is that with our present roster of exceedingly prominent speak- ers I fail to understand how a doctor in our area can afford not to be a part of the Acedamy. Also, in May of this year the Executive Council began publishing a news letter, entitled “News and Views,” which sets forth all worth-while items and events which might be of medical interest.

All the foregoing naturally leads to the crown- ing event in general practice organization. That took place at the American Medical Association meeting in Atlantic City. At the San Francisco meeting in 1946 the general practitioners there assembled decided to create an association out- side the American Medical Association for doc- tors in general practice. Dr. Paul Davis of Akron, Ohio, was elected temporary chairman. A com- mittee was instructed to draw up a constitution and by-laws to be presented to a meeting of all general practitioners attending the convention at Atlantic City in June of this year. Between 150 and 200 doctors in general practice met on the evening of June 10, 1947, listened to the read- ing of the constitution and by-laws, and voted unanimously for their adoption. Officers were elected, the name for the organization decided, and without fanfare or disturbance there came into existence the American Academy of Gen- eral Practice.

Everyone left Atlantic City imbued with a kind of exalted spirit of achievement and from the president through all the officers and dele- gates there seems to be the desire to make the American Academy of General Practice second to none in medical organization through the entire country. A recent communication from Dr. Davis states that applications for membership are com- ing in at the rate of 100 to 150 a week.

If socialized, state, or government controlled medicine is thwarted, it will and must be done through the organization of that great 85 per cent of doctors in general practice, and the unselfish cooperation of that organization with all special- ist groups.

Robert C. MeElvain, M.D., St. Louis

THE PRICE OF GOVERNMENT MEDICINE

(Continued from page 24)

ment. The administration of such a plan, how- ever, should not be in the hands of our federal government but left to the states, each to work out its own medical care problem to comply with its peculiar geographic or environmental situation.

Socialized medicine, political medicine, or what- ever it is called, has a price too high in inherited liberties. It can never approach in value the benefits of the present system of free enterprise.

AMERICAN COLLEGE OF SURGEONS

ANNOUNCES SIX SECTIONAL MEETINGS

Dr. Arthur W. Allen, president of the American College of Surgeons, announces the scheduling of six sectional meetings in 1948 for Fellows of the College, the medical profession at large, and hos- pital personnel. Each meeting will be two days in length and will include conferences for hospital per- sonnel as well as sessions for the medical profes- sion. The showing of medical motion pictures will begin each day’s program at 8:30 a. m. There will be luncheon meetings each day and a dinner meeting on the first evening. The latter will be followed by a symposium on cancer. Panel discussions on scien- tific subjects, led by internationally known authori- ties in each field of surgery, will be held each morn- ing and afternoon. The list of meetings follows:

Toledo — January 20-21, Commodore Perry Hotel.

Atlanta — January 26-27, Ansley Hotel.

Oklahoma City — Jan. 30-31, Oklahoma Biltmore Hotel.

Denver — March 1-2, Cosmopolitan Hotel.

Minneapolis — March 15-16, Hotel Nicollet.

Halifax — May 17-18, The Nova Scotian.

Among the subjects to be discussed at the scien- tific sessions will be fractures of the upper and lower extremities; pediatric surgery; importance of the use of blood and fluids and of adequate nutrition in surgery; early diagnosis and proper treatment of cancer; organization and functioning of cancer clinics and cancer detection centers; intestinal ob- struction; management of wounds, surgical incisions and fresh traumatic wounds; urologic surgery; plas- tic surgery; vascular surgery; and panel operations on elderly patients with special reference to the reduction of the surgical risk.

Among the subjects which will be discussed at the hospital conference will be the increasing use of hospitals ; expansion of hospital facilities ; higher standards of training for hospital ad- ministrators ; improvement in personnel policies ; increasing cost of hospital service ; better rural hospital service ; coordination of hospital with health and welfare activities in the community; Blue Cross and medical service plans, and de- creasing average days’ stay in hospitals.

32

Journal of Iowa State Medical Society

January. 1948

VETERANS ADMINISTRATION

Medical Department, Des Moines Hospital

The medical department of the Veterans Hos- pital in Des Moines, like the other professional departments of the institution, strives to attain one goal : to give each veteran entitled by law to medical care the best available medical serv- ice. This is a difficult goal to reach, for medi- cal science is vast and new and better methods of handling the sick are constantly being devel- oped.

In order to give the sick veteran the best pos- sible medical care to the end that he may be restored to health with the least delay if his illness is curable, or be made as comfortable as care and science can make him if his disease is in- curable, the available space at the Veterans Hos- pital has been divided into the following wards :

( 1 ) diseases of the chest and vascular system ;

(2) gastro-intestinal and metabolic diseases; (3) infectious diseases; (4) general medical ward; (5) neuropsychiatric ward; (6) convalescent ward. Each ward has a bed capacity of from forty to fifty.

The professional personnel consists of a chief of medicine, three consultants in internal medi- cine. five ward physicians, two full time Veterans Administration physicians, and from ten to fifteen resident physicians. The chief of medicine and the consultants have held certificates from the Board of Internal Medicine for some time. All the ward physicians have passed either all or part of their Board examinations. The residents are carefully selected, well trained men who are acquiring more knowledge and experience as they strive to practice ideal medicine on the ward.

During the year which is now' coming to a close we have had approximately 2,900 admittances to the department of Medicine, and the average stay in the hospital has been about twenty-eight days — this in spite of the fact that we maintain a convalescent ward for persons who should have domiciliary care but who cannot be sent to domi- ciliary homes because beds are not available for them.

Without the slightest bit of doubt the most effective factor for the promotion of the practice of ideal medicine in this institution is our resi- dent training program. This program increases the knowledge and experience of each participant in direct proportion to his individual participation

in it. Since the residents take the most active part they naturally benefit most, but the benefits accruing to ward physicians, consultants, and the chief of medicine are also great. And every bit of applicable new knowledge at once redounds to the patient’s benefit.

The training program consists of general staff meetings on Monday, medical ward rounds on Tuesday, clinical-roentgenologic conferences on Wednesday, clinicopathologic conferences on two evenings a month on Thursday, reviews of recent literature twice a month on Thursday, and medical conferences on Friday. In addition, each resident who is not actively engaged in clinical research of his own is required to write a summary of the re- cent literature on a subject of his own choosing every three months. At the present time six of the residents in medicine are devoting part of their time to various clinical research problems of their own choosing.

This training program is available to all physi- cians in Des Moines and to all visiting physicians, and all are welcome to attend and participate in our discussions. It is felt that such visits will be beneficial to the medical personnel of the in- stitution as well as to the visiting physicians.

Daniel J. Glomset. M.D.

MINUTES OF MEETINGS OF STATE SOCIETY OFFICERS AND COMMITTEES Meeting of the Committee on Medical Service and Public Relations

November 23, 1947

The Committee on Medical Service and Public Relations held an informal meeting in the Lowry Hotel in St. Paul on Sunday morning, November 23. Those present were: Doctors Fred Stemagel, Martin I. Olsen, R. D. Bernard, D. C. Conzett and R. C. Gutch of the committee; H. A. Spilman, presi- dent; J. E. Reeder, president-elect; Robert L. Parker, assistant secretary; T. F. Thornton, delegate; Char- lotte Fisk, and Mr. T. A. Hendricks of the Council on Medical Service of the American Medical Asso- ciation.

The revised fee schedule of the Division of Voca- tional Rehabilitation was reviewed and approved; expansion of the public relations work of the com- mittee was discussed and it was voted to ask the trustees for additional funds in 1948 to do more field work and make more professional contacts. Iowa Medical Service problems were also discussed. The meeting adjourned at 10 a. m.

Vol. XXXVIII. No. 1

Journal of Iowa State Medical Society

33

WOMAN'S AUXILIARY NEWS

MRS. Keith M. Chapler, Chairman of Press and Publicity Committee, Dexter, Iowa

President — Mrs Fred Moore, 634 40th St., Des Moines 12 President-elect — Mrs. A. G. Felter, Van Meter Secretary — Mrs Charles A. Nicoll, Panora Treasurer — Mrs. M. A. Royal, 1138 Thirty-seventh Street, Des Moines 11

PROGRAM SUGGESTIONS

The program committee, in making a survey of the Auxiliaries to the Iowa State Medical Society, finds that its members have much work to do. Pro- grams must therefore be prepared to aid members to meet their responsibilities and to fulfill the pur- poses and objective as given in our National Auxili- ary constitution. We know what a tremendous in- fluence women can exert in their communities, and it is our responsibility that right attitudes toward the medical profession be formed.

There is a decided interest of lay members of women’s organizations (such as Women’s Clubs, the Parent-Teacher Associations, and Legion Auxili- aries which parallel those of our auxiliary) in the advancement of the prevention of disease and better legislation pertaining to health and welfare. We are members of an organization with authentic informa- tion at our hands; hence, the greater our respon- sibility collectively and individually to disseminate information in order that the individual and com- munity understanding of medicine and its scientific achievements will be understood. In the proportion we meet our responsibility will our organization be of value to mankind and the medical profession. Therefore the general objectives of our program are :

1. To mould public opinion with correct informa- tion.

2. To know what the medical profession means to the human race.

3. To learn what the community can do to im- prove its health by understanding work of existing services of other groups and evaluating the com- munity needs.

4. To be prepared to discuss public health matters on any occasion.

5. To build a feeling of friendship between the doctors and wives.

Definite program suggestions and resource mate- rial have been prepared by the program committee and will be sent to all members.

LEGISLATIVE TIPS

Congress is in session again. As doctors’ wives, we should watch and be ready to lend our influence in the right direction in regard to medical legisla- tion. The Taft and the Wagner-Murray-Dingell Bills for National Health will inevitably reappear

for discussion. E. J. McCormick, M.D., condensed the doctors’ viewpoint on federalized medicine very concisely in an article “Doctor, U. S. A.” which ap- peared in the February, 1947 issue of “Elks Maga- zine” in response to Senator Wagner’s “Clinic, U. S. A.” in the January, 1947 issue of the same magazine. He stated:

“Despite the claims of Mr. Wagner and his asso- ciates, voluntary prepayment plans are giving and will give better service at less cost than any form of compulsion. Subscribers to voluntary plans have increased as much as 365 per cent in some cases. Old-line insurance companies are making plans to cover greater numbers of the urban and rural popu- lations. Compulsion is un-American and undemo- cratic. With a staggering national debt, an enor- mous government pay roll and with an ever grow- ing federal personnel the taking over of the Blue Cross and this country’s great voluntary hospital system, as well as the doctors, nurses and dentists, would in all probability be the blow capable of breaking the morale of the American taxpayer.

“American doctors have endorsed such proposed legislation as the Hill-Burton Bill and favor other progressive legislation and appropriations which give to the American people more hospitals and health centers and which will extend and improve medical research and education. We favor federal aid to states where need is demonstrated, but we are unalterably opposed to regimentation of medi- cine, dentistry, labor or any other group by the federal government.

“Much of our illness is not dependent on medical science but on the need for higher standards of living extended to a greater number of people. Nu- trition, housing, clothing and recreation are as essen- tial to health as good medicine, and no amount of political or socialized medicine will counteract the lack of these essentials.”

It might be apropos at this point to state that the voluntary medical plan has been more than success- ful in Iowa. Iowa Medical Service reports a net enrollment of 35,432 as of Dec. 1, 1947 which is an increase of more than 3,000 during the month of November. There are subscribers in 71 counties in Iowa (Bulletin of Polk County Medical Society, December, 1947).

The United States Chamber of Commerce has pre- pared some general tips for writing your Congress-

34

Tournal of Iowa State Medical Society

January, 1948

man. They are worth reading and remembering, so we pass them on to you.

1. Address him as The Honorable , M. C.

(Member of Congress) or U. S. S. (U. S. Sen- ator)— and be sure who is what. Address sen- ators, Senate Office Building, Washington, D. C., and representatives, House Office Build- ing, Washington, D. C.

2. Be local. Tell him how a national question af- fects your business, your industry, your community.

3. Be businesslike, brief but not terse.

4. Be specific; if you’re for something, say so. If not, don’t hedge.

5. Be polite; congressmen deserve dignified treat- ment.

6. Be reasonable; seek only possible things.

7. Be yourself; use your own letterhead and let- ter style.

8. Request action; your man is elected to do some- thing.

9. Ask for an answer; you’ve told him where you stand, now ask him where he stands.

10. Be appreciative; thank him for good votes; compliment his better speeches, and praise his staff, too.

RECOMMENDED READING

Dr. E. L. Bortz, President of the A.M.A. urges Auxiliary members to study the book, Medicine in The Changing Order.

The Board of Trustees of the A.M.A. recommends the provocative legislative material on medicine which is being* distributed by Shearin Medical Leg- islative Service, 610 Columbian Building, Washing- ton 10, D. C. Weekly service available at $15 will probably not appeal to doctors’ wives as much as Marjorie Shearin’s Blueprint for the Nationalization of Medicine at 25 cents per copy.

NOMINATING COMMITTEE At the fall board meeting, the nominating commit- tee for state Auxiliary officers was selected. In accordance with the constitution, three members were appointed by the president and two were elected from nominations made by committee chair- men. The appointments by the president were Mrs. James A. Downing, Des Moines, chairman; Mrs. Edward A. Hanske, Bellevue, and Mrs. Jay C. Decker, Sioux City. Mrs. H. I. McPherrin of Des Moines and Mrs. Howard W. Smith of Woodward were elected by ballot from nominations made by committee chairmen. All Auxiliaries are asked to send recommendations to Mrs. Downing.

NURSES’ LOAN FUND If you read your last News Page you learned that your auxiliary has one nurse in training at Iowa Lutheran Hospital in Des Moines and another one at Iowa City who will be our responsibility by Janu-

ary, 1948. This gives us a wonderful feeling to know that we are helping these girls take this training which will make them invaluable to humanity.

To finance this, your board of directors voted that each Auxiliary be responsible for fifty cents per member per year and I am happy to report that several auxiliaries have already done their bit. Dal- las-Guthrie was first to report and they didn’t stop at fifty cents per member; they made it one dollar, a total of $14.50. Fort Dodge was next with $8.50 and Polk is very busy buying and selling clever little bill-folds to help earn their money. You, too, may use this means of meeting your obligation if you will write your chairman, Mrs. William Hom- aday, 612 Forty-fourth Street, Des Moines, Iowa.

MEMBERS AT LARGE — You too may help us in this project by sending your contribution to your chairman. You may also contact your schools and secure the names of any girls interested in nursing. As a committee of one your responsibility is great, and we are counting on your help. Further informa- tion will be sent upon request.

Mrs. William R. Hornaday, Chairman

ACTIVITIES OF COUNTY AUXILIARIES Cerro Gordo County

Doctors’ wives in Cerro Gordo and neighboring counties were guests of the Cerro Gordo County Medical Society at a dinner meeting in connection with the cancer institute held in Mason City Novem- ber 11.

Mrs. L. William Swanson, chairman, with Mrs. Harry G. Marinos, Mrs. Draper L. Long, and Mrs. Soren S. Westly made arrangements for the meet- ing. The program of the Iowa Cancer Society was presented by Mr. White, executive director, and Mrs. Fred Moore spoke on the Woman’s Auxiliary.

Montgomery County

The Montgomery County Medical Society and Auxiliary met for a Christmas dinner December 11 at the Hotel Johnson, Red Oak, after which the members were entertained in the home of Dr. and Mrs. F. A. Hansen. Each group held the yearly business meeting. The Auxiliary voted to give one dollar per capita to the Nurse’s Loan Fund, and to give added support to the Hygeia program. Officers elected for the coming year were: Mrs. H. C. Bas- tron, president; Mrs. H. Borre, vice president; and Mrs. E. M. Sorensen, secretary-treasurer.

Marian E. Nelson

Polk County

The Woman’s Auxiliary to the Polk County Medi- cal Society met November 21 for luncheon and bridge at Younkers Tea Room. The Polk County Auxiliary has taken on several projects for the com- ing year. At the present time several of the mem- bers are helping in the Christmas Seal booths throughout Des Moines. In the spring the Auxiliary in conjunction with the Iowa Society for Crippled (Continued on page 40)

Vol. XXXVIII, No. 1

Journal of Iowa State Medical Society

35

HISTORY OF MEDICINE IN IOWA

Edited by the Historical Committee

Dr. Walter L. Bierring, Des Moines, Chairman Dr. Henry G. Langworthy, Dubuque, Secretary Dr. Charles L. Jones, Gilmore City Dr. Clyde A. Henry, Farson Dr. Lester C. Kern, Waverly

Dr. Charles H. Morse, Eagle Grove, Oldest Practicing

Physician in Iowa

Walter L. Bierring, M.D., Des Moines

In the illustrated Grafic of the Chicago Sunday Tribune, Oct. 19, 1947, appeared the interest- ing story entitled “For 66 Years an Iowa Doc,” and gave a graphic account of Dr. Charles H. Morse of Eagle Grove as an active practitioner of medicine at 92 years of age.

Among the illustrations is the medical school graduating class of 1881 University of Iowa, com- prising a group of eight young physicians. Among them we note Dr. Max E. Witte, later superin- tendent of the State Mental Hospital at Clarinda; Dr. William L. Allen of Davenport, well known surgeon of his period and former president of the Iowa State Medical Society; and Dr. Peter Joor for more than 50 years a general practitioner at Maxwell, Iowa.

Dr. Morse came to Eagle Grove in the spring of 1881, and has practiced there ever since. He is quoted as speaking of his future home as “ — frog pond,” but he lived to see and have a large part in the draining of the swamps, build- ing of permanent roads, and making Eagle Grove a happy place in which to live.

The Tribune account describes many interest- ing experiences common to the pioneer physician, such as driving in one day 100 miles to Luverne, back to Eagle Grove, to Vincent and back again just in time to start a new day; of swimming the Boone river with his hypodermic, morphine and atropin wrapped in a rubber sheet strapped on his back, relieving a woman patient with cholera morbus, and swimming the river again on the return trip. For many years he was a member

of the school board and had an active part in the civic and social progress of his home city. His- torically it is stated that he was born at Maquo- keta, Iowa, Jan. 1, 1856; he read medicine with Dr. Powers of Parkersburg.

Dr. Morse is proud of his part in stimulating a petition to the Board of Regents of the State Laii versity for a more graded course of medical study, which was instituted during his senior year. His frequent attenance at postgraduate courses in Chicago and eastern medical centers is a further attest of his constant endeavors to keep in the midcurrent of medical progress. He was one of many who greatly admired the late Dr. W. W. Bowen of Ft. Dodge, and an enthusiastic partici- pant at the testimonial dinner extended to Dr. Bowen a few years ago.

Dr. Morse acquired his first automobile in 1906, and since then has had fourteen cars.

From 1909 until after the close of World War I he built and operated with, Dr. W. C. Grath the first hospital in Eagle Grove. After the death of his colleague he discontinued the hospital.

His obstetric service numbered more than 1,500 newcomers. It has been the privilege of Dr. Morse to witness the greatest progress of medical science, to contribute in no small means to the ad- vancement of medicine in Iowa, and to gain the affectionate regard of professional colleagues and the love of patients and friends all along the way.

May he enjoy many more years of joyful living and useful labor.

36

Journal of Iowa State Medical Society

January, 1948

THE JOURNAL BOOK SHELF

BOOKS RECEIVED

DISEASES OF THE NOSE, THROAT AND EAR — By William Lincoln Ballenger, M.D., F.A.C.S., Late Professor, School of Medicine, University of Illinois, Chicago; and Howard Charles Ballenger, M.D., F.A.C.S., Associate Professor and Acting Chairman of the Department of Otolaryngology, Northwestern University School of Medicine, Chicago; Surgeon, Department of Otolaryngology, Evanston Hospital, Evanston, III.; assisted by John Jacob Ballenger, B.S., M.D., Research Fellow in Otolaryngology, Northwestern University School of Medicine, Chicago. Ninth edition. Lea & Febiger, Philadelphia, 1947. Price, $12.50.

THE FOOT AND ANKLE: Their Injuries, Diseases, Deformities and Disabilities — By Philip Lewin, M.D., F.A.C.S., Associ- ate Professor of Bone and Joint Surgery, and Acting Head of Department, Northwestern University Medical School; Professor of Orthopedic Surgery, Postgraduate Medical School of Cook County Hospital ; Attending Orthopedic Surgeon, Cook County Hospital ; Consulting Orthopedic Surgeon, Municipal Contagious Disease Hospital, Chicago : Formerly Colonel, Medical Arts Corps, Army of United States; Senior Attending Orthopedic Surgeon, Michael Reese Hospital. Third edition. Lea & Febiger, Philadelphia, 1947. Price, $11.

GIFFORDS TEXTBOOK OF OPHTHALMOLOGY — By Francis Hi Adler, M.D., Professor of Ophthalmology, University of Pennsylvania Medical School. Fourh edition. W. B. Saun- ders Co., Philadelphia, 1947. Price, $6.

HOW LIFE IS HANDED ON — By Cyril Bibby, M.A., M.Sc.,

F. L.S., Senior Lecturer at the College of St. Mark and St. John, London : Sometime Scholar of Queen’s College, Lon- don; Author of “Sex Education: A Guide for Parents, Teach- ers, and Youth Leaders.” Emerson Books, Inc., New York, 1947. Price, $2.

LABORATORY MANUAL OF MICROBIOLOGY FOR NURSES — By Elizabeth S. Gill, B.S., R.N., Instructor in Nursing, Department of Nursing, College of Physicians and Surgeons, Columbia University, New York; and James T. Culbert- son, Ph.D., Professor of Bacteriology and Parasitology, Uni- versity of Arkansas School of Medicine, Little Rock. Ark. ; formerly Assisant Professor of Bacteriology, College of Physicians and Surgeons, Columbia University, New York.

G. P. Putnam’s Sons, New York, 1947. Price, $1.50.

PHARMACOLOGY THERAPEUTICS AND PRESCRIPTION

WRITING for Students and Practitioners — By Walter Ar- thur Bastedo, Ph.G., Ph.M. (Hon.), M.D., Sc.D. (Hon.), F.A.C.P., Consulting Physician, St Luke's Hospital, Staten Island, and the Staten Island Hospital ; President, United States Pharmacopoeial Convention 1930-1940; Member of Revision Committee, U S. Pharmacopoeia. Formerly Cura- tor of the New York Botanical Garden, Attending Physician, City Hospital, New York, Instructor in Pharmacology, Cor- nell University, Associate in Pharmacology and Therapeutics, and Assistant Clinical Professor of Medicine, Columbia Uni- versity. Fifth edition. W. B. Saunders Co., Philadelphia, 1947. Price, $8.50.

A PRIMER OF CARDIOLOGY — By George E. Burch, M.D., F.A.C.P., Associate Professor of Medicine, Tulane Uni- versity School of Medicine; Senior Visiting Physician, Charity Hospital; Consultant in Cardiovascular Diseases, Ochsner Clinic: Visiting Physician, Touro Infirmary, New Orleans: and Paul Reaser, M.D., Instructor in Medicine, Tulane University School of Medicine: Assistant Visiting

Physician, Charity Hospital, New Orleans. Lea & Febiger, Philadelphia. 1947. Price, $4.50.

SURGICAL DISORDERS OF THE CHEST: Diagnosis and

Treatment — By J. K. Donaldson. B.S., M.D., F.A.C.S . (Lt. Col., A.U.S.) Diplomat American Board of Surgery: Associate Professor of Surgery and in Charge of Thoracic Surgery, University of Arkansas School of Medicine, e c.. Sugrical Staff, St. Vincent's Infirmary and Visiting Staff, Baptist Hospital, Little Rock, Arkansas. Formerly Thoracic Surgeon to Arkansas State Hospital for Nervous Diseases: Associate Surgeon, Robert B. Green Hospital, Visit ng Surgeon to Santa Rosa, Nix, and Medical Arts Hospitals, San Antonio, Texas. Second edition. Lea & Febiger, Philadelphia, L947. Price, $8.50.

SYNOPSIS OF OBSTETRICS AND GYNECOLOGY— By Aleck W. Bourne, M.A., M.B., B.Ch. (Camb.), F.R.C.S. (Eng.), F.R C.O.G., Consulting Obstetric Surgeon, Queen Char- lotte's Hospital, London; Obstetric Surgeon, St. Mary’s Hospital. London: Consulting Surgeon, Samaritan Hos-

pital for Women: Examiner in University of Cambridge; formerly Examiner to Central Midwives Board, and Con- joint Board <>f England. Ninth edition. The Williams and Wilkins Company, Baltimore, 1945. Price, $5.

A TEXTBOOK OF CLINICAL NEUROLOGY with an Intro- duction to the History of Neurology — By Israel S. Wechsler, M.D., Clinical Professor of Neurology, Columbia University. New York; Neurologist, the Mount Sinai Hospital; Consult- ing Neurologist, Montefiore Hospital and Rockland State Hospital, New York. Sixth edition. W. B. Saunders Co.. Philadelphia, 1947. Price, $8.50.

A TEXTBOOK ON PATHOLOGY OF LABOR, THE PUER PERIUM, AND THE NEWBORN— By Charles O. McCor- mick, A.B., M.D., F.A.C.S., Clinical Professor of Obstetrics, Indiana University School of Medicine; Consulting Obstetri- cian to William H. Coleman Hospital for Women, Indianap- olis City Hospital, and Sunny Side Sanitarium. Second edi- tion. The C. V. Mosby Companv, St. Louis, 1947. Price, $8.50.

UNIPOLAR LEAD ELECTROCARDIOGRAPHY: Including

Standard Leads, Unipolar Extremity Leads and Multiple Unipolar Precordial Leads — By Emanuel Goldberger, B.S., M.D.. Adjunct Physician, Montefiore Hospital, New York; Cardiographer and Associate Physician, Lincoln Hospital, New York; Diplomate of the American Board of Internal Medicine; Clinical Lecturer in Medicine, Columbia Uni- versity, Faculty of Medicine. Lea & Febiger, Philadelphia, 1947. Price, $4.

THE 1947 YEAR BOOK OF PEDIATRICS — Edited by Isaac A. Abt, D.Sc., M.D., Emeritus Professor of Pediatrics, Northwestern University Medical School : Consulting Physi- cian, Children's Memorial Hospital, St. Luke’s Hospital and Michael Reese Hospital, Chicago; with the collaboration of Arthur F. Abt, M.D., Associate Professor of Pediatrics, Northwestern University Medical School; Attending Pedia- trician, Michael Reese Hospital ; Attending Pediatrician, La Rabida Jackson Park Sanatorium; Consultant in Pediatrics, Chicago Board of Health and Consultant in Pediatrics, Great Lakes Naval Hospital, Great Lakes, 111. The Year Book Publishers, Inc., 1947. Price. $3.75.

400 YEARS OF A DOCTOR'S LIFE — Collected and arranged by George Rosen, M.D., and Beate Caspari-Rosen, M.P. Henry Schuman, New York, 1947. Price, $5.

REVIEWS

BOOK

INFANT NUTRITION By P. C. Jeans, A.B., M.D., Professor of Pediatrics, College of Medicine, State Uni- versity of Iowa, Iowa City; and William McKim Marriott, B.S., M.D., Late Profes- sor of Pediatrics, Washington University School of Medicine; Physician in Chief, St. Louis Children’s Hospital, St. Louis. Fourth edition. The C. V. Mosby Company, St. Louis, 1947. Price, $6.50.

In the fourth edition of his text, Infant Nutrition, Dr. Jeans records the advancements made in infant nutrition since 1941, the date of the previous edition.

The author summarizes the nutritional requirements of the normal and sick infant. He describes the characteristics of the various food elements and dis- cusses the processes of digestion and absorption in infancy and the variation of these processes in dis- ease. Common infectious diseases are discussed spe- cifically and their relation to nutrition made evident. Most of the strictly nutritional diseases of infancy are discussed in detail. Various methods of the arti- ficial feeding of infants are presented as well as a discussion of breast feeding. Mineral and water metabolism are reviewed.

The text includes a well illustrated chapter on

Vol. XXXVIII, No. 1

Journal of Iowa State Medical Society

37

technical procedures in infancy. A list of drugs frequently used in infancy and their dosages are given. A chart of fluids for parenteral use is pre- sented with maximum quantity, route, rate, and indications listed for each fluid.

The book is authoritative, concise and readable. It fulfills the desire of its author that it be useful to the medical student and practitioner.

J. McM.

HEADACHE

By Louis G. Moench, M.D., Assistant Clin- ical Professor of Medicine, University of Utah School of Medicine; Internist, Salt Lake Clinic, Salt Lake City. The Year Book Publishers, Inc., Chicago, 1947. Price, $3.50.

This short, well illustrated volume of 200 pages divided into ten excellently arranged and easily read chapters is one of the General Practice Manuals. It is pleasantly complete.

The author compiles in this book what information is at present available on headache from his own brilliant research and that of Lewis, Wolff, Von Storch, Lennot and Horton.

The fact that headache is man’s most common com- plaint and is the result of so many diverse conditions makes this one of the few really essential books in any physician’s library.

L. G.

HISTORY OF MEDICINE

By Cecilia C. Mettler, A.B., Ed.B., A.M., Ph.D., Late Assistant Professor of Medical History, University of Georgia, School of Medicine, and Late Associate in Neurology, College of Physicians and Surgeons, Colum- bia University. Edited by Fred A. Mettler, A.M., M.D., Ph.D., Associate Professor of Anatomy, College of Physicians and Sur- geons, Columbia University. The Blakiston Company, Toronto, 1947. Price, $8.50.

This volume is replete with well documented notes regarding the history of medicine, presented by a well qualified author. Specialized subjects include anatomy and physiology, pharmacology, pathology and bacteriology, physical diagnosis, medicine, neurology and psychiatry, venereology, dermatology, pediatrics, surgery, obstetrics and gynecology, ophthalmology, otology and rhinolarynology.

E. M. G.

A HAND-BOOK OF OCULAR THERAPEUTICS

By the late Sanford R. Gifford, M.D.,

F.A.C.S., Professor of Ophthalmology, Northwestern University Medical School, Chicago; revised by Derrick Vail, M.D., D.O. (Oxon.), F.A.C.S., Professor of Oph-

thalmology, Northwestern University Med- ical School, Chicago, 111. Fourth edition, thoroughly revised. Lea & Fehiger, Phila- delphia, 1947. Price, $5.

The above title is completely expressive of the contents of this valuable book. The method of pres- entation of the facts concerning diagnosis and treat- ment of ocular diseases is easily readable and con- cisely written. The “meat” is obtainable- without too much reading of voluminous pages of material.

The grouping of subject matter is very good, and the fact that there is no- chapter on disorders of mus- cular apparatus adds to the effectiveness of this par- ticular work rather than detracting from it.

Another interesting feature is that neither the author nor the revisor has gone “overboard” on sulfa drugs and penicillin but has presented them in a very conservative manner.

It is felt that this book, printed in large easily readable type, completely fills the need for which it was originally compiled.

G. S. M.

DIABETIC GUIDE

By E. B. Winnett, M.D., Des Moines, and A. G. Lueck, M.D., Des Moines. American Lithographing and Printing Co., Des Moines, 1947. Price, $1.75.

The authors have made available to the diabetic patient a valuable reference manual. Its size and compactness permits ready accessibility, a factor so important to the new diabetic. The lucid manner in which the various phases of the management and especially the complications of diabetes is handled should assist greatly in assuring the patient of hav- ing a more competent control of his problem.

The part devoted to the historical phase of dia- betes, the various diet lists, and the tables of equiva- lents and substitutions provide the patient with the necessary information relative to his disorder.

Doctors Winnett and Lueck are to be commended for their successful effort in bringing this timely booklet to- the diabetic patient.

G. E. M.

SEX POWER IN MARRIAGE With Case Histories

A realistic analysis concerning the sexual and emotional problems of marriage. By Edwin W. Hirsch, B.S., M.D. Research publications of Chicago, 1947. Price, $3.

This volume outlines the methods used by its author in analyzing and treating the sexual and emotional problems of marriage. A pattern of life adjustment has proven most helpful in the treat- ment of these problems. Numerous case reports are presented.

E. M. G.

38

Journal of Iowa State Medical Society

January, 1948

SOCIETY PROCEEDINGS

MEETINGS Black Hawk County

The annual business meeting’ of the Black Hawk County Medical Society was held at 6 p. m. Decem- ber 2 at the Elks Club, Waterloo. New officers were elected.

Butler County

Newly elected officers of the Butler County Medi- cal Society are Dr. B. V. Anderson, Greene, presi- dent; Dr. E. M. Mark, Clarksville, vice president; and Dr. F. F. McKean, Allison, secretary-treasurer.

Cerro Gordo County

Dr. Draper Long of Mason City was elected presi- dent of the Cerro Gordo County Medical Society at the annual dinner meeting held at the Green Mill. Dr. L. W. Swanson was named vice president; Dr. J. W. Lannon, secretary; and Dr. H. G. Marinos, treasurer. Speakers at the meeting were Wilbur R. Quinn, Des Moines, executive director of Iowa Medical Service, Inc., and Frank Nicols, Des Moines, special representative of Hospital Service, Inc., of Iowa.

Greene County

The Greene County Medical Society met for 6:30 p. m. dinner November 17 at the Woman’s Club House. Guests of the group were the Greene Coun- ty Nurses’ Association, Greene County hospital board, and the hospital superintendent. Miss Jessie Norelius of Des Moines, executive secretary of the Iowa State Nurses’ Association, spoke on “Nursing and Its Professional Standing in the World Today.”

Hancock Winnebago Society

At a meeting of the Hancock Winnebago Society held December 8 the following officers were elected: Dr. David Shaw, Britt, president; Dr. Ivan E. Brown, Forest City, secretary-treasurer.

Iowa County

Dr. D. F. Miller of Williamsburg has been elected president of the Iowa County Medical Society for the coming year. Other officers named were: Dr. Thomas Clark, Victor, secretary-treasurer; Dr. I. J. Sinn, Williamsburg, and Dr. C. F. Watts, Marengo, delegates; Dr. L. A. Miller, North English, alter- nate.

Iowa and Illinois Central District Medical Association

The quarterly meeting of the Iowa and Illinois Central District Medical Association was held No- vember 19 in the LeClaire Hotel, Moline, 111. Din- ner was served at 6:30 p. m. following which Dr. B. K. Ozanne of Moline spoke on “Use of Curare in Anesthesia.” Guest speaker for the evening was Dr. Henry T. Rickets of Chicago whose subject was “Newer Aspects of Diabetic Management.”

Johnson County

Johnson County Medical Society met at Oakdale December 3 for dinner and the annual business meet- ing. Dr. Stephen C. Ware of Iowa City was named president; Dr. R. T. Tidrick, vice president; Dr. R. C. Hardin, secretary-treasurer; Dr. A. W. Ben- nett, Dr. Stuart C. Cullen and Dr. Henry R. Jenkin- son, delegates. Dr. Charles W. Gray of the sanato- rium staff spoke on “Streptomycin in the Treatment of Pulmonary Tuberculosis.” Case presentations to illustrate the topic were made by Dr. Arthur C. Wise, also of the sanatorium.

Lee County

Dr. Frank L. Poepsel was elected president of the Lee County Medical Association at a meeting held December 10. Dr. Raymond Cooper, Keokuk, was elected vice president and Dr. Ferris D. Evans, Keokuk, was named secretary-treasurer. The pro- gram of the meeting included talks on “Recent Ad- vances in the Treatment of Heart Disease” by Dr. Lucien W. Ide and “Rational Treatment of Anterior Poliomyelitis” by Dr. W. D. Paul. Both men are from the State University of Iowa College of Medi- cine.

Linn County

The Linn County Medical Society will meet at Hotel Roosevelt, Cedar Rapids, January 22 to hear Dr. Sterling Bunnell of San Fr- icisco speak on “Re- construction of the Hand.”

Marshall County

The Marshall County Medical Society held its regular monthly meeting at the Methodist Church, Marshalltown, December 2. The annual election of officers was held with Dr. R. C. Wells becoming president; Dr. Ralph Carpenter, vice president; and Dr. E. C. Knight, secretary-treasurer. All are from Marshalltown. Dr. John H. Randall of Iowa City presented a talk on “Cancer of the Female Genital Tract.”

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Journal of Iowa State Medical Society

39

Montgomery County

The Montgomery County Medical Society met at Hotel Johnson December 11 for the annual Christ- mas dinner for members and their wives. After the dinner the group was entertained at the home of Dr. and Mrs. Fred A. Hansen.

Pocahontas County

Members of the Pocahontas County Medical So- ciety met December 8 at the home of Dr. J. H. Rhodes of Pocahontas. The following officers were elected: Dr. H. L. Pitluck, president; Dr. J. B. Thielen, vice president; Dr. Charles L. Jones, secre- tary-treasurer; Dr. W. F. Brinkman, delegate; Dr. J. B. Thielen, alternate.

Polk County

The Polk County Medical Society met at the Des Moines Club, Des Moines, December 17 for a 6:30 p. m. dinner. Dr. Nathaniel G. Alcock, Professor of Urology and Acting Chief of the Department of Urology at the University of Iowa College of Medi- cine, spoke on “Tumors of the Adult Kidney.”

Scott County

The Scott County Medical Society met December 2 for a 6 o’clock dinner at the Lend-A-Hand Club, Davenport. The scientific portion of the program consisted of a talk by Dr. Darrell A. Campbell, surgical director of Wayne County General Hospital, Eloise, Mich., on “The Surgical Therapy of Pan- creatic Disease,” and a film entitled “Perineal Pros- tatectomy.”

Sioux Valley Medical Society The winter meeting of the Sioux Valley Medical Society will be held at the Martin Hotel, Sioux City, with all-day meetings scheduled for January 28 and 29. The smoker, followed by a program, will be held January 27 at 8 p. m.

Taylor County

The Taylor County Medical Society met recently at Clearfield. Following dinner there was election of officers. The outgoing officers were re-elected. A round-table discussion concluded the evening.

Wapello County

The Wapello County Medical Society will meet January 6 at St. Joseph Hospital, Ottumwa. Fol- lowing dinner Dr. C. C. Scheifley of Rochester, Minn., will discuss “The. Surgical Risk in Heart Disease.”

Woodbury County

Dr. Thomas J. Dry, cardiology consultant at the Mayo Clinic, Rochester, Minn., and associate pro- fessor of medicine at the University of Minnesota, spoke at the November meeting of the Woodbury County Medical Society. His subject was “The Management of Cardiovascular Decompensation.”

PERSONALS

Dr. R. L. Barton of Dubuque spoke to the Kiwanis Club of that city November 10. He discussed the use of penicillin in treating venereal disease.

Dr. Charles W. Beckman of Iowa City began prac- tice in Kalona the first of December. He is asso- ciated with Dr. D. G. Sattler. A graduate of the State University of Iowa College of Medicine with the class of 1944, Dr. Beckman interned at Roper Hospital in Charleston, S. C. Following that he served two years in the Army Medical Corps and recently completed four months’ work at Sacramento County Hospital.

Dr. Buell Buchtel of Corydon recently closed his office and moved to New Orleans, La., where he will specialize in x-ray at the Ochsner Clinic. Dr. Buchtel was in x-ray work during his military service.

Dr. Ralph A. Dorner, associate professor of sur- gery at University Hospitals, resigned, effective Jan. 1, 1948, to enter private medical practice limited to chest and general surgery. He will be associated with Dr. J. B. Synhorst of Des Moines.

Dr. Thomas F. Edwards located in Hopkinton and began the practice of medicine and surgery recently. A native of Iowa, Dr. Edwards is a graduate of the St. Louis University School of Medicine and a vet- eran of World Wars I and II.

Dr. J. H. Gasson has moved to Shenandoah after practicing five years in Bedford.

Dr. F. M. Kilgard has opened offices for the prac- tice of medicine and surgery in Indianola. A gradu- ate of the University of Illinois College of Medicine, Chicago, with the class of 1928, Dr. Kilgard practiced seventeen years in Phoenix, Ariz., before moving to Indianola last July.

Dr. J. P. McManus and his family left Graettinger, where he had practiced for nineteen years, for Los Angeles, Calif., where they plan to make their home.

Dr. Mark Piper has taken over the practice of Dr. E. J. Lessenger of New London while the latter is confined to his home because of illness.

Dr. E. D. Plass, professor and head of the Depart- ment of Gynecology and Obstetrics at the University Hospitals, spoke on cancer to the Iowa City Rotary Club November 13.

Dr. John L. Powers recently opened offices in Estherville, having come from the Caylor-Nickel Clinic and hospital in Bluffton, Ind. He also will practice part-time in Graettinger, occupying the offices vacated by Dr. J. P. McManus.

Dr. Kirby Shiffler, who completed a three year

40

Journal of Iowa State Medical Society

January, 1948

research course at Vanderbilt University Hospital, Nashville, Tenn., has moved to Des Moines and an- nounced his intention to enter practice. While in Nashville he specialized in obstetrics and gynecology.

Dr. Adolph Soucek, assistant superintendent of the Cherokee State Hospital, has been named acting superintendent following the resignation of Dr. Charles F. Obermann.

Dr. George I. Tice is opening an office at the Forester’s Building, Mason City, in association with his father, Dr. C. B. Tice. A graduate of the State University of Iowa College of Medicine in 1940, Dr. Tice served two years in the armed forces. He com- pleted a fellowship in surgery at the Mayo Clinic October 1.

Dr. K. E. Wilcox of Muscatine addressed the Mus- catine County Farm Bureau Women’s Committee December 10 at Hotel Muscatine. He spoke on cancer.

Dr. Nathan A. Womack, professor of clinical sur- gery at Washington University, St. Louis, has ac- cepted the position of head of the Department of Surgery at the State University of Iowa.

DEATH NOTICES

Barnes, Benjamin Spafford, aged 63, of Shenan- doah died December 12 following a short illness. A graduate of the Rush Medical College with the class of 1909, Dr. Barnes had practiced in Shenandoah thirty-five years. He was a member of the Page County and Iowa State Medical Societies.

Deering, Albert Benson, of Boone, aged 73, died December 12 at his home as the result of a heart attack suffered a few days previously. Dr. Deering was graduated from the Northwestern University Medical School, Chicago, in 1898, and following a year’s service in the Spanish American War he came to Boone. He was a member of the Boone County and Iowa State Medical Societies.

Hankey, Daniel Clyde, aged 64, of Council Bluffs, died November 20 while on a hunting trip near that city. Death was caused by a blood clot in an artery of the heart. Dr. Hankey was graduated from Harvard Medical School, Boston, Mass., with the class of 1915. He was a member of the Pottawatta- mie County and Iowa State Medical Societies.

Thoms, Adolph Nicholas, aged 55, of Cedar Falls, died December 15 at his home following a long ill- ness. Following his graduation from the Creighton University School of Medicine, Omaha, in 1916, Dr. Thoms practiced in Fort Dodge, coming to Cedar Falls in 1937. He was a member of the Black Hawk County and Iowa State Medical Societies.

ACTIVITIES OF COUNTY AUXILIARIES

(Continued from page 34)

Children is sponsoring an exhibit and sale of arti- cles made by the handicapped of the state. At this meeting the members voted to take an active part in the Iowa State Nurse’s Loan and Recruitment project. It was voted to amend the bylaws and raise the dues to two dollars per year.

Anne Keen, Secretary

Warren County

May we welcome the newest Woman’s Auxiliary organization. The doctors and their wives in War- ren County had dinner together on November 25. Mrs. Fred Moore, president of the State Auxiliary, was a guest.

After a joint discussion of the possibilities of organizing a health council in the county to coor- dinate the efforts of all the health organizations, the groups separated for their meetings. The Aux- iliary was organized with six charter members. Mrs. C. H. Mitchell of Indianola was elected president and Mrs. M. B, Cunningham of Norwalk secretary- treasurer.

NEW PSYCHOLOGY PROFESSOR AT S. U. I.

Pres. Virgil M. Hancher has announced the ap- pointment of Dr. Woodrow M. Morris to be assistant professor of clinical psychology and senior psycholo- gist at the Psychopathic Hospital at the State University of Iowa.

Dr. Morris will come to Iowa City on February 1 from his present position as Director and Chief Psychologist, Division of Special Clinical Services, Bureau of Psychological Services, Institute of Human Relations, University of Michigan.

Prior to naval service as a clinical psychologist in the neuropsychiatric service of the U. S. Navy Hospital at Great Lakes, 111., Dr. Morris was chief psychologist of the Pontiac State Hospital, Pontiac, Mich. While there he was also consultant to the Oakland County Probate Court, the juvenile court and the Michigan Children’s Aid Society.

MIDWEST RADIOLOGIC CONFERENCE

The 1948 Midwest Radiologic Conference will be held at the Hotel Schroeder, Milwaukee, Wis., Feb- ruary 6 and 7. It will be followed immediately thereafter by the annual conference of teachers of radiology in Chicago on February 8. The dinner speaker on Friday evening, February 6, will be Robert R. Newell, M.D., Professor of Radiology, Stanford University School of Medicine, San Fran- cisco, Calif.

Inquiries concerning the details of the meeting may be addressed to Dr. A. Melamed, Secretary, Milwaukee Roentgen Ray Society, 425 East Wis- consin Avenue, Milwaukee 2, Wis.

JOURNAL

ojf the

Iowa State Medical Society

Vol. XXXVIII, No. 2

DIABETES IN PREGNANCY Ralph A. Reis, M.D., Chicago, 111.

The combination of pregnancy and diabetes is a relatively new one because, before the advent of insulin in 1921, most of the diabetic women did not become pregnant. They did not become pregnant because of the pituitary dysfunction that accompanies untreated diabetes, and because of the resultant amenorrhea and sterility. As late as 1910, Whitridge Williams at Johns Hop- kins was able to collect only 65 cases in the whole world literature of diabetic women who were pregnant and who carried the pregnancy to term.

Uncontrolled diabetes is exactly the same now as it was in the pre-insulin days. The uncon- trolled diabetic who is pregnant must face a maternal mortality of somewhere around 27 o' 28 per cent and can expect to run a 60 to 70 per cent chance of her fetus not surviving after it is born.

Insulin, intelligently used, will control diabetes. It will regulate the pituitary function. This re- sults in normal menstrual cycles and in a normal type of fertility.

The result is that, since the advent of insulin, we find the combination of pregnancy and dia- betes rather common. The figures at Johns Hopkins run something like 1 in 282 pregnancies. At Michael Reese we have found that 1 out of everv 350 women we deliver is a diabetic. This means that in the course of the year, with about 2,600 deliveries, we have 6 to 8 diabetic patients.

In considering the problem of diabetes and pregnancy we must take into account the type of diabetes which is present. If it is a diabetes that has come on in adult life, and especially if it is a diabetes which has come on at the most frequent decade, that is — between 35 and 44 years of age — these women develop problems not onlv of diabetes but of hypertension. With the hypertension comes a large incidence of the tox-

Presented at the Ninety-Sixth Annual Session, Iowa State Medical Society, Des Moines, April 16, 17, and 18, 1947.

No. 2

emias of pregnancy. They develop evidences of renal damage, and as a result of the hyper- tension, a tendency toward cardiac damage. This is in contradistinction to the juvenile type of dia- betic, the individual who has had diabetes since childhood, in whom the problems are entirely separate.

Let us make sure, when we find a reducing sub- stance in the urine of a pregnant woman, that this woman has diabetes. Let us remember that lactosuria is not an uncommon finding in preg- nancy. To get a positive test with Benedict’s solution, you must have over 100 mg. per cent of lactose in the urine. One to 2 per cent of all pregnant women will excrete that much, until about the thirty-seventh or thirty-eighth week of pregnancy, at which time the incidence rises. During the day or two preceding the day of de- livery, at least 30 to 35 per cent of these women will show a reducing substance which is lactose. This lactosuria remains through delivery and during the first ten or twelve days postpartum.

The second condition that we must differen- tiate from true diabetes is the so-called renal glycosuria, in which a change in the renal thres- hold lets sugar spill out of the blood stream by way of the kidneys and make its appearance in the urine. These patients do not have a true diabetes in that they do not have an elevation of blood sugar. It has been said, however, that these patients who show evidence of renal glyco- suria during pregnancy are the patients who will in subsequent years develop a true diabetes. Whether this is true or not, I do not know.

With true diabetes, there is not only the glyco- suria but also an elevation of the blood sugar. We find an elevation above the normal values which, by our method at the hospital, are 60 to 90 mg. per cent.

If. then, we have made a diagnosis of a true diabetes as a result of testing the blood sugar, we have to consider two things : the effect of the pregnancy on the diabetes and the effect of the diabetes on the pregnancy.

Des Moines, Iowa, February, 1948

42

Journal of Iowa State Medical Society

February, 1948

Diabetes is always more difficult to control when a patient is pregnant. Almost invariably there is a change in her sugar tolerance which produces difficulty in regulating and controlling the glycosuria and the elevated blood sugar. As far as I know, there is at present no way of predicting in which direction this change is going to take place. These changes in sugar tolerance can be a decrease, in which case the individual needs more insulin and a more rigid diet to con- trol her glycosuria. It may be due to a hyper- pituitary function, and I say “may” because, again, we do not know. We do know, however, that this decrease is found not only in diabetes at the time of pregnancy but also whenever there is a change in endocrine balance. We find it, then, at puberty. We find it again at the meno- pause, and we find it in many of these women as a recurrent event every month during the men- strual time. Many of the more severe diabetics need a step-up of insulin during the week of each month in which they menstruate.

On the other hand, some of these diabetic pa- tients have an increased tolerance and, to our surprise, we find that they need less insulin. It has been said, and it is in the literature repeat- edly, that many diabetics improve toward the end of pregnancy. It has been postulated that this improvement is due to the fact that, as the fetus matures, the fetal pancreas becomes active, and the fetal pancreas takes over some of the load that the maternal pancreas cannot handle. As far as we know, there is no definite clinical evidence to substantiate this. This is a postulation and a theory which has no basis.

Another problem in sugar tolerance is tied up with the frequent nausea and vomiting which oc- curs in the first trimester. In these patients we often find it difficult to control the glycosuria and to maintain normal body weight and prevent acidosis. It is probable that one of the ideas which has arisen, that diabetes improves as the pregnancy progresses, is due to the fact that the patient is less refractory and more responsive after the first trimester is over and after the period of nausea and vomiting has passed.

There is a third effect of pregnancy on diabetes, and that has to do with the increased muscle effort that accompanies labor. The muscle ex- ertion depletes the glycogen reserve in the liver and, therefore, again upsets the sugar balance.

Again in the postpartum period there is an increased tolerance and decreased need for insulin for about ten days.

There is also an increased tendency toward acidosis and ketosis, which is due to two things :

first, the normal increase in the basal metabolic rate which accompanies every pregnancy ; and, second, the change in the carbon dioxide com- bining power which is definitely diminished as pregnancy goes on in the presence of diabetes.

Let us reverse the picture and talk for a moment on the effects that uncontrolled diabetes has on pregnancy. We find first that there is a decrease in fertility and a decrease in the power to con- ceive, but there is also a definite increase in the incidence of spontaneous abortion and of imma- ture labor rather than premature labor. If more of our diabetics would go into premature labor during the last trimester, many of our problems, as far as the baby of the diabetic mother is con- cerned, would be solved.

Everyone has written and talked repeatedly of the tremendous increase in the toxemias of preg- nancy that are found in diabetic women. In the nondiabetic, the incidence of toxemia is about 7 per cent. Mengert, when he was at the Uni- versity of Iowa, reported an incidence of 24 per cent ; Adair in Chicago, of 50 per cent. In 40 diabetics, whose babies I will discuss shortly, there was not one who had any evidence of toxe- mia. By that I mean no hypertension, no albumi- nuria and no edema.

I would like to believe that this was due to our careful prenatal coverage and to our good ob- stetrics, but that is a little difficult to believe. I am rather inclined to think that this is an oddity due to the fact that the majority of patients were younger women. Twenty-eight of the 40 were primiparas in the middle twenties. I think it is a coincidence that we happened to get such a relatively large series of younger women who, therefore, showed very little evidence of toxe- mia. But at least it refutes the idea of Priscilla White and the workers in Boston who have em- phasized the fact that toxemia will be present in 67 or 70 per cent of the pregnant diabetic women. They believe that an endocrine imbalance is not only the cause of the diabetes but is likewise a cause of the high incidence of toxemia.

One of our big problems in diabetes, and espe- cially in the last trimester, is the high incidence of fetal death in utero. When it occurs, it occurs usually in the last month. It has been said to be due to acidosis or to toxemia.

We are working at the moment on a new idea. In the laboratory we are collecting all of the placentas of diabetic women that we can procure, and by special staining methods are trying to determine whether there is any evidence of pre- mature senility of the placenta. Something must happen to that placental circulation because these

Vol. XXXVIII, No. 2

Journal of Iowa State Medical Society

43

babies of diabetic women will go along unevent- fully ; then suddenly, after the thirty-sixth, thirty- seventh or thirty-eighth week you will find, to your chagrin, the woman whose diabetes has been controlled, turns up with no fetal heart tones.

We have a feeling that this is possibly con- nected with the same type of change that we see in the younger adults who have developed their diabetes as children, in whom there is evidence of premature sclerosis, of early hypertension, of sclerotic and degenerative changes not only in the kidneys, heart and blood vessels, but also, particularly, in the retina and in the cerebral cir- culation.

We feel that possibly the placenta, being the youngest tissue in the body and being the one that matures and becomes senile most rapidly, may be subjected to this same type of sclerotic change which is found so commonly in the juven- ile diabetic.

The fetus of a diabetic woman is notoriously oversized. It is oversized for two reasons. It is originally large, which is probably due to an excessive amount of the growth hormone from the pituitary. It is also overweight for its particular size, and it has been assumed, though we cannot prove it, that this overweight is due to the continuing hyperglycemia to which the baby is constantly subjected. However, if that were true, the well controlled diabetic who is not allowed to have a hyperglycemia during pregnancy and does not have more sugar in the blood than is normal, would not be subjected to this same excessive carbohydrate stimulation. Yet we find that these women have exactly the same oversize and overweight babies as do the women who are not as well controlled.

This oversize and overweight of the fetus is a very important factor. It is, next to fetal death in utero, the cause for the fact that 25 to 50 per cent of the babies of diabetic mothers do not sur- vive. Either they die in utero or they go to term and into spontaneous labor. Being overly large and overweight, at the same time, the resultant dystocia causes not only trauma to the mother but, in many instances, death of the infant. If they do not die from the dystocia due to their oversize, then many of them die from the hypo- glycemia in the first hours of birth.

There is said to have been some increase in the frequency of hydramnios and in malforma- tions, but the increase is so slight that I do not believe it to be significant.

The great cause of neonatal death occurring in the first 1-4 hours after birth are marked hypo- glycemia, anoxia and lethargy. These babies do

not tend to breathe spontaneously or normally. They not only must be stimulated to breathe properly at first but they must be continually stimulated during the first three or four hours.

We have come to feel that it is safe to say that practically all maternal deaths from diabetes in ■- pregnancy today are due either to no treatment or to poor treatment.

It has been our aim to keep these patients on a diet that is as near normal as possible, with the exception of two factors, a low fat and con- centrated carbohydrate intake. Also, we have found these