I

^ In Exchange

Digitized by the Internet Archive in 2017 with funding from

The National Endowment for the Humanities and the Arcadia Fund

https://archive.org/details/rockymountainmed4619colo

Rocky Mountain Medical Journal

Official Journal

of

The Colorado State Medical Society The Montana State Medical Association The New Mexico Medical Society The Utah State Medical As sociation The Wyoming State Medical Society The Colorado Hospital Association The Rocky Mountain Medical Conference

VOLUME XLVI January to December, 1949

EDITORIAL BOARD

Lyman W. Mason, M.D., Associate Editor for Colorado and Chairman of Editorial Board, 1214 Republic Bldg., Denver

Douglas W. Macomber, M.D., Scientific Editor, 1820 Gilpin St., Denver

Raymond P. Peterson, M.D., Scientific Editor for Montana, Murray Clinic,

Butte

Herbert T. Caraway, M.D., Associate Editor for Montana, 1 15 North 28th St.,

Billings

Carl H. Gellenthien, M.D., Scientific Editor for New Mexico, Valmora Sanatorium, Valmora

H. L. January, M.D., Associate Editor for New Mexico, First National Bank

Bldg., Albuquerque

R. P. Middleton, M.D., Scientific Editor for Utah, Boston Bldg., Salt Lake City

W. H. Tibbals, Associate Editor for Utah, 316 Atlas Bldg., Salt Lake City

Earl Whedon, M.D., Scientific Editor for Wyoming, 304 South Main St.,

Sheridan

Arthur Abbey, Associate Editor for Wyoming, Box 897, Cheyenne

Roy R. Anderson, Editor for Colorado Hospital Association, Presbyterian

Haspital, Denver

Harvey T. Sethman, Managing Editor, 835 Republic Bldg., Denver

I

Press of the

Western Newspaper Union

Psychological Factors in Everyday Practice — O. Spurgeon English, Philadelphia.

Current Therapeutic Procedures in Coronary Disease — William S. Middleton, Madison, Wis- consin.

^ _4i;MOCHRO]v/[ATOSIS WiTH ApLASTIC OR REFRACTORY

— Eugene Hildebrand, F. H. Crago and A. Layne, Great Falls.

Invers^n of the Uterus — Raymond Mundt, npoint. New Mexico.

"noma of the Skin— T/ioma.s K. Mahan, rand Junction.

Malignancy Records — Claude L. Shields. Salt Lake City. ■/’ •’

(For Complete Table of Corit‘(m(nf‘

Turn the First Pagei'^,^'‘

25c Per Copy

$2.50 Per Year

criteria in

syphilotherapy

MAPHARSEN

PARKE, DAY

-XyC;

“Therefore, more than in any other disease, it is necessary in the treatment of an individual patient with syphilis to follow a thera- peutic regimen which, after long-term study in large series of patients, has been established as satisfactory for the particular type of syphilis under consideration.”*

<jm 4)£ /im

long-term study

more than a decade of clinical evaluation.

large series of patients

over two hundred million injections already administered.

satisfactory

high therapeutic effectiveness with notable safety in causing dis- appearance of spirochetes, healing of lesions and reversal of sero- positivity in a large percentage of cases.

MAPHARSEN ( oxophenarsine hydrochloride, P. D. & Co.) is supplied in single dose ampoules of 0.04 Gm. and 0.06 Gm., boxes of 10, and in mul- tiple dose ampoules of 0.6 Gm. in boxes of 10.

*Cecil, R. A.: A Textbook of Medicine. Philadelphia, W. B. Saunders Co., 1947, p. 370.

APR 1 2 195a

N

E TV

<:MdealSv!^mi

. . . Designed by a former Government expert

Simplified Bookkeeping System and Income Tax Record

Special

Book

for

Doctors

and

Dentists

Loose-Leaf Book — Actual Size 9'/2*^'/i Inchoi

Easy, inexpensive bookkeeping — no experience required. Facilitates preparation of Income Fax Reports. One loose-leaf book does it all. In- cludes Bulletin and Advisory Services. Meets all federal and state tax requirements.

D-size, $5; E-size, $3.50; F-size, $2 postpaid, each complete. 2% tax in Colorado. Mail or phone orders; use charge account.

STATIONERY CO. yl

KEystone 0241

1641 California St. Denver 2, Colorado

Qea. (1.

Orthopedic Brace and Appliance Co.

1628 Court Place MAin 3026

Write for Measuring Chart

Table of Contents

VOLUME 46 NUMBER 1

JANUARY, 1949

Page

Editorials

This Is Worth Memorizing 17

Total Socialization in England 17

American War Hospitals in England 19

Silhouettes From the A.M.A. House of Delegates 19

Correspondence 20

4-

Original Articles

Psychological Factors in Everyday Prac- tice, O. Spurgeon English 21

Current Therapeutic Procedures in Coron- ary Disease, William S. Middleton 27

Hemochromatosis With Aplastic or Re- factory Anemia, Eugene Hildebrand, F.

H. Crago and John A. Layne 32

Inversion of the Uterus, Raymond Mundt.. 36

Carcinoma of the Skin, Thomas K. Mahan 38

Malignancy Records. Claude L. Shields 43

■f

Organization

Colorado

Colorado Demands Action by A.M.A. ! 48

Report of Delegates to A.M.A. Regarding

Interim Session 50

Preliminary Program National Confer- ence on Medical Service 52

Dr. Sudan Hails His Successor 54

Obituaries 54

Denver Children’s Hospital Summer

Clinics 56

Auxiliary 56

Colorado Medical School Notes 58

Utah

Obituaries 58

Medical School Notes 60

Wyoming

The 1949 Meeting 60

Natrona County Medical Society Elec- tions 60

4-

Colorado Hospital Association 62

Tuberculosis Abstracts 66

The Book Comer 70

2

Rocky Mountain Medical Journal

R. J. Reynolds Tobacco Co., Winston-Salem, N. C.

4cc«rdmg t@ a Nationwide surveys

MORE DOCTORS SMOKE CAMELS THAN ANY OTHER CIOARETTE

Doctors smoke for pleasure, too! And when three leading independent research organiza- tions asked 113,597 doctors what cigarette they smoked, the brand named most was Camel!

Test for yourself what throat specialists reported when a 30-day smoking test revealed:

NO THROAT IRRITATION

due to smoking

CAMELS!"

MAKE YOUR OWN 30- DAY CAMEL MILDNESS TEST. Smoke Camels, and only Camels, for 30 days. Prove for yourself how mild Camels are!

Hundreds of men and women, from coast to coast, recently made a similar test. They smoked an average of one to two packs of Camels a day for 30 days. Their throats were carefully examined by throat specialists. And after a total of 2470 examinations — these throat specialists re- ported "not one single case of throat irritation due to smok- ing Camels!”

But prove it yourself ... in your "T-Zone” (T for Taste and T for Throat). Let YOUR OWN TASTE tell you about the rich, full flavor of Camel’s choice tobaccos. Let YOUR OWN THROAT give the go.od news of Camel’s cool, cool mildness.

for January, 1949

3

ROCKY MOUNTAIN MEDICAL JOURNAL

Tit/« Registered, U.S. Patent Office Publication Office:

835 Republic Building (1612 Tremont Place), Denver 2, Colorado Telephone C Kerry 5521.

EDITORIAL BOARD

Colorado: Douglas W. Macomber, M.D., Scientific Editor, 1820 Gilpin St., Denver; Lyman W. Mason, M.D., Associate Editor, 1214 Republic Bldg., Denver, (Chairman of Editorial Board).

Montana: Raymond F. Peterson, M.D.,, Scientific Editor, Butte, Mont.; Herbert T. Caraway, M.D., Associate Editor, Billings, Mont.

New Mexico: Carl H. Gellenthein, M.D., Scientific Editor, Valmora, New Mexico; Harold L. Janu- ary, M.D., Associate Editor, First National Bank Bldg., Albuquerque, New Mexico.

Utah: Richard P. Middleton, M.D., Scientific Editor, Boston Bldg., Salt Lake City; W. H. Tibbals, Associate Editor, 316 Atlas Bldg., Salt Lake City.

Wyoming: Earl Whedon, M.D., Scientific Editor, Sheridan; Arthur R. Abbey, Associate Editor, P.O. Box 897, Cheyenne.

Hospital Assn.: B. B. Jsita, M.D., Editor, 230 Metropolitan Bldg., Denver.

Managing Editor: Harvey T. Sethman, 835 Republic Bldg., Denver. Business Manager: Helen Kearney, 835 Republic Bldg., Denver.

Ownerahip and Sponaorahipt The Rocky Mountain Medical Journal is owned by the Colorado State Medical Society and is published monthly as a non- profit enterprise for the mutual benefit of the or- ganizations which Jointly sponsor it. It is published under the direction of the Board of Trustees of the Colorado State Medical Society, assisted by an Edi- torial Board representing: the sponsoring organiza- tions. It is the Official Journal of the Colorado State Medical Society, the Montana State Medical Associa- tion, the New Mexico Medical Society, the Utah State Medical Association, the Wyoming State Medi- cal Society, the Rocky Mountain Medical Conference, and the Colorado Hospital Association.

Manascrlptst Scientific Articles, Case Rei>orts, etc., from any state for which this is the Official Journal should be submitted to the Scientific Editor for that state as named in the Editorial Board, above. Other material from any participating state should be sub- mitted to the Associate Editor for that state as named above. Manuscripts from outside the Rocky Mountain area should be sent direct to the Journal office. Manuscripts must be typewritten, double or triple spaced, using only one side of each sheet. It is the policy of this Journal to omit bibliographies.

Adverttaingi National representatives: The Coop- erative Medical Advertising Bureau, 535 North Dear- born Street, Chicago 10, 111. Local advertising from firms in the Rocky Mountain area should be submit- ted to the Associate Editor of the appropriate state or to the Journal office. Advertising forms close on the 20th of the month preceding publication; allow ten days additional to insure submitting proofs for approval.

Sabscrlption : |2.50 per year in advance, postpaid in the United States and its possessions; single copy, 25 cents plus postage. Subscription is included in medical society dues of sponsoring state medical organizations.

Copyright! This Journal is copyright, 1949, by the Colorado State Medical Society. Requests for permis- sion to reproduce anything from the columns of this Journal should be addressed to the Journal office.

Second Clns* Hatter: Entered as second class mat- ter Jan. 22, 1906, at the Postoffice at Denver, Colo., under the Act of Congress of March 3, 1879. Accepted for mailing at special rates of postage provided for in Section 1103, Act of Oct. 3, 1917 ; authorised July 17, 1918.

Essential Automobiles Given Prioritjr — We Recommend

CAPITAL CHiVROLET COMPANY

Featuring COMPLETE REPAIR SERVICE — Including Body, Fender and Paint Work

CAPITAL CHEVROLET COMPANY

Phone: TAbor 5191 13th Ave. at Broadway to Lincoln Denver, Colo.

Don't miss important telephone calls

Let us act as your secreta^ while you are away, day or night: our kindly voice conscientiously tends your telephone business, accurately reports to you when you return.

Telephone ANSWERING Service call Atpine mm

Cambridge Dairy Grade “A” Milk Is Produced and Processed at 690 S. Colo. Blvd.

We do not handle Shipped-in Milk produced Where? How and by Whom? Doctors know the difference Now Homogenized Vitamin D Milk is available for baby feeding and family use.

We Invite Your Inspection and Appreciate Your Recommendation.

INC.

New York 13, N. Y. Windsor, Ont.

1. Follis, R. H., Jackson, D., Eliot, M. M., and Park, E. h. : Am: Jour. Dis. Child., 66:1, July, 1943.

2. Stearns, Q.:Jour. Lancet, 63:344, Nov., 1943.

Throughout the

years . . .

From birth to at least the age of 14 years,

investigators now agree children are susceptible to rickets, with scarcely diminished frequency.’

The critical periods of active skeletal growth are found in infancy and childhood, lasting through at least the years just preceding puberty.'

DRISDOL, trademark reg. U. S. & panada CARTOSE, trademark reg. U. S. & Canada

ODORLESS . . .TASTELESS . . . ECONOMICAL Average dose for infants 2 drops, for children 4 to 6 drops, in milk.

Throughout these formative years patient cooperation assuring an adequate vitamin D intake is readily obtained by the use of

WINTHROP-STEARNS

SPECIFICALLY DESIGNED FOR INFANT FEEDING Less FERMENTATION LESS DIGESTIVE DISTURBANCES

CARTOSE®

MIXED CARBOHYDRATES

IN EASY-TO-USE LIQUID FORM Compatible with all milk formulas Bottles of 16 fl. oz. Write for Formula Blanks

THE COLORADO STATE MEDICAL SOCIETY

Next Annual Session: Shirley-Savoy Hotel, Denver; Sept. 20, 21, 22, 23, 1949

OFFICERS

Terms of Officers and Committees expire at the Annual Session in the year Indicated. Where no year is indicated, the term is for one year only and expires at the 1949 Annual Session.

President: Casper F. Hegner, Denver.

President-elect: Fred A. Humphrey, Fort Collins.

Vice President: Lester L. Ward, Pueblo.

Constitutional Secretary (three years) : George B. Buck, Denver, 1951. Treasurer (three years): George C. Shivers, Colorado Springs, 1950.

Additional Trustees (three years); Ervin A. Hinds, Denver. 1949; E. H. Munro, Grand Jurction, 1949; S. P. Newman, Denver, 1950; Claude D. Bonham, Boulder, 1951.

(The above nine officers compose the Board of Trustees of which Dr. Ervin A. Hinds is the 1948-1949 Chairman.)

Board of Councilors (three years): District No. 1; Clemens F. Eaklns, Brush, 1951: No. 2; Ella A. Mead, Greeley, 1951; No. 3: L. G. Crosby. Denver, 1951: No. 4: banning E. Likes, Lamar, 1950: No. 5: Guy H. Hopkins. Pueblo, 1950: No. 6: Lester E. Thompson, Salida, 1950; No. 7: A. L. Burnett, Durango, 1949: No. 8: Lawrence L. Hick, Delta, 1949; No. 9: W. W. Sloan, Hayden, 1949 (Chairman of Board for 1948-49).

Board of Supervisors (two years): A. B. Gjelium, Del Norte, 1949: L. W. Lloyd, Durango, 1949: B. 0. Howlett, Golden, 1949; Scott A. Gale, Pueblo, 1949: L. D. Dickey, Fort Collins, 1949: N. A. Madler, Greeley, 1949 (Chairman of Board for 1948-49); L. D. Buchanan, Wray, 1960; W. F. Deal, Craig, 1950: G. C. Cary, Grand Junction, 1950: W. A. Campbell, Colorado Springs, 1950: Balph S. Johnston, Sr., La Junta, 1950: William A. Liggett, Denver, 1950.

Delegates to American Medical Association (two years): George A. Unfug, Pueblo, 1949 (Alternate: Herman C. Graves, Grand Junction, 1949); William H. Halley. Denver, 1960 (Alternate: Kenneth C. Sawyer, Denver, 1950).

Foundation Advocate: Walter W. Klnc, Denvv.

Executive Office Staff: Mr. Harvey T. Sethman, Executive Secretary: Miss Helen Kearney, Assistant Executive Secretary; llr. Evan A. Edwards, Field Secretary; Miss Mary E. McDonald, Committee Secretary; 835 Be- publlc Building, Denver 2, Colo., Telephone CHerry 5521.

General Counsel: Mr. J. Peter Nordlund, Attorney-at-Law, Denver.

STANDING COBIMITTEES

Credentials: George B. Buck, Denver, Chairman, ex-officio; others to be appointed.

Public Policy: Kenneth C. Sawyer, Denver, Chairman; McKlnnle L. Phelps. Denver, Vice Chairman; John S. Bouslog, Denver; F. B. Calhoun, Denver; Frank B. McGlone, Denver; T. M. Bogers, Sterling; Sidney An- derson, Alamosa; Bichard L. Davis, La Junta; Herman C. Graves. Grand Junction; John L. McDonald. Colorado Springs: Lawrence D. Dickey, Fort ColUns; George E. Bice, Pueblo; John D. OUlaspie, Boulder. Ex-officio

members: Casper F. Hegner, President; Fred A. Humphrey, President-elect;

George B. Buck, Constitutional Secretary.

Sub-Committee on Legislation: H. I. Barnard, Denver, Chairman; others to be appointed.

Health Education (two years): A. C. Sudan. Denver, Chairman, 1949;

J. D. Bartholomew, Boulder, 1949; B. J. Savage, Denver, 1949; B. T. Porter, Greeley. 1949; Bobert B. Bradshaw, Alamosa, 1949; L. W. Bortree, (k)lorado Springs, 1950; F. 0. Bobertson, Denver, 1950.; J. L. Sadler, Port Collins, 1950; Harold T. Low, Pueblo, 1950; John H. Amesse, Denver, 1950; E. H. Munro, Grand Junction, 1950.

Scientific Work: W. B. Condon, Denver, Chairman; Bobert S. Liggett,

Karl F. Arndt, Frank T. Joyce, Marshall G. Nims, Vincent G. Cedar-

blade, all of Denver.

Sub-Committee on Scientific Exhibits: Frank C. Campbell, Chairman; Nolle Mumey, Edgar W. Barber, B. W. Vines, all of Denver.

Arrangements: To be appointed.

Medicolegal (two years): B. W. Arndt, 1950, Chairman; George B. Packard, Jr., 1950; K. D. A. Allen, 1950; C. S. Bluemel, 1949; all of Denver. Two others to be appointed.

Medical Education and Hospitals: George F. Wollgast, Denver, Chairman; W. W. Sloan. Hayden: F. B. Pingrey, Durango; E. B. Mugrage, Denver; D. W. McCarty, Longmont: A. E. Lubchenco, Denver.

Library and Medical Literature: A. J. Markley, Denver, Chairman; T. E Beyer, Denver; J. J. Connor, Delta; H. Dumont Clark, Denver.

Medical Service Plans; F. H. Good, Denver, Chairman; C. E. Honstein, Port Collins; James B. Blair, Denver; Vernon L. Bolton, (kilorado Springs; Scott A. Gale, Pueblo; John A. Weaver, Jr., Greeley; John E. Hyland, Monte Vista; Thomas K. Mahan, Grand Junction.

Necrology: W. H. Wilson, Denver, Chairman.

PUBLIC HEALTH COMMITTEES

General Committee on Public Health: Consists of the chairmen of the following eleven public health subcommittees, presided over by Bobert W. Dickson, Denver, as General Cbairman.

Cancer Control: J. C. Mendenhall, Denver, Cbairman; John B. Grow, Denver; S. W. Holley, Greeley: T. Leon Howard, Denver; James B. Mc- Naught, Denver; Eoger G. Howlett, Golden: James W. McMullen, Colorado Springs; James E. Donnelly, Trinidad; Lanning E. Likes, Lamar; Thomas

K. Jlahan. Grand Junction.

Crippled Children: I. E. Hendryson, Denver. Chairman: Mary L. Moore, Grand Junction; Bichard H. Mellen, Colorado Springs; Sidney B. Bland- ford, Jr., Denver; Paul B, Hildebrand, Brush; Samuel P. Newman, Denver.

Industrial Health; B. F. Bell, Loiivlers. Chairman; A. B. Woodbume, Denver; Vincent F. Kelly, Leadville; D. W. Boyer, Pueblo; H. G. Harvey, Jr.. Denver: Bobert Woodruff, Denver; Frank J. McDonough, Grand Junction.

Local Health Units: Monroe B. Tyler, Denver, Chairman; Harold E Haymond. Greeley; B. B. Richards. Fort Morgan: Nicholas S. Saliba, Wal- senburg; Marvel L. Crawford, Steamboat Springs; R. Sherwln Johnston, Jr., La Junta.

Maternal and Child Health: John R. Evans, Denver, Chairman; Joseph H. Lyday. Denver; John M. Nelson, Denver: Tracy D. Peppers, Greeley: J. H. Woodbridge, Pueblo; M. E. Snyder, Colorado Springs.

Mental Hygiene: Bradford Murphey, Denver, Chairman; E. James Brady, Colorado Springs; Frank H. Zimmerman, Pueblo: Paul A. Draper, Colorado Springs; J. P. Hilton, C. S. Bluemel, John M. Lyon, G. H. AsUey, Lewis C. Overholt, Clarke H. Barnacle, Harold R. Carter, all of Denver.

Milk Control; George W. Stiles, Denver, Chairman; Max M. Glnsburg, Denver; N. J. Miller, D.V.M., Eaton; Millard F. Schafer, Colorado Springs; Robert W. Vines, Denver; Mr. Wendell Vincent, Denver.

New Hospital Construction: D. R. Collier, Wheatridge, Chairman; Henry M. Powell, Colorado Springs; Mr. John R. Peterson, Fort Collins; Florence B. Sabin, Denver; Herbert A. Black, Pueblo.

Public Water Supplies: E. I. Dobos, Denver, Chairman; Robert Barnard, Eagle; William C. Shontz, San Luis; Carl W. Maynard, Pueblo; W. B. Crouch, Colorado Springs; H. D. Palmer, Denver; E. Robert Orr, Fnilta.

Tuberculosis Control: John I. Zarit, Denver, Chairman; W. J. Hlnzel- man, Greeley; H. M. Van Der Schouw, Wheatridge: John P. McGraw, Pueblo; Arthur Rest, Denver; H. Calvin Fisher, Denver; T. D. (hinningham, Denver.

Venereal Disease Control: Sam W. Downing, Denver, Cbairman; Paul B. Stidham, Grand Junction; H. E. Coakley, Pueblo; D. E. Newland, Denver: Joseph H. Patterson, Denver. James R. McDowell, Denver.

SPECIAL COMMITTTES

Rocky Mountain Medical Conference (five years): L. Clark Hepp, Denver, 1953; G. P. Lingenfelter, Denver, 1952, Chairman; Ward Darley, Denver, 1951; L. W. Bortree, Colorado Springs, 1950; George H. Gillen, Denver, 1949.

Advisory to Auxiliary: Fred A, Humphrey, Fort Collins, Chairman; Ervin A. Hinds, George R. Buck, Denver.

Midwinter Clinics: Samuel B. Childs, Jr., Chairman; Raymond C. Chat- field, E. L. Binkley. Jr., A. J. Kauvar, Terry J. Gromer, aU of Denver.

Rehabilitation: W. W. Haggart, Denver, Chairman; Atha Thomas, Den- ver; Lawrence T. Brown, Denver; J. E. A. ConneU, Pueblo: Thad P. Sears, Ft. Logan; Kenneth C. Sawyer, McKlnnle L. Phelps, (leorge B. Buck, Bradford Murphey. all of Denver.

Advisory to the Goodwill Industries’ Rehabilitation Program: Lewie C. Overholt, Chairman; William H. Halley, Maurice Katzman, Terry J. Gromer. Lorenz W. Frank, William B. Lipscomb. Irvin E. Hembrson, all of Denver.

Rural Hdalth Commission: Leonard N. Myers, Cheyenne Wells, Chairman;

V. V. Anderson, Del Norte; James S. Orr, Fruita; Keith F. Krausniek, Lamar; Robert M. Lee, Fort Collins. Ex-offlcio member; Fred A. Hum- phrey, Fort Collins.

Medical Disaster Commission; Foster Matchett, Denver, Chairman; Karl Arndt, Denver, Secretary; Mark S. Donovan, Harry C. Hughes, Adolph J. Kafka, Roderick J. McDonald, William F. Stanck, Henry Swan, Karl F. Sunderland, all of Denver; Lawrence W. Holden, Boulder; Richard H. Mellen, Colorado Springs; Richard H. Altmix, Englewood; Jacob 0. Hall, Estes Park; Thad P. Sears, Fort Logan; Donald E. Cowen, Fort Morgan; Kenneth E. Prescott, Grand Junction; Walter A. Seboen, Greeley; David

W. McCarty, Longmont: David W. Boyer, Pueblo; J. G. Espey, Craig; Leo W. Lloyd, Durango; Keith F. Krausniek, Lamar; Bobert M. Lee, Ft. Col- lins; George H. Lord, Aurora; J. Gordon Hedrick, Wray; James P. Bigg, Grand Junction. ■

Lay Organization Standards: George R. Buck, Fredrick H. Good, Ken- neth C. Sawyer, Frank B. McGlone, T. D. Cunningham, Bradford Murphey, Casper F. Hegner, John S. Bouslog, all of Denver.

Study of Child Welfare Clinics: Balph H. Verploeg, .Denver, Chairman; J. W. White, Pueblo' Jackson L. Sadler, Fort Collins; L. E. Maurer, Boulder; Haney M. Tupper, Grand Junction; Harvey S. Rusk, Pueblo.

Liaison to Colorado State Nurses Association: John B. Evans, Samuel P. Newman, Denver.

Liaison to Colorado Bv Association; W. S. Dennis, Chairman; A. C. Sudan, R. W. Arndt, aU of Denver.

Medical-Dental Liaison: Guy W. Smith, Denver, Chairman; George E Warner, Denver; Calvin N. Caldwell, Pueblo.

Representative to Rocky Mountain Radio Council: William E. Hay, Denver; (Alternate: Chauncey A. Hager, Denver).

Representative to Belle Bonfils Memorial Blood Bank: 0. S. Pbilpott, Denver.

Representatives to Liaison Council on Graduate Education (two years) :

L. R. Safarik, Denver, 1949; Harold I. Goldman, Denver, 1950.

Delegate to Colorado Interprofessional Council (five years): K. D. A. .Allen, Denver, 1949; (Alternate: Carl A. McLauthlin, Denver, 1949).

6

Rocky Mountain Medical Journal

Today, there is a wealth of clinical evidence supporting the use of Meonine as a supplement to the protein-rich diet usually prescribed for liver damage associated with malnutrition, pregnancy, allergy, certain chemical poi- sons, and alcoholism.

Typical of this evidence is a Beams-Endicott paper*. The authors reported that a methionine supplement seemed to cause regeneration of the liver parenchyma, in cirrhotic patients, irrespective of the amount of protein and vitamins in the diet.

Complete bibliography on request. Meonine is supplied in 0.5 gram tablets. Wyeth, Philadelphia, Pa.

*Beam8, A. J., and Endicott, £. T., Histologic changes in the livers of patients with cirrhosis treated with methionine. Gastroenterology 9:718-735 (Dec.) 1947.

MEONINE

for liver damage

(dl-Mefhionine Wyefh)

7

for January, 1949

7

MONTANA STATE MEDICAL ASSOCIATION

OFFICERS

Terms of Officers and Committees expire at the Annual Session in the year indicated. Where no year is Indicated, the term is for one year only and expires at 1949 Annual Session.

President: Thomas L. Hawkins, Helena.

President-elect: Thomas F. Walker. Great Falls.

Vice-President: R. G. Johnson, Harlowton.

Secretary-Treasurer: Herbert T. Caraway, Billings.

Delegate to American Medical Association: Raymond F. Peterson, Butte, 1950: Alternate. Thomas B. Moore, Kalispell, 1950.

STANDING COMMITTEES

Executive Committee: T. L. Hawkins, Helena, Chairman; T. F. Walker. Great Falls; H. T. Caraway, Billings; L. W. Allard, BlUings; M. A.

ShilUngton, Glendive.

Economics Committee: J. C. Shields, Butte, Chairman; C. P. Brooke. St Ignatius: R. B. Durnin, Great Falls; Leland G. Russell, Billings; S. D.

Whetstone, Cut Bank.

Legislative Committee: J. M. FUnn, Helena, Chairman; F. D. Hurd,

Gnat Falls; P. E. Kane, Butte; J. C. MacGregor, Great FaUs; Claude

M. Mears, Helena.

Necrology and History of Medicine Committee: L. W. Brewer, Missoula, Chairman; I. J. Bridenstine. Missoula; J. H. Irwin, Great Falls; Claude M. Mears. Helena' J. P. Ritchey, Missoula.

Public Relations Committee: H. W. Gregg, Butte, Chairman; W. L. DuBois, Cut Bank; R. V. Morledge, Billings ; W. H. Stephan, Dillon; Dora Walker, Great Falls.

Legal Affairs and Malpractice Committee: J. C. MacGregor, Great Falls, Chairman; Raymond Eck, Lewistown; W. E. Harris, Livingston; John E. Hynes, Billings; R. D. Knapp, Wolf Point.

Program Committee: C. H. Fredrickson, Missoula, Chairman; H. T. Caraway, Biliings' H. W. Gregg, Butte; J. J. McCabe, Helena; E. S. Murphy, Missoula.

Interprofessional Relationship Committee: L. W. AUard, Billings, Chair- man: C. R. Canty, Butte; S. A. Cooney, Helena; S. N. Preston, Missoula; F. I. Sabo, Bozeman.

Nominating Committee: H. H. James, Butte, Chairman; E. L. Anderson, Fort Benton; R. D. Harper, Sidney; J. J. Make, Anaconda; W. R. Mc- Elwee, Townsend.

Auditing Committee: E. H. Lindstrom, Helena, Chairman; F. H. Crago, Great Falls; R. D. Harper, Sidney; G. W. Setzer, Malta; R. 0. Johnson, Harlowton.

Cancer Committee; Mary E. Martin, Billings, Chairman; W. F. Caeb- more, Helena; C. H. Fredrickson, Missoula; B. F. Peterson, Butte; W. C. Robinson, Shelby.

Maternal and Child Welfare Committee: F. L. McPball, Great FaUs, Chairman; L. W. Brewer, Missoula; P. L. Eneboe, Bozeman; Maude M. Gerdes, Billings: D. L. Gillespie, Butte; A. L. Gleason, Great Falls; E. L. Hall, Great FaUs; D. S. MacKenzie, Jr., Havre; R. E. Mattison, Billings; 0. M. Moore, Helena; F. W. Paul, Kalispell; C. W. Pemberton, Butte; S. N. Preston, Missoula; A. E. Rltt, Great Falls.

Tuberculosis Committee; F. I. Terrill, Galen, Chairman; C. B. Craft, Bozeman; E. A. Dolan, Anaconda; A. R. Kintner, Missoula; J. A. Layne, Great Falls.

Fracture and Orthopedic Committee; J. K. Colman, Butte, Chairman; L. C. Allard, Billings; W. H. Hagen, BilUngs; S. L. Odgers, Butte; J. C. Wol- gamot. Great Falls.

Rural Health Committee: B. C. Farrand, Jordan, Chairman; R. A. Benke, KaUspeli; W. A. Lacey, Havre; W. G. Tanglin, Poison; J. H. Williams. Culbertson.

Industrial Welfare Committee: R. B. Richardson, Great Falls, Chairman; M. A. Gold, Butte: P. E. Logan, Great Falls; D. S. MacKenzie, Jr., Havre; R. E. Walker, Livingston.

Rheumatic Fever and Heart Committee: F. R. Schemm, Great FaUs, Chairman; D. T. Berg, Helena; H. W. Gregg, Butte; A. R. Kintner, Mis- soula; P. E. Logan, Great Falls; F. H. Lowe, Missoula; J. J. Malee, Anaconda; 0. M. Moore, Helena; H. W. Power, Conrad; R. E. SmaUey, BilUngs.

SPECIAL COMMITTEES

Emergency Medical Service Committee: R. F. Peterson, Butte, Chairman; Paul J. Gans, Lewistown; J. J. McCabe, Heletu; S. A. Olson, Glendive; L. G. Russell, Billings.

lAB Fee Schedule Committee: H. H. James, Butte, Chairman; E. H. Lindstrom, Helena; J. J. Malee, Anaconda; D. S. McKenzie, Jr., Havre; F. K. Waniata, Great FaUs.

Collection
	Accounts
All reports show a trend toward slower and harder collections in the months ahead. At the first sign of neglect you will save money if they are turned over to us for collection. Comparison of collection results, backed by 35 years of experience, proves you obtain greater results at less cost, when you list your accounts
with
The American Medical and De Suite 524, 810 14th St. TAbor 2331	intal Association Denver, Colorado

8

Rocky Mountain Medical Journal

: only 2 or 3 drops

PRIVINE 0.05%

a distinguished nasal

vasoconstrictor

HIGHLY POTENT: Prompt, complete relief from nasal congestion and hyper- secretion usually results from only 2 or 3 drops of Privine hydrochloride 0.05%. Each application provides 2 to 6 hours of nasal comfort.

BLAND. NON-IRRITATING: Privine is prepared in an isotonic aqueous solution buf- fered to a pH of 6.2 to 6.3. Artificial differences in osmotic pressure between solution and epithelium are avoided. Thus, stinging and burning usually are absent.

Privine is generally free of systemic effect. The occa- sional sedative effect that may be noted in infants and young children is usually due to gross overdosage. Since there is no central nervous stimulation, Privine may be applied before retiring with no resultant interference with restful sleep.

Privine: 0.05% in i-ounce dropper bottles and i-pint bottles; 0.1% strength reserved for office procedures, in i-pint bottles only.

PHARMACEUTICAL PRODUCTS, INC., SUMMIT. NEW lERSEY

PRIVINE (brand of naphazoline) — Trade Mark Reg. U. S. Pat. Off. ‘2/1424M

for January, 1949

9

NEW MEXICO MEDICAL SOCIETY

OFFICERS — 1948-1949

President: P. L. Travers, Santa Fe.

President-Elect: J. W. Hannett, Albuquerque.

Vice President: I. J. Marshall, Roswell.

Secretary-Treasurer: H. L. January, Albuquerque.

Councilors (3 years): W. D. Dabbs, Clovis; A. C. Shuler, Carlsbad. Councilors (2 years): K. 0. Brown. Santa Fe; C. H. Gellenthlen, Valmora. Councilors (1 year): Carl Mulliy, Albuquerque; L. S. Evans, Las Cruces.

COMMITTEES — 1948-1949

Basic Science: W. E. Nlssen, Albuquerque, Chairman; Le Grand Ward, Santa Fe; Vincent Accardl, Gallup.

Rural Medical Service: M. D. Moran, Farmington, Chairman; W. B. Cantrell, Hot Springs; Stuart W. Adler, Albuquerque.

Cancer: Murray M. Friedman, Santa Fe, Chairman: Van A. Odle, Boswell; J. B. Van Atta, Albuquerque; J. W. Grossman, Albuquerque: B. W. Maher, Albuquerque. ^

Venereal Disease Control: Sam Jelso, Albuquerque, Chairman; V. B. Berchtold, Santa Fe; L. M. Miles, Albuquerque; L. S. Evans, Las Cruces; H. L. January, Albuquerque.

Legislative: Albert Lathrop, Santa Fe, Chairman; W. 0. Connor, Albu- querque; W. R. Lovelace, II, Albuquerque; Walter A. Staiir, Las Vegas; George S. Morrison, Roswell; R. 0. Brown, Santa Fe.

Public Relations; D. A. McKinnon, Jr., Albuquerque, Chairman; James L. McCrory, Santa Fe; H. M. Mortimer, Las Vegas; Frank W. Parker, Jr., Gallup.

Tuberculosis: R. 0. Brown, Santa Fe, Chairman; C. H. Gellenthlen, Valmora; D. 0. Shields, Albuquerque; H. S. A. Alexander, Santa Fe.

Advisory Committee on Ins. Compensation: Eugene W. Flske, Sants Fe, Chairman; John F. Conway, Clovis; A. C. Shuler, Carlsbad; B. E. Forbls, Albuquerque.

Committee on National Emergency Medical Service: A. E. Reymont, Santa Fe, Chairman; C. M. Thompson, Albuquerque; L. G. Bice, Albuquerque; Walter A. Stark, Las Vegas.

Ocuiist f^reicription Service ^xciuiiveii^
SHADFORD-FLETCHER OPTICAL	CO.
Dispensing Opticians	AComa 261 T
228 16th Street, Denver, Colo.

These fine Dairy Cattle, a portion of City Park’s large herd of Guernsey and Holstein cows, are scientifically fed and cared for, continuously tested by competent veterin- arians. Only through such precise watchfulness does City Park Milk receive Grade “A” designation which it enjoys. Choose City Park’s regular Grade “A” Pasteurized or Homogenized milk today — notice the particularly clean, fresh flavor.

’Phone EAst 7707

Cherry Creek Drive — Denver

10

Rocky Mountain Medical Journal

• •

safe contra

lt\®

•.,a\

- \o»'®

ilfOUf

THE UTAH STATE MEDICAL ASSOCIATION

OETICERS 1»48-1949 President: 0. A. OgHvle, Salt Lake City.

President-elect; C. H. Jenson, Ogden.

Past President: J. C. Hubbard. Price.

Honorary President: 0. W. French, Coalville.

First Vice President: J. G. McQuarrie, Richfield.

Second Vice President; Ezra Cragun, Lewi.ston.

Third Vice President: R. W. Farnsworth. Cedar City.

Secretary: Ray T. Woolsey, Salt Lake City.

Executive Secretary: Mr. W. H. Tibbals, Salt Lake City.

Treasurer: L. B. White, Salt Lake City.

Councilor First District: J. G. Olson. Ogden.

Councilor Second District: V. L. Rees. Salt Lake City.

Councilor Third District; L. W. Oaks. Provo.

Delegate to A.M.A., 1948: James P. Kerby. Salt Lake City.

Altirnate Delegate to A.M.A.. 1948: J. J. Weight. Provo.

Editor of the Utah Section of the Rocky Mounnain Medical Journal: R. P. Middleton, Salt Lake City.

STANDING COMMITTEES Rocky Mountain Medical Conference Continuing Committee: R. P. Mid- dleton, Chairman, Salt Lake City, 1949; K. B. Castleton, Salt Lake City, 1950; Clark Rich, Ogden, 1951; Noall Z. Tanner, Layton, 1952; T. B. Seager, Vernal, 1953.

Scientific Program Committee; Ray T. Woolsey, Chairman, Salt Lake City; Drew M. Peterson, Ogden; Stanley N. Clark, Provo; P. M. Howard, Salt Lake City; V. P. White, Salt Lake City; L. V. Broadbent, Cedar City: Paul A. Pemberton. Salt Lake City.

Public Policy and Legislation Committee: F. R. King, Chairman, Price, 1951; Jesse J. Weight, Provo, 1949; M, L. Crandall, Salt Lake City, 1949; V. L. Stevenson, Salt Lake City, 1949; N. F. Hicken, Salt Lake City. 1950: Omar Budge, Logan, 1950; John Coletti, Salt Lake City, 1950; W. B. West, Ogden, 1951: R. V. Larson. Roosevelt, 1951.

Medical Defense Committee: W. J. Thomson, Chairman, Ogden, 1949; R. W. Owens, Salt Lake City, 1949; J. L. Hansen, Vernal, 1949; Homer Smith. Salt Lake City, 1950; L. N. Ossman, Sait Lake City, 1950; Erwin

D. Zeman, Ogden. 1950; Charles W. Woodruff, Salt Lake City, 1951;

James Westwood, Provo. 1951: L. H. Merrill, Hiawatha, 1951.

Medical Education and Hospitals Committee: I. Bruce McQuarrie, Chair- man, Ogden. 1949; L. J. Paul. Salt Lake City, 1949; 0. A. Ogilvie, Salt Lake City, 1949; G. G. Richards, Salt Lake City, 1950; Bay T. Woolsey, Salt Lake City, 1950; T. E. Robinson, Salt Lake City, 1950;

Seth E. Smoot, Provo. 1951; George H. Curtis. Salt Lake City, 1951;

R. 0. Porter. Logan, 1951: R. H. Young, Ex-Officio. Salt Lake City.

Medical Economics Committee; Russell Smith. Chairman, Provo, 1949; A. R. Denman, Helper. 1949; W. T. Ward. Salt Lake City, 1950: W. R. Merrill, Brigham City. 1951: Ralph Pendleton, Salt Lake City, 1951.

Public Health Committee: John R. Bourne, Chairman, Roosevelt, 1949; F. D. Spencer. Salt Lake City, 1950; Ralph ElUs, Ogden, 1951.

Military Affairs and National Emergency Committee: Chrles Woodruff, Chairman. Salt Lake City; L. J. Paul, Salt Lake City; Mazel Skolfield, Salt Lake City; W. M. Gorishek, Standardville L. R. Cullimore, Orem; Ray H. Barton, Magna: D. T. Madson, Price; Riley G. Clark, Provo; Willis Hayward, Logan; Dean Tanner, Ogden.

Tuberculosis and Cardiovascular Diseases Committee: Elmer M. Kil- patrick, Chairman, Salt Lake City; Ray Rumel, Salt Lake City; D. 0. N. Lindberg, Ogden; W, C. Walker, Salt Lake City; Donald M. Moore, Ogden; Don C. Merrill. Provo.

Cancer Committee: 0, A. Ogilvie. Chairman, Salt Lake City: S. W. Fennemore, Price; E. D. Zeman, Ogden; W. G. Noble. Richmond; Harold Austin, Provo; Stanley G, Rees, Gunnison; Paul K. Edmunds, Cedar City; F. G. EskeLson, Vernal; K. B. Castleton, Salt Lake City.

Fracture Committee: A. M. Okelberry, Chairman, Salt Lake City; Clark Rich. Ogden; Roy H, Robinson, Kenilworth; S. M. Budge, Logan; Norman R. Beck, Salt l.ake City; Louis Perry, Ogden; J. G. McQuarrie, Richfield; D. C. Evans, Fillmore.

Necrology Committee: W. T. Hosier, Chairman, Provo; L. A. Stevenson, Salt Lake City: Jos. A. Phipps, Salt Lake City.

Industrial Health Committee: Paul S. Richards, Chairman, Bingham Canyon; L. J. Tauter, Salt Lake City; Frank Gorishek, Helper; Byron Daynes, Salt Lake City; E. B. Kuhe, Salt Lake City; D. C. Barker, Ogden.

Advisory Committee to the Woman’s Auxiliary: Vernal Johnson, Chair- man, Ogden: 0. P. Heninger, Provo; L. G. Moench, Salt Lake City; James

K. Palmer, Salt Lake City.

Public Relations Committee: R. P. Middleton, Chairman, Salt Lake City; Louis P. Matthei, Ogden; R. W. Farnsworth, Cedar City; Quinn A. Whit- ing, Price; Clyde J. Daines, Logan; Ray E. Spendlove, Vernal: H. L Goodwin, Salt Lake City; Gilhert Wright, Salt Lake City; Roy B. Hammond, Provo.

Inter-Professional Committee: J. Leroy KimbaU, Chairman, Salt Lake

City; C. C. Hetzel, Jr., Ogden; T. E. Bauman, Park City; Paul Clayton, Salt Lake City; Ralph G. Rigby, Salt Lake City.

Mental Hygiene Committee: Roy A. Darke, Chairman, Salt Lake City:

L. G. Moench, Salt Lake City; Wm. D. Pace, Salt Lake City; George Cochran. Salt Lake City; E. L. Weimers, Provo.

Fee Schedule Committee; K. B. Castleton, Chairman, Salt Lake City;

Howard K. Belnap, Ogden; J. E. Trowbridge. Bountifid; U. R. Bryner,

Salt Lake City; W. Leroy Smith, Salt Lake City; J. R. Wherritt, Heber City; 0. W. Budge, Logan.

Special Committee to Study Dues: H. R. Reichman, Chairman, Salt

Lake City: Eliot Snow. Salt Lake City: Ezra Cragun, Lewiston.

Rural Health Committee: J. J. Weight, Chairman, Provo; J. G. McQuarrie, Richfield; J. P. Burgess, Hyrum; Noall Z. Tanner, Layton. .

i^etter ^iow*ri at l^eaAonaLft prices		^^enuet Oxt^^en ^nc.
“Orders Delivered to Any City by Guaranteed Service”		Corner 10th and Lawrence Sts. TAbor 5138
Special attention given to floral tributes Also Hospital Flowers		Medical Gas Division MEDICAL OXYGEN
Call KEy stone 5106		CARBON DIOXIDE-OXYGEN MIXTURES
'Park floral C'o Sfor^		AVIATORS’ BREATHING OXYGEN WATER COMPRESSED NITROGEN
		WATER COMPRESSED AIR
1643 Broadway Denver, Colo. ^		Twenty -Four Hour Service

COLOR PROCESS, tv lir/ LINE & HALFTONE J A A

BEN DAY iLH U

ILLU5TRATOR5-DESIGNERS

PHOTO

ENGRAVERS

12

Rocky Mountain Medical Journal

NEO'IOPAX is available as a stable, crystal-clear solution of disodium N-methyl-3, 5-diiodo-chelidamate in 10, 20 and 30 cc. ampuls of 50% concentration and in 10 and 20 cc. ampuls of 75% concentration.

Boxes of 1, 5 and 20 ampuls.

BIBLIOGRAPHY : I. Simon S.: J.A.M.A. 138:127, 1948. 2. Pearman, R. O.: New England J. Med. 228:507, 1943. 3. Kearns, W. M., Hefke, H., and Morton, S. A.: J. Urol. 56:392, 1946

CORPORATION . BLOOMFIELD, NEW JERSEY

IN CANADA, SCHERINC CORPORATION LIMITED, MONTREAL

NEO-IOPAX

(BRAND OF SODIUM I O D O M ETH A M ATE )

Its optimal radiopacity produces clear delineation of the urinary tract permitting diagnostic interpretations to be made confidently.

NEO-IOPAX IS SAFE. Its un- blemished recoi'd^— more than fifteen years of effective urinary tract visualization without a single fatality reported in the literature — xema.ms to be equalled.^ Administered intravenously, using proper technic, Neo-Iopax is remarkably free from even minor side-effects.^’®

accurate,

safe

urography

UJI”: =■ NEO-IOPAX * IS ACCURATE.

NEO-IOPAX

THE WYOMING STATE MEDICAL SOCIETY

OFFICERS

President: George E. Baker, Casper.

President-Elect: DeWitt Dominick, Cody.

Vice President: K. E. Krueger, Ro^ Springs.

Treasurer: P. M. Schunk, Sheridan.

Corresponding Secretary: George H. Phelps, Cheyenne.

Delegate A.M.A.: R. H. Reeve, Casper.

Alternate Delegate A.M.A.: W. A. Buntea, Cheyenne.

Executive Secretary: Mr. Arthur Ahbey, Cheyenne.

COMMITTEES

Rocky Mountain Medical Conference: Earl Whedon, Chairman, Sheridan; George N. Phelps, Cheyenne; H. L. Harvey, Casper; C. W. Jeffrey, Rawlins;

L. W. Storey, Laramie.

Syphilis Committee: N. E. Morad, Chairman, Casper: G. M. Groshart, Worland; L. H. Wilmoth, Lander; L. G. Booth, Sheridan: F. H. Halgler, Midwest.

Cancer Committee: Earl Whedon, Chairman, Sheridan; John Gramllch, Cheyenne; DeWitt Dominick, Cody; J. R. Newman, Kemmerer; E. W. New- man, Cheyenne,

Medical Economics Committee: C, L. Rogers, Chairman, Sheridan; Nels A. Vicklund, Thermopolls; R. A, Corbett, Saratoga; G. R. James, Casper;

S. S. Hellewell, Evanston.

Fracture Committee: Philip Teal, Chairman, Cheyenne; Silva J. Giovale, Cheyenne; Robert V, Batterton, Rawlins; Lowell D, Kattenhorn, Powell; Joseph E, Hoadley, Gillette,

Medical Defense Committee: George Baker, Chairman, Casper; Andrew Bunten, Cheyenne; E, W, DeKay, Laramie,

Councillors; Earl Whedon, Chairman, Sheridan: R. J, Boesel, Cheyenne; E, W, DeKay, Laramie; George Baker, President, Casper; George Phelps, Secretary, Cheyenne,

Advisory to Woman’s Auxiliary: John R. Bunch, Chairman, Laramie; Virgil L, Thorpe, Newcastle; H. J. Aldrich, Sheridan; G. B. Savory, Chey- enne.

Advisory to Workmen’s Compensation Department: J. D. Shingle, Chair- man, Cheyenne; G. H. Phelps, Cheyenne; W. A. Bunten, Cheyenne; R. H. Reeve, Casper; Albert T, Sudman, Green River; P, M. Schunk, Sheridan. *

Industrial Health Committee: K. E, Krueger, Chairman, Bock Springs; Willard Pennoyer, Cheyenne; Thomas B, Croft, Lovell; Eugene Pelton, Laramie.

Veterans’ Affairs and Military Service Committee: A. J. AUegretti, Chair- man, Cheyenne: Jack Rowlett, Laramie; Everett Ellis, Cheyenne; Bernard Sullivan, Laramie; G. W, Koford, Cheyenne; Bernard Stack, Thermopolls; J. W. Sampson, Sheridan; DeWitt Dominick, Cody; Paul B. Holtz, Lander; George E, Baker, President, Casper; George Phelps, Secretary, Cheyenne.

Blue Cross Hospital Committee: B. I. Williams, Chairman, Cheyenne, 1950; W. A. Bunten, Cheyenne, 1949; E, W, DeKay, Laramie, 1951; Cedric Jones, Cody, 1952,

Public Policy and Legislation: George Phelps, Chairman, Cheyenne:

Andrew Bunten, Cheyenne; George Baker, President, Casper; G. W, Koford, Cheyenne; E. W. DeKay, Laramie; G. W. Henderson, Casper.

National Physicians Committee: George Phelps, Chairman, Cheyenne;

Andrew Bunten, Treasurer, Cheyenne; E, W. DeKay, Laramie; George Baker, Casper,

Poliomyelitis Committee: H. L. Harvey, Chairman, Casper: N. A. Vicklund, Thermopolls: Leo Keenan, Torrington; DeWitt Dominick, Cody; Philip Teal, Cheyenne; Franklin Yoder, Cheyenne; F, A. Mills, Rawlins.

State Institutions Advisory Committee: J. F. Whalen, Chairman, Evans- ton; George Phelps, Cheyenne; C, W, Jeffrey, Rawlins; Earl Whedon, Sheri- dan; G, M, Groshart, Worland; R. H, Kanable, Basin,

Necrology Committee: Earl Whedon, Chairman, Sheridan; John B. Krahl, Torrington; Franklin Yoder, Cheyenne.

Rural Hdaith Committee: Paul Holtz, Chairman, Lander; Andrew Bun- ten, Cheyenne: Samuel Worthen, Afton; Wm. K, Rosene, Wheatland; Claude Raffl, Basin.

Public Health Department Liaison Committee: E. C, Ridgeway, Chair- man, Cody; R. P. Fitzgerald, Casper; R. V. Batterton, BawUns; J. W. Sampson, Sheridan; B, C. Stratton, Green River; WiUard Pennoyer,

Cheyenne,

Child Health Committee: Paul W. Emerson, Chairman, Cheyenne; John Gramllch, Cheyenne: Thomas Croft, Lovell; Bernard Sullivan, Laramie;

Paul R, Holtz, Lander; Geo, E. Baker, Casper; A, R, Abbey, Cheyenne.

Council on National Emergency Medidal Service: George H. PheBm. Chairman, Cheyenne; R. H. Reeve, Casper; DeWitt Dominick, Cody; E, W. DeKay, Laramie; K, S, Kruegeri Rock Springs; P. M. Schunk, Sheridan.

COLORADO HOSPITAL ASSOCIATION

OFFIC/EmS

President: Frank G. Palladlno, Community Hospital, Boulder. President-Elect: Walter G. Christie, Presbyterian Hospital, Denver.

Vico President: Hubert W. Hughes, St. Anthony Hospital, Denver. Treasurer: Sister Mary Thomas, Mercy Hospital, Denver.

Executive Secretary: B. B. Jaffa, M.D., Denver.

Trustees: Roy B. Prangley, SL Luke's Hospital, Denver (1949); James P. Dixon, M.D., Denver General Hospital, Denver (1949); Louis Llswood, National Jewish Hospital, Denver (1950); DeMoss Taliaferro, Children’s Hospital, Denver (1950); Roy R. Anderson, Presbyterian Hospital, Denver (1951): Rev. Allen H. Erb, Mennonite Hospital, La Junta, Colo. (1951).

Delegate to the American Hospital Association: Herbert A. Black, M.D., Parkview Hospital, Pueblo.

Alternate: Msgr. John R. Mulroy, Catholic Hospitals, Denver.

STANDING COMMITTEES Auditing: Ben M. Blumberg, Chairman, (1948), General Bose Me- morial Hospital, Denver; M. A. Moritz (1949), Denver General Hospital, Denver; B. W. Pontow (1950), Colorado General Hospital, Denver.

IhNistitutlon and Roles; Samuel S. Golden, M.D., Chairman, Beth Israel Hospital, Denver; Henry B. Hill, Weld County Hospital, Greeley; Sister H. Johanna, Sacred Heart Hosplt^, Lamar.

Legislative: Msgr. John R. Mulroy, Chairman, Catholic Hospitals, Denver; DeMoss Taliaferro, Children’s Hospital, Denver; Carl Ph. Sebwalb, Denver; Robert C. Kniffen, Colorado General Hospital, Denver; Herbert A. Black, H.D., Parkview Hospital, Pueblo.

Membenhip; Leo W. Beifel, Chairman, St. Vraln Hospital, Longmont; B. B. Jaffa, M.D., Denver.

Nominating: Herbert A. Black, M.D., Chairman, (1948), Parkview Hoopltal, Pueblo; John C. ShuU, (1949), Porter Sanitarium and Hospital. Denver; Hubert W. Hughes, (1950), St. Anthony Hospital, Denver.

Program; Boy B. Prangley, Chairman, SL Luke’s Hospital, Denver; B. B Jaffa, M.D., Denver.

Nursing and Public Education: DeMoss Taliaferro, Children’s HosplUL Denver; Sister M. Louis, St. Anthony Hospital, Denver; Miss Merle Love, R.N., Presbyterian Hospital, Denver; Sister Maria Graria, B.N., Gloekner Sanatorium, Colorado Springs; Frank G. Palladlno, Community Hospital, Boulder.

Resolutions; S. Russ Denzler, Chairman, Colorado Hospital, Canon City; Carl Ph. Sebwalb, Denver; Walter 0. Christie, Prebyterian Hospital. Denver.

SPECIAL. COMBII’TTEES

Public Relations: John C. Shull, Chairman, Porter Sanitarium and Hos- pital, Denver; James P. Dixon, M.D., Denver General Hospital, Denver; Sister Mary Luitgard, St. Thomas More Hospital, Canon City.

Rates and Charges: Hubert W. Hughes, Chairman, SL Anthony Hos- pital, Denver; Walter G. Christie, Presbyterian Ht^pltal, Denver; Ben M. Blumberg, General Rose Memorial Hospital, Denver; Msgr. John & Mulroy, Catholic Hospitals, Denver; Leo W. Beifel, St. Vraln Hospital, laingmont; Roy R. Prangley, St. Luke’s Hospital, Denver; DeMoss Taliaferro, Chlldrcn’c Hospital, Denver.

Hospital Survey and Planning: James H. Walker, Chairman, Good Sa- maritan Hospital, Sterling; Arthur A. Fisher, Architect, Denver; B. B. Jaffa, M.D., Denver.

State Board of Health Advisory: Msgr. John B. Mulroy, Chairman, Catho- lic Hospitals, Denver; DeMoss Taliaferro, Children’s Hospital, Denver; B. B. Jaffa, M.D., Denver.

Delegate to Colorado Inter-Professional Council: Hubert W. Hughes, SL Anthony Hospital, Denver.

Representatives to Liaison Connell on Cradoato Education: Boy B. Prangley, St. Luke’s Hospital, Denver; Frank G. PaUadioo, Community Hospital, Boulder.

A

id Speed in ^redcription

eruice

ccurac^ ana ^peea in i" reAcrip

DORR OPTICAL COMPANY

421 16th Street

Denver, Colorado

KEystone 5511

14

Rocky Moumtaim l^feoxcAL Journal

Zke Jmportame of Protein M^^uacy Jn 'Diabetes Ji^ititus

It appears in the light of recent experience that the daily protein requirement of the diabetic has been underestimated and calls for an upward revision.

The success obtained in diabetic retinopathy from the use of high protein diets emphasizes the deleterious possibilities of hypoalbumin- emia in this metabolic disease.

In view of the excellent results observed from a high protein intake, in many forms of hepatic disease, a dietary rich in protein is suggested as a therapeutic measure in the management of liver enlargement, one of the frequent complications of diabetes.^ Since impaired liver function reduces the efficacy of insulin, prevention of liver enlarge- ment by a liberal allowance of protein in the daily diet of the dia- betic appears an important factor in the control of this disease. With an estimated 2,000,000 diabetics in the United States^ every benefit achieved in this field makes itself felt on a truly large scale.

Meat is an outstanding source of protein in the dietary of the patient with diabetes mellitus for these reasons: It is notably rich in protein, from 17 to 20 per cent of its uncooked, and from 25 to 30 per cent of its cooked weight. The protein of meat, regardless of cut or kind, whether fresh, cured, or canned, is biologically complete. All meat is of excellent digestibility — from 96 to 98 per cent. Fur- thermore, meat ranks with the best sources of B vitamins, potassium and phosphorus, all of which are essential factors in the metabolism of carbohydrate.

^Nutrition in Diabetes, Nutrition Rev. 6:257 (Sept.) 1948.

^Diabetes and Arteriosclerosis in Youth, Editorial, J.A.M.A. 135:1074 (Dec. 20) 1947.

The Seal of Acceptance denotes that the nutri- tional statements made in this advertisement are acceptable to the Council on Foods and Nutrition of the American Medical Association.

American Meat Institute

Main Office, Chicago -,..Vieitiberf Ihroughciut tt'e United States

for January, 1949

15

HSI

^WaViirted supetiof ^

The incidence of mild protein deficiencies in children, predisposing toward infections and edema, is reported'-^ much greater than generally realized. Infant and adolescent requirements— not only for tissue repair and maintenance, but also for growth— are much higher than in adulthood.^ To insure adequate protein intake in infancy, Dkyco — Borden's high-protein infant food — is ideally suited as a basis for formula building. It furnishes all the essential amino acids. Its low fat content minimizes gastro-intestinal upsets due to fat intolerance, while its intermediate carbohydrate content lends itself for prescription with or without added carbohydrate. Quickly soluble in cold or warm water, Dryco contains adequate vitamins A. B|, B^ and D, plus essential milk minerals.

R*f«r«ncM: 1. Dodd. K.and Minot, A. S.; /. Pediat., 8:442, 1936.

a. Dodd. K. and Minot. A. S.: /. Pediat., 8:452, 1936. 3. Sahyun, M.s Am. J. Dig. Dis., 13:59, 1946.

BORDEN’S PRESCRIPTION PRODUCTS DIVISION

350 Madison Avenue, New York 17, N. Y.

fn Canada writa The Borden Company, Limited Spadina Crescent, Toronfo.

DRYCO is made from spray-dried, pasteurized, superior quality whole milk and skim milk. Provides 2500 U.S.P. units vitamin A and 400 U.S.P. units vitamin D per reconstituted quart. Supplies 3IV2 calories per tablespoon. Available at all drug stores in I and It/z lb. cans.

16

Rocky Mountain Medical Journal

Complete Therapy for Pernicious Anemia

Potent liver extract is the only substance which has been proved to provide complete therapy for macrocytic anemias. The concentration of all Lilly liver extracts is such that the amounts contained in the recommended daily dose will, in the average uncomplicated case of pernicious anemia in relapse, produce a standard reticulocyte response and cause the red-blood-cell count to return to normal within a period of sixty days. This standardization is in accordance with the recommendations of the United States Pharmacopoeia Anti-Anemia Preparations Advisory Board.

Lilly injectable liver extract preparations include —

Liver Extract Solution, Crude, Lilly, in strengths of 1 and 2 injectable U.S.P. units per cc.

Liver Extract Solution, Purified, Lilly, in strengths of 5, 10, and 15 injectable U.S.P. units per cc.

ELI LILLY AND COMPANY, INDIANAPOLIS 6, INDIANA, U.S.A,

FramabU reprints of this illustration are available

THE MEN RESPONSIBLE FOR MRS. BROWN'S BLOOD COUNT

You, the physician, are ultimately responsible for the successful management of patients afflicted with pernicious anemia. You and your assistants carefully determine the patient’s response to measured doses of liver extract, but back of that is the responsibility of the men who make the product.

It is reassuring to both physician and patient to know that the liver extract employed has met exacting standards before release.

Fresh frozen liver is handled in abattoirs according to Lilly specifications and is checked by skilled Lilly inspectors before acceptance. The frozen liver is then ground and extracted in equip- ment designed by Lilly engineers. Lilly liver extracts, whether for parenteral or oral administration, are assayed on hospitalized pernicious anemia patients in relapse by clinicians experienced in hematology. Thus, from the grinding of the frozen liver to the final packaging and inspection, the production of Lilly liver products is supervised by competent specialists. They, too, feel deeply their responsibility for Mrs. Brown’s blood count.

LILLY SPECIALISTS SERVE THE MEDICAL PROFESSION

SRocky

Colorado Montana New Mexico Utah Wyoming

JANUARY

1949

y\/lountaLn

yvledical Journal

E-ditorial ^

This Is Worth Memorizing!

p\R. ANTHONY B. DIEPENBROCK of San Francisco recently wrote to an officer of the American Medical Associa- tion. He stated that in this day and age when everybody is talking himself hoarse about medical plans and programs, he would like to offer his own 13-point program which “might be interesting to our colleagues.” The letter has already been widely quoted, but without further explanation we present Dr. Diepenbrock’s “program” in full:

1. Continue to sit on your fat derriere and do nothing.

2. Be apathetic and, like 5,000,000 registered Republican voters who failed to vote, do not bother to make your opinion known. If you think, as they did, that your opinion or your vote is not worth anything, the opposition will agree with you and act accordingly, as they have.

3. Write an occasional letter to your Congress- man, tell him off, and then explain proudly to the interns in the surgical dressing rooms how smart you are and what a stinker your Congressman is.

4. Tell everybody you see that the gag is up, and we might as well prepare for the inevitable.

5. Moan and groan and issue explosive and unprintable epitheths.

6. Refer to your medical leadership as a group of impotent, ineffective and bumbling igno- ramuses.

7. Make speeches before sympathetic lay au- diences, and concert those who already believe in free enterprise.

8. Don’t bother to tell your county society heads, your state society heads, or your national association heads what you want them to do. Expect them to find a way for you without your guidance.

9. Scream about high medical society dues and forget that our friends in the trades union de- mand many times what we pay: in other words, make the situation as difficult as possible, then grumble about it.

10. Oppose any program developed by the majority of your colleagues because it demon- strates your superior wit and your general greatness.

11. Remain superbly and learnedly dignified when Joe Doakes asks why you oppose state medicine. Brush him aside with any insult you can think of. Joe will like you for that.

12. Don’t bother to use the selling methods which actually bring messages before the public. Continue to depend on occasional radio feature programs. Billboard advertising, newspaper ad- vertising, national magazine advertising, radio advertising and, above all, continuous and daily radio spot programs over national hookups and all such like are too commercial, too trouble- some, too expensive and too undignified: don’t use them.

13. Above all, disregard the “little guy” — the one with a vote. Tell him nothing; push him around. He doesn’t know anything anyhow.

V <4 ^

T otal Socialization In England

A TOUR of the United States has recently been completed by Sir Archibald Mc- Indoe, the English surgeon. He has made a number of talks to various groups regarding the status of medical practice in England. He states that there is much misapprehen- sion regarding England among the doctors of America. Furthermore, after considerable observation and thought, he is not sure that the calamity of state medicine is far off in this country.

England differs politically from the United States. During the past twenty years she has developed a third party, the Socialist. It started as the Fabian Society which now has come to rule England. The Society intends to nationalize England’s re- sources, labor, and production. England and her people have respect for law, order, and political authority. We in America have less regard for the latter. England

for January, 1949

17

is financially broke and must find a way of paying for what she needs; at least one- half of the populace must be fed from out- side resources. Her present social security program intends that every individual in the country shall be entitled to freedom and want from womb to tomb. This plan is expressed in three ways — unemployment and old age insurance, abolishment of in- dustrial injuries compensation, and state control of all hospitals (except the teach- ing institutions) .

The doctors of England were given a plan of panel practice in keeping with the above, for the simple reason that they did not submit a plan of their own. (A.M.A. please note!) A hostile people, the press, and the House of Commons resented what they interpreted, rightly or wrongly, as un- fair or selfish financial ambition on the part of the doctors. Ninety per cent of the doctors voted against the plan, but there was no alternative to its acceptance. They were told that they did not have to go in, but each was at liberty to make his living, if he could, out of the five per cent of people who did not accept or were not entitled to “free” medical care. Obviously very few physicians could afford to take such a risky gamble with essentially every wage-earner and his family entitled to medi- cal care in return for compulsory with- holding of the equivalent of one dollar and a half from his earnings. For this premium, he is entitled to old age benefits, medical and hospital care, industrial acci- dent coverage and prosthesis — even includ- ing eye glasses.

The doctors were offered what appeared to be a fairly attractive proposition; ap- parently luscious bait was placed in the trap to gain their cooperation, if not their enthusiasm. The physician ultimately, after his useful professional life, receives a pen- sion which is two-thirds of the average in- come of the last three years of his practice. This pension does not die with him, if his wife survives, but is concluded with her death. The doctor is still entitled to earn all that his inclination and physical stamina will permit. But, as with any other Englishman, he cannot keep more than

18

3,200 pounds (approximately $12,000), for the government takes all beyond that.

The medical profession of England is mak- ing the best of it and for the most part seems to have resigned itself to making the plan succeed if it is within its power to do so. Most of the doctors are carrying on with the well-known British stoicism. The doctors who are wise, and also able, are not rupturing their arteries and dilating their hearts seeking a greater income for their King. Many have relaxed and are taking a few months off each year. They seem not to worry too much. They go home and rest, at times when we American doctors would be inclined to return to the office or the hospital.

Regarding their philosophy, perhaps the English doctors have something. We know what political medicine would do to our patients, to the whole public, and to medical progress in the United States. We must fight it, and the outcome of the battle is not yet fully determined. There may yet be time to convince the American people and the American Congress that freedom is worth preserving. Nevertheless, whether we and those still-too-few people who know the facts win or lose the struggle, we doctors would do well to save our coronaries, enjoy life like human beings as we go along and live, and live longer.

^ ^

American War Hospitals In England

A PPROXIMATELY one hunderd hospi- tals were set up in England by the United States during World War II for the use of our armed forces. Some were in spacious manor houses, material surviving evidence of a fabulous way of life which has passed; others were composed entirely of temporary, ten to twenty-five year, struc- tures; a few were of good and permanent construction, to be turned over to the Eng- lish for perpetual use of communities sorely in need of augmented hospital facilities. In this way the old lend-lease balance was titlted a bit toward the right, as if it made any difference.

One of the prominent American hospitals in England was the Churchill Hospital at

Rocky Mountain Medical Journal

Oxford. Statistics are not available to us, but it may be that more Americans visited Oxford than any English city other than London, It was a favorite spot for mili- tary personnel on leave, as were Canter- bury, Cambridge, Stratford-on-Avon, Ches- ter, Edinburgh, among a number of others. Oxford was sought for its educational re- sources, historical significance, and for its beauty. Many medical conferences were held at Churchill Hospital, and facilities of Radcliffe Infirmary, Oxford Medical School and other institutions were available for educational pursuits. Hospitality of the faculty and others toward Americans made excursions to Oxford double attractive in contrast to the toils of war.

At hand is a recent clipping from an Oxford newspaper which would interest the hundreds of American doctors and nurses who served or attended the Churchill Hos- pital. It is entitled “New Maternity Home — Oxford 40-Bed Block.” The new block has been converted from a section of the hospital as the Americans left it and it is anticipated that it will accommodate at least a thousand maternity cases annually. In conjunction with the Radcliffe, it pro- vides also a school of midwifery. Inci- dentally, midwifery is a prominent part of medical service in Britain— and the mid- wives’ morbidity and mortality statistics are not bad. Probably they call for medical help in time when they need it, but at any rate midwifery serves well a crying need in that country. They are proud of their ultra-modern converted American hos- pital. We should be interested in the dis- position of the other similar structures after we cleared out and returned the island to those who were glad to get it back.

Oxford was peculiarly free from air raids — and, as far as we know, so was Heidel- burg. It was common belief at the time that Hitler had relations, or at least friends, among the large headed, bespectacled, hol- low-chested eccentrics who frequent edu- cational centers, especially in the Old World. Some sort of a “deal” was thought to pre- vail for mutual protection of these educa- tional centers and their contents — not books.

but rather nazis, communists, fifth column- ists. But perhaps it was only army grape- vine, the most facile of all communication media, or maybe simply a strange coinci- dence.

SILHOUETTES

from the A.M.A. House of Delegates

At the Interim Meeting of the American Medi- cal Association in St. Louis the House of Dele- gates voted, unanimously, to levy an assessment of twenty-five dollars on each member of the association. It is important to emphasize that this action was taken by the House of Delegates. It is equally important to realize that the sug- gestion that this assessment be levied came from the delegates of several states and did not origi- nate with the Board of Trustees or with any council or committee of the association. It was the thought and the action of the House of Dele- gates— ^your representatives in the structure of our association.

The purpose of this levy is, briefly, to carry to the public through the newspapers of the United States factual data concerning the ac- complishments, the activities and the objectives of the medical profession. It is designed to tell the whole truth to all of the people. And that should be a great treat for all of the people. The management of this program must, of neces- sity, be vested in our administrative body — the Board of Trustees.

The wishful thinkers are vocal and in print. They are predicting failure to collect this assess- ment. They prophesy that the American Medi- cal Association will be “split down the middle.” That’s what they think. Let’s show ’em!

Twenty -five dollars is (as those two fine yoimg American boys who shovel our snow say) “some lettuce.” Consider the barter value of twenty- five dollars: It will purchase three orchids or a pair of shoes for your wife, or two to four neckties, or one-half to one hat for your daugh- ter, or a minimum amount of feminine unmen- tionables, or three and one-half bottles of Johnny Walker or Old Granddad.

But, it will purchase, also, professional dignity and security, spiritual integrity, intellectual in- dependence, freedom in thought, action, ambi- tion and achievement, and a decent disregard of sob sisters, pot boilers, pseudo political up- lifters, the lap dogs of foreign ideologies and other emotional tripe.

The defeatist attitude has been abroad in orxr profession these last two months. “What’s the use” and “you cannot beat the government”

for January, 1949

19

These mental (?) reactions are normal and, therefore, not impressive. It is our duty to help the people and the government. What is this mythical and fearsome entity “government”? Government is you and you and you and Luke McGluke on the street corner and under the viaduct. None other.

Our short, stormy but magnificent history as a nation is littered with the unembahned mum- mies of defeatist thought. The Great American Desert, that pitiful backwoodsman Lincoln, those deluded Wright Brothers at Kitty Hawk, Morse, Steinmetz, Henry Ford, and back yonder a fel- low called John Paul Jones. When ordered to “strike colors” on his battered and sinking ship, John Paul Jones rephed, “We have just begim to fight!” Here is the lesson of history. To your battle stations, gentlemen. Give us youth and vision or give us testosterone.

Thoughts of a Maverick

Is there not, in the administrative bodies of our association, a place for that dynamic, fair- minded, outspoken gentleman. Dr. Paul R. Haw- ley? Or do we save the chaff and throw away the grain? * • ♦

With an expanding program, certain voluble editors will find need for several more ghost writers. * • *

Colorado introduced a resolution on behalf of and with the verbal concurrence of the delegates of fourteen additional states. The Speaker, at the end of the session, requested that such antics ^ be avoided in the future. This smells more like Chicago than Philadelphia — a sort of childish gasp of a failing bureaucrat.

WILLIAM H. HALLEY, M.D.

Correspondence

Editor’s Note: The lollowinff letter, received by Dr. C. F. Hegner, President of the Colorado State Medical Society, is published with the permission of both writer and Dr. Hegner.

Walsenburg, Colo., November 13, 1948.

Dear Dr. Hegner;

This is still America or I wouldn’t be writing to you in this way.

I am greatly concerned over socialized medi- cine, which President Truman will try to force on the public. Of course such a program will mean that the government has control of our bodies and our minds. It will mean loss of personal freedom and regimentation in its highest form. It will mean the government will set itself up as a welfare state. It will be bad for

the people but it will also be tragic for you physicians.

You are not organized as a union and I hope that you never will be. Still, you have your county, state and other organizations. Trucksters, railroad men, telephone operators and clerks and others get their way by striking. Can you not, through your county organizations, state organi- zations, etc., make such an organized protest of refusal that you can save America and your- selves?

Doctors are ethical, but the cause seems great enough for doctors to fight.

This does not call for an answer, but I sin- cerely hope that you doctors can keep America free. There are two months left.

Very sincerely,

MRS. K. L. B.

In the opinion of the Editor, this letter does deserve an answer, and in Dr. Halley’s “Silhouettes,” above, one form of reply is plainly indicated.

To the Editor:

For the benefit of the members of the five constituent State Medical Societies served by the Rocky Mountain Medical Journal, I refer to the following incident which I recently ex- perienced at the Palmer House in Chicago.

On June 16, 1948, I handed to the doorman at the Palmer House a suitcase for checking until after a meeting then in progress in that hotel. I was given a numbered baggage check. On claiming the bag in the late afternoon I was advised it was lost. After two days of patient waiting I demanded a search for same since I had pointed out an identical bag and my name was on an attached tag. Nine days later — Jime 25 — the bag was found in one of the hotel rooms. Since this bag contained everything not on my person and including memos and correspondence necessary to certain arranged-for professional and business confer- ences, the value of the trip was seriously re- duced. Substantial purchases of toilet articles and clothing in order to remain through the meeting were required.

The hotel passed the matter of responsibility on to an insurance carrier which claims all re- sponsibility is limited to $50.00 because of the following which appears on the back of the baggage check given me: “The property checked hereunder is accepted only upon the following conditions: (1) the hotel’s liability is limited, pursuant to Illinois statutes, ' to the following amounts; Valises, traveling cases and contents — $50.00. Boxes, parcels or packages and contents — $10.00.” However, to date the insurance com- pany “decline to make a voluntary payment” of my claim.

If the reader is in the habit of carefully noting the printed matter on the back of a baggage check given by a hotel — especially when hurry- ing to get to a meeting then in progress — this warning is unnecessary, but it would be wise before placing baggage in the custody of any hotel to determine the value of the case and contents in view of the law under which the hotel limits its responsibility.

C. T. BURNETT, M.D.

Denver.

20

Rocky Mountain Medical Journal

Original Articles

PSYCHOLOGICAL FACTORS IN EVERYDAY PRACTICE*

O. SPURGEON ENGLISH, M.D.

PHILADELPHIA, PENNSYLVANIA

This paper is presented with misgiving, since as a psychiatrist becomes aware of many things which cause people emotional distress and places them before his col- leagues, he may seem to be criticizing his colleagues for these things are too often overlooked, or perhaps we simply pamper human beings in general. However, you are aware* that civilization has growing pains; technocracy has cured many which came from long hours of laborious work; medicine and surgery have cured some due to macroscopic and microscopic pathology of the soma. Psychiatry has become aware of microscopic stresses within the psyche which add up to unhappiness, inefficiency and illness — and it is these, encountered in daily practice, which are under discussion. We are coming to know more about people and what hurts them in the mind, and this must become general knowledge and be spread by the doctor. The doctor always has been a great teacher and this role is becoming more important all the time, es- pecially in teaching man about himself.

One fact of interest which has assumed great importance in medicine within the past fifty years is that we begin life as children and grow up with difficulty. One patient said, “I never really grew up. I only grew older.” At any rate, we grow up only relatively well, since to grow up or to mature emotionally means to be able to endure stresses and distresses while assum- ing responsibilities, and to work happily and enjoy communion with our fellow man. To be able to do these things guarantees freedom from disease syndromes classed as psychoneuroses and psychosomatic condi- tions. But this must be difficult to accom- plish, since after centuries of living we have

‘Presented at the Fifty-second Annual Meeting of the Utah State Medical Association, September 11. 1947. From the Temple University Medical School.

more social problems in the world today than ever before, and people are concerned that the highly developed mind of man will not settle them but instead will proceed to destroy themselves and every good thing on earth.

Dependency

As we study human personality, we find that passive state of childhood, with em- phasis on being cared for, has a powerful pull upon the individual child. Parents and teachers attempt to combat it by appeal, rewards, reminders, cajolery, sternness and punishment. Some parents or parent sub- stitutes succeed in creating a responsible, diligent individual whose hold upon life and enjoyment of things in it is so great he is practically never tempted to inertia or the questionable pleasures of dependency, con- tinued idleness, being cared for through hos- pitalization, remaining at home because of symptoms, or prolonging convalescent time from illness or operation. However, an ap- palling number of people do not succeed in avoiding these conditions during their life- time.

Training of physicians for years over- looked an important observation — that man’s physiology is trained to responsibility along with man himself. Man must learn to eat as well as learn the alphabet; he must learn to control the lower bowel and blad- der as well as learn the multiplication table; he must learn to control his heart rate under conditions of danger and re- sponsibility, and he must learn how to with- draw from life at periodic intervals in sleep in order to effect necessary rest and repair. While these physiological phenomena have certain automaticity, they are not complete- ly so, and the learned component is impor- tant in maintaining health.

Furthermore, what we have glibly re-

fer January, 1949

21

ferred to as instinct — that which was in- born and needed no learning — is not neces- sarily serving us in a complex world. We refer to the fact that mothers know how to I ear their young. They did a good job when home and child rearing was the cen- tral focal point of their lives, but the time has come when their interests are more scattered and being the teachers of a well- ordered mind which included a well-inte- grated and functioning physiology is no longer their first love and concern in an increasing number of instances. It is an increasingly important part of the physi- cian’s job to teach them the importance of this role as well as to equip himself to re- pair damage wrought by ignorance or neg- lect of the human being’s basic needs for health.

The discomforts of being young, of being a child, of being dependent, are many and continuous. Children are sick and tired and cry with distress many times when they have no broken bones, no bruised tissues, no fever, and no invasion with organisms.

The “dis-ease” which comes from merely being alive and needs the sunny smile of friendship, the soothing breeze of satisfac- tions of hungers and the invigorating air of approval for effort needs ministering to in the home, and if it isn’t there, the one who misses it will visit health resorts, doc- tors’ offices, or clinics for it — often futilely. This is because sometimes the defect in emotional structure between neurology and physiology is so great it cannot be replaced, no matter how well understood. But in many instances it is replaceable and fails to be replaced because it is not understood.

This may sound to some like theorizing or philosophizing, but actually these are ob- servations which have been proved and can be proved again and again.

If a mother is coming home from market with both arms l^aden and leading the dog and her child of three is too tired to go on, sits down until he is carried, one may think it is annoying or cute, depending upon the mood one is in. But when a valuable em- ployee feels the same way when his em-

ployer needs his service, it becomes a com- plex problem in diagnosis and treatment; it may involve the lives of many people, much money and wasted energy.

This is why the doctor of today needs to know much about that intangible but pow- erful force operating between the neuro- logical and physiological structure. We call this force the personality. It needs more than the common sense, we are often so proud of, to understand its workings. It takes uncommon sense to know its many ramifications and manifestations.

A man, aged 46, complained of gastro- intestinal symptoms in January, 1947. He was operated upon for removal of the ap- pendix and drainage of the gallbladder. He was told they “had never seen a worse ap- pendix,” and even though there were no complications and he made an uneventful recovery, his family doctor told him, “You shouldn’t go to work for six months.” He had been a stationary engineer for seven- teen years, and after three months’ idleness he began to have pain in the back, pain in left side of head, and began to feel shaky and dreaded to lose his mind. He has been out of work eight months and shows no in- tention of returning to it until he feels completely comfortable. His wife has had to go to work to support him and their daughter. Careful study has shown no dis- ease, but he is determined that he can’t go to work until he is made well. More history revealed that at the age of 27 he had had a “nervous breakdown” with fatigue and gastro-intestinal symptoms and insomnia, and a specialist had told him his job was “too big for him.” He changed jobs and improved, but always after that when under stress he would get various body aches and pains and some indigestion. If these emo- tional factors of his earlier history had been understood, it would have been clear that to suggest six months’ rest for this man was playing into the hands of his dependency and might bring about reactivation of old illnesses. A prolonged convalescence can be as harmful to efficiency as that prolonged period back of the lines was for the patient during the war. The psyche should be

22

Rocky Mountain Medical Journal

evaluated pre-operatively just as is now done with heart, lung, and kidney.

Evaluating the Presenting Symptom

Behind the symptoms presented to the doctor there may lie a great need to be un- derstood regarding some emotional pain or distress. The presenting symptom is mere- ly the bridge over which the patient tries to walk in gaining rapport with the wise and understanding person that the physician is supposed to be. A patient once said, “It is harder to bear the suffering of grown-up children like us patients than the suffering of little children.” Such a statement could be regarded in different ways. It is true we expect mental suffering from children and not from adults. But the truth of the matter probably is that not many of us can stand much suffering of any kind in other people, nor do we know very much about what to say or do about it. At the present stage of our civilization, children have to endure or repress a great deal of suffering because neither its cause nor effect is un- derstood. When the adult suffers he may be more insistent and hence harder to avoid or be put off. Moreover, we are more baf- fled by suffering we cannot understand and alleviate. If we do not understand and al- leviate the suffering of children when it is simple, we aren’t likely to do any better with that of adults when time has made it much more complex.

Understanding the Tendency to Act Childishly (Regression)

Patients cooperate better if they feel their doctor knows human nature and accepts it philosophically. One patient who suffered from fatigue said, “I’d like to go to bed in a nice hospital for six months and have the doctors and nurses very solicitous of me; to have them bring me my meals on a tray and to have my friends call on me, bringing me flowers and presents. But I’d die rather than admit that to a soul I know.” In this statement we see clearly the desire to re- gress to a childish state of living. If we ac- cept this confused attitude, does this mean the patient is going to lie down on the job — just because we admit we understand? Not

at all. Enough insight and honesty alone are present to keep her from it, and to be aware of and sympathetic to her wish puts us in a position to offer some encouraging support that will be helpful. In passing, we might say that many patients are actually doing what this woman only admitted she would like to do. The regressive forces have been stronger and produced enough symtomatology and incapacitation to put them in the hospital bed with some symp- tom or group of symptoms. To their credit, it must be said that they do not understand their wish, or wishes, but if they are to be made well and remain so we must under- stand their wishes to be dependent and cared for, and help them avoid becoming victims to their emotions through illness.

The practice of medicine requires sociolog- ical knowledge as well as all the other diagnostic therapeutic technics. We must understand and help them not only because our job is to understand and cure ill people, but also because the whole world must un- derstand itself if we are to make any head- way with the many causes of human un- happiness, strife and impediments to prog- ress, such as broken homes and marriages, industrial strife, class and racial struggles, delinquency and war. The forces which make the individual sick make society sick, and vice versa, and changes won’t come if knowledge of human nature remains in the hands of a few. Knowledge of self, i.e., knowledge of the working of our emotions and ideas which implement them, must be- come the property of everyone. The doctor is the logical one to do a great deal of teaching about it. He has prestige; he has centuries of reputation of having worked for the public good; he is regarded as a scientist. The ill man has much to gain personally from listening. Moreover, who is more interested in the problem of cre- ating better adjusted human beings unless it be the clergyman? And who has better access to human beings than the doctors?

Sharing a Distressing Siutation

A woman of 35 recently arrived from Puerto Rico, entered the hospital for pain in the lower abdomen and back. She was

for January, 1949

23

a well-educated woman married to a man not only less well-educated but emotionally and imaginatively more obtuse. She bore him three children, the last one being def- initely unwanted and she had made sev- eral tries at abortion. Coincident with the birth of the third child, she became frigid and began to have pain in the lower back and abdomen. In efforts to remove the pain she had appendectomy, hysterectomy and oophorectomy. She and her husband became more estranged and she became on increasingly poor terms with his family.

She left the country, leaving the children with the grandparents, and came to the States looking for work and a solution to her problem. But she missed her children and familiar surroundings and was unhappy here and the pain was worse. All physical findings were negative. She said, “I’ve had an unhappy past and I see nothing in the future.” She was going back to Puerto Rico to a husband and family situation full of distress, but it seemed a little better than staying in a new country in unfamiliar surroundings away from the children.

She needed a doctor who was not intent on taking away the pain immediately. He needed to be able to let her have it for awhile — to share it with her, perhaps even in the beginning to have her subtly re- proach him for his lack of skill as a doctor — while he explained to her the way the body absorbs pain from the mind, and who would encourage her to do the best she could in spite of pain and make as much peace as she could with unfriendly relatives. She found such a doctor; in fact, one who spoke her native tongue, and made rapid improve- ment, and said, “If I could find a doctor hke you when I go home, I feel sure I could stay well enough to carry on.” There seems no question but what we must train medical students to avoid the conviction that they must cure a patient completely and quickly so that they 'do not have to see him for a long time, else their ability as physicians is open to question. We need to have more of the philosphoy of the good parent who, while he does not encourage dependency, neither does he shake off those

whd need him too forcibly, and so soon that they have not been properly strengthened.

The Danger of Efforts at Quick Symptom Removal

The pressure upon the doctor to relieve a symptom quickly is not as great as he often believes. Patients will endure symptoms a long time, as we know, both from their history and from the discovery in many cases of serious pathology which they have been ignoring. While it is true that most patients want relief when they consult a physician, they will be patient if told that the cure takes time and that there is no specific drug or operation which will bring quick cure for their condition. The urge to give quick relief to a condition which is due to personal conflict with the individual, either with his conscience or his environ- ment, has led to the injurious use of seda- tives, electroshock, glandular therapy, ton- ics, vitamins, injections of iron and other preparations, when no proved indication for their use exists. The good results, when they occur, must then be due usually to suggestion; but when relapse occurs, as in- evitably it does, the effect is never as good in subsequent treatment. It is then more difficult to switch to a psychotherapeutic approach than it would have been to begin such at the first visit. In comparison, one must admit that relapses occur after psy- chotherapeutic treatment also, but the re- sumption of treatment by this means gives results, while the effect of non-specific suggestive medications has worn off. More- over, one has an enlightened patient to deal with who does not mind the challenge of going to work upon himself, and making that effort to get interested in the world outside of himself again. One very impor- tant ally on the side of the psychotherapeu- tic approach is that everyone wants to live more interestingly and more constructively. Finally, there is the fact that the patient is doing his share in the therapy, instead of just saying reproachfully and dependency, “Doctor, your last medicine doesn’t help me. What are you going to do now?”

An example of this is a married woman, aged 29, with two children, who developed

24

Rocky Mountain Medical Journal

fears of dying, accompanied by palpitation, shortness of breath, weakness and dizziness. She had been brought up in a home with a mother who suffered from depression of spirits, irritability, and many physical com- plaints and was prone to nag and forbid. The patient was freed from this dull ex- istence momentarily before marriage, but following marriage in the early twenties, and being confined to the house by two children, the resentment and depression she had accumulated through so many years’ contact with a neurotic mother asserted it- self and she developed symptoms. We ex- plained the origin of such symptoms, as- sured her as to their harmlessness and urged her to try to get out of the home and live a little. She at first hopelessly said she couldn’t get anyone to stay with the children, but by our emphasizing this move as not just a luxury but the necessary es- sence of her therapy, she and her husband made arrangements for the children, ven- tured forth to parties, dancing, bowling and skating. She became symptom free, quite rapidly in a three-month period, and remained so for one and a half years, out of contact with medical care. Then one day she got a return of symptoms again quite suddenly and returned, and it was plain in a few moments of conversation that she had let her outside life drop and was back living the same dull, uninspired, unsociable life her mother had lived. She said, “I gradually got back in a rut again without realizing it.” With a few instructions she was again symptom free in three weeks, this time as a result of again putting into effect what she had learned the first time. She said, “i don’t think I’ll forget so soon this time.” Her husband was told, “If you want to keep your wife welf, go out with her periodically where she can enjoy herself and thereby give her something pleasant to think about for a few days which will help neutralize the bleakness of her childhood which now floods her mind and threatens to overcome her.” He understood and has kept it up. In passing, we might remark that an under- standing and cooperative spouse is a great asset in psychotherapy.

Symptoms arising from faulty attitudes toward life require specific treatment for their personality reactions. To treat un- specifically is to foster invalidism with fixed symptoms which may eventually be- come resistant to psychotherapy because the faulty personality pattern has become too firmly set.

Finally, in closing, a word or two about watching carefully our own beliefs and prejudices and asking ourselves every now and then whether we are really rendering the right decisions for our patients, or whether we are applying worn-out con- cepts, exercising a personal prejudice, or being too hurried or too indifferent to find out the patient’s real wish or to discuss the matter with him in a manner that will fit his problem. One doctor says, for example, “No mother should have the care of her own child. At birth it should be handed over to a nurse to care for. The mother is emotionally too wrapped up in the child to be good for it.” A mother said, “I had to beg my doctor to let me nurse my baby and finally he gave in.” A woman whose child needed a transfusion asked to have an explanation of what this entailed for her and the child, and the doctor im- patiently said, “I know how to give a trans- fusion. Don’t you trust me?” The mother was offended, went through with the trans- fusion and then crossed this doctor off her list for any future service to her family, as she said, “No one had ever had a trans- fusion in our family. Naturally, one wants to know what that means in terms of time and discomfort. I can’t say, ‘You’re won- derful, Doctor, everything you do is all right,’ even though that seems to be what he wants.” People want to know and are entitled to know more about these things than in the old days of secrecy about what was done for illness. This woman’s reac- tion represents a growing trend of thinking in the minds of a more enlightened public, which doctors must be aware of and meet.

Some doctors have acquired an undue anxiety about the prescription of sedatives, seeing in every patient a potential addict. They refrain from giving a sedative or

for January, 1949

25

hypnotic the first night in the hospital or before an operation because of this belief, and the patient spends several uncomfort- able hours unnecessarily while his good-will toward the hospital and doctor are put to a strain. If the patient needs a laxative, he may appreciate being asked which one he customarily uses, if any, and the amount, and be prescribed the same, instead of a blanket dosage for every one of some favor- ite drug favored by the physician which may turn out to be too much or too little.

A patient recently said, “I like Dr. Jones, but I feel he is too busy for me. I went in with a hundred questions but I had only two minutes of his time and couldn’t get any satisfaction.” Now, when the doctor is busy and patients would like to discuss their illness at length, a successful comprise may be to recognize the need and say, “I can’t discuss your illness to the extent you would hke, but I’ll answer your three most im- portant questions today if you will put them briefly and concisely and take up more with you next time.” It would often turn out that the patients won’t have three questions but if they have more they still have gained considerable satisfaction from having the three most important ones answered.

Then, there is the physician who feels that no patient should be told he has in- curable disease and the others who feel the patient should always be told he has an incurable disease. It would seem that a middle road is the only rational one. Some want to know the truth about their illness, can cope entirely adequately with the news and certainly deserve to be told and may attend to some very important things when told, as well as make the best use of their remaining time in life. Others do not want to be told, could not well stand to be told, would live their remaining days miserably if told, and if such is the case, they can well be left in ignorance, with only the other family members being informed of the true state of affairs.

The doctor has shaved off his beard and laid aside his long-tailed coat, but he still has the respect of the public. Yet he must keep it — and we submit that to do so he

must replace the austerity with a greater knowledge of how human personality func- tions. We must find out what human beings need and try to discover in what degree helping them to get what they want and need is important for their welfare. We are finding out that lessening emotional tur- moil and promoting serenity as far as pos- sible is not a luxury for the human race, but a necessity. Since the doctor is one of the foremost leaders in human welfare, the application of knowledge of the emotions is an increasingly important part of his arma- mentarium.

In fact, as we learn more about how peo- ple can get along with less unhappiness and conflict, the psychiatrist would like to make every colleague an ally in an effort to re- duce in size that vast reservoir called the unconscious mind. The doctor works through his colleagues and the colleagues work through the adult patient and they in turn through the children. Finally, the speed of increased knowledge is rapid if we, as doctors, earnestly assume our teaching as well as our healing role.

POSTGRADUATE COURSE IN ENDOCRINOLOGY

The Postgraduate Committee of the Associa- tion for the Study of Internal Secretions, under authority of its Council, announces a course of lectures and demonstrations in Clinical Endo- crinology to be held in Oklahoma City at the Skirvin Hotel, February 21 to 26, 1949, inclusive. The faculty will consist of prominent investi- gators and clinical endocrinologists in the va- rious branches of the medical sciences in the United States and Canada. This course will be a practical one of interest and value to both the general practitioner and the speciahst. A fee of $100 will be charged for the entire course and the attendance will be limited to 100. Reg- istration will be in order of checks received. Should there be an insufficient number of ap- plicants to warrant the course, the registration fee will be immediately refunded in full. Please forward application on your letterhead, together with your check payable to the Association for the Study of Internal Secretions, to Henry H. Turner, M.D., Chairman of the Postgraduate Committee, 1200 North Walker Street, Oklahoma City 3, Oklahoma. Due to other meetings being held in Oklahoma City at the time of this as- sembly, satisfactory hotel accommodations will be difficult to procure on short notice; there- fore, it is suggested that all applicants make their reservations early, directly with hotels of their choice. Some of the better downtown hotels in Oklahoma City, listed according to their proximity to the Skirvin are: Skirvin Tower, Huckins, Wells-Roberts, Biltmore and Black.

26

Rocky Mountain Medical Journal

CURRENT THERAPEUTIC PROCEDURES IN CORONARY DISEASE*

WILLIAM S. MIDDLETON, M.D.

MADISON, WISCONSIN

Much of the present knowledge of coro- nary disease stems from the clinical studies of contemporary clinicians. Among them George Dock and James B. Herrick in the United States and John Parkinson in Eng- land deserve especial notice. Within the span of an active career Herrick has per- force preached first a need for diagnostic consciousness of coronary thrombosis and then the necessity of greater critical judg- ment. Errors of commission are exceeding errors of omission in its diagnosis. In press- ing his thesis he cited some twenty-eight conditions that were mistaken for coronary occlusion. Perhaps selfish abstraction has led the medical profession to serious con- cern in the prospect of an unusually high incidence of this vascular accident among its own members. For a time Levine and Hindle allayed this fear by adducing evi- dence that there is no such differential be- tween the physicians and the general popu- lation, even though coronary-artery disease is the most frequent cause of death among doctors. Dublin and Spiegelman in a careful analysis of the situation, however, deter- mined that the death rate of male physi- cians from coronary disease is one and four-fifths times that of white males of the same ages in the general population.

With a clarification of diagnostic criteria interest next centered upon the prognosis of coronary thrombosis. This knowledge opened the door to logical therapy. With this shifting emphasis came renewed at- tention to the underlying anatomy and physiology of the coronary circulation. The old Weigert-Cohnheim controversy over the fundamental nature of the arterial termina- tions has resolved itself long since by the demonstration of anastomoses. These con- necting channels vary in size and ap- parently become functional only when the demand arises upon interference with the lumen of a normally responsible vessel.

’From The Department of Medicine, University of Wisconsin Medical School. Read before the Fifty- second Annual Meeting-, Utah State Medical Associa- tion, September 11, 1947.

Such arterial communications may be (a) intercoronary, (b) through the vessels of Thebesius, (c) by way of the arteriae telae adiposae or (d) through vessels in pericar- dial synechiae. The sympathetic nerves sup- ply vasodilator fibres to the coronary arter- ies, whereas vasoconstriction is effected through the vagi. The coronary arteries may be the seat of any disease to which the gen- eral vascular bed is heir. Early in the in- flammation or degeneration of a vascular tube the responses to any stimulus are ex- cessive. Beyond the capacity to respond to such stimuli the artery may anatomically represent a rigid or an occluded tube.

To simplify the discussion, coronary sclerosis with resultant thrombosis may be taken as the type. Obviously there are many other diseases affecting the coronary system. Independently arteriosclerosis may lead to narrowing and occlusion of coronary arterial branches. The customary result of such gradual nutritional encroachment is myocardial fibrosis. In this light coronary thrombosis on an arteriosclerotic basis can never be acute in its pathologic background. Furthermore, the pathologic outcome of coronary thrombosis depends on the size and importance of the vessel occluded, the adequacy of anastomoses and the time fac- tor in the ultimate complete obstruction. Smaller, less vital vessels may be occluded without serious consequence, provided there be adequate collateral arterial support and time to bring it into effective play. If these several factors be not favorable and myo- cardial nutrition fail, infarction ensues. Le- vine has divided the periods of pathologic events subsequent to coronary thrombosis on rather arbitrary but highly practical grounds. Anemia, edema and hemorrhagic extravasation dominate the histologic pic- ture for the first three or four days. Necro- sis comes to the fore from the fourth day to the end of the third week. Fibrosis is inconspicuous early and does not take a prominent place until after the third week.

for January, 1949

27

Its reparative role is rarely adequate until the fifth or sixth weeks. Deviations from such a formula will be frequent, but they do not detract from its broad application. Dependent upon the ischemia of the epi- cardium and endocardium adjacent to the myocardial infarct reactive inflammation of these serous membranes may be antici- pated. The pericardial reaction proceeds from sero-fibrinous to fibrous stages. As indicated, through such adhesions a poten- tial source of improved nutrition may come. The approximation of the pericardial layers and their sealing may further act as an ef- fective “blowout” patch. Within the cham- bers of the heart at the site of the infarction mural thrombi may occur. Particularly is such thrombosis prominent in aneurysms of the heart incident to myocardial infarction. These intracardiac thrombi carry an ever- present threat of remote embolism. On the other hand it is conceivable that they serve an “anti-leak” function similar to “fillers” in the inner tubes of pneumatic tires.

Translated into the clinical course these pathologic processes find expression in sev- eral manners. The gradual encroachment of arteriosclerosis upon the myocardial nu- trition leads to symptoms that are best con- sidered as coronary insufficiency. The most widely recognized among these is angina pectoris. This symptom takes on a more ominous portent when the precipitating cause from a physical standpoint becomes decreasingly less and then assumes the characterization of angina of decubitus. Just as significant of coronary insufficiency is indigestion on effort after eating. Heberden clearly appreciated this relationship in an- gina pectoris, since he wrote, “They who are afflicted with it, are seized while they are walking (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast.” Dyspnea removed from the effort and un- explained weakness are less definite symp- toms from this cause; but they must be con- sidered in the composite picture of coronary insufficiency. In gradual myocardial fi- brosis from coronary sclerosis congestive failure ultimately eventuates in most sub-

jects. Immediate death upon coronary oc- clusion depends upon some serious inter- ference with conduction. Surviving this immediate threat the second danger, namely that of rupture of the heart, may be en- countered from the third day to the end of the third week after the occlusion. A con- siderable number of patients with acute coronary occlusion and myocardial infarc- tion under my care have died from this on the fifth day. This experience has not been an isolated one. Embolism from mural thrombosis may usually be expected before the fourteenth day. In the experience of the State of Wisconsin General Hospital the greatest mortality from coronary thrombo- sis is incident to delayed cardiac failure. Obviously this picture is in some measure colored by the exclusion of the group of early fatalities.

With this background the therapeutic at- tack may be more clearly ordered. The prophylactic approach to the degenerative diseases is not well defined. Obviously un- derlying constitutional states, such as dia- betes mellitus and hypertension, should re- ceive appropriate attention. In the major- ity of individuals arteriosclerosis is an in- cidental finding and general hygienic measures alone prevail. Among these, mental and psychological equilbrium are more important than physical protection. Tobacco should be interdicted by reason of its vasospastic effect. While this action may represent an individual idiosyncrasy, its elimination is still justified. Tea and coffee have no contraindication if used in moderation. Alcoholic beverages in small amount need not be denied, if the patient be in the habit of their reasonable use. In- deed, they have the incidental property of vasodilatation. The diet requires especial notice. Arteriosclerosis is singularly prev- alent in obese individuals. Experimental and clinical evidence supports a cholesterol fault of metabolism in the etiology of ar- teriosclerosis. Beyond a peradventure weight reduction is a prime indication in obese subjects with arteriosclerosis. Fur- ther, the diet for all potential or established coronary patients must take the factor of

28

Rocky Mountain Medical Journal

cholesterol sources under advisement. Let it be borne in mind, however, that the demonstrability of vascular change of this order is proof of their irreversibility. The prophylaxis should anticipate this point. Perhaps Osier’s admonition should be ex- tended to the choice of one’s grandparents, for there is a vascular pattern among fami- lies. Whether this circumstance depends upon environment or heredity remains to be proved.

From the standpoint of the active therapy of coronary sclerosis the xanthin deriva- tives have been widely recommended. Their usefulness has been questioned in some quarters, but experimental evidence and clinical experience justify the use of theo- phyllin 0.1 to 0.2 gram (IVz to 3 grains), three times a day. Mild sedation, such as phenobarbital 0.015 to 0.030 gram (V4 to V2 grain) three times a day, may supplement psychotherapy and advice in affording re- laxation. Nitroglycerin and the nitrites have their traditional position in the treatment of angina. The results from androgens have not justified the early optimism that at- tended their use. Among the measures ad- \dsed for the reduction of the circulatory re- ‘ quirement the most radical was total thy- i roidectomy. Its unphysiologic principles should have condemned this procedure a j priori. More recently thiouracil and propyl- jj thiouracil have been proposed with the same I design. They have the virtue of simplicity, I control, and reversibility. Further trial of i these drugs is necessary to establish their I availability in coronary insufficiency. When cardiac failure becomes the dominant ex- I pression of coronary sclerosis, appropriate . measures of physical rest, diet, digitalis and ; other details of cardiac support will be in- voked.

With the warning of the symptoms and signs of coronary insufficiency frank coro- ; nary thrombosis may be postponed or i j averted. On the other hand this accident I in all of its classical features may occur I without premonitory signals of distress, i Conversely the atypical and silent forms ! may baffle the most astute diagnostician. The therapeutic targets are specific, namely,

for January, 1949

control of pain and hypoxia, sedation, pro- tection of the myocardium, improvement of the coronary blood flow, prevention of em- bolism and of propagation of the thrombus, preservation or restoration of normal con- duction and maintenance of minute volume output of the heart (control of cardiac de- compensation). Absolute bed rest, with mental as well as physical relaxation, is the first indication in the treatment of acute coronary occlusion. Ordinary sedatives and analgesics do not suffice to meet this de- mand. Morphine sulfate (0.015 gram — 14 grain) should be given intravenously. The hypodermic route will require several times this dose without an assurance of satisfac- tory results. The repetition of morphine will depend upon the effective control of mental unrest and pain. Since papaverin alone of the alkaloids of opium gives smooth muscle relaxation, it has been recommended in place of morphine in this connection. The earlier dosage (0.030 to 0.060 gram) did not give adequate control, but the more recently advised 0.060 to 0.2 gram (1 to 3 grains) doses, intravenously, have been efficacious. Oxygen has been one of the most satisfac- tory agents for the control of the pain of coronary occlusion. At the same time dyspnea and systemic hypoxia are com- batted. The approved dosage is 6 liters per minute by the oro-pharyngeal route until equilibrium is established. Thereupon the flow may be reduced to 4 liters per minute. As a rule in the State of Wisconsin General Hospital oxygen is administered routinely at levels of 4 to 6 liters per minute for the first fifteen days to three weeks after cor- onary thrombosis. The philosophy of this procedure lies in the histologic evidence of the curve of myocardial necrosis. A much more extended experience will be required to establish the validity of this position. Practically most of the patients are much more comfortable; but the question is not susceptible of experimental resolution since the general vascular picture in the coronary arterial system cannot be duplicated in ani- mals. Attendant upon vascular occlusion are waves of nerve impulses. The vagal re- sponse leads to vasoconstriction. To block

29

this possible contribution to coronary im- pairment atropine has been used. The recom- mended dose of 0.001 gram (1/60 grain) is precariously close to the level for vagal release. If it be repeated as recommended, serious tachycardia may occur. Aminophyl- lin (0.5 gram) intravenously is advised early in the course of coronary thrombosis. Later it may be given by mouth in doses of 0.1 to 0.2 gram (IVa to 3 grains) three times a day.

The incidence of embolism, remote throm- bosis and the propagation of a coronary thrombus has been variously estimated at from 10 to 35 per cent. Certainly these thrombo-embolic complications of coronary occlusion constitute a considerable problem. With the availability of anticoagulant agents a clinical attack has been made. Peters, Guyther and Brambel reported a controlled series of patients with coronary thrombosis treated with dicumarol. Embolic phenom- ena were reduced to one-eighth and the mor- tality to one-fifth of the untreated group. In general the extending experience has confirmed this report. Meyer, Bingham and Axelrod recommended 5 mgm. of dicumarol per kilo as an initial dose by mouth and 1.5 mgm. per kilo sufficiently frequently to keep the prothrombin level between 25 and 35 per cent. Subsequently the general rule has made 300 mgm. of dicumarol the first dose. If the prothrombin percentage is above 20 per cent on the succeeding day, 200 mgm. is given. If the value is below 20 per cent, no dicumarol is given on the sec- ond day. If the curve of decline of pro- thrombin has been slow the dose of dicu- marol is increased. If rapid, the subsequent doses should be decreased or the interval lengthened. This anticoagulant therapy should be continued through the period of bedfastness in patients with coronary thrombosis. The technical difficulties in the laboratory control of dicumarol effect by repeated prothrombin determinations, in the judgment of some clinicians, outweigh the advantage of an effective anti-coagulant that can be administered by mouth. Its oc- casional hazard in hemorrhage can be con- trolled by transfusion of fresh whole blood or more specifically by the intravenous in-

jection of 40 to 60 mgm. of synthetic vi- tamin K.

Since the initiation of the depression of prothrombin is delayed for twenty-four to forty-eight hours after the oral administra- tion of dicumarol, the support of promptly acting heparin has been evoked in conjoint therapy. Given intravenously, heparin leads to an immediate prolongation of the clotting time (10 minutes) and its effect is lost within two or three hours. Hence hepa- rin may be used to initiate anti-coagulant therapy in the prospect of a continuation of this basic action by dicumarol. The ad- vised dose of heparin for intravenous use is 50 mgm. every four hours. Continuous intravenous drip methods are too difficult for a wide acceptance. The therapeutic ob- jective is a prolongation of clotting at least twice normal time (to 12 or 15 minutes). This plan presupposes the discontinuance of heparin as soon as the prothrombin falls to 30 per cent under the concurrently ad- ministered dicumarol. Loewe and Rosen- thal’s suggestion of Pitkin’s menstruum as a vehicle for heparin permits deep subcuta- neous injection and prolonged therapeutic action through slow absorption. The effect of a single subcutaneous injection will last for eighteen to forty-eight hours. Hence it offers the prospect of a more easily con- trolled anti-coagulant for long continued use in coronary thrombosis. Much wider experience in its use is required before heparin in Pitkin’s menstruum will replace dicumarol. The antidote for heparin is protamine. Multiple transfusions of fresh blood are likewise efficacious.

The diet of a patient subsequent to coron- ary thrombosis requires especial attention. Early, especially if the stomach be unre- tentive, parenteral fluids should be ad- administered. To avoid the risk of right heart embarrassment, isotonic solution of glucose is preferred. Five hundred cubic centimeters of 5 per cent glucose may be given slowly by the intravenous route three times a day. Although the caloric value of this nutrient source is small, it represents rapidly available energy for the lamed myo- cardium. Food by mouth should be offered

30

Rocky Mountain Medical Journal

in small quantities, preferably in five small rather than the customary three average meals. To observe the above implied indica- tion an adequate carbohydrate intake should be especially preserved. Should edema be a presenting manifestation, low sodium intake will become a prime indica- tion. The patient on low sodium may take fluids as he desires. Mercurial diuretics with or without preparatory ammonium chloride may later be required.

Although most of the contraindications to digitalis are theoretical, it should be re- served for frank or impending decompensa- tion. Rarely will these indications require rapid digitalization. As a rule the course may be planned with a three-day objective of therapeutic action. Cardiac arrhythmias are potential sources of serious danger in coronary thrombosis. Nevertheless the pro- phylactic use of quinidine has not seemed justified. A small minority of these pa- tients experience such faults of conduction and the action of quinidine is so rapid (10 to 15 minutes by the oral route) that little added hazard exists in its deferment until the development of the arrhythmia. A fixed formula for its administration has proved especially useful. Bearing in mind the fact that the action of quinidine is exerted for only two hours, the pattern is:

a. Quinidine sulfate 130 mgm. (2 grains) ; repeated in two hours as a test for quinine idiosyncrasy, b. Quinidine sulfate 260 mgm. (4 grains) every two hours day and night for thirty-six hours, or until the normal sinus rhythm is restored, if it be before that period. Experience has proved that con- tinuance of these doses beyond thirty-six hours is usually unavailing, c. Maintenance levels are established first by reducing the individual dose and then by lengthening the interval. Usually complete withdrawal is possible; but a gradual reduction after the suggested plan makes it possible to retrace one step at a time rather than to repeat the entire course of quinidine in event of an escape from therapeutic control.

Surgery has made material contributions to the treatment of coronary disease. In general most of the surgical procedures

coronary circulation through new pericar- dial sources. Thorel established the exist- have evolved from attempts to improve the ence of fresh blood supply in pericardial adhesions. Beck pursued this approach by suturing the pectoralis major to the epi- cardium. O’Shaughnessy brought the omen- tum through the diaphragm for the same purpose. Subsequent suggestions have in- cluded a series of measures to create arti- ficial synechiae between the layers of the pericardium. Divergent from this plan have been Fauteux’s direct attacks upon the coronary system. By the application of the Leriche principle of periarterial sympathec- tomy to the coronary artery and simulta- neous ligation of the great cardiac vein he has shown a distinct circulatory advantage to the myocardium of experimental ani- mals. Carried over into clinical experience the results have been promising; but a much wider application of the method will be re- quired to establish its place in practice. Most recently Vineberg and Jewett have suggested transplantation of the internal mammary artery into the wall of the left ventricle for the purpose of improving its nutrition. These experimental studies have not yet been supported by clinical trial, but new vascular channels have appeared in the myocardium of dogs after the transplant. Attempts to transfer the prospects of any operative procedure from the experimental animal to the human subject with coronary disease must always take into account the usual widespread vascular handicap in the latter. Until it is possible to duplicate this condition in animals and from that baseline to induce coronary occlusion, the clinical projection and application of experimental studies will be presumptive and the results relatively fortuitous.

The convalescence from a coronary acci- dent is frequently tedious. Recognizing every grade of myocardial handicap, minor episodes admittedly escape notice or pro- gress to an uneventful convalescence with- out unusual protection. On the other hand, serious degrees of disability to fatality may succeed initially inconsequential manifesta- tions. The prognosis of coronary thrombo-

jor January, 1949

31

sis is beset by many pitfalls. Accordingly- conservatism is the best policy. Physical rest in bed must be enjoined for six weeks in the average subject. Compromises in the reduction of this period may be made in the victims of lesser attacks under carefully controlled conditions. Conversely, a certain number with severe reactions must remain in bed for several months to insure the es- tablishment of a maximal collateral circu- lation and myocardial reserve. Physical in- activity can be carried to inordinate ex- tremes. The period of recuperation may be reached when carefully graduated exercise becomes the key to more adequate myocar- dial recovery. Mental rest must likewise be insured. Detachment from business and family cares is essential. Tobacco in all forms must be eschewed by reason of its vasoconstrictor influence. Although this ef- fect is much more profound in some indi- viduals than in others, it is the safest plan to generalize. Alcohol, tea, and coffee have a vasodilator effect and may be used in moderation. With freedom from symptoms

of coronary insufficiency and an improve- ment in myocardial reserve will come in- creasing ' interest in mental and physical outlets. This period carries a grave re- sponsibility for the physician. Whereas up to this point the patient has been pro- tected from a real knowledge of the exact conditions, now the physician must make him a partner in the ultimate plan of cam- paign. The anatomic, physiologic, and pathologic factors in the situation are out- lined in principle. The coronary handicap is cited, usually somewhat on the optimis- tic side. The myocardial reserve is dis- cussed as an element which may be spent extravagantly or protected by judicious liv- ing. Always the patient must be informed of the penalty of probable invalidism inci- dent to wasteful expenditure of this reserve. Conversely, the prospect of years of com- fortable useful living under careful control should leave no doubt in his mind as to the physician’s position; but such conferences must be sympathetically realistic. As Long- cope said, “Why ward off death if in the attempt we kill living?”

HEMOCHROMATOSIS WITH APLASTIC OR REFRACTORY

ANEMIA*

EUGENE HILDEBRAND, M.D., F. H. CRAGO, M.D., and JOHN A. LAYNE, M.D.

GREAT FALLS, MONTANA

Severe anemia is an uncommon finding in hemochromatosis. However, six cases of aplastic or refractory anemia accompanying hemochromatosis have been reported’ - ^ Dive of these six cases had a cellular bone marrow, of the type sometimes referred to as “pseudoplastic anemia.” We are report- ing this case in order to add one more to the previously reported five cases with a cellular bone marrow, and also for the pur- pose of recalling Mallory’s views about the role of copper poisoning in the etiology of hemochromatosis.

REPORT OF CASE

History: C. N., a 50-year-old male, was first seen by Dr. F. R. Schemm in June, 1944, because of weakness of a degree which interfered with

♦Presented in part before the Mid-Western Sec- tion of the American Federation for Clinical Re- search, in Chicago, on October 30, 1947. From the Departments of Medicine and Pathology, Great Falls Clinic, Great Falls, Montana.

his occupation. He had been treated elsewhere during the preceding eight months because of anemia, receiving ferrous sulfate orally and liver extract intramuscularly. His previous health had been good. His mother died in 1919 of what was diagnosed as pernicious anemia.

He had been employed continuously in a copper refinery for twenty-five years, working in the electrolytic department where he handled sheets of copper wet from the vats. His gloves were quickly worn through, and his underwear and the skin of his body would be stained with green copper salts.

Physical examination in June, 1944, revealed a mild pallor of the skin and mucous membranes. The skin was soft and of a feminine type, and there was no pigmentation. There was a paucity of body hair; he shaved about twice a week. Pubic hair distribution was of the ferninine type. The testes were small and the genitalia were poorly developed. Blood pressure was 130 milli- meters of mercury systolic and 90 millimeters diastolic. There was no demonstrable enlarge- ment of liver, spleen or lymph nodes.

Laboratory data: Urinalysis was normal. Hemo- globin was 13.4 grams per 100 c.c., erythrocyte count 4,220,000, leukocyte count 5,800, with a differential count of 55 per cent polymorphonu-

32

Rocky Mountain Medical Journal

clear neutrophiles, 4.4 per cent lymphocytes, and 1 per cent basophiles. There was slight anisocy- tosis of the erythrocytes. The reticulocyte per- centage, was 1.1. Platelet count was 130,000. Gastric analysis was performed on several oc- casions and free hydrochloric acid was never found to be present in the gastric secretion, even following histamine. Roentgen examination of the stomach, small intestines, and colon was per- formed on three occasions during the next two and one-half years, and was always normal, except for the presence of a few small diverticuli in the lower ileum. Roentgenographic examina- tion of the skull was normal. Electrocardiogram was normal.

Clinical course: Initial diagnosis was deferred and the patient was treated symptomatically with 45 drops of diluted HCl (USP), and 1.0 gram of ferrous sulfate a day. He received only these medications during the next fifteen months, until September, 1945, at which time his hemo- globin was 12.9 grams, erythrocyte count 3,900,- 000, and his leukocyte count 6,400, with a normal differential (see Table I). Since this represented an essentially unchanged hemogram from that of fifteen months previously, it was decided to de- termine the effect of large doses of liver extract. He received 300 units of liver extract administered intramuscularly in a period of twelve days. One week later his hemoglobin was 11.7 grams, erythrocyte count 3,540,000, leukoycte count 3,650, of which 47 per cent were polymorphonuclears, 46 per cent lymphocytes, 4 per cent monocytes, 1 per cent eosinophiles, and 2 per cent basophiles. Platelet count was 178,000. This reticulocyte percentage was 0.8. The clotting time was 4 minutes and 45 seconds. The bleeding time was 16 minutes. There was complete lack of clot retraction in forty-eight hours. Coincident or subsequent to the oral administration of ascorbic acid, vitamin K, and calcium, his bleed- ing time and clot retraction returned to normal, and remained essentially normal thereafter.

The patient had first complained of some paresthesias and numbness of the hands in Au- ugust, 1945, prior to the period in which he re- ceived intensive liver therapy. Neurologic ex- amination was otherwise normal, and the par- esthesias did not improve following the liver extract.

In August, 1946, he wa^. admitted to the hos- pital for further study, as the diagnosis of pri-

mary splenic neutropenia was being considered. Again, the patient’s chief complaint was weakness, and his physical examination was essentially un- changed from that of twenty-seven months ear- lier. Urinalysis was again normal. During the eleven months from September, 1945, to August, 1946, the patient’s hemoglobin had decreased gradually to 9.3 grams per 100 c.c., but his erythrocyte count remained at about 3.9 millions. His leukocyte count decreased to 1,800, of which only 36 per cent were granulocytes. Examination of the peripheral blood smears revealed hypo- cromia of the erythrocytes, polychromasia. Jolly bodies, and occasional stippling. Bone marrow biopsy showed that erythopoiesis was perhaps somewhat increased and that granulopoiesis was quite active. Neither occult blood nor ova were present in the feces. Bromsulfalein test of liver function was normal. Only a trace of urobilino- gen was present in a 24-hour collection of urine.

Splenectomy was decided upon in the hope that the granulopenia of the peripheral blood and the anemia might be due to abnormal function of that organ. The patient elected to have this surgery performed at the Mayo Clinic, where all of the above mentioned diagnostic studies were repeated under the direction of Dr. Byron E. Hall with similar results. The splenectomy was performed on September 6, 1946. The spleen weighed 155 grams. No accessory spleen was found. Careful exploratory examination of the other abdominal organs revealed no abnor- mality. Microscopically, a diffuse hemosiderosis of the spleen was present (Fig. 1).

There was no change in the level of the patient’s hemoglobin, or his leukocyte count after operation, and the granulopenia persisted. There was an excretion of 44 milligrams of unrobilino- gen per day in the feces over a four-day period, indicating that hemolysis was not a factor in the production of the anemia.

A review of the patient’s course up to this time, therefore, led to the following conclusions: !. although occasional macrocytes had been ob- served in smears of the peripheral blood, the normal urobilinogen studies and the low normal reticulocyte counts would exclude an hemolytic anemia; 2. morphologic studies of the bone mar- row and failure to respond to large doses of liver extract administered intramuscularly had excluded pernicious anemia; 3. the persistence of the neutropenia and anemia following sple-

TABLE I

Summary of Hematologic Data During Last 32 Months of Patient’s Life.

	Hemoglobin	Erythrocyte	Percentage	Total	Percentage
	Grams per	count in	reticulated	leukocyte	of
Date	100 c.c.	millions	erythrocytes	count	granulocytes
June 1, 1944	13.4	4.2	1.1	5,800	55
September 19, 1945^	12.9	3.9		6,400	72
October 8 ,1945^	11.7	3.5	6.8	3,650	47
August 30, 1946^	9.3	3.9	0.6	1,800	36
October 7, 1946^	7.4	3.4	0.5	3,400	27
November 21, 1946	6.5	3.3	0.4	3,300	17
Januarv 20, 1947	3.5	1.19	2.3	6,500	12

’^During the preceding fifteen months the patient had received only l.() gram of ferrous sulfate daily; no liver extract was administered in this fifteen month period.

“This was on© week after the patient had received 300 units of liver extract intramuscularly in a period of twelve days.

“Immediately preceding splenectomy.

‘‘Four weeks after splenectomy.

for January, 1949

33

FIG. 1. Section of spleen removed fifteen months before death. A diffuse hemosiderosis is present (X 100).

nectomy was additional evidence tending to ex- clude the case as being one of the primary splenic neutropenia; 4. the hemosiderosis found in the spleen now appeared to be very im- portant, and the diagnosis of hemochromatosis was entertained for the first time.

Oral gluecose tolerance test (the patient weighed 143 pounds and 100 grams of glucose were used) was performed on November 4, 1946, with the following results:

Glycosuria

Fasting sugar 100 mgm. per 100 c.c 0

30 min. after glucose 208 mgm. per 100 c.c 0

00 min. after glucose 228 mgm. per 100 c.c 0

120 min. after glucose 216 mgm. per 100 c.c 0

180 min. after glucose 188 mgm. per 100 c.c 0

The patient was again given large doses of liver extract intramuscularly, and iron and folic acid orally. Daily urobilinogen excretion in the feces (for a four-day period) was 125.4 milli- grams per day. There was but a trace of urobi- linogen in a 24-hour collection of urine. The percentage of reticulated erythocytes varied from 0.4 to 1.1. Serum calcium was 9.6 milli- grams per 100 c.c. The patient became progres- sively weaker, and two homologous blood trans- fusion of 500 c.c. each were given. These were the only transfusions which he received. Epistaxis occurred more frequently. In spite of supportive treatment, the hemoglobin dropped to 3.5 grams, the erythrocyte count to 1.2 millions, and the granulocytes to 12 per cent. He gradually be- came weaker and died on Januay 31, 1947.

Necropsy examination: Orily the positive find- ings will be recorded. The liver weighed 1,900 grams. The consistency was very slighly in- creased and its cut surface was brown in color. About half of the pancreas appeared to be re- placed by adipose tissue, but otherwise it ap- peared normal. The bone marrow of the lumbar

vertebrae was light red in color and appeared to be fairly abundant. The rib and sternal mar- row was red in color, but appeared sparse in amount.

Microscopic examination: Liver. The liver cells all contained a small amount of brown pigment uniformly distributed throughout the liver substance without regard to the lobules (Fig. 2). The pigment granules varied some- what in size and shape, but for the most part they were small. The granules stained blue with the Prussian Blue reaction. There was slight atrophy of the liver cords in the mid- portion of the lobules. Moderate numbers of lymphocytes and large monuclear cells were found in the fibrous tissue of the triads. A small amount of pigment was found in macrophages in the triads.

FIG. 2. Section of liver obtained at necropsy. Iron- staining pigment was uniformly distributed throughout the liver substance (x 430).

Pancreas: The secretory elements showed no change. The islets showed no evidence of de- generation or of fibrous tissue replacement. No evidence of pigmentation was found in the pancreas.

Skin: The basal layers of the epidermis con- tained finely divided brown pigment, but did not exceed that normally found. The pigment appeared to be limited to the basal cells.

Bone marrow: The sternal marrow was very cellular. There was a marked reduction in the erythrocytic series, and progenitors of the gran- ulocytic series were also decreased in number. Many plasma cells were present. Large num- bers of promyelocytes and large mononuclear cells were seen. The megakaryocytes appeared normal. No evidence of pigmentation was seen. No difference was noted in the marrow of the ribs and the vertebrae.

The microscopic appearance of the spleen,

34

Rocky Mountain Medical Journal

which was removed at operation, has been de- scribed above.

Pigment granules which stained blue with the iron stain were found in mucosal cells of the gastrointestinal iract, in the stratum granulo- sum of the adrenals, and in most of the sections taken from the brain.

Pituitary: No abnormality was noted, and no pigmentation was seen.

Testes: There was moderately active sperma- togenesis of the left testicle; the interstitial cells were somewhat reduced in number. There was marked atrophy of the right testicle and only a few inters atial cells remained. There was no evidence of pigmentation of any of the cells.

Discussion

Hemochromatosis is usually characterized by the triad of bronzing pigmentation of the skin, cirrhosis of the liver, and diabetes mellitus. Pigmentation of the skin, although not always present, may be an early sign. The cirrhosis is usually associated with an enlarged, firm liver, ascites and/or jaun- dice. The diabetes varies in severity from mild to marked.

It would appear that there are two clini- cal types of hemochromatosis. The first type is represented by the classical form of the disease in which the visceral symptoms and signs depend upon the extent of fibrous tissue reaction in the various organs. Anemia is not marked, as the patients in this group are capable of utilizing iron in the formation of hemoglobin. The second type is represented by those patients who present certain or all of the above char- acteristic features, and in addition, develop an inability to utilize iron properly in the formation of hemoglobin. In this latter group of patients, the iron derived from the destruction of intrinsic and transfused blood I is not used again to form hemoglobin, but, as the result of a disturbance of metabolism as yet not understood, it is deposited in the various organs including the bone marrow®. ! In them, we encounter the paradox of a j patient having a cellular bone marrow, a large excess of iron in the body, and yet j progressively falling levels of hemoglobin I and erythrocytes in the peripheral blood.

In our patient, symptoms referable to I anemia were his presenting complaint; pig- j mentation of the skin never developed, and although the glucose tolerance curve was elevated, glycosuria was never demon- . strated. Chesner® has recorded a similar

case (although in a 14-year-old boy) with- out pigmentation or diabetes in whom the presence of anemia preceded the onset of all other symptoms by approximately six years. Sheldon^ and others have observed no evidence of increased hemolysis in pa- tients with hemochromatosis and our find- ings of normal urobilinogen excretion in urine and feces are in accord with this concept.

As Herbut and his associates® ® have pointed out, it is increasingly evident that there are many combinations and various degrees of fibrosis and pigmentation of the liver and pancreas, with and without dia- betes, and that the relationship between cirrhosis, diabetes and hemochromatosis is more than casual. It is the opinion of these investigators that alloxan or an allied sub- stance causes necrosis of the periportal hepatic tissue and islets of Langerhans, re- sulting in cirrhosis of the liver and diabetes, and that abnormal retention of iron (wheth- er derived endogenously or exogenously) results in hemosiderosis.

The possible relationship between pro- longed exposure to copper and the metabol- ism of iron is interesting. ' While Mallory’s^® conclusions as to the importance of copper poisoning in the production of hemochro- matosis are not universally accepted, our case inclines us to speculate with Mallory about the role of copper in certain cases at least. Insofar as we can determine, no comprehensive study has been made of the incidence of hemochromatosis in workers exposed to absorbable copper. It would only be possible to conduct such a study on a long range basis over many years. The co-workers of our patient in the de- partment where exposure was extreme had rarely worked more than a year or two there, and the few who had worked five to ten years or more were not traceable.

Conclusions

1. An additional case of hemochromatosis associated with refractory anemia and cellu- lar bone marrow is reported, furthering the concept that there are two clinical types of this disease.

2. The urobilinogen excretion in the urine

for January, 1949

35

and feces of this patient revealed no evi- dence of increased hemolysis.

3. The question of the role of copper poi- soning as an etiological factor in hemochro- matosis appears in this case.

REFERENCES

^Kark, R. M. : Two Cases of Aplastic Anemia. Guy’s Hosp. Reports, 87:343, July, 1937.

“Mackey, R. : An Unusual Case of Aplastic Anemia With Organ Changes Re.sembling Hemochromatosis. Med J. Australia, 1:172, Feb. 7, 1942.

“Bomford, R. R., and Rhoads, C. P. : Refractory Anemia. Quart. J. Med., 10:175, July, 1941.

^Zeltmacher, K., and Bevans, M. : Aplastic Anemia

and Its Association With Hemochromatosis. Arch. Int. Med., 75:395, June, 1945.

“Rath, C. E., and Pinch, C. A.: Sternal Marrow Hemosiderin. A Method for the Determination of Available Iron Stores in Man. J. Lab. and Clin. Med., 33:81, Jan., 1948.

“Chesner, C. : Hemochromatosis. Review of Liter- ature and Presentation of a Case Without Pigmenta- tion or Diabetes. J. Lab. and Clin. Med., 31:1029, Sept., 1946.

’Sheldon, J. H. : Haemochroinatosis. London. Ox- ford Medical Press, 1935.

“Herbut, P. A., Watson, J. S., and Parsons, E. : Alloxan in Experimental Hemochromatosis. Am. J. Clin. Path., 16:506, Aug., 1946.

“Herbut, P. A., and Tamaki, H. T.: Cirrhosis of the Liver and Diabetes as Related to Hemochroma- tosis. Am. J. Clin. Path., 16:506, Oct., 1946.

’“Mallory, P. B. : The Relation of Chronic Poison- ing With Copper to Hemochromatosis. Am. J. Path., 1:117, Jan., 1925.

INVERSION OF THE UTERUS*

WITH REPORT OF CASE RAYMOND MUNDT, M.D.

CROWNPOINT, NEW MEXICO

Postpartum inversion of the uterus may be intra-uterine or incomplete, when the fundus does not pass the cervix; intra- vaginal, incomplete or complete, when the uterus remains in the vaginal canal; extra- vaginal, and complete, when the inverted organ prolapses outside the introitus.

Frequency

Stated variously by different authors: Mc- Cullough, one to 30,000 deliveries; Dublin Rotunda Hospital, one to 160,000; while Stander reports one to 4,000 at New York Lying-in Hospital.

Etiology

Marked laxity of the uterine walls and probably thinness, especially of the pla- cental site, increased intra-abdominal pres- sure or too vigorous Crede’s maneuver, traction upon the umbilical cord, are all factors. Vogel believes that most cases are due to the violence, as the great majority occur outside the hospital. Harer and Sharkey found that 76 per cent were due to faulty technic. The complication may follow abortion, but most cases follow full term delivery. Stander found the majority in multiparae, while Vogel recorded more than 50 per cent in primiparae.

Symptoms

Shock and threatened collapse are usual, but the symptoms may be slight and the

’Opinions expressed in this article are those of the author and do not constitute official statements of the Office of Indian Affairs, U. S. Department of the Interior. The author is Senior Physician at the Eastern Navajo Hospital.

condition discovered only at subsequent examination.

Diagnosis

Abdominal palpation reveals the absence of the fundus, vaginal examination reveals a mass in the vagina if the inversion is more than intra-uterine. Prolapsed extra- vaginal inversion is, of course, quite ob- vious.

Treatment

DeLee and Stander recommend manual reposition if the case is seen soon after the onset. If the placenta is still attached, Stander recommends that it be left until re- placement is completed. Spinelli devised an operation in which the anterior cul-de- sac is opened, the uterus split virtually through its anterior surface, reverted and satured. DeLee advised vaginal packing, also the colpeurynter, in resistant cases. Huntingtin, et al., opened the abdomen and pulled the fundus up with Allis clamps; Haultain, after opening the abdomen, in- cised the cervical ring posteriorly and pushed the fundus from below. Norton believes that vaginal hysterectomy is the treatment of choice in cases of complete inversion and devised an ingenious method for the control of hemorrhage. He used a tonsil snare with rubber covered wire about the neck of the uterus.

■ f

Prognosis

If the case is seen early, modern methods of treatment should nullify mortality.

36

Rocky Mountain Medical Journal

Zangemeister, quoted by DeLee, gave the mortality as 23 per cent in 1913. Stander in 1940 reported a mortality of zero in eight cases at New York Lying-in Hospital. I. S. Clarkson, Jr., in 1945 summarized the mortality statistics.

CASE REPORT

Mrs. A. T., aged 20, was admitted December 8, 1947, with the chief complaint of being unable to void since delivery of her first child in the hogan three days previously. There had been no medi- cal or nursing care; it is probable that she was attended by a native “Medicine Man” who may have made pressure on the abdomen and trac- tion on the umbilical cord to deliver the pla- centa. As she understood no English, it was impossible to learn whether or not the third stage was completed.

Physical examination revealed a well de- veloped, well nournshed Navajo primipara, ap- pearing to be in moderate shock. The skin and mucosae were pale, the supra-pubic region was distended and tender, bloody lochia was present. Attempts at voiding caused the appearance of a raw red mass at the vaginal orifice. She was catheterized and 1,950 c.c. of cloudy urine ob- tained. This was normal except for hyaline and granular casts. After perineal preparation, the mass was palpated with the gloved hand and found to be the uterus, completely inverted.

The blood pressure was 110/60; temperature, 98.6F.; pulse, 84; respiration, 20. The blood count was: R.B.C. 2,040,000; hemoglobin, 50 per cent (Dare); W.B.C., 24,650; segs., 88; juveniles, 1; stabs, 2; s. lymphs, 7; Monocytes 1, blood type 0. The vaginal smear was positive for Gonoccoccus. The Wasserman report as negative was received later.

Treatment and Course: Penicillin 20,000 units i.m. three hourly was given for nine days. This was increased to 40,000 units on three postopera- tive days. Crude liver extract 2 c.c. i.m. was given for ten days. Ferrous sulfate 18 grains daily was given for four days and 9 grains daily for ten days. Demerol 100 mg. per hypo was given on admission and on the third and fourth hospital days for pain. Sulfamerazine and sodium bicarbonate in full dosage was given for three days preoperatively and nine days post- operatively. Blood plasma 500 c.c. intravenously was given on the day of admission, 500 c.c. whole blood was given two days preoperatively, 300 c.c. one day preoperatively. During operation 500 c.c. 10 per cent dextrose in water, 500 c.c. normal saline, 300 c.c. whole blood and 250 c.c. plasma were given. Postoperatively 500 c.c. plasma, 1,000 c.c. whole blood and 1,000 c.c. 5 per cent dextrose in normal saline were given. A warm potassium permanganate vaginal douche was given on each of two preoperative days.

Precperative Course: On the third hospital day, the patient voided voluntarily; catheteriza- tion was required up to that time. The tempera- ture rose to 99.8 F. on the second hospital day, pulse 120, respiration 24; these fell to normal on the third hospital day. The blood pressure was 120/60 preoperatively on the fourth day; the R.B.C. was 3,650,000 with hemoglobin 65 per cent (Dare); urinalysis showed a trace of sugar and many bacteria, but was otherwise normal.

Operation: On the fourth hospital day, a supra- cervical vaginal hysterectomy was done under spinal anesthesia with novocaine 150 mg. In order to prevent any mishap with the intra- venous needle, venesection was done on the right arm and a cannula inserted. Fluid, plasma or blood were kept running during the operation.

Findings: The uterus of large puerperal size, completely inverted, edematous and covered with decidua was lying in the vagina. The bladder Was not involved in the inversion as tested by soimding. The cervical stump was friable and hemorrhagic.

Procedure: The uterus was delivered with

a tenaculum and a No. 12F catheter was clamped about the neck. The uterus was incised longi- tudinally, each round ligament and uterine tube was sature ligated with chromic gut, cut and allowed to retract. The area of each uterine artery was suture ligated with chromic gut, the ends left long and clamped. The uterus was amputated below the tourniquet, the edges of the stump were grasped with Allis forceps and the tourniquet removed, the edges were satured with chromic gut, continuous, bleeding points inside were sature ligated with the same. The stump was then closed with chromic gut inter- rupted, and frosted with sulfathiazole crystals. Two vaginal packs were placed in the posterior fornix and one in the anterior, extruding ends were caught in a sature which was taped to the abdomen. A pessar catheter was placed in the bladder, allowed to drain and clamped. Hemorrhage during operation, moderate. Shock, none.

The immediate postoperative condition was good; temperature, 99 F.; pulse, 82; blood pres- sure, 110/70. Intravenous fluid, plasma and whole blood were continued.

Postoperative Course: The first postoperative day, the temperature was 100.4 F., the pulse 112, the respiration 28, the blood pressure 114/80. The next day the T.P.R. dropped to normal and subsequently did not exceed 99.6 F., 88 and 24. On this day the vaginal packs were re- moved; there was a trickle of blood, so one fresh pack was frosted with sulfathiazole crystals and inserted into the fornices. There was no evidence of infection. Two days later, this pack v/as removed and there was no further hemor- rhage. The pessar catheter was also removed. On the fifth and sixth days the patient was assisted to the bathroom and on the seventh day, was up and about the ward. Vaginal examina- tion the ninth day showed the cervix to be in place, a mucoid discharge (negative for gonococ- cus) was present. The patient was discharged in good condition on the tenth postoperative day.

Pathological Report: The report of the Na- tional Institute of Health follows:

Diagnosis: Uterus with decidual reaction.

Gross: The specimen received is a firm piece of yellow-white homogenous tissue measuring 3x3x2 cm. One surface is brownish in color.

Microscopic: The sections studied consist large- ly of a pale staining edematous myometrium, and a surface layer of blood clot, infarcted tissue, and blood sinuses with intervening decidual cells. Among the latter are found a number of small patches of syncitial trophoblasts. A few scattered endometrial glands are found. The microscopic appearance does not differ signifi- cantly from that ordinary expected postpartum.

for January, 1949

37

Comment

This case was in a primipara as were more than 50 per cent of those reported by Vogel. It probably followed rough handling as reported by DeLee, Stander, et. al. The patient was in partial shock as noted by these authors. Because of the bladder dis- tention, abdominal palpation did not im- mediately reveal the diagnosis, but vaginal examination did.

This case would be classed as a complete intravaginal inversion. Because of the large uterine size, edematous condition and in- fection, manual reposition, the Spinelli or Huntington operations were deemed inad- visable.

Vaginal hysterectomy as done was con- sidered less shocking to the patient and offered the best chance of avoiding a fa- tality. Undoubtedly, the amount of blood, plasma and parenteral fluids, as well as the penicillin and sulfonamides aided great- ly in the favorable outcome. Unquestionable early recognition of this condition is of great importance; as DeLee states, the fundus has been torn off under the notion that it was the placenta, cut off as a tumor, or the whole uterus pulled out as a second twin. All obstetricians should keep this condition in mind as a possible complica- tion, especially in cases that they have not personally delivered.

CARCINOMA OF THE SKIN*

THOMAS K. MAHAN, M.D.

GRAND JUNCTION, COLORADO

Carcinoma of the skin is the most com- mon form of cancer with which we have to deal. In a large series of cases, cancer of the skin comprised 40 per cent of the total number of cases of cancer.' Since the ra- diation therapy department of St. Mary’s Hospital was opened, 50 per cent of the cancer cases seen have been primary in the skin. This comparatively high incidence is partly due to the fact that x-ray and radium therapy were not locally available before the opening of our department. We un- doubtedly see and treat some patients who, because of the apparent mildness of their symptoms, would not have traveled 200 or 250 miles to receive treatment for a skin cancer but who will come into a local clinic for treatment. Nevertheless as time goes on we shall probably continue to see a high percentage of skin cancers in our patients because so many of them pursue an out-of- doors occupation. Exposure to sun is such a commonly accepted etiologic factor that this condition has been called “Farmers Skin” and “Sailors Skin.”

Frequent exposure to certain physical agents like light, sun, x-ray, radium, heat and cold all predispose to skin cancer. An

‘Presented at the Annual Western Colorado Spring Clinics, Grand Junction, Colorado, April 3, 1948.

example of this is the Kangri cancer which develops on the abdomen of certain orien- tals who wear an earthenware charcoal heater on the abdomen. During the war we saw a much higher incidence of skin cancer in men who were in training for months in the desert than we see now in a comparable age group in civilian practice. An example of exposure to certain hydro- carbons is the famous chimney sweeps’ can- cer of the scrotum. An example of the role played by certain drugs and chemicals is the cancer occurring on the palms of the hands and soles of the feet of people who have received arsenical treatments. Car- cinoma not infrequently occurs in the site of old chronic inflammatory change such as scars, sinus tracts, and areas of lupus vul- garis.

A brief review of the microscopic anat- omy of the skin will recall to your mind that the skin consists of an underlying layer of connective tissue called the dermis or corium and an overlying epidermis con- sisting of five layers. The surface division of the epidermis, called the stratum cor- neum, consists of epithelial cells which have become dry, flat, and horny — the cells near the surface being flattest. The deeper cells being more typical and rounded. The stra-

38

Rocky Mountain Medical Journal

turn corneum is thick on the palms of the hands and plantar aspects of the feet. It is thinnest over the face, flexor surface of the elbows, the abdomen and the prepuce. The next layer is the stratum lucidum, a thin colorless band of irregular cells just be- neath the stratum corneum. These cells do not have recognizable nuclei in the ordinary stained slide. The third layer is the stratum granulosum. It consists of two or three layers of flattened irregular cells having demonstrable nuclei. Immediately beneath it is the broad rete mucosum or the stratum spinosum also called the malpighian layer. It consists of muitiple rows of polygonal cells having large oval nuclei and arranged in a mosaic pattern. These cells are more flattened in the superficial layers and rounder in the deeper layers. This is the stratum most concerned with normal and pathologic growth. It lies just superficial to the fifth and deepest layer, the stratum germinativum or basal cell layer which consists of a single layer of columnar cells situated on the so-called basement mem- brane, an imaginary line which separates the epidermis from the corium.^

Many of us were taught that the basal cell was the parent cell of the epidermis. As these cells multiplied and developed, they were pushed toward the periphery under- going the changes of the different layers until they came to lie in the stratum cor- neum as dead flattened cells waiting to be desquamated by a newer generation of de- veloping cells. Andrews^ refers to some studies which suggest that actually mitoses occur throughout both the basal cell and the prickle cell layers and most of the cells growing over a wound arise in the prickle cell layer.

Carcinoma of the skin covers a wide va- riety of pathologic conditions. The two main types are basal cell carcinoma and squamous cell or prickle cell or epidermoid carcinoma. I intend to confine my remarks to these two conditions. Basal cell car- cinoma develops from the basal cells of the malpighian layer. It is characterized by multiple foci whose individual cells have a palisade arrangement. These tumors are of

slow evolution, almost never metastasize but tend to local recurrence after removal. Squamous cell carcinoma is characterized by overgrowth of adult squamous cells which breaks through the basement line. Cornification or pearl formation is fre- quently seen. This type is faster growing and metastasizes to the regional lymph nodes. There is a third cancer, the baso- squamous cell which, as it name implies, has some of the characteristics of both.

The clinical appearance of both types is fairly typical and the diagnosis is usually apparent from the clinical examination. The basal cell cancer usually begins as a pin- head size waxy or pearly nodule; however, it may occasionally develop on a pre-exist- ing keratosis. Gradually it enlarges by the development of other waxy nodules which coalesce to form an elevated plaque having a waxy color. Frequently telangiectatic ves- sels are seen to course over it. A crust forms in the center, sooner or later the crust is knocked off, the base may bleed, then it may go through a stage of apparent healing, then another crust forms. This cycle is repeated many times. A history of the lesion getting “better and worse,” “bet- ter and worse,” can usually be obtained. Finally, there is a large ulcer which may or may not be crusted over with rolled waxy borders. As the lesion advances, it destroys any and all underlying tissues so that eventually the whole nose or the whole side of the face may be eaten away. The course is characterized by chronicity. These changes take years to occur with little per- ceptible change from month to month.

Squamous cell carcinoma arises, more often than not, on a pre-existing keratosis. If the crust of a hyperkeratosis is removed and the base is raw and bleeding, from a practical standpoint, one may assume that malignant degeneration has begun. The cancer begins as a dry waxy growth with an indurated button base. There is a horny overgrowth in the center which can be separated fairly easily but leaves a bleeding base. On the lip, the lesion is constantly moistened so that it becomes ulcerated with- out the waxy keratinization. It grows and

3&

for January, 1949

invades the underlying tissues. The ulcer- ated surfaces may be cauliflower like, with a foul exudate. Squamous cell carcinoma metastasizes rather rapidly on the extremi- ties, slower on the face.

The clinical differentiation between squa- mous cell and basal cell lesions is frequently possible, occasionally difficult and some- times impossible. If the history extends over three or four years, it is probably ba- sal rather than epidermoid. A lesion 1 cm. in diameter and less than a year old is probably squamous. The basal lesion has a rolled waxy border, the squamous cell has an elevated, hard, ringlike margin. A great deal of stress has been laid on the location of the lesion as a differential point. One must remember that either lesion may occur anywhere on the skin but basal cell is most common on the face above the lips in a band of skin extending up to the level of the eyebrows and the tops of the ears while the squamous cell lesion is more com- mon on the ears, at the muco-cutaneous junctions, on the extremities, the penis and the vulva. Squamous cell lesions occur in a younger age group than the basal cell.

Carcinoma of the skin must be differen- tiated from other skin conditions. Syphilis, “the great imitator,” frequently simulates skin cancer. However, carcinoma frequently occurs on the face and hands while chancre is rare in those locations. Cancer will usually have a history measured in years, chancre in weeks and gumma in months. The Wasserman reaction and dark field ex- amination are further aids.

Lupus vulgaris is becoming more rare all the time but it still occurs. It is a disease of childhood whereas skin cancer is a dis- ease of old age — Ackerman^ states that it is rare before 40 years of age. However, one of our patients with a squamous cell car- cinoma of the lip is a young farmer twenty- nine years old. Another differential point is that the lesion of lupus is composed of small brownish nodules and it frequently heals on one edge while advancing on an- other. One confusing feature is that cancer frequently occurs in a lupus scar. Guinea pig inoculation is sometimes of inestimable

value.^ Hyperkeratosis, as was mentioned earlier, has a scale formation which sepa^ rates, leaving a dry base. If the base oozes blood or serum, it is probably an early epithelioma. Fungus infections occasion- ally attack the skin in a manner similar to cancer but they usually occur in a younger age group and the lesions are multiple and scattered. Psoriasis may be confused with multiple basal cell lesions of the skin <of the chest. Psoriatic lesions in the skin of the elbows and knees may make the differ- entiation. Biopsy may be necessary to ex- clude nonpigmented nevi and nonpigmented malignant melanoma. The latter is very radio-resistant so that differentiation is im- portant.

After a clinical diagnosis is made, the first step in the treatment is to obtain an ade- quate biopsy. This is often omitted because we are so frequently correct in our clinical diagnosis, we tend to become overconfident. In a series of 2,000 carcinomas of the skin, 90 per cent were accurately diagnosed clin- ically while in a series of 1,000 lesions which were clinically considered to be be- nign, 15 per cent were found to be carcin- oma when studied histologically.^ An ade- quate biopsy of all cases in which there is the slightest doubt regarding the clinical diagnosis will occasionally save the physi- cian considerable embarrassment.

To be satisfactory, a biopsy should fulfill certain criteria. An inadequate biopsy will only serve to further confuse the clinician. If a negative report is received and the le- sion is clinically malignant, the biopsy should be repeated.

How can one be sure of obtaining a sat- isfactory specimen? One way is to visualize the malignant lesion as an open face goose- berry pie with a margin of normal sur- rounding skin represented by the pie crust. One removes a wedge in much the same manner as a pie is ordinarily cut. The wedge need not be wide; it may be quite narrow, but it should extend from the cen- ter well beyond the limits of the lesion to include an outer crust of normal tissue and it should be deep enough to include all layers of the skin.

40

Rocky Mountain Medical Journal

The treatment of skin cancer may be di- vided into the treatment of the primary le- sion, treatment of metastasis, and treatment of the advanced case. Wide surgical ex- cision is unquestionably a gratifying treat- ment for skin lesions. Unfortunately this is not applicable to all portions of the body. For example, a large area of skin may be sacrificed from the back or the thigh but removal of significant areas of skin from the nose or eyelid necessitiates rather ex- tensive plastic repair.

If surgical excision is practiced, wide and deep removal is imperative. A general rule to follow is to remove from .5 to 1 cm. of surrounding normal tissue. Anything less is a definite invitation to recurrence. Suc- cessful cancer surgery requires a state of mind diametrically opposite from the sur- geon’s normal philosophy. Usually he must be interested in conserving as much tissue as possible. The oncologist must be willing to sacrifice as much tissue as can possibly be lost and still, by means of plastic repair, preserve a functioning part. Cautery ex- cision offers no advantage over the clean scalpel. It has the disadvantage of distort- ing the pathologic specimen. The latter is an important consideration because the pathologist should be required to express his opinion as to whether or not the removal was complete.

X-ray and radium therapy have a wider field of usefulness because, in most in- stances, they can destroy the disease with less deformity of the remaining tissues than is possible with surgery. The resulting scar and deformity must be considered because most of these lesions are on the exposed portions of the body. Ninety-eight per cent of basal cell lesions and 75 per cent of squamous cell lesions are on the head and neck.*’’

An epidermoid carcinoma of the lower lip may be cured by either surgery or ir- radiation. Surgical removal requires a V section well beyond the limits of the cancer with a plastic repair of the entire lower lip. The same lip treated with irradiation will have a soft, flat, or slightly depressed pale scar about 1 cm. in diameter bigger than the

original lesion. Many of these are not vis- ible at three or four feet distance. Surface application of radium, when it is possible to use it, gives a better cosmetic result than x-ray and x-ray gives a better result than interstitial needles. Of course other con- siderations than the cosmetic result fre- quently govern the choice of treatment.

The choice of treatment, then, depends on the limitations which the location of the cancer imposses, the peculiarities of be- havior of the various types of cancer, and the advantages and disadvantages of each method of treatment. These may be dis- cussed under the following headings modi- fied from the outline by Pack.®

1. Location: Tissue difficult of plastic re- pair should be treated with irradiation. Tis- sue overlying bone or cartilage should be treated with surgery. This statement does not apply to the nose or the ear. Consider- able care must be used in these two sites but other considerations make careful and judicious irradiation the treatment of choice. The eyelids should be treated with low voltage roentgen ray, protecting the eye to prevent cataract or iridocyclitis. The skin over the bony prominences of the hands and feet is poorly nourished so it is best treated with surgery. Late radionecrosis or recur- rence often follows treatment to the scalp. Radium is preferable to x-ray in this loca- tion.

2. Type of cancer: Spindle cell epidermoid cancer is radio resistant and should be treated surgically. Paget’s disease should be considered as a carcinoma of the breast and amputated. Carcinoma in burns and scars should be treated surgically but car- cinoma in a draining sinus may be treated with x-ray.

3. Recurrence: The recurrence should be treated by a different means than the pri- mary was treated. For example, if the pri- mary lesion was treated with x-ray, the recurrence should be treated surgically and vice versa.

The treatment of metastasis is fortunately not a frequent problem. It has been va- riously estimated that 6 to 18 per cent of patients who had no metastasis when the

for January, 1949

41-

primary was treated, will later develop metastases.^ When it occurs it is a grave sign. Irradiation therapy cannot cure squa- mous or spindle cell carcinoma metastasis to regional nodes. If intensive irradiation cannot sterilize a metastatic node there is no logic in the prophylactic irradiation of the regional nodes using doses of one-fifth to one-half the maximum permissible irra- diation. Therefore the treatment must be surgical and requires a radical neck dissec- tion. One instance where irradiation might be preferable to surgery is in the case of involvement of a solitary pre-auricular node. The possibility of facial paralysis after surgical excision is real and this par- ticular node is so superficial as to render it more susceptible to irradiation. Duffy^ es- tablished indications for neck dissection for intra-oral lesions. The same indications may be used in consideration of all cancer of the head and neck. They are: 1. The primary lesion should be controlled. 2. The primary lesion should be limited to one side of the mouth. Of course this does not ap- ply as regards the skin. 3. The carcinoma should show marked histologic differentia- tion. This is not so important in the skin as in the mouth. 4. The metastases must be limited to one group of nodes in two con- tiguous cervical triangles. 5. The carcinoma must not have perforated the capsule of the lymph node. 6. There must not be an adenopathy on the other side. However, some do not consider bilateral involvement a contra-indication. 7. There must not be a distant metastasis. 8. The patient should be in good condition.

Prophylactic neck dissection is not war- ranted because of the risk involved and the small percentage of patients who will later develop metastasis have a fair chance for survival with adequate radical treatment after metastases have developed. So we' feel that neck dissection should be reserved for those patients who meet the conditions laid down by Duffy.

Occasionally one sees a patient with skin cancer so advanced as to make any treat- ment futile. Therapy is directed toward making the patient comfortable and keeping

the lesion clean. If a large foul ulcerating lesion can be kept clean, a great deal will have been done to make the patient more comfortable. Frequent dressings with oc- casional spraying with sulfa powder or local application of penicillin will suppress secon- dary infection. Zinc ointment or aluminum paste will soothe the surrounding macerated skin. Five to 10 per cent of cancer cases terminate in fatal hemorrhage.® I know of no way of combatting hemorrhage in large skin lesions except with pressure bandages and adequate sedation.

Acetyl salicylic acid will go a long way toward relieving pain if it is used in ade- quate dosage. The patient may be instructed to take one or two aspirins every hour if necessary until he is relieved. I have seen patients carried long periods of time on comparatively large doses of aspirin with- out adverse systemic effect. Later barbit- urates may be added to the aspirin with good effect, still later codeine may be neces- sary. If the patient complains of epigastric distress from the aspirin, he may be re- lieved with concomitant doses of sodium bi- carbonate. Finally all of these things fail and we must resort to more powerful nar- cotics. The use of alcohol injections both to nerve roots and intravenously for its systemic effect may postpone the use of the narcotics. I have had inadequate experience with cobra venom to express an opinion re- garding it.

The prognosis in adequately treated early carcinoma of the skin is good. It has the best prognosis of all malignant neoplasms but this advantage is frequently decreased or lost by procrastination, neglect, or inade- quate treatment. Recurrent basal cell or squamous cell lesion has a much worse prognosis than the original lesion. The presence of regional metastases markedly decreases the prognosis in squamous cell lesions. The prognosis in unselected basal cell lesions is usually given as about 90 to 93 per cent five-year cure and 70 to 80 per cent for squamous cell lesions. The prog- nosis is about the same whether the method of treatment is radiation or surgical. For example. Hale and Holmes, in an unselected

42

Rocky Mountain Medical Journai

series of 1,422 cases, treated 1,035 with ir- radiation with 12 per cent failures and 387 were treated surgically with 12 per cent failures. The moral to these figures ap- pears to be early and adequate treatment.

REFERENCES

’Ackerman, L. V., and Del Regato, J. A.; “Cancer Diagnosis, Treatment, and Prognosis.” St. Louis, 1947, C. V. Mosby Co.

^Andrews, G. C. : “Diseases of the Skin.” Third Edi- tion, Philadelphia, 1947, W. B. Saunders.

®McKee, G. M., and Cipollaro, A. C. : “X-rays and Radium in the Treatment of Diseases of the Skin.” Philadelphia, 1946, Lea & Fiblger.

<Torrey, F. A., and Levin: Quoted by (1). ,

'Pack, Geo. T.: “Treatment of Cutaneous Epithe- lioma.” Arch of Derm, and Syph., 53:576-585, June, 1946.

'Lenz, Maurice: "Radiotherapy of Epithelioma of the Skin.” Arch of Derm, and Syph., 53:588-596, June, 1946.

’Duffy, J. J. : in Pack, G. T., and Livingston, E. M. : “Treatment of Cancer and Allied Diseases.” New York, 1940, Paul B. Hoeber, Inc.

'Morgan, Hugh: “The Care of the Patient With Terminal Cancer.” Rocky Mt. Med. Jour., February, 1948.

'Hale, C. H., and Holmes, G. W. : “Carcinoma of the Skin.” Radiology, 48, 563-568, June, 1947.

MALIGNANCY RECORDS

CLAUDE L. SHIELDS, M.D.

SALT LAKE CITY

The original purpose of this paper was to analyze data on cancer as treated by the general surgeon in a small city and compare with statistics from large medical centers. It was first read before the Salt Lake Sur- gical Society. Later it was rearranged for the educational program of the Interna- tional College of Surgeons to emphasize the need of careful case history study and read before a group of young surgeons.

The etiology of cancer continues to chal- lenge scientific endeavor. However, when the observations made and the results of animal experiments of the last few years are considered, the progress which is being made is impressive. It is not the purpose in this material to upholdr any particular theory as to malignancy, but due to such interesting and encouraging finding, lending hope to the solution of the cancer problem, I desire to urge a more extensive and united movement on the part of the medical profession in gathering and recording data. It is desirable that forms used in making records be of a uniform type eventually, although it is probably hardly feasible just at this time. The uniform type of record, if it is developed successfully, should make the work in connection with cancer simpler. It would make the attack on cancer more ef- ficient and valuable and when a study is undertaken it would be less difficult to work out conclusions.

In order that we may more nearly paral- lel important findings in animal experimen- tation, it is proposed more space be given

pertinent questions than is now found on most existing forms. Space for a more ade- quate family history, asking for the names of the individuals with their addresses, or place of death, and cause of death would seem necessary. A question asking about previous infection, irritation or injury at the site of the lesion; should appear on such a form. It would also seem desirable that consideration be given the character of the early nourishment of the individual.

I realize some of the difficulties in the way of unification of record forms. I have changed my system four times. In the sum- ming up of the report of the Committee on Clinical Records of the American Hospital Association in 1937, in response to a ques- tionnaire sent to 231 widely distributed hos- pitals, the following was the result: “Twen- ty-seven per cent replied that they had found the record forms suggested by the previous committee useful; 21 per cent had not found them useful; and 6 per cent re- plied that they had not seen these forms. Seventeen per cent had adopted some of the form proposed; 35 per cent had not adopted any of the forms and 46 per cent did not make any reply to the questionnaire.”

That report is somewhat discouraging from an unification point of view, but it does show a widespread appreciation of the importance of records. Thus our efforts to- ward more complete records, especially in malignancy cases, should be stimulated to further effort as an important factor in the study of carcinoma. The proposal has been

for January, 1949

43

made in some states that committees of physicians be appointed for the purpose of studying forms for obtaining records of can- cer cases. Such state committees, it has been pointed out, could work with a com- mittee on cancer control and the committee on clinical records. It has been suggested that when a record form is worked out which will meet requirements copies be sent to the county medical societies within the state and that the cooperation of these so- cieties in the project be invited. It was urged that these societies be encouraged to use these forms in making records of all cancer cases, both institutional and non- institutional, such records to be properly filed at some designated place.

Should such a unified system of obtaining data on malignant cases be adopted gener- ally, much valuable information, which is not now obtained, ought to be forthcoming. But whether unification of record forms eventuates or not, it is plain that the im- portance of records in cancer is being real- ized throughout the country. In any group of 100 white females, statistics indicate that thirteen will die of cancer. It is estimated that 450,000 persons in the United States are afflicted with cancer. Many facts come out with regard to cancer which require ex- tremely carefully prepared and most ac- curate records. There appears to have been in recent years a definite increase in cancer of the breast. Cancer of the breast has also been shown to be more frequent among women who have not nursed children. A decrease in cancer of the cervix has been shown. Cancer of the cervix is more fre- quent among women who have had children and have torn cervices than in women who have never been pregnant. There are fewer women out of every 100 who nurse children and fewer who suffer injury to the birth canal, of course.

But such information is not available un- der our pre\/^ailing system of record keeping. There has been little investigation of the hereditary factors in cancer in humans. Here and there a family has been selected for intensive study, but the data obtained have been meager for definite conclusions.

Maud Slye studied many generations of mice, showing that she could breed cancer in mice in three generations. But there is a difference between mice and men, say the skeptics, as to the hereditary cause of can- cer. It was in 1932 that McFarland and Meade published a paper on the genetic origin of tumors, supported by their simul- taneous and symmetrical occurrence in homologous twins. Their studies seemed to indicate that if a tumor developed in an identical twin in a given organ at a given time, the same type of tumor would develop in the other twin in the corresponding or- gan, at or near the same time. The con- clusion was that it may be logical to infer that each of the new beings will be sub- jected to a considerable degree to the same inheritance factors. Cancer of the breast has developed in homologous twins within a few months of each other. Such was re- ported by Mumford. These tumors devel- oped at the age of 90. In 1939, Phillips of the Mayo Foundation reported a case of bi- lateral mammary carcinoma in identical twins. It appeared in the first twin three years before it appeared in the second.

Recently Bittner and his co-workers of the Jackson Memorial Laboratory at Bar Har- bor, Maine, performed some interesting feeding experiments on mice born to fe- males showing a high breast tumor inci- dence. These young mice were removed from their mothers as soon as recorded and fostered by females of a type showing low breast tumor incidence. Of these fostered females and their progeny 23.1 per cent de- veloped breast tumors while the incidence of the breast tumors among the control mice was 83.2 per cent. They concluded that their experiments indicated that some influence is transmitted in mothers’ milk which is of prime importance in determin- ing the incidence of breast tumors; that the incidence of tumors may be decreased by fostering females of a high breast tumor stock by low tumor stock mothers.

C. C. Little recently stated, “In tissue cul- ture the cancer cell is not malignant. It does no harm. It speedily and effectively outgrows most other types of cells. The

44

Rocky Mountain Medical Journal

only thing that makes it sinister, abnormal, and an outlaw is the fact that it ordinarily arises in an environment pledged to limita- tion, inhibitation, regulation and selective opportunity for growth. None of these things are recognized by the cancer cell, which is engaged in living independently with a high degree of primitive biologic ef- fectiveness.”

As I have stated, I changed my own sys- tem of records four times and this made a study I have finished very difficult. An outstanding problem was that of following the patient who might have been treated in one, two or three hospitals and tracing the history in each institution. Some cases came directly to the hospital from another physician and had no office history. Such a difficulty is not found in large clinics, but it will be found in private practice operat- ing in more than one hospital. Incorporat- ing hospital record data into office records overcomes this. When findings and proce- dure in an operation is dictated to the hos- pital historian, it is well to instruct her to make a carbon copy of the report which may be attached to the office history of the patient, along with all laboratory data and any other hospital records. This makes it easier to carry on a statistical study of any particular disease, because all of the records are available, and it is not necessary to trace them in various hospitals.

When a patient returns after a lapse of years, the physician may have forgotten many essential details which he can find in his office records. The following illustrates the type of office history forms I have adopted. It is a modification of the Mayo Clinic record system which I set up in the office of Dr. A. J. Hosmer in 1914. The most lecent changes in this system is the allow- ance of more space for urine analyses, blood work, and blood pressure records. This is essential for a private office as the patient is usually seen over a longer period of time than in large clinics when the patient is away from home for a check-up. Following is the forms used:

Card A — Alphabetical classification of patients’ names.

Card B — Diagnosis listing.

Card C — History sheet.

Card D — Reporting form for American College of Surgeons.

This report consists of records of cancer cases treated from the year 1913 to 1943.

1. Number of records studied, 567.

2. Number found unoperable, 369.

3. Records discarded because contact with pa-

tient lost, 33.

4. Discarded because early pathologic studies

were inadequate, 53.

5. Records used for study of five-year cures,

113.

6. Number of five-year cures, 23.

7. Per cent of five-year cures, 4.91.

Breakdown of cures into cancer types:

Location of Tumor No. Kind of Treatment

Cervix 4 Cures by radium only

Breast 6 1 cured by x-ray

5 cured by operation Sarcoma 2 Both cured by ampu-

tation

Miscellaneous 5 Cured by operation

It will be noted from above that there are a large number of discarded charts because of loss of contact with the patients. Fifty- three charts were discarded because of in- adequate pathologic study, there being no full time pathologist in charge of the hos- pital laboratory during that period of time. This shows that a vast amount of work is done in hospital records which is absolutely valueless when they are used to study the progress of cure in cancer cases. During this thirty-year period approximately one patient each month, a total of 368, was ex- amined in the office or at their homes and found to have far advanced malignancies for which the only treatment prescribed was to alleviate pain, and make the patient as comfortable as possible.

These figures are the basis for the pes- simism of a majority of surgeons with re- gard to cancer therapy. They do not show one case of cancer of the stomach cured, and I cannot remember a single case in my practice of a gastric carcinoma surviving more than five years after operation.

In many of these cases the Schiller test was used. However, it was not very help- ful in making an early diagnosis of cancer of the cervix. The vaginal smear as ad- vised by Meige, et al., may be of some help.

for January, 1949

45

However, in the cases where we have found cancer cells in the vaginal smear, other methods of diagnosis have shown the car- cinoma to be in an advanced stage.

Text-books and some -authorities have stated that carcinoma is rare after the age of 80 years. These figures show a relatively large number of persons in the years be- tween seventy-five and eighty-five dying from carcinoma. Ninety-one deaths were found to occur in this age period. Nettleship has stated, “It is suggestive, too, that the average age specific mortality rate for gas- tric cancer is, as for other forms of gas- trointestinal cancer, progressive with age. Among white persons, the mean age at the time of death is 65, and the maximum num- ber of deaths in any one ten-year age pe- riod occurs between the ages of 65 and 74. Previously the peak was at an earlier age period.”

One group of cases, of which I have rec- ords, was made up of eight cases of perni- cious anemia which later developed car- cinoma. The most unusual case in this group was the wife of a chiropractor, who had been treated by her husband until cord symptoms causing paralysis below the twelfth thoracic segment compelled her to seek a medical examination. Dr. Perce then gave her sufficient liver extract to abolish all symptoms, including paralysis, for one and one-half years. We saw her during a relapse, and again she was treated for eight months by liver and hydrochloric acid ther- apy. When she returned a year later she was found to have a carcinoma of the car- diac end of the stomach extending into the esophagus. She was referred to Dr. James Percy, who performed a cautery trans- thoracic resection esophagogastrostomy which gave excellent palliative results for two and one-half years, when the pa- tient died from a mediastinal metastasis.

Owens has estimated that there are 450,- 000 persons with cancer in the United States and Mullen holds that one-third of this great number, or 150,000, should ap- proximate the number of cases of gastric cancer. Reports of a large number of sur- geons indicate that only about 5 per cent of

gastric carcinoma cases are amenable to surgical treatment. The outlook for cancer of the breast is more optimistic, because the surgeon is consulted before the serious symptoms develop.

The symptoms listed by Lahey for gastric carcinoma are: 1. indigestion, 2. anorexia, 3. pain, 4. loss of weight. 5. vomiting, 6. dys- phagia, 7. weakness, 8. hemorrhage, 9. con- stipation, 10, diarrhea, 11. mass.

It is obvious that if many of these symp- toms were observed in breast cancer, the surgeon would be reasonably sure of distant metastasis. Most of the patients having breast lesions now seek medical diagnosis as soon as a lump is evident in the breast, and then the surgeon has an opportunity of using inspection, palpation, x-ray, transil- lumination, and biopsy. This is not possible in early gastric carcinoma. The surgeon should be more daring in diseases of the gastrointestinal tract, and that exploratory operations should be performed more fre- quently in the attempt to cut down the large group of inoperable gastric carcinomas is indicated by these figures.

Hegner, in a recent statement on carcin- oma of the breast, said: “The present day preaching of the curability of cancer is not founded on fact. It cannot so be predicated until we know the cause and cure. It is easier and more certain to prevent than it is to cure. Our slogan should be to prevent rather than to cure cancer. Far better to remove a probable cancer with a certainty of cure, than attempt eradication of a posi- tive cancer with a probability of cure.”

AMERICAN COLLEGE OF SURGEONS AN- NOUNCES 1949 SECTIONAL MEETING SCHEDULE

The American College of Surgeons announces that six two-day Sectional Meetings will be held between January 7 and April 13, 1949, for physicians and surgeons, and professional per- sonnel of hospitals. A seventh meeting to be held in the West the latter part of April will be announced later. The latest developments in medical science and in hospital service will be presented at each meeting. The schedule follows :

January 7-8: Edgewater Park, Mississippi, Edge- water Gulf Hotel.

January 14-15: Houston, Texas, Rice Hotel. February 11-12: Kansas City, Missouri, Hotel Presi- dent.

March 15-16: Washington, D. C., Statler Hotel. March 21-22: Buffalo, New York, Statler Hotel. April 12:13. Edmonton, Alberta, MacDonald Hotel.

46

Rocky Mountain Medical Journal

Bowel Regulation in Peptic Ulcer...

In the medical management of un- complicated peptic ulcer, “regula- tion of bowel function is essential. ... A combination of antacid pow- ders . . . having mildly laxative effects or the use of a hydrogel sub- stance, such as agar agar or Meta- mucil, will produce results.”

By furnishing a water-retaining, gelatinous residue in the large bowel, Metamucil acts gently without irritation to promote smooth, normal evacuation.

METAMUCIL

is the highly refined mucilloid of Plantago ovata (50%), a seed of the psyllium group, combined with dextrose (50%) as a dis- persing agent.

S EARLE RESEARCH IN THE SERVICE OF MEDICINE

*Gerendasy, J.: Modern Treatment of Peptic Ulcer, J. M. Soc. New Jersey ^J;84 (March) 1946.

for January, 1949

47

Organization

National Affairs - Proceedings - Programs - Society Notices - News - Auxiliary

Colorado Demands Action by A.M.A.!

The following letter should need no explana- tion or introduction. Mimeographed copies of the original were sent simultaneously to the secretarial offices of all state medical societies, to all ranking officers of the American Medical Association, and to members of the A.M.A. House of Delegates.

December 14, 1948. Dr. George F. Lull, Secretary,

American Medical Association,

535 North Dearborn St.,

Chicago 10, Illinois.

Dear Doctor Lull:

Believing that immediate constructive action is imperative to the success of the American Medical Association’s educational program, the Board of Trustees of the Colorado State Medical Society in regular session December 11, directed that your Board be respectfully requested to act forthwith on these two proposals:

1. Immediate creation of the necessary ma- chinery to enable an AMA spokesman, the President or yourself as circumstances warrant, to answer promptly and categorically those pub- lic comments by national figures who oppose our American system of medical practice, such as Mr. Ewing and Mr. Dingell. The people deserve a reply.

2. The calling of an AMA sponsored con- ference of top-level state society executive sec- retaries and public relations directors as soon as possible but not later than January 15 to work under the guidance of the AMA steering committee in actually formulating a national program of publicity, factual advertising and subsidiary educational activities.

It is our earnest belief that these proposals merit the fullest consideration and that time is of the essence. The zero hour is near. Action must not be delayed!

Since the House of Delegates authorized the $25 assessment, we have received from every section of our state, comments to the effect that the physicians want to know what will be done with this money. A typical Colorado county society met a few evenings ago and every member said he would be glad to pay the assessment provided he knew what sort of a program was planned, if it would be earnest and vigorous, and when it would start. These men cited the current Colorado program, based on increased dues, as an example of action and results. They expect the same sort of action and leadership from the AMA. They must not be disappointed or let down. We feel it must be forthcoming (1) because we are in a fight and must take the initiative within a matter of days and (2) because aggressive action and knowledge of a sound national program is essential to an informed membership and to cooperation in raising the necessary funds.

We feel a spokesman is necessary to answer certain statements at the national level. None should go unchallenged. We feel that President Sensenich should immediately clarify the matter of the assessment, which was not done at St. Louis, and we attach a suggested statement which will inform the public of the fact that the AMA is not raising a “slush fund.” We think Rep. Dingell should have been answered when he said more than half of the AMA membership would not pay the assessment. The AMA must arouse its members to prove him false. There are other instances. We must take the offensive! We cannot permit the proponents of political medicine do all the talking! That mistake was made by a once-great political party in the recent election.

In suggesting a January conference to map the educational and publicity program, we hereby offer to make available for such a gathering, a representative from Colorado. It is our belief that the guidance and counsel of our excellent state society executives are invaluable and needed at this time.

We further believe there is need for immediate implementing of a general national pattern which each state society can follow. Here are some other considerations:

What are the half dozen most important things that any state society can do now? Can we develop a punchy campaign slogan? Will the program utilize radio, and if so, how? Do we contemplate paid advertisements in weekly news- papers to cover the rural areas? How effective is advertising directed to World War II vet- erans? How can we best tell the story of the total costs of medical care? What are some of the technics which all state societies can use in working with various groups and or- ganizations, with the press and radio, with special writers, women’s page editors, etc.? What can be done at the national level to encourage radio programs and commentators, magazines and other outlets to bring the problem out in the open and tell the whole story? What can be done to get into production immediately: (1) a small pamphlet which adequately informs the physician about the federal medicine prob- lem so that he can make a brief and intelligent speech which the socializers must squirm to answer and (2) a small, attractive and brief series of pamphlets to educate the public, to be produced by the AMA and distributed by the states, to be used in mailings and as give- away pieces at meetings?

These are just a few of the problems, as we see them. These must be decided and decided very soon so that every physician in the nation may be informed and may be en- listed in the campaign. Time is running out! We urge that our proposals be given immediate attention.

Sincerely,

COLORADO STATE MEDICAL SOCIETY.

Casper F. Hegner, M.D., President.

Ervin A. Hinds, M.D., Chairman, .Board of Trustees.

48^

Rocky Mountain Medical Journal

GRAPH OF MEASLES INCIDENCE

The above graph is based on U. S. P. H. measles incidence figures for a ten year period.

— without fear of side reactions

There’s one sure way of silencing crying youngsters and nervous mamas who complain about reactions — specify Cutter Immune Serum Globulin— Human. Successful results with this product are not happenstance. They come from:

1 . The right raw material — fresh venous blood from normal donors.

2. The water-clarity of a hemolysis-free and non-pyrogenic product.

3. The concentration of 160 mgm. per cc. of gamma globulin— main- tains consistent globulin potency yet permits low volume adjustable dosage:

For prevention —

0.1 cc. Immune Serum Globulin For modification —

0.02 cc. Immune Serum Globulin

intramuscularly, per pound body weight

Prepare now for measles’ peak season just ahead. Notify your pharmacist the amount of gamma globulin you ex- pect to use-^and specify Cutter.

CUTTER laboratories * BERKELEY 10, CALIFORNIA

Prevent or modify measles with —

IMMUNE SERUM

for;; JANXJARYj- 1949 1.; fv - •?!

49

REPORT OF DELEGATES TO A.M.A. REGARDING INTERIM SESSION

On November 30, the House of Delegates of the American Medical Association met in St. Louis at the 1948 Interim Session.

As may well be imagined, this meeting had undertones of urgency that have seldom been present. The threat of government medicine after our last national election was bringing matters to a head at an unprecedented rate. The American Medical Association’s deliberations have not been noted for their rapidity in meeting the exigencies of the moment, except in times of great stress and strain. This year the business of the House was transacted rapidly and there was very little bickering over small matters. There were, of course, only two matters of paramount interest to come up at this time. The first was embodied in a resolution introduced by Dr. Wil- liam Halley and which carried with it the signa- tures of the delegations from the following states: Arizona, California, Colorado, Connecticut, In- diana, Kansas, Michigan, Minnesota, Montana, Ohio, Pennsylvania, Texas, Utah, Washington, and Wisconsin.

The resolution read as follows:

WHEREAS, The people of the United States right- fully look to the American Medical Association for leadership in all matters affecting the health of this nation; and

WHEREAS, Much erroneous information has been given to the public on the subject of standards, costs and distribution of medical care and it has become imperative that this widespread false propaganda fa- voring governmental management of medical prac- tice be immediately contradicted by factual informa- tion disseminated to all citizens of this country; therefore, be it

RESOLVED, By the House of Delegates: That the American Medical Association, through its Board of Trustees, forthwith undertake the preparation of a dignified and wholly factual national publicity and advertising campaign to accomplish this purpose, the campaign to be presented simultaneously and uniformly in both the national periodical press and, by distribution to the constituent state associations and component county societies, in the newspapers of the entire United States.

A number of other resolutions of similar pur- pose were pooled in the Reference Committee. There was apparently no particular opposition oecause there was a common realization that to adequately present the side of organized medi- cine to the public would cost money.

The other important questions were the reso- lutions concerning the approval of the integra- tion of the Blue Cross, Blue Shield, and Asso- ciated Medical Care Plans plus a requested na- tional insurance set-up. There was a great deal of contradictory feeling in regard to these pro- posals and considerable lack of understanding of their scope and purpose. A Reference Committee was appointed to thrash out this question. The Colorado delegation and, I presume, many others, talked over the proposals involved with both proponents and opponents of this plan until the small hours of the morning on two preceding nights. The special Reference Committee men- tioned sat from 9 o’clock in the morning until

3 o’clock in the afternoon without pause and then brought in an approval of the plan, with the ex- eption of the substitution of a national enroll- ment agency in the place of a national insurance company. This compromise passed the House promptly and unanimously.

The mere statement that the House of Dele- gates of the American Medical Association spon- sored these two matters doesn’t sound particular- ly startling unless you reflect on the fact that they constitute a complete reversal of the think- ing on the part of a great many of the medical profession.

To those of us in the Rocky Mountain states and Michigan, Texas, and California, who have long been aware of the dangers confronting us, it was merely the fulfillment of a plan already overdue. Whether we are too late in the field with too little, remains to be seen.

Your alternate enjoyed the opportunity of serving at this particular meeting, but found it physically and intellectually impossible to fill the shoes of Dr. George Unfug. To me, the in- teresting side-lights were the decisive attitude of the delegates, the willingness to cooperate, and the pleasure of being in on the ground floor when aggressive and constructive legislation was occurring.

After listening to General Paul Hawley explain the purposes of the national insurance set-up as a reinsuring body with a bicameral control and with the power evenly divided between the or- ganizational officers and the medical profession, many of us lost our fear of the scheme. General Hawley pointed out one other very important fact. This was that to the best of his knowledge, in no country where socialized medicine had taken over were the previously established health organizations assimilated by the govern- ment. One of the objections to such plans which had previously alarmed me, was that if such an agency should fail it could easily be taken over by the government and the whole voluntary structure be so engulfed. However, this seems not to have occurred. The prepayment plans of other countries have been wrecked but not assimilated because they were obviously not able to compete against at least partially tax sup- ported government measures, either in their extent of care or the cost of membership.

I believe this issue will be raised again at the next regular meeting of the American Medical Association and that every member of the State Society should inform himself on this proposition so that the delegates at the next meeting may know the will of the members.

HERMAN C. GRAVES, M.D., (Alternate for Delegate George A. Unfug, M.D.), for himself and WILLIAM H. HALLEY, M.D.

50

Rocky Mouiitain Medical Journal

even

after

40

a woman's work is never done...

Dishes, dustpans, a thousand details . . . the three "d's" of household drudgery. .. ore challenge enough at any ago, but a stock of dinner dishes con look mountain high to the woman in the menopause. This is a disquieting aspect of tho doily life of such patients that physicians con bring into proper perspective with "Premor/n/^

'"'^Premorin'' therapy, it has been found, has in it a certain "plus" that produces a sense of well-being in most women. "Premarin" quickly relieves the symptoms of the menopause. It is orally active, and is rapidly absorbed from the intestine.

While sodium estrone sulfate is the principal estrogen

in "Premarin," other equine estrogens estradiol,

equilin, equilenin, hippulin . . . are probably also pres- ent in varying amounts as water soluble conjugates.

ESTROGENIC SUBSTANCES (WATER SOLUBLE) also known as CONJUGATED ESTROGENS (equine)

Ayerst, McKenna & Harrison Limited 22 East 40tli Street, New York 1 6, New York

-1901

for January, 1949

51

NATIONAL CONFERENCE ON MEDICAL SERVICE

PRELIMINARY PROGRAM

Palmer House, Chicago, Illinois, February 6, 1949

9:00 A.M. Registration: Foyer of Red Lacquer Room, Fourth Floor, Palmer House.

9:30 A.M. Call to Order.

Appointment of Committees.

Address of the President — E. F. Sladek, M.D., Traverse City, Michigan.

9:45 A.M. Legalized Medical Research.

Medical Problems — Chris J. D. Zarafonetis, M.D., University of Michigan.

Legal Problems — George Wakerlin, M.D., University of Illinois.

10:25 A.M. Title to be announced — James R. Mc- Vay, M.D., Kansas City, Missouri; Chairman, Council on Medical Service, A.M.A.

10:50 A.M. Progress of the World Health Or- ganization— Frank Calderone, M.D., Director, American Office, World Health Organization.

11:05 A.M. Progress of the World Medical Asso- ciation— Creighton Barker, M.D., Executive Secretary, Connecticut State Medical Asso- ciation.

11:20 A.M. Medical Program of the United Mine Workers of America V/elfare and Retirement Fund — Warren F. Draper, M.D., Executive Medical Director.

11:40 A.M. Discussion Period.

12:15 P.M. Subscription Luncheon.

1:00 P.M. The A.M.A. Puts on Its Fighting Togs — Speaker to be announced.

2:00 P.M. What’s Happening in Washington This Week — James D. Boyle, United Public Health League.

2:30 P.M. Discussion. To be opened by Joseph S. Lawrence, M.D., Director of the Washing- ton Office, A.M.A.

2:40 P.M. Panel Discussion on Postgraduate Education of the Doctor.

(a) Responsibility of Medical Schools in Continued Postgraduate Education of the Doctor — George N. Aagaard, Di-

rector of Postgraduate Medical Ed- ucation Program, University of Min- nesota.

(b) Function of the State Medical Society in Postgraduate Work— C. W. Smith, M.D., Harrisburg, Pennsylvania.

(c) Survey Findings on Specialization in Colorado — Harold I. Goldman, M.D., Denver, Colorado.

3:40 P.M. Discussion Period.

4:00 P.M. Can Corporations Such as Hospitals Legally Engage in the Practice of Medicine? — Wilbur Bailey, M.D., Los Angeles, Cali- fornia.

4:30 P.M. Report of Committees and Election of Officers.

5:00 P.M. Adjournment.

(Note: All papers will begin exactly as sched- uled. No speaker will be allowed to speak over- time.)

AMERICAN BOARD OF OBSTETRICS AND GYNECOLOGY, INC

The next written examination and review of case histories (Part I) for all candidates will be held in various cities of the United States and Canada on Friday, February 4, 1949.

Arrangements will be made so far as is possible for candidates to take the Part I examination (written paper and submission of case records) at places convenient for them. Candidates who successfully complete the Part I examination proceed automatically to the Part II examina- tion to be held May 8 to 14, inclusive, 1949, at the Hotel Shoreland, Chicago, Illinois. Notice of the exact time and place of the Part I and Part H examinations will be sent all candidates well in advance of the examination date. Clos- ing date for reapplication for admission to the Part H examinations will be April 1, 1949.

New bulletins are now available for distribu- tion upon application and give details of all changes in Board requirements and regulations made at the annual meeting of the Board held in Washington, D. C., May 16 to May 22, 1948. These relate both to candidates and to hospitals conducting residency service for training.

Application forms and bulletins are sent upon request made to American Board of Obstetrics and Gynecology, Inc., 1015 Highland Building, Pittsburgh 6, Pennsylvania.

The typical congenital, anteflexed uterus is a small uterus with a long, conical cervix.

52

Rocky Mountain Mepical Journal

No milk laboratorY in the world more modern!

This is the new three and one-half million dollar Sturgis (Michigan) Similac Laboratory. This additional capacity was made necessary by your confidence in Similac, and your in- creasing use of the product in your infant feeding practice.

The years of basic and clinical research which preceded the introduction of Similac, established with us a habit for

m & R DIETETIC LABORATORIES,

research. And the many years of accept- ance which Similac has enjoyed since its introduction, make us fully con- scious that continuing research is an obligation.

In our present resources to fulfill this obligation we take a pardonable pride.

But our greatest pride will continue to be the high esteem in which Similac is held by Doctors everywhere.

INC. • COLUMBUS 16, OHIO

> ■ _ ... - ^mmmi ;

for January, 1949

53

Dr. Sudan Hails His Successor

The American Medical Association’s first “family doctor of the year” was quick to con- gratulate his successor on November 20 when the AMA House of Delegates in session at St. Louis voted the second annual general practi- tioner award to Dr. W. L. Pressly of Due West, South Carolina. A few hours after the AMA action, Dr. A. C. Sudan sent the following tele- gram to Dr. Pressly:

“Regret deeply I am unable to shake your hand while extending sincere congratulations and assuring you I concur most heartily with the American Medical Association delegates in their designation of you as recipient of the General Practitioner award. By honoring you the American Medical Association brings honor to itself and a great profession.”

Dr. Sudan, chosen at Cleveland, Ohio, a year ago by the American Medical Association to re- ceive the newly created award, was unable to attend the interim session at St. Louis.

Obituaries

GEORGE B. GILMORE

Dr. George Benjamin Gilmore of Colorado Springs, Colorado, died on November 28, 1948, at the age of 67.

Born in Lawrence, Kansas, in 1881, Dr. Gil- more attended Northwestern University Medical School, graduating in 1903. He was licensed in Colorado the following year.

A member of the El Paso County and Colorado State Medical Societies, Dr. Gilmore had always shown a keen interest in medical and civic affairs. Long a practicing physician, his passing will be mourned by the many who had come to know and respect him.

BROOKS D. GOOD

Dr. Brooks D. Good, Managing Director and President of the Cragmoor Sanatorium Founda- tion of Colorado Springs, died on November 4, 1948, at the age of 52.

Born in Abbey ville, Mississippi, on April 1, 1896, Dr. Good received his medical education at the University of Mississippi and Tulane. He interned at Charity Hospital in Vicksburg, Mis- sissippi.

Dr. Good had been associated with the sana- torium since 1923, becoming its head in October, 1947.

DALE O. GROVES

Dr. Dale O. Groves of Colorado Springs died on October 12, 1948, at the agex)f 67.

Born in Corning, Kansas, on August 22, 1881, Dr. Groves graduated from the Central Medical College of St. Louis, Missouri, in 1903. He was licensed to practice in Colorado in 1905 and the next year opened his office in Calhan, Colorado. He continued practice in Calhan until 1927, at which time he moved to Colorado Springs.

Dr. Groves was a member of the El Paso County and Colorado State Medical Socities. He

was elected to membership in 1931 and in 1941 became an honorary member.

Dr. Groves’ passing will be mourned by, the many who had come to know him during his years of active practice.

DAVID HENRY LAWRENCE

Dr. David Henry Lawrence, Jr., of Denver, died on November 30, 1948, at the age of 41.

Born in Galveston, Texas, on January 12, 1907, Dr. Lawrence received his premedical education at the University of Texas, graduating with a Bachelor of Arts degree in 1928. He then at- tended the University of Colorado School of Medicine, graduating in 1932.

Dr. Lawrence interned at St. Luke’s Hospital in Denver, following which he had a surgical residency at Colorado General and Denver Gen- eral Hospitals. He was elected to membership in the Denver County and Colorado State Medi- cal Societies in October, 1934. Dr. Lawrence was a diplomate of the American Board of Surgery.

ROBERT S. LILLA

Dr. Robert S. Lilia of Nucla, Colorado, died on November 1, 1948, at the age of 50.

Born in Webster, Massachusetts, on December 25, 1898, Dr. Lilia attended Notre Dame for his pre-medical education and graduated in medicine from Jefferson Medical College in Philadelphia.

Dr. Lilia served for a number of years in the United States Army. When his health failed he came to Cortez, Colorado, and later moved to Nucla. It was in Nucla he had practiced the past six years.

Dr. Lilia was a member of the San Juan County and Colorado State Medical Societies. Widely known throughout Southwestern Colo- rado, he will be greatly missed by his many patients and friends.

WILLIAM F. SINGER

Dr. William Frederic Singer of Pueblo, Colo- rado, died on October 25, 1948, at the age bf 78.

Born in New York in 1869, Dr. Singer gradu- ated from Syracuse University College of Medi- cine in 1896. He obtained his license to practice in Colorado the same year, and a short time later was elected to membership in the Pueblo County Medical Society.

Having practiced in southern Colorado for fifty-four years. Dr. Singer was widely known throughout the area. His death will be mourned by his many friends in and out of the profession.

ROBERT P. E. STARR

Dr. Ellis Starr died in Denver on November 10, 1948, at the age of 67, following a two months illness.

Born in Glasgow, Kentucky, on November 27, 1881, Dr. Starr graduated from the University of Louisville Medical College. During his more than thirty years of active practice in Kansas he limited his work to eye, ear, nose and throat. Two years ago Dr. Starr retired and moved to Denver.

He was a member of the American Medical Association and since moving to Denver became affiliated with the Denver County and Colorado State Medical Societies.

54

Rocky Mountain Medical Journal

Announcing...

DIHYDROSTREPTOMYCIN

A New, Dramatic Advance In Antibiotic Therapy

* Less Frequent Allergie Manifestations

* Unsurpassed Purity

* Undiminished Antibacterial Activity against Mycobac- terium tubercufos/s

Dihydrostreptomycin Merck is a new, highly purified antibiotic, chemically distinct from streptomycin, and characterized by greatly re- duced neiurotoxicity.

Allergic manifestations due to dihydrostrep- tomycin therapy are rare, and no local skin irri- tation or other allergic phenomena have been reported thus far among personnel who fre- quently handle this drug.

Dihydrostreptomycin Merck and Strepto- mycin Calcium Chloride Complex Merck may be used interchangeably in the treatment of tuberculosis.

S'-

-■

DIHYDROSTREPTOMYCIN

MERCK

(supplied as the sulfate or the hydrochloride)

MERCK & CO., Inc. RAHWAY, N. J.

for January, 1949

Denver Children s Hospital Summer Clinics

The professional staff of