new vistas for the . .
Effective control of seizures, social acceptance, and recognition of employment potential are providing new vistas for the majority of epileptic patients. Accurate diagnosis and adequate therapy, as in present-day management, can be expected more confidently than ever before to restore such patients to as full a life as is compatible with their condition.
DILANTIN* SODIUM
(diphenylhydantoin sodium, Parke -Davis)
Alone or in combination, DILANTIN continues as an anticonvulsant of choice for control of grand mal and of psychomotor seizures. In addition to its notable
effectiveness, DILANTIN has little or no hypnotic effect.
DILANTIN Sodium is supplied in a variety of forms— including Kapseals® of 0.03 Gm. (Vz gr.) and 0.1 Gm.
(IVz gr.) in bottles of 100 and 1,000.
Capsule Clinics
I. A. Wien, M.D.
• The preoperative diagnosis of Meckel’s diver- ticulum is rarely made by means of a roentgeno- logic examination since visualization of the diver- ticulum may be misinterpreted as an intestinal loop. Marshall, S. F., and Baker, A. L.: Lahey Clin. Bull. 9 (April) 1955.
• Indications for the surgical treatment of a gas- tric ulcer (resection) are: high suspicion of ma- lignancy as shown by x-ray or gastroscopic exami- nations, penetration of the ulcer, recurrent gastric ulcer, hemorrhage, acute perforation and gastric retention. Kiefer, E. D.: Lahey Clin. Bull. 9 (April) 1955.
• It is estimated that 800 persons die yearly in the United States of complications of hypertension
due to pheochromocytoma. It is to be remembered that the condition is often mistaken for thyrotoxi- cosis. Newton, T. H., et al.: New England J. Med. 252 (June 9) 1955.
• The invention of the ophthalmoscope by Her- mann Ludwig Ferdinand von Helmholtz in 1851
paved the way for a succession of new and more refined methods of treatment of the eye — especially of glaucoma. Habegger, H.: New England J. Med. 252 (June 9) 1955.
• A marked reduction in oxygen consumption oc- curs during hypothermia, and thus prolonged
regional ischemia of parenchymatous vital organ systems may be permitted. This principle has been utilized to permit circulatory occlusion in cardiac surgery and interruption of the aorta for resec- tion of aneurysms. Bernhard, W. F.: New England J. Med. 253 (August 4) 1955.
• Carcinoma of the genitals comprises only 2 per cent of the cancers in men, whereas it accounts
for about 27 per cent of all cancers in women. Frohman, I. P.: Med. Ann. 24 (October) 1955.
• Supervoltage irradiation (1 and 2 million-volt) has the following advantages: higher depth dose,
milder skin reaction, less shielding of tumors by
bone, less risk of radionecrosis of bone and better defined x-ray beams. Phillips, R.: Med. Ann. 24 (October) 1955.
• Acute viral hepatitis has been found to be promptly terminated by means of the Knott
technic of blood irradiation therapy. Olney, R. C.: Am. J. Surg. 90 (September) 1955.
• Primary reticulum-cell sarcoma of bone is a ma- lignant tumor that originates in a single site,
metastases usually by the lymphatics, produces pain and swelling, and has a relatively good prog- nosis, five year survival rate approaching 50 per cent. Wilson, T. W., and Pugh, D. G.: Radiol. 65 (September) 1955.
• Osteomyelitis of the spine may develop during the course of urinary tract infection, and this is
best explained in the light of Batson's work demon- strating numerous anastomoses between the ve- nous plexus of the pelvic organs and that of the spinal column. Leigh, T. F., et al.: Radiol. 65 (Sep- tember) 1955.
® It is believed that calcium deposits in the hand are a result of local stress and strain with necrosis and deposition of calcium phosphate and calcium oxalate in the area. Carroll, R. E., et al.: J.A.M.A. 157 (January 29) 1955.
• Despite an intensive search for effective anti- fungal chemotherapeutic agents, there is, at
the moment, no reliable therapy for histoplasmosis, coccidioidomycosis, moniliasis, torulosis, and pul- monary blastomycosis. Advances in Medicine and Surgery, Graduate School of Medicine, University of Pennsylvania, W. B. Saunders Co., Philadel- phia, 1952.
• Seven conditions which account for 90 to 95 per cent of the pathology in abdominal emer- gencies are: acute appendicitis, perforated peptic ulcer, acute cholecystitis, acute salpingitis, acute hemorrhagic pancreatitis, renal colic, and acute coronary disease. Thorek, P.; Missouri Medicine 52 (June) 1955.
Missouri Medicine in Review
Leo H. Pollock, M.D.
FORTY YEARS AGO
After completing fifty years of continuous serv- ice on the medical staff of the St. Louis Mullanphy Hospital, Dr. Norman Bruce Carson, the dean of the surgical profession of St. Louis, was tendered
a surprise dinner and pre- sented with a gold loving cup at the hospital on No- vember 24 by members of the staff.
For years it has been a lamentable fact that the number of attendants car- ing for the insane charges in the St. Louis City Sani- tarium has been wholly inadequate. This hard- worked class of city em- ployees who give their whole time and attention to the care of the insane, receives the same pit- tance that they did thirty or forty years ago, a meager stipend of $28.00 or $30.00 per month with board.
The organization meeting of the Perry County Medical Society was held at Perryville, November 23. Dr. George A. Blaylock was elected president; Dr. James W. Russell, vice president, and Dr. F. M. Vessells, secretary.
Dr. John Sturgis of Perrin was stricken with paralysis about December 8 and is in a serious condition. He is 73 years old and has been a mem- ber of Clinton County Medical Society and the State Association for many years.
Dr. M. A. Bliss of St. Louis and Dr. LeGrand Atwood of Ferguson have been elected original founders of the National Historical Society.
The American College of Surgeons begins the new year with an announcement that it has se- cured from its fellows an endowment fund of $500,- 000. This fund is to be held in perpetuity, the in- come only to be used to advance the purposes of the college. By this means lasting progress toward the purposes of the college is assured. The college, which is not a teaching institution but rather a so- ciety or a college in the original sense, now lists about 3,400 fellows in Canada and in the United States. Without precedent for swiftness of develop- ment it stands today a powerful factor both in the art and in the economics of surgery.
The Clinton County Medical Society met at Lathrop, December 22, 1915, and after being royal- ly entertained and feasted on “possum and sweet taters” by our good friends, Dr. and Mrs. McCon- key, we proceeded with our regular business.
The Webster County Medical Society held its annual meeting at Marshfield, December 14, with
the president, Dr. Good, in the chair. It is with much pride that we forward to the Secretary of the State Association our check for $30.00, cover- ing the 1916 dues of our entire membership. We want to be the first on the Roll of Honor this year.
TWENTY-FIVE YEARS AGO
Dr. Mazyck P. Ravenel, Columbia, professor of preventive medicine and bacteriology at the Uni- versity of Missouri, was appointed consultant in public health and medical education to the Mis- souri State Board of Health, December 2, 1930. Dr. Ravenel is an internationally known authority on public health, hygiene and sanitation. The sci- entific accuracy of Dr. Ravenel’s work and his abil- ity as a pioneer bacteriologist were established through a controversy with the eminent German scientist, Dr. Koch, when Dr. Ravenel proved in opposition to Dr. Koch’s contention, that human beings can contact the bovine type of tuberculosis under certain conditions.
When press dispatches brought the sad news to American readers on November 22 of last year that Dr. Ernst Fuchs, emeritus professor of oph- thalmology in the University of Vienna, had died on the preceding day, thousands of physicians re- called the name and kindly face of the man who was regarded as one of the world’s outstanding authorities on diseases of the eye. He was without a doubt the chief authority on the histopathology of the eye. Professor Fuchs was in his eightieths year at the time of his death.
The American College of Surgeons will hold a sectional meeting for the states of Missouri, Iowa and Kansas at St. Joseph, January 5 and 6.
The Hodgen Lecture for 1931 will be delivered before the St. Louis Medical Society by Dr. W. Ed- ward Gallie, professor of surgery at the University of Toronto Faculty of Medicine, on January 13, 1931. His subject will be “Recent Advances in the Transplantation of the Fibrous Tissues.”
The name of the Jewish Memorial Hospital un- der construction on Fiftieth Street between Holmes and Troost, Kansas City, has been changed to Menorah Hospital. The hospital is about half com- pleted and will cost approximately $1,000,000. It will be ready for occupancy about June, 1931.
Preventive medicine in Colombia has received a severe setback according to authorities of that coun- try by the death of sixteen children and the severe illness from diphtheria of thirty-three others, caused by the accidental administration of diph- theria toxin instead of antitoxin by an intern in a private hospital at Medellin, Colombia. The intern became insane after the tragedy.
(Continued on page 8)
6
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Both tablets are deep-scored and of the
for ease of handling and breaking by arthritic fingers.
anti-rheumatic/anti-allergic/anti-inflammatory
supplied: 1 mg. oral tablets, bottles of lOO.
White, 5 mg. oral tablets, bottles of 20 and lOO.
PFIZER LABORATORIES
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Missouri Academy of General Practice
William F. Wagenbach, M.D.
The Seventh Annual Assembly
The Seventh Annual Assembly of the Missouri Chapter of the American Academy of General Practice, held at Jefferson City on October 26 and 27, was an outstanding success and showed the re- sults of previous experience and improvement.
Beginning on the previous evening, the Board of Directors met, with a number of visitors, and dis- patched a large agenda of business. The following morning, Dr. George M. Wood, President, called the meeting to order for the transaction of busi- ness and the election of officers. The following were elected, as recommended by the nominating committee: President Elect, Dr. Charles Martin, St. Louis; vice president, Dr. Roy W. Pearse, Ne- vada; secretary-treasurer, Dr. J. H. Trollinger, Jackson; board of directors, Dr. W. C. Allen, Glas- gow; Dr. A. E. Spelman, Smithville, and Dr. John T. Crowe, Cape Girardeau.
The scientific program followed immediately aft- er the business meeting, consisting of a presenta- tion by Dr. Ashton Graybiel, Pensacola, Florida, on “Practical Hints on Clinical Electrocardiogra- phy”; Dr. William Hudson, Detroit, on “Treatment of Pulmonary Tuberculosis With Reference to Home Treatment”; Dr. Thomas Thale, St. Louis, “The Use of Serpasil and Thorazine in Office
Practice for the Mentally Disturbed,” and a panel on “Cancer of the Cervix and Uterus” by Drs. A. E. Spelman, Smithville; Victor B. Buhler, Kan- sas City, and Clarence Davis, Columbia.
On Wednesday evening Rabbi Isserman, St. Louis, spoke on “The Dignity of Man” at the ban- quet. His wonderful oratory held the audience en- thralled and it was generally agreed that he was one of the best speakers the Academy has had.
On Thursday, Dr. Hudson spoke on “Diagnosis and Treatment of Patients With Symptoms of Chest Diseases”; Dr. Robert Bollinger, Kansas City. Kan- sas, “Management of Problem Diabetics With Re- view of Insulin and Emphasis on Newer Insulins”; Dr. A. K. Busch, St. Louis, “The Use of Serpasil and Thorazine in the Institutional Care of the Men- tally 111,” and Dr. Ashton Graybiel, “Certain Limi- tations in Using Subjective and Symptomatology in Regulating the Activities of the Cardiac Patient.”
The convention adjourned at 4: 30 p. m. It was an outstanding meeting with a total registration for the doctors of 109.
At the business meeting there was some discus- sion of a change of cities for the next convention. Because of the time element, it was deemed advis- able to hold the next convention in Jefferson City.
Missouri Medicine in Review
( Continued from page 6 )
During the year of 1930 the Five-County Medical Society, consisting of the counties of Butler, Dunk- lin, New Madrid, Pemiscot and Stoddard, carried out a plan for postgraduate work at home. The group held meetings annually. The smallest num- ber of doctors present at any meeting was forty- five, the largest sixty-seven, weather conditions being the cause of the smaller number.
TEN YEARS AGO
The end of the war made possible a session of the House of Delegates of the American Medical Association in Chicago during the period from De- cember 3 through December 5. It expressed its opposition to federal compulsory sickness insur- ance as proposed by the Wagner-Murray-Dingell bill and also to the ordinary proposals made by Senator Pepper in his bill for maternal and infant care.
Dr. C. T. Herbert, Cape Girardeau, was elected president of the Southeast Missouri Medical As- sociation at its 69th annual meeting held at Cape Girardeau on November 5.
Dr. Ben Brasher, Lexington, spoke before a par- ent-teacher association in Lexington on November 14 and told of the condition of child health among Arab children which he had witnessed while in service.
In honor of the memory of Dr. John L. Benage, the Iberia Junior College has created a loan fund for the assistance of young men and women to become physicians and nurses.
Dr. A. E. Monroe, Sedalia, has been appointed county physician of Pettis County.
Deaths: McComb, James A., M.D., Lebanon, a graduate of Beaumont Hospital Medical College, St. Louis, 1887; honor member and former presi- dent of Laclede County Medical Society; aged 82; died November 15. Finney, William B., M.D.. Ken- nett, a graduate of St. Louis College of Physicians and Surgeons, 1820; honor member of Dunklin County Medical Society; aged 87; died October 27.
8
Now, you can prescribe an antibiotic ( Filmtdb Erythrocin) that provides specific therapy against staph-, strep- or pneumococci. Since these organisms cause most bacterial respiratory infections (and since they are the very organisms most sensitive to Erythrocin) doesn’t it make good sense to prescribe Erythrocin when the infection is coccic?
STEARATE
Since Erythrocin is inactive against gram- negative organisms, it is less likely to alter intestinal flora— with an accompanying low incidence of side
effects. Also, your patients seldom get the allergic reactions sometimes seen with penicillin. Or loss of accessory vitamins during Erythrocin therapy. Filmtab Erythrocin (100 and 250 mg.), bottles of 25 and 100. (JJjvOtt
STEARATE
®Filmtab — Film sealed tablets; patent applied for.
165
Woman’s Auxiliary
Mrs. Frank B. Leitz, President
Early in November it was our privilege to at- tend the Twelfth Annual Conference of State Pres- idents, Presidents-Elect, National Officers, and Na- tional Committee Chairmen, Woman’s Auxiliary to
the American Medical As- sociation, which was held at the Hotel Drake, Chi- cago, Illinois.
The theme of the con- ference was that chosen by our National President, Mrs. Mason G. Lawson, for her administration, “Active Leadership in Community Health.”
The first morning of the conference Ernest B. Howard, M.D., Assistant Sec- retary, American Medical Association, spoke on “Social Security Disability Benefits.” Dr. Howard told of the beginnings of Social Security during the depression year of 1934, and of how the plan was amended in 1939. What started out as welfare with some elements of insurance has become a sys- tem of redistribution of wealth. It was suggested that we become thoroughly familiar with HR 7225.
Each National Committee Chairman acted as moderator of a panel covering her particular chair- manship. Panel participants were presidents of state auxiliaries. In addition to participants each panel included guest speakers and resource au- thorities.
We were assigned to the Today’s Health panel, with Mrs. C. Rodney Stoltz, Watertown, South Dakota, as moderator. Today’s Health has been re- ferred to as “Our Baby” and that was the general theme of the four panel participants. Acting as Re- source Authorities were W. W. Bolton, M.D., As-
sociate Director, Bureau of Health Education, A.M.A.; Mr. William Hetherington, Managing Pub- lisher, Today’s Health, and Mr. Robert Enlow, Di- rector of Circulation, Today’s Health. It was de- veloped that not too long ago Today’s Health was considered a sick baby in that it did not pay its own way. With the number of subscriptions in- creasing, its health status is much improved. Aux- iliary members were, of course, urged to continue to work toward increasing the number of subscrip- tions. The slogan — “Buy a copy, Sell a copy, Give a copy” — used in another state was recommended for use by all states and all auxiliary members.
The legislation panel with Mrs. Charles L. Good- hand, Parkersburg, West Virginia, as moderator was extremely interesting. Topics discussed by panel participants were: The Bricker Amendment, Military Medicine, Federal Aid to Medical Educa- tion, Jenkins-Keogh Legislation, Mortgage Loan In- surance and Health Reinsurance. Resource Author- ities for the legislation panel were Mr. C. Joseph Stetler, Director, Law Department, A.M.A., and Mr. R. G. Van Buskirk, Staff Associate, Law De- partment, A.M.A.
During one of the luncheon meetings Elmer Hess, M.D., President, A.M.A., was guest speaker. Dr. Hess, in his own most impressive way, urged that all eligible members of all medical families be registered to vote, and then make best possible use of their right of franchise.
The entire conference was inspirational. There was good, warm fellowship.
As we registered we were given large, easy-to- read name plates. This led another guest at the Hotel Drake, after a few days of sage observation, to comment, “What kind of a meeting is this? It seems to be all Chiefs and no Indians.”
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Missouri State Board of Medical Examiners
Duff S. Allen, M.D., President
The Scope of Our Work
In the September 1955 issue of Missouri Medi- cine we outlined briefly the duties of the State Board of Medical Examiners of Missouri. There still remains some uncertainty, however, in the
minds of several of the members of the Missouri State Medical Association with regard to the respon- sibilities of the Board, the methods by which its ac- tivities are financed, and its relationship to the phy- sicians of the state and the state government.
In February 1945 a new Constitution was adopted in this state and with the new Constitution the State Board of Medical Ex- aminers was placed under the Department of Edu- cation. This was a logical move since this Board is primarily concerned with the educational qualifi- cations of physicians. We must be conversant with medical education not only in the United States but in foreign countries as well. We are the ones who must determine whether a candidate has had the proper medical education to qualify him for permission to take our State Board Examinations. We can and do refuse to allow graduates of in- ferior medical schools this privilege.
In addition to the granting of licenses by exami- nation and by reciprocity your Board has two other duties to perform: (1) To investigate, to cite and to cause suit to be brought against those who are practicing medicine without a license, and (2) to revoke the license of a physician who becomes morally unfit to practice medicine. There are 6,653 licensed physicians in the State of Missouri, and they are a quite honorable group. During the last year we have revoked the licenses of two physi- cians, one who was convicted of becoming an abor- tionist and one who became a drug addict. At this rate we will get around to all of us in a little over 3,000 years.
How are the monies raised to finance the activi- ties of your Board? They come not from taxation but mainly from us, the physicians of the state. We take up and spend our own collection. Our bi- annual registration fees supply most of this money, but some is derived from examination fees, from endorsements to other states and from reciprocity fees. This money is set aside by the State Treasurer
for our special use. The recent increase in the bi- annual registration fee from $3.00 to $5.00 has given us money, for the first time, sufficient to pay for the needed expert investigators. It may be of interest to you to know that the salary of a Board member is $10.00 per day, minus $0.20 for Social Security, and, of course, we are paid only when we are in formal session. We have had eight such formal sessions in 1955, each of which has lasted from one to three days.
Perhaps the scope of the work of the Board can be more easily appreciated by a brief resume of our record for the year 1955. During that year we gave complete State Board Examinations four times. A total of 279 doctors were given examina- tions, 257 of these passed and twenty-two failed to pass. Most of these twenty-two who failed to pass were graduates of foreign medical schools. One hundred ten licenses were issued by reciprocity from other states or by endorsement from the Na- tional Board of Medical Examiners.
We have been proud of our record in bringing to task those who have been practicing medicine without a license. During the last year we have instituted twenty-four such investigations. We have obtained a permanent injunction, for the first time, against a naturopath who was practicing medicine. A permanent injunction is better than a convic- tion for the practice of medicine without a license. In this state the punishment for contempt of court, a violation of a permanent injunction, is often more severe than for the illegal practice of medi- cine. Thus it seems that our laws with respect to the practice of medicine could stand a little strengthening here and there.
14
Missouri Medicine
JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION
Copyright, 1955 by Missouri State Medical Association. All Rights Reserved.
Vol. 53
January, 1956
Number 1
Cardiac Arrhythmias
In Physical or Emotional Stress
MICHAEL BERNREITER, M.D., Kansas City
Cardiac arrhythmias brought about by physical or emotional stress in patients without demonstra- ble heart disease are, in my experience, not a rare occurrence. The rising incidence of these rhythmic disorders, including premature beats, paroxysmal tachycardia and auricular fibrillation, may well make their first appearance in a normal heart after strenuous exertion or severe mental strain. Many patients with rhythmic disturbances of the heart will, on careful questioning, disclose a history of recent psychic conflict or emotional strain.
The interpretation of this condition as primarily a psychosomatic disease has perhaps little scientific support. However, the possible importance of psy- chic factors in the etiology of these conditions is worthy of careful investigation. Emotional strain is always difficult to evaluate as an etiologic factor in disease; but despite these difficulties, one cannot dismiss the possible relation of emotion to the precipitation of cardiac arrhythmias.
There is rather strong circumstantial evidence that unusual and violent physical exertion also may be an important causative factor in the initia- tion of even fatal disturbances in the rhythm of the heart. These disturbances may vary from oc- casional to frequent prematurities originating in the auricles or ventricles to the more serious par- oxysms of tachycardia, flutters and fibrillations. While these attacks are more common in patients with organic heart disease, they are not uncom- mon in individuals free from any demonstrable cardiac pathology.
In the cases reported here there has been a close relationship betwreen the onset of the cardiac ar- rhythmia and the period of physical or mental stress.
case reports
Case 1. A 45 year old white male was admitted to
the hospital because of palpitation and faintiness of about three hours duration. His previous health had been good and he had worked for six years in his pres- ent employment. On the afternoon of admission he had a violent argument with his supervisor which was soon followed by pounding of the heart and giddiness never experienced before. An electrocardiogram after ad- mittance showed auricular fibrillation. Blood pressure was 100/80. After rest, sedation and quinidine a regular rhythm was established. Further investigation during his hospital stay revealed no cardiac pathologic con- dition and no other unusual findings. Paroxysms of auricular fibrillation were easily produced if the pa- tient was irritated by the house staff or by the nurses.
Case 2. A 53 year old man had always been in good health. At 10:00 a.m. one day he lifted a 150 pound load. He experienced a feeling of giddiness, palpitation and dyspnea. He was taken to the hospital in an am- bulance and on arrival he was pale and in a shock-like state. Electrocardiogram showed ventricular tachy- cardia. Rest, sedation and pronestyl terminated the attack. A repeat electrocardiogram and other labora- tory findings were within normal limits. Weight lift- ing while in the hospital on several occasions brought on short paroxysms of tachycardia.
Case 3. A 40 year old man had always been nervous, tense and easily excited. At 4:00 p.m. on the day of admission he had an argument with his foreman and was subsequently dismissed. He immediately became nauseated and experienced violent pounding in his chest. On arrival in the hospital an electrocardiogram was taken which showed a paroxysmal auricular tachy- cardia. Injections of prostigmin, together with carotid sinus pressure, established a regular sinus rhythm within approximately one hour. Further studies re- vealed no pathologic condition and an electrocardio- gram taken several days after admission was within normal limits.
Case 4. A married woman about 34 years of age col- lapsed suddenly on the street while witnessing a seri- ous car accident. She arrived in the hospital by ambu- lance in a state of shock. The pulse was slow and diffi- cult to obtain. An electrocardiogram showed a com-
19
20
CARDIAC ARRHYTHMIAS— BERNREITER
Missouri Medicine January, 1956
plete heart block. The diagnosis was Adams-Stokes syndrome. She was given oxygen, epinephrine and the electrical pacemaker was used. She made a prompt recovery and a follow-up electrocardiogram was taken while the patient gave a detailed account of the accident. There was no difficulty in reproducing a com- plete heart block in this patient during these periods, the electrocardiogram showing progressive changes from AV block to ventricular tachycardia, electrical alternans and cardiac standstill.
SUMMARY AND CONCLUSIONS
The four cases presented are typical for the con- dition discussed. Acute changes in cardiac rhythm were induced in each individual after unusual body effort or emotional strain. During the alarm reaction of the general adaptation syndrome in- creased capillary permeability, hemo-concentration, hypertension and hypotension were evidenced. Ex- ercise and emotional stress may also cause an in- crease in blood viscosity and hematocrit, and a de- crease in sedimentation rate, coagulation and pro- thrombin time. The central nervous system and the endocrines also appear involved by the action
of neurohormones (adreno-sympathogenic) and hormone ( adrenal -corticoids and thyroid). In sum- mary it may be stated that physical exertion and emotional stress may lead to almost all types of cardiac arrhythmias and death in the abnormal as well as the normal heart. An attempt is made to describe some of these phenomena that occur during the alarm reaction and their possible re- lationship to the production of ectopic rhythms.
432 Professional Bldg.
BIBLIOGRAPHY
1. Weiss, E., and English, O. S.: Psychosomatic Medicine, 1954, W. B. Saunders Company, Philadelphia.
2. Selye, H., and Fortier, C.: Adaptation Reactions to Stress, Proceedings, Association for Research in Nervous and Mental Disease, 1950, Williams and Wilkins Co., Baltimore, Maryland, P- 3.
3. Stevenson, T., and Duncan, C. H.: Alterations in Cardiac Function and Circulatory Efficiency During Periods of Life Stress as Shown by Changes in the Rate, Rhythm, Electro- cardiographic Pattern and Output of the Heart in Those With Cardiovascular Disease, in “Life Stress and Bodily Disease,” Proceedings, Association for Research in Nervous and Mental Diseases, 1950, the Williams and Wilkins Company, Balti- more, Maryland, p. 799.
4. Schneider, R. A.: Relation of Stress to Clotting Time and Other Biophysical Alterations, in “Life Stress and Bodily Disease,” Proceedings, Association for Research in Nervous and Mental Disease, 1950, Williams and Wilkins Company, Baltimore, Maryland, p. 818.
. . . the humblest of my patients today
I noted a cartoon dealing with the cost of medicine. My thoughts wandered to the father and mother looking at the small figure so still in the big bed. It all seemed to have happened very quickly. The small boy coming in from the drench- ing rain. Next day the sore throat. Then the hor- rible cough, high fever, nurses, doctors, never- ending vigil, hope and despair, and finally, death. Death entered the White House as devastatingly as though it had been a hovel. Eight dollars worth of antibiotics would have had Willie Lincoln well within a week or less.
Not so remote in time, Calvin Coolidge, Jr. blis- tered his heel on the tennis court. Infection and septicemia followed. Once again death eluded every barrier to invade the White House and carry away the President’s son. Five to $10 worth of sulfonamide or broad spectrum antibiotic tablets would have saved a life — a precious child.
William McKinley was struck down by an assas- sin’s bullet. It took him nine days to die. The wound in itself would be considered trifling to- day. But the President died of the peritonitis that followed.
Warren Harding died of pneumonia, another
disease which is rapidly taking its place among the diseases of the past.
What does all this mean to us today? It means that the humblest of my patients today is infinite- ly better off than were the most powerful in the world just a few years ago. For half a day’s pay the laborer of today can buy these precious me- dicaments which the Lincolns, the Coolidges, the McKinleys, the Hardings, and untold others could not obtain at any price.
Tremendous sums are spent in research. Super- human effort is spent by countless dedicated men and women so that for a few insignificant dollars all boys and girls filled with promise for life and loved by their parents, the wives and husbands, the fathers and the mothers, yes, the grandfathers and the grandmothers in my reception room, may live with the least physical and emotional agony. I’m humbly thankful.
Herman B. Kipnis, M.D., Chicago Sun-Times,
May 17, 1955.
Reprinted by permission from The Bulletin for Medical Research, July-August 1955. Reprints suitable for framing are available for 50 cents from the National Society for Medical Research, 208 N. Wells St., Chicago 6.
Ringworm of the Scalp
A Clinical Survey
NORMAN TOBIAS, M.D., St. Louis
Since scalp ringworm is a fairly common endemic infection in the St. Louis area, it should be ac- curately diagnosed and treated properly to avoid the possibility of epidemic spread. Limited to children under the age of 14, it is often treated with ointments for long periods without proper supervision. Under these conditions spread of the disease is inevitable among siblings in the family, school or playmates. Individual susceptibility and close contact with the infected hairs are necessary for infection to occur. Even though the clinical appearance of the lesion is suggestive of ring- worm, the diagnosis must be verified by the Wood light and microscopic wet preparations; and the type of fungus classified by making a culture of the infected hairs. The culture is important from the therapeutic and prognostic standpoints as M. audouini infections require x-ray epilation for their eradiation while M. lanosum (canis) in- fections usually clear up within three weeks with topical antifungal ointments.
Not every patchy dermatitis in a child’s scalp is ringworm but the disease may not be obvious to the naked eye; secondary infection may mask the clinical features, and no two cases appear exactly alike. It is therefore important to consider every case of patchy alopecia, scaling or crusting in a child’s scalp as ringworm until it is proven other- wise.
Although the disease does not affect the gen- eral health it is a general nuisance. The dermatol- ogist is concerned about the danger of infection to other patients, the mother is worried about the long ordeal of therapy and the child’s psyche may be affected by the fact that he has to wear a protective cap and be labeled “exhibit A” like the lepers of the middle ages. From every angle the disease is a nuisance in the office, the clinic, the home and the classroom.
CLINICAL TYPES
Tinea capitis is not a skin disease but an in- fection of the hairs with specific fungi which have an attraction to hair keratin for some un- known reason. Three types are recognized in this zone: (1) Microsporon lanosum (canis) which is parasitic for cats and dogs and which readily infects children; (2) M. audouini which is strict- ly a human parasite and is only spread from child to child by contacts directly or indirectly; (3) and the Triochophyton tonsurans, which is a Mex-
ican import and has been reported in Texas and California. Sporadic cases are appearing in other states. The latter type is of great interest because it has unusual features: it may affect adolescents and adults and it does not fluoresce under the Wood light. Even the clinical appearance may be atypical with seborrheal, psoriasiform and follic- ular pustular lesions predominating, according to Pipkin.1
Another uncommon manifestation of scalp ring- worm is a tender boggy scalp lesion called kerion (from the Greek word for honey-comb) which is associated with M. lanosum infections and may be mistaken for an abscess. Mild fever, irritability and local adenopathy are present and local alopecia may result after the lesion involutes. Parents should be forewarned of this possibility so that x-ray epilation, if administered, will not be unjustly incriminated. Kerion is an allergic re- sponse to the invasion of the hair follicles with destruction of the fungi in situ (fig. la).
Clinically, M. lanosum infections are more obvious since the patches are more inflammatory
Fig. la. Kerion is a suppurative type of reaction in some cases of M. lanosum infection. The lesion is painful and regional adenopathy is always associated with it. b. M. lanosum scalp ringworm in a common site in boys (clipper area), is probably acquired in a barber shop.
and studded with pustules and broken-off hairs. Typical “rings” (fig. lb) may be present on the nape of the neck, face or upper extremities as di- rect inoculations from infected hairs coming in contact with the non-hairy skin. M. audouini in- fections are more difficult to detect since the patches consist of noninflammatory areas of partial alopecia in which the surviving hairs are luster- less. Under the Wood light the true extent of the infection may be surprising (fig. 2).
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Fig. 2. M. audouini infection with extensive involvement.
DIAGNOSIS
Four measures are necessary in diagnosis: (1) a high index of suspicion, (2) the Wood light examination (a Stroblite black tube lamp is pref- erable to the purple X bulb) ; (3) microscopic examination of the fluorescent hairs (using 30 per cent potassium hydroxide solution) ; (4) implanta- tion of several of the infected hairs on Sabouraud media to determine the species of fungus from the character of the culture growth (fig. 3). From
Fig. 3. Scalp ringworm cultures, 1. M. audouini showing pigment, 2. M. lanosum.
seven to ten days are required for the colony to grow large enough for study. The hairs should be sent to a mycologist or pathologist experienced in this work. Before hairs are re- moved for study the scalp should be thoroughly shampooed with tincture of green soap to re- move residual ointments or medication. The hair should be permitted to grow long enough in boys to extract suitable specimens for study.
INCIDENCE
Of eighty cases in this series, sixty-two were in boys and eighteen in girls. M. audouini in- fections were found in sixty-one, M. lanosum in
Fig. 4. M. lanosum infection acquired from a kitten.
Fig. 5. M. lanosum infection in a girl.
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Fig. 6. M. audouini infection, a neglected case. Duration of seven months.
Fig. 7. Alopecia areata which may be mistaken for ring- worm. Note absence of hair, inflammation and scaling.
sixteen, T. gypseum (fulvum) in two and T. violaceum in one. All of these cases occurred in middle income families, none in the high income bracket. Many of these cases were first diagnosed by Public Health school nurses. The neglected or far advanced cases were in the minority and were from neighboring Illinois or Missouri coun- ties or in recent arrivals from rural areas.
Dr. J. Earl Smith, Health Commissioner of the City of St. Louis, in a personal communication, stated that in 1949, 413 cases of scalp ringworm were reported to his department; in 1952, 299 cases were reported. These cases do not represent the true incidence of the disease, at least in the preschool group, although it is a reportable disease. Early diagnosis and treatment will pre- vent epidemics and reduce the strain on the facil- ities of those who must treat these cases.
PRETREATMENT INSTRUCTIONS
While awaiting the results of cultures, parents are advised to carry out the following: (1) boys get haircuts at home (burn all clippings); (2) kittens or puppies on the premises should be taken to a veterinarian for Wood light examination; (3) any broken-off hairs discovered on the pillow or
sheets should be removed at once and burned; (4) a “beany” acceptable to the child should be worn at all times; (5) a fungicidal ointment, pref- erably Salundek (Wallace and Tiernan), should be applied daily to the entire scalp until a final diagnosis is made.
SOURCE OF INFECTION
Of the eighty cases in this series of private cases, twenty-eight were direct contacts with in- fected children; fifteen were probably acquired from infected kittens; the cinema appeared to be the source of infection in seven, and eight cases had doubtful contacts with infected playmates. It was not possible to examine the barber shop as a source of infection as the health departments in the City and County have adequate facilities for this work. One source of infection that may be overlooked is the symptomless carrier, but routine examination of all children in public and parochial schools should overcome this problem.
The physiologic and biologic conditions neces- sary for infection are not known. Local im- munity, personal hygiene and the virulence of the invading fungi are important factors. Klingman2 has demonstrated experimentally that some form of minor trauma is a prerequisite for infection to take place. The longer hair in girls offers a meas- ure of protection; they are less apt to exchange headgear or to engage in strenuous sports.
PROGNOSIS
Regardless of what type of therapy is used, scalp ringworm will usually undergo spontaneous cure at or near the age of puberty. For this reason the examiner may decide to withhold x-ray epilation in M. audouini infections in older chil- dren. The disease may also undergo complete in- volution if secondary infection is present. Al- though Livingood and Pillsbury3 reported 25 per cent spontaneous cures in a series of M. audouini infections and in 75 per cent of M. lanosum cases, it is not practical to await this phenomenon from the standpoint of public health and the per- sonal desires of the parents.
DIFFERENTIAL DIAGNOSIS
During epidemics especially, many cases sus- pected of a positive Wood light reaction prove to be examples of pseudo fluorescence. In a series of thirty-four cases suspected of having scalp ringworm, three were only scars, six impetigo, four pustular folliculitis, twenty were patches of seborrhea and one was trichotillomania. In alopecia areata, the bald areas are smooth, devoid of hair and noninflammatory. In seborrhea, the hairs are normal and the scales are limited to the skin.
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TREATMENT
The management of a case depends on the type of fungus found in the culture. M. lanosum in- fections will clear up within three weeks as a result of local therapy with tincture of iodine, 5 per cent ammoniated mercury or a 5 per cent sul- fur ointment. Asterol ointment should not be used in children as it has neurotoxic effects. However, in extensive or stubborn cases or when parental cooperation is not obtained, x-ray epilation is advisable. In all M. audouini infections, x-ray epilation is mandatory since local therapy is not satisfactory and may require from three to five months for results. It is presumed that x-ray epilation will be performed by an experienced and skilled operator and the Adamson-Kienboch meth- od employed.
Follow-up of Cases Treated With X-Ray. — Let- ters were addressed to the mothers of fifty chil- dren who had received x-ray epilation, with thirty-one replies. All except one reported com- plete cures. The exception was a case from a rural area, which required bacon grease to effect a final cure! In three cases the regrowth of hair was stated to have acquired a slight reddish tint; in four cases the hair was somewhat curly; and in one case there was slight thinning of the hair over the right parietal area. One mother reported a premature loss of the baby teeth in her child three months following x-ray epilation. A second inquiry six months later resulted in reports that the hair in the latter group was normal in color and texture.
Ointment Therapy. — At the present time there is no effective local therapy that is dependable in M. audouini infections. Sullivan and Bereston4 ex- amined thirteen antifungal preparations and con- cluded that only those containing di-chloro-sal- icylanilide were effective in the majority of the cases. In the absence of controls and the possibil- ity of spontaneous cures, scalp ringworm cures must be critically evaluated. Ointment therapy re- quires at least five months for a cure, the therapy is tedious for both child and parent and results are not dependable. However, in small commun- ities where x-ray epilation is not available, oint- ment therapy is worth a trial.
Manual Epilation. — When done under the Wood light, the extraction of infected hairs with the forceps, if skillfully performed, may be successful in controlling small patches of ringworm. In some x-ray epilated scalps, a few infected hairs may be left in the follicles and should be removed with the forceps. In children who squirm during the procedure, local anesthesia with an ethyl chloride spray may permit the work to be completed suc- cessfully.
Criteria for Cure. — The scalp infection is not considered cured until (1) all fluorescent hairs have disappeared by examination of the entire scalp under the Wood light; (2) there is regrowth of normal hair and, (S') examination of the scalp at two week intervals for ninety days reveals no fluorescent hairs.
Psychologic Factors. — In every case of ring- worm of the scalp, there is a worried mother or parent and a harrassed child. The mother is con- cerned with the origin of the infection, the pos- sibility of infection of the other children, the duration of treatment, the curtailment of schooling and the possibility of permanent alopecia follow- ing x-ray epilation. Each of these matters should be discussed at the time of the first visit. The child whose “beany” or muslin cap marks him as a bearer of an infectious disease should be given assurance of cure within a reasonable time, re- growth of hair and acceptance by his group. The protective cap should be dyed the color of the hair to avoid undue notice. In most communities the child is permitted to attend school as long as he is under medical supervision, conforms to local health regulations and cooperation of the parents is forthcoming.5
SUMMARY
Scalp ringworm should be regarded as a public health problem. The first physician to see the case should confirm his diagnosis by Wood light, mi- croscopic and culture studies.
In the absence of an accurate diagnosis, the use of ointments may prolong the disease, spread the infection to contacts and cause possible fungus resistance.
X-ray epilation by an expert is the only ac- ceptable and reliable cure for M. audouini in- fections.
Until another “miracle drug” is discovered which will cure every case of M. audouini infec- tion within a reasonable length of time, x-ray epilation remains the only satisfactory method of curing this nuisance, tinea capitis.6
634 N. Grand Blvd.
BIBLIOGRAPHY
1. Pipkin, J. L.: Tinea Capitis in Adults and Adolescents, Arch. Dermat. 66:9 (July) 1952.
2. Klingman, A. M. : The Pathogenesis of Tinea Capitis Due to M. Audouini and M. Canis, J. Invest. Dermat. 18:231-246, 1952.
3. Livingood, C. S., and Pillsbury, D. M.: Ringworm of
the Scalp: Prolonged Observation, Family Investigation,
Cultural and Immunologic Studies in 125 Cases, J. Invest. Dermat. 4:43 (February) 1941.
4. Sullivan, M., and Bereston, E. D.: A Study of Topical Therapy in Tinea Capitis, J. Invest. Dermat. 19:175, 1952.
5. Storkan, M. A.: Psychological Factors in the Manage- ment of Tinea Capitis, J.A.M. Worn. A. 9:356, 1954.
6. Lewis, G. M.; Cawthon, K. S., and Hopper, M. D.: Tinea Capitis (Microsporon audouini) : Has There Been Re- cent Progress in Therapy?, N. Y. J. Med. 52:2105-2109, 1952.
Postgraduate Review
Colonic Diverticulosis
Management of Complications
CHARLES P. McGINTY, M.D., Cape Girardeau, and CARL E. LISCHER, M.D., St. Louis
Colonic diverticulosis is a condition which occurs commonly in people past middle age. The etiology is unknown.
While diverticulosis and simple diverticulitis are usually amenable to conservative measures, the complications of diverticulitis are quite serious and require surgical management in most instances. The subject of recurrent mild diverticulitis com- monly seen in office practice is well covered by Horner.8 The details of medical management are adequately outlined in “Current Therapy for 1955. ”4
It is not the purpose of this paper to discuss theories of etiology, incidence of the condition or give historical information and descriptions of pathology. These subjects are thoroughly covered in several excellent publications (Boyd,2 Maingot,13 and Johnson10) .
In recent years, definitive bowel resection and anastomosis, once reserved for the management of neoplasms, has been used with excellent results in the treatment of complicated diverticulitis. Tes- timony of this is given in many surgical papers (McMillan and Janieson,16 Ransom,21 and Welch25).
The common complications of diverticulitis are intestinal obstruction, localized or generalized peri- tonitis due to perforation, fistula formation, hemor- rhage and recurrent, disabling bouts of diverticuli- tis with scarred, strictured sigmoid colon. This dis- ease simulates many others. It may present clini- cally as an abdominal mass, gastrointestinal hem- orrhage, internal or external fistulae, perforated appendix, cholecystitis, urinary infection or car- cinomatosis.
The following cases illustrate many facets of this disease.
REPORT OF CASES
Case 1. A. S. A white male, aged 66 years, was ad- mitted to St. Luke’s Hospital on July 27, 1954. He had noted the onset of pain in the lower abdomen about three days before admission and this had persisted. He had had no bowel movement during that period. On admission, his abdomen was distended markedly and was tender generally. The white blood count was 11,000, the hemoglobin 16 grams and the temperature was 37.4 C. An x-ray examination of the abdomen showed marked distention of the large intestine from the cecum to the sigmoid. No mass was palpable. He previously had been admitted on May 19, 1948, because of pain in the lower abdomen and rectum. At that time a mass could be palpated above the prostate on rectal
From the Surgical Service of St. Luke’s Hospital, St. Louis.
examination. Barium enema revealed diverticula in- volving the descending and sigmoid colon, with marked narrowing of the mid-sigmoid. The patient was treated with sulfasuxidine and a bland diet. He improved on this conservative regimen and had little trouble until readmitted in July 1954. After the patient was ade- quately hydrated, a transverse colostomy was done. At exploration, a smooth, firm mass was palpated in the sigmoid colon. The colostomy functioned well and the patient was relieved of symptoms. A barium enema on August 5 revealed diverticulosis of the left colon with a persistent area of constriction in the mid-sigmoid. This was thought to be more suggestive of diverticulitis than of carcinoma. The patient was reexplored on Aug- ust 12, 1954, with resection in mind. On opening the abdomen, the entire left colon was found to be thick- ened, edematous and adherent to surrounding struc- tures, making resection impossible. The abdomen was closed. The patient was sent home with the colostomy functioning and did well. He was readmitted on October 28, 1954, and the sigmoid area containing the inflam- matory mass and stricture was resected. An end-to-end anastomosis was accomplished with little difficulty. On January 17, 1955, the transverse colostomy was closed by an end-to-end anastomosis. The patient has done well to the present date.
This is a not infrequent case of an inflammatory mass in the sigmoid causing intestinal obstruction, and points out several things. One is the con- fusion with carcinoma and the help that the radiologist may be able to give in differentiating betwen the two conditions (Rowe and Kollmar22). The second point is that the time element be- tween the colostomy and resection of the involved area is important. Adequate time must be allowed for all acute inflammatory reaction to subside so that the resection might be easily accomplished. The third point is that this represents a case of recurrent inflammatory reaction in the left lower quadrant, which over a period of years made sur- gery mandatory. In some of these cases, an elec- tive one stage resection might be indicated to forestall such a serious complication as this man suffered. Many surgeons are urging a more ag- gressive attack on recurrent diverticulitis before serious complications arise (Moore and Kirksay1 ' ). The mortality from the complications of diver- ticulitis is stressed by Lewis.11
Case 2. H. G. A white male, aged 70 years, was ad- mitted to St. Luke’s Hospital on February 1, 1955, with a picture of intestinal obstruction due to a palpable tumor mass in the left iliac fossa. The symptoms began one week previously with an upper respiratory infec- tion, followed shortly by abdominal pain and vomiting. He became obstipated and his abdomen began to swell.
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On admission, his temperature was 37.5 C., pulse 80, blood pressure 115/65 and a relatively normal blood picture. The abdomen was distended and there was a mass palpable in the left iliac fossa. X-ray examina- tion of the abdomen showed marked distention of the small and large intestine to the descending colon (fig. 1). A Cantor tube was introduced because bowel
Fig. 1. Flat plate of abdomen which might be interpreted as large bowel obstruction or adynamic ileus.
sounds were still present. The tube functioned well and by the next day the abdomen was much less dis- tended. In the morning he passed flatus and in the afternoon he had two stools. Proctoscopy was carried out to 25 cm. and no lesion could be seen. On February 4 a barium enema was done, which showed diverticu- losis and a narrowed segment of sigmoid with intact mucosal pattern (fig. 2). The radiologic impression was that this mass and stricture were inflammatory, secondary to diverticulitis and that there was no evi- dence to suggest carcinoma.
The patient had begun to run a high fever and showed a badly disturbed electrolyte picture at this time, because of a persistent marked diarrhea. The stools became positive for blood and the peri-anal region became badly excoriated. By February 10, 1955, the diarrhea had been controlled but the potassium had dropped to 2.1 in spite of oral and intravenous administration of potassium chloride. The diarrhea subsided and the patient gradually improved during the next two days; but on February 4, 1955, the diar- rhea started again and fever recurred. The stools had been carefully analyzed for evidence of amobae or other parasites. Cultures had shown a good growth of E. coli and other gram negative bacilli, with only a
Fig. 2. Barium enema done three days later, showing marked improvement in the intestinal obstruction. Diverticu- losis is demonstrated with narrowing of a portion of sigmoid. The mucosal pattern is intact.
few staphylococci. The patient had been on Penicillin and Streptomycin and later intramuscular Achromycin. An upper gastrointestinal series and cholecystogram on February 16 showed a large hiatus hernia, duodenal diverticulum, gallstones, urinary bladder stones and some pylorospasm. Overnight, on February 17, 1955, the patient became obstructed completely. On the morning of February 18 he was in critical condition with marked distention and vomiting. In the operating room an endotracheal tube was inserted under topical an- esthesia and large amounts of greenish vomitus were aspirated from the tracheobronchial tree. The patient was then given pentothal-cyclopropane while a trans- verse colostomy was quickly performed. Generalized peritonitis was not present, but a smooth non-fluctuant mass was palpable in the low sigmoid region. The pa- tient recovered from severe aspiration pneumonia and was released from the hospital on March 19, 1955, in good condition. The involved sigmoid area was re- sected eight weeks later, and an end-to-end two layer silk anastomosis was done. Three weeks following that, he was readmitted and the transverse colostomy was closed. The patient is now doing well.
This represents severe intestinal obstruction due to an inflammatory mass and also a problem in differential diagnosis which easily could be con- fused with carcinoma. In retrospect, it is seen that mistakes were made in his management. Since he responded so well to intestinal decompression by intubation, a one stage resection was being planned. Meanwhile, the patient got worse and
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almost died. It would probably have been much better to have done a transverse colostomy early in his course and thus have prevented the almost fatal persistent diarrhea, electrolyte disturbance and recurrence of complete obstruction.
Case 3. M. B. A white female, aged 63 years was ad- mitted to St. Luke’s Hospital on July 25, 1954, complain- ing of aching pain and tenderness in the left lower quadrant, pain in the low back and legs, anorexia and weight loss of 25 pounds during the preceding six weeks. She appeared well, except for marked tender- ness in the left lower quadrant and the presence of a cul-de-sac mass palpable through the rectum. Procto- scopic examination revealed the lumen to be closed at the 10 cm. level by edematous, red mucosa. No evi- dence of tumor was seen. On barium enema, the entire colon could be canalized, but there was some delay in canalization of the retrosigmoid area, the same general area where the mass could be palpated (fig. 3) . Numer- ous diverticula were seen throughout the colon and were most numerous in the sigmoid region just proxi- mal to the strictured area, which measured about 18
Fig. 3. Repeat barium enema demonstrates diverticula which makes this condition more likely benign.
cm. in length. After the colon had been prepared on sulfathallidine and enemas, on August 3, 1954, an ex- ploratory laparotomy was done, with the diagnosis of either carcinoma or diverticulitis being considered. At operation, a mass was found in the region of the lower sigmoid and attached to the pelvic wall, uterus and small intestine. The tissues were edematous and friable, making dissection very difficult, so that this was aban- doned. A transverse colostomy was done through the
upper portion of the incision. Because of a low grade septic temperature and the persistence of a globular mass, which was possibly fluctuant, in the cul-de-sac, a posterior colpotomy was done on August 16, 1954. No pus was obtained and little drainage ensued. However, the patient became afebrile and continued to do well. Because carcinoma had not been definitely ruled out, exploratory operation was done on August 24, 1954. This was three weeks after colostomy. Marked inflam- matory reaction was still present in the pelvis around the lower sigmoid. A colotomy was done and a sterile sigmoidoscope was introduced. The involved area of sigmoid was red and edematous so that the lumen was almost completely occluded. It was felt that this mass was inflammatory and that carcinoma could be ruled out. The colon was closed with no further exploration done. The patient has continued to do well and a resection of the sigmoid area is being considered for the near future.
This is a case of recurrent diverticulitis in the left lower quadrant causing low grade intestinal obstruction and presenting a palpable mass. It once again demonstrates a difficulty in making a differential diagnosis between carcinoma of the sigmoid colon and diverticulitis. It also dem- onstrates the folly of even considering resection during the acute phase. The most important thing about this case is that it illustrates a valuable diagnostic step; that is, the use of the sterile sigmoidoscope through a colotomy to differentiate between an actual malignant growth and an in- flammatory condition. Care should be used so that malignant cells are not spilled. Many radical operations and even multiple organ resections have been done on cases of diverticulosis thought to be carcinoma with local invasion.
Case 4. C. F. A white male, aged 67 years, was ad- mitted to St. Luke’s Hospital on December 27, 1954, for excision of a vesico-colic fistula. This patient had been known to have diverticulosis of the sigmoid colon for two years. He had been noting suprapubic pain thirty minutes prior to and relieved by each bowel movement. He was hospitalized for five days at that time and im- proved on a conservative regimen. There was a past history of coronary thrombosis five years previously. Ten days after being discharged from the hospital, he developed a vesico-colic fistula, manifested by dysuria, suprapubic pain and the passage of gas and feces per urethra. Cystoscopy was performed and the vesical orifice of the fistula was cauterized. This was repeated numerous times on an out-patient basis during the ensuing months with considerable temporary relief. He was rehospitalized in March 1954 with another episode of acute sigmoid diverticulitis. This again improved on conservative management. He was readmitted in No- vember 1954 because of persistence of the vesico-colic fistula and recurrent left lower quadrant and supra- pubic pain. On this admission a transverse colostomy was done as a preliminary to resection of the sigmoid. On December 27, 1954, three weeks later, the patient was readmitted and the involved portion of the sigmoid, including the fistula, was resected. The bladder wall was involved by much scar tissue and the small open- ing in the bladder could not be closed. A retention catheter was placed in the bladder because of this. The upper sigmoid was anastomosed to the rectum with
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a single row of interrupted silk sutures, after the splenic flexure had been mobilized. This patient died from cardiac complications three days postoperatively and the autopsy revealed a large aneurysm of the left ventricle and marked coronary arteriosclerosis. The bowel anastomosis was intact and there was no peri- tonitis.
This is an example of one of the worst com- plications of diverticulitis, that of vesico-colic fis- tula. Colcock states that diverticulitis is the most common cause of vesico-colic fistula. This man underwent numerous cystoscopies and consider- able discomfort and inconvenience. It was because of this that an attempt was made to alleviate his disorder in spite of his precarious cardiac status. In the therapy of this condition there is a choice of a three stage or a one stage resection. In this case, preliminary colostomy was decided upon, with subsequent resection of the involved area and closure of the fistula with the colostomy to be closed at a later date. Many such cases are man- aged by a one stage resection, after adequate bowel preparation, if there is no element of ob- struction or active inflammation present at the time. The subject of vesico-colic fistula is thoroughly discussed in many articles (Mayo and Blunt,14 Morrisey,18 Colcock,3 Ormond20).
Case 5. O. L. A white male, aged 62 years, was ad- mitted to St. Luke’s Hospital on August 10, 1954, be- cause of benign prostatic hypertrophy which was treat- ed by transurethral resection. During his postoperative course, shortly before he was to be discharged, he sud- denly developed signs of peritonitis, including general- ized abdominal rigidity, tenderness and pneumoperi- toneum. The latter was confirmed by x-ray examination (fig. 4) . A diagnosis of perforated peptic ulcer was con-
Fig. 4. Erect film of abdomen, demonstrating marked pneu- moperitoneum from perforation of the cecum.
sidered. Laparotomy revealed a perforation of the cecum with generalized peritonitis. The colon was markedly distended and a mass was palpated in the sigmoid colon. A large rubber tube was inserted into the cecum through the perforated area and this was exteriorized as a cecostomy. Alter a rather stormy course the patient recovered. The cecostomy closed
after several weeks as the obstruction in the sigmoid region resolved with the subsidence of the inflamma- tory mass. Subsequent barium enemas revealed marked involvement of the sigmoid region by a diverticulosis. The patient is having bowel movements per rectum and is relatively asymptomatic at this time. He is be- ing considered for a one stage resection of the sigmoid.
This presents an unusual complication in that the cecum perforated. It is not unusual to have intestinal obstruction itself caused by diverticuli-
Fig. 5. This woman had marked diverticulosis with a coincidental carcinoma of the recto-sigmoid. It was not an annular constricting lesion, which might be suggested on x-ray, but rather a polypoid tumor.
tis, or to have a perforation of the cecum second- ary to intestinal obstruction by cancer of the dis- tal colon; but, in reading the literature, no other cases of perforation of the cecum secondary to diverticulitis were noted. Cecostomy is not usually recommended for decompression and by-passing of the fecal stream in sigmoidal diverticulitis, be- cause of its inadequacy in completely diverting the fecal stream. There is a great tendency for an acute diverticulitis to recur before other specific therapy can be instituted. In this case, in which the cecum was already perforated, there was little choice. This patient has been fortunate, in that no subsequent episodes of acute inflammation have occurred thus far.
Case 6. S. H. A white woman, aged 78 years, was first seen in St. Luke’s Clinic on February 7, 1955, be- cause of a brown, pigmented lesion on the right brow. During physical examination, a polypoid lesion was
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noted 10 to 12 cm. up in the rectum on the anterior wall. A biopsy was done and it was found to be adeno- carcinoma. Barium enema revealed marked diverticulo- sis of the sigmoid and descending colon with a con- stricted area in the sigmoid (fig. 5). At operation, on February 11, 1955, after adequate bowel preparation, a difficult resection of the rectosigmoid was done, which necessitated mobilization of the splenic flexure. Because of a rather precarious low anastomosis, a transverse colostomy was done to defunctionalize the remaining colon temporarily. Three weeks later, the colostomy was resected and closed by end-to-end anastomosis. This was quite difficult because of edematous omentum and mesentery of the transverse colon. The newly anastomosed colon functioned poorly for the first week, causing distention limited to the right colon. This eventually opened up well and the patient recovered without further difficulty. She was discharged on March 25, 1955.
This case illustrates the coexistence of a de- formity of the sigmoid colon caused by diverticuli- tis and carcinoma of the sigmoid colon. There has been much interest in this subject, but no evidence has been given thus far to show that carcinoma occurs more commonly or less commonly in as- sociation with diverticulitis (Shaiken24). As to the surgical management, this would have been a one stage resection, except that the anastomosis was so low in the pelvis that a transverse colostomy safety factor was thought necessary. The patient suffered considerable morbidity, however, from the closure of the colostomy only three weeks post-operatively in this case.
Case 7. T. M. A white male, aged 65 years, was ad- mitted to St. Luke’s Hospital on May 18, 1955, with a history of chronic constipation and small caliber stools for ten years. During the last year he had noted tenesmus and occasional bloody stools, associated with a 15 to 20 pound weight loss. He also complained of “arthritis” of the lumbar region and some pain in the lower extremities. Barium enema revealed a 3 cm. polyp in the sigmoid region with concurrent diverticu- losis of the sigmoid and ascending colon. Stools were positive for blood. The patient also had urinary symp- toms due to prostatic enlargement. Sigmoidoscopic ex- amination was normal. After adequate bowel prepara- tion with enemas, cathartics and neomycin, the sig- moid colon was resected and a two-layer silk end-to- end anastomosis was accomplished. The specimen con- tained a large, pedunculated, benign polyp, along with several diverticula. The patient made a rapid recovery, except for some urinary difficulty. He is to be read- mitted at a later date for prostatic surgery.
Quite a controversy has occurred as to whether diverticulosis can be a common cause of intestinal bleeding. In this instance, the bleeding was un- doubtedly coming from this large, benign polyp, even though there are a number of cases on record in which minimal to massive hemorrhages from diverticulosis have been reported. Noer19 re- views twenty-eight reported series for a total of 324 cases of bleeding out of 2,894 cases of divertic- ulitis for an average of 30 per cent.
Case 8. B. P. A white male, aged 36 years, was ad- mitted to St. Luke’s Hospital on September 29, 1954.
About two and a half years prior to admission, he had suffered an attack of left lower quadrant pain, asso- ciated with fever and constipation. He continued to have occasional short lived bouts of left lower quad- rant pain and constipation. On several occasions he thought he could feel a “lump” in the left lower quad- rant. His symptoms were usually brought on by in- gestion of “rough” foods such as popcorn. Four days before this admission, he ate some popcorn. The next day he awoke with left lower quadrant pain and fever. He was hospitalized elsewhere the next day and given Penicillin. On the day of admission to St. Luke’s, he had suddenly become much worse. He had an episode of sudden pain in the left lower quadrant and fainted. After that, his abdomen became distended and he be- gan to vomit. The abdominal pain became generalized.
On admission to St. Luke’s Hospital, his temperature was 40.3 C., the white blood count was 14,800 and the hemoglobin was 16. The abdomen was generally tender and quite distended. There was marked muscle guard, especially over both lower quadrants. The patient was given intravenous fluids, started on antibiotics and within two hours had an emergency laparotomy which revealed generalized peritonitis with feces floating free in the lower abdomen. A perforation in a diverticulum of the sigmoid was found. This area was edematous, friable and quite vascular. Large Penrose drains were inserted and a transverse colostomy was done. The pa- tient recovered nicely and was sent home with the transverse colostomy functioning and still some dis- charge from the drainage site in the left lower quad- rant. He was seen again on November 23, 1954, and was doing well, except for slight drainage in the left lower quadrant. A barium enema at that time re- vealed diverticulosis of the sigmoid with no evidence of tumor. The patient was sent home and went back to work for several weeks. On March 29, 1955, the in- volved area of sigmoid was easily resected and an end- to-end anastomosis with two layers of silk was accom- plished. On April 8, 1955, the transverse colostomy was closed. The patient did well and has had no further difficulty to date.
This case represents a generalized peritonitis secondary to perforation of a diverticulum. The patient had, undoubtedly, had recurrent divertic- ulitis for several years. The fact that he was 36 years old makes this an unusual case because it is generally a condition of people over 50. It was managed by a three-stage resection with good re- sults. Note that the time lapse between the initial episode and resection was six months.
Recently two cases of perforation of non-in- flamed sigmoidal diverticula have been reported by Fitts and Anderson.5
Case 9. B. K. A 75 year old woman was seen in St. Luke’s Clinic on December 23, 1954, complaining of abdominal pain and black diarrhea of five days' dura- tion. The pain was localized to the right lower quad- rant where an orange sized mass was palpated. The diarrhea had ceased twenty-four hours previously. She was hospitalized with the impression of appendiceal abscess or carcinoma of the cecum. The admission laboratory studies showed the white blood count to be 6,400, with a normal differential; hemoglobin 15 grams and the stool was negative for blood. The tem- perature was 36.8 C. A barium enema done as an emergency measure showed colonic diverticulosis, in-
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eluding the ascending colon. No diverticulum could be filled in the exact area of the palpable mass. There was no x-ray evidence of an intrinsic cecal mass. Gallblad- der function was normal. It was agreed that an inflam- matory mass, probably secondary to diverticulitis, was being dealt with, so the patient was placed on a bland diet, sulfasuxidine by mouth and bed rest. During the ensuing three days, the patient became much more comfortable and the right lower quadrant mass disap- peared. She was discharged on January 6, 1955, feel- ing quite well. She has been temporarily lost to follow- up.
The black diarrhea this woman described may have been due to bleeding, but this could not be proven. Diverticula of the cecum are much more rare than in any other portion of the colon, but there are several cases reported. When they do occur, they are frequently solitary. Jonas9 in 1940 reported fifteen cases of solitary cecal diverticula that he found in the literature, plus an additional five cases treated at Johns Hopkins Hospital. He did not include cecal diverticula occurring as a part of generalized colonic diverticulosis. These solitary diverticula seemed to occur in a somewhat younger age group. They were most frequently confused with acute appendicitis and carcinoma of the cecum. Some were treated by exclusion of the diverticulum and other cases required right colectomy.
Sanderson and Madigan23 recently reported two cases of solitary diverticulitis. The first was a case of diverticulitis of the cecum simulating an appendiceal abscess in a 42 year old woman. This was treated by right colectomy. The second oc- curred in a 34 year old white woman as a di- verticulum of the right part of the transverse colon requiring segmental bowel resection.
Case 10. E. R. This 78 year old white woman had suffered from chronic constipation associated with oc- casional abdominal cramps for many years. She was first seen at St. Luke’s Hospital in October 1949 for repair of a right inguinal hernia. Because of her gas- trointestinal complaints, a barium enema was done at that time which showed many diverticula in the de- scending colon and sigmoid. This patient was read- mitted on March 13, 1951, because of prolapsed hemor- rhoids. She had continued to complain of cramping lower abdominal pain and difficulty in bowel move- ment. A proctoscope could be passed only 8 cm. Hemor- rhoidectomy was delayed for another barium enema which again showed a picture similar to that men- tioned before. In August 1951 a hemorrhoidectomy was done. The patient had passed bright, red blood per stool during the last few weeks and this was assumed to be from hemorrhoids. On August 9, 1954, the pa- tient was once again brought back into the hospital because of 30 pound weight loss, abdominal pain as before and eight to ten loose, black stools per day, whereas she had previously had chronic constipation. Even though her stools were loose, they were associ- ated with marked tenesmus. The anal sphincter was quite tight and the bowel was impacted. She was given enemas and the diarrhea soon subsided. A barium enema revealed uiverticula as before. The patient was put on Metamucil and a bland diet. Her anal stricture was repaired on August 20, 1954. She improved follow-
ing this but was readmitted on January 18, 1955, be- cause on follow-up examination in the clinic, a definite mass could be palpated high and anteriorly in the rectum, above the uterus. On January 24, 1955, she was given a general anesthetic and a careful pelvic and rectal examination was done. A tubular, indurated mass could be outlined above the rectal ampulla, which was felt by all who examined her to be thick- ened, fibrosed sigmoid colon. The sigmoidoscope could be passed 15 cm. and then the lumen became small and the bowel gave a sensation of rigidity from that point upward. The mucosa was intact. Because of the patient’s age and general poor condition, operation was not done and she was discharged again on sympto- matic therapy for diverculitis. She has continued along the same course as before, with slight improvement.
Were this woman younger and in better physical condition, she would undoubtedly benefit greatly from a one stage resection of the sigmoid colon and she may yet come to this. She could probably be saved considerable morbidity, provided she could withstand the surgery.
Case 11. A. B. This 62 year old white woman was first admitted to St. Luke’s Hospital on February 4, 1952, complaining of cramping pain and tenderness in the left lower quadrant, of five days’ duration. There was marked tenderness and muscle guard, with some regional tenderness and a poorly defined mass in the left lower quadrant. The white blood count was 13,100 and a diagnosis of left lower quadrant abscess due to ruptured diverticulum was entertained. Exploratory operation was done the same day. At operation, a well walled off inflammatory mass around the sigmoid was encountered. This area was drained and the abdomen closed. The patient made a satisfactory recovery and only a slight amount of drainage occurred. This woman has been followed in the St. Luke’s Clinic and has since required a hemorrhoidectomy and repair of a rectocele. She still complains of constipation, tenesmus and severe pruritus ani, associated with kraurosis vulvae, but has had no more attacks of left lower quadrant pain.
In retrospect, exploration was not necessary on this patient, but it is difficult to decide, many times, when simple diverticulitis has progressed into the stage of peridiverticulitis or localized ab- scess. Most writers feel that these cases should be treated with antibiotics, bed rest and observa- tion and that most of them will subside on this regimen (Horner8). A one stage resection of this area was contraindicated because of the acute in- flammation present.
Case 12. A. K. This patient had been hospitalized elsewhere from March 1 to March 22 because of con- gestive cardiac failure. Hhe was 72 years old. The his- tory at that time, other than that associated with car- diovascular status, was that he had suffered with in- termittent constipation for several years.
Physical examination, other than the cardiac find- ings, showed that the liver was palpable three finger breadths below the costal margin and seemed to have a sharp, tender edge. It was thought that the right kidney was “palpable, floating and horizontal.” During that admission, several stools had been reported posi- tive for occult blood.
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He was admitted to St. Luke’s Hospital on May 19, 1952, because shortly after his previous release from the hospital, a mass had been noted in the right lower quadrant. This mass was painless and movable.
A barium enema had shown what was interpreted to be a mass impinging on the cecum. The barium enema also showed multiple colonic diverticula involv- ing the ascending colon, transverse and descending colon. It was felt that this mass might be a carcinoid tumor or a carcinoma of the cecum. Sigmoidoscopic examination was normal.
On May 21, a laparotomy was done through a right rectus incision and a large tumor mass was found in- volving the lateral wall of the cecum. A number of diverticula were found throughout the colon. There was one large, inflamed diverticulum in the ascending colon, about three inches from the cecum. The cecum and ascending colon were resected to just beyond the hepatic flexure and an ileocolostomy was formed. The patient’s postoperative course was relatively uncom- plicated.
The specimen consisted of a 6 cm. length of ileum, ileocecal valve and cecum, with about 10 cm. of ascend- ing colon. The entire serosa was reddened and shaggy and several fluid filled diverticula were noted. There was an adherent, cystic mass about 8 by 5 cm. in size, with a thin, pale wall, filled with yellow mucoid ma- terial, coming off the cecum. This mucocele directly communicated with a large diverticulum in the wall of the cecum (fig. 6). Microscopic section showed that the lining of the mucocele sac consisted of atrophic mucosa made up of a single row of large goblet cells. There were no glands, stroma or mucosal lymphoid tissue. At some levels, the epithelium was perfectly flat. The pathological diagnosis was mucocele of a cecal diverticulum.
This is an unusual case. No reported cases of mucocele arising in a diverticulum of the colon were found in the literature. It is easy to see how this lesion might be confused with carcinoma of the colon. Right colon resection was the indicated treatment.
TYPES OF OPERATIONS
I. Cecostomy.
This is to be condemned except for unusual cases because the fecal stream is incompletely diverted and the inflammatory process may not subside.
II. Colostomy.
A. Sigmoid: Later resection of involved bowel is made difficult by this procedure. It was former- ly used as permanent colostomy when no further attempt was to be made toward resection.
B. Transverse: Transverse colostomy will com- pletely divert the fecal stream if care is taken to separate the two loops adequately. Otherwise, stool may spill over into the distal loop. The right half of the transverse colon should be used so that later mobilization of the splenic flexure will not be inter- fered with. It is suggested that the colostomy should not be closed until after the involved portion of bowel has been resected and the anastomosis is healed. Recurrent difficulty usually results unless this rule is followed (Wilson26). In patients who are treated by colostomy alone, i.e., poor risks, oc- casionally recurrence of the active process has hap-
Fig. 6. Photograph of gross specimen showing a large mucocele of a diverticulum.
pened. Loyd-Davis12 reports a current pelvic ab- scess in one instance and another patient that de- veloped a vesico-colic fistula under such circum- stances. When the colostomy is closed as the last operation in a three stage procedure, we feel that it should be resected and an end-to-end anastomo- sis of the transverse colon done.
C. Incision and drainage of abscess: This is usu- ally unnecessary if a diverting colostomy is done and frequently leads to a fecal fistula causing de- lay in resection.
D. One stage resection of involved portion of bowel: This is preferable to three stage or two stage method, providing certain criteria can be met: (1) If peritonitis is present, obviously a one- stage procedure is out of the question. (2) Marked local inflammatory reaction causing adhesions to surrounding structures would make resection quite difficult and cause considerable morbidity. (3) In- testinal obstruction of more than a slight degree is a definite contraindication to resection and pri- mary anastomosis. (4) Bowel must be adequately prepared.
The two main reasons for attempting to do pri- mary resection are: (1) Cancer is difficult to rule out in many instances. A three stage procedure over six to twelve months, as some have recom- mended in the past, might be a fatal delay. (2) In
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COLONIC D1VERTICULOSIS — McGINTY AND LISCHER
Missouri Medicine January, 1956
general, one operation is easier on the patient than three.
E. Two stage resection: This usually means pri- mary resection with a concomitant transverse colos- tomy. This is used mainly when the surgeon feels that his anastomosis is insecure and prefers to let it heal while the stool is diverted. The colostomy can usually be closed in two to three weeks.
F. Three stage resection: This must be used in cases of generalized peritonitis, marked local in- flammation or intestinal obstruction. In general, it has been quite safe even though three anesthetics and three operations are involved. The main dis- advantage is that resection of a concurrent carci- noma might be delayed.
G. Exteriorization or obstructive resection: In general, this method of handling the situation is not necessary and is frowned upon. Rare instances might occur in which this would be indicated. Gil- christ6 recommends this procedure in certain cases of perforation of a diverticulum.
A summary of indications for operation might then be listed as follows: Three stage: (1) Gen- eralized peritonitis due to perforation of a diver- ticulum, (2) localized abscess not responding to conservative treatment, (3) intestinal obstruction.
One stage: (1) fistula (may require three stages in some instances), (2) in presence of carcinoma, or when carcinoma cannot be ruled out, (3) bleed- ing, (4) chronic stenosing diverticulitis forming a narrow, stiff, chronically inflamed sigmoid, (5) re- current diverticulitis incapacitating patient.
DIAGNOSTIC STEPS TO RULE OUT CARCINOMA
1. Barium enema is by far the most important. In most instances, strictures caused by diverticuli- tis are longer and have intact mucosal pattern, while carcinoma leaves a shorter defect with in- terrupted mucosal pattern. These radiologic cri- teria are outlined by Rowe and Kollmar22 in an excellent review of diverticulitis complicated by carcinoma.
2. Sigmoidoscopy. It is unusual, actually, to see diverticula through the sigmoidoscope because they occur too high. This procedure may reveal a carcinoma of the rectosigmoid, however.
3. Colotomy and sterile endoscopy is suggested as an excellent method of ruling out carcinoma. Little has been written about using this procedure in attempting to differentiate between diverticulitis and carcinoma. It has been used for years as a method for locating polyps at the time of colotomy. The colon is opened longitudinally through a taenia coli after packs have been properly placed to pro- tect the other abdominal viscera. A purse string suture is placed and a sterile sigmoidoscope is in- serted through the colotomy. In diverticulitis the involved mucosa will appear reddened and edema- tous, usually causing a smooth narrowing of the bowel lumen that is characteristically different from carcinoma. Biopsy is not usually necessary, but may be taken if the surgeon so desires. Care
is taken to avoid spilling contents of the bowel, so that tumor will not be transplanted in cases of car- cinoma. Rubber shod clamps are placed on either side of the colotomy. By using this method, a dif- ficult one stage resection can be avoided and a transverse colostomy done in preparation for late resection after the acute inflammatory reaction has subsided.
SUMMARY
1. Twelve case histories are presented to illus- trate various complications of colonic diverticulosis and a discussion of their surgical management is given.
2. An unusual case, a mucocele of a diverticulum of the colon, is reported.
3. An evaluation of the various types of opera- tions for complicated diverticulitis is given.
4. Diagnostic steps to rule out carcinoma are listed with emphasis on colotomy with sterile sig- moidoscopy in questionable cases.
1912 Broadway
457 N. Kingshighway
BIBLIOGRAPHY
1. Bartlett, Marshall K., and McDermott, William V.: Sur- gical Treatment of Diverticulitis of the Colon, New England J. Med. 248:49, 1953.
2. Boyd, William: Surgical Pathology, Philadelphia, W. B. Sanders & Co. ed. 6, p. 273.
3. Colcock, Bentley D.: Colovesical Fistula, Surg. Clin. N. America 32 :909, 1952.
4. Conn, Howard F.: Current Therapy, Philadelphia, W. B. Saunders & Co., 1955. p. 208.
5. Fitts, William T., Jr., and Anderson, Lewis D.: Spon- taneous Perforation of Sigmoid Colon in Presence of Di- verticulosis, J.A.M.A. 52:1427, 1952.
6. Gilchrist, R. C., and Economou, Steven: Surgical Treat- ment of Diverticulitis, Arch. Surg. 70:276 (February) 1955.
7. Hickey, Robert C.: Massive Colonic Bleeding Secondary to Diverticulitis, Gastroenterol. 27:754 (May) 1954.
8. Horner, John L.: A Study of Diverticulitis of the Colon in Office Practice, Gastroenterol. 21:223 (June) 1952.
9. Jonas, August, Jr.: Solitary Cecal Diverticulitis, J.A.M.A. 115:194 (July) 1940.
10. Johnson, Thomas A.: Colonic Diverticula. In: Bockus, Henry L.: Gastroenterology, Philadelphia, W. B. Saunders & Co. vol. II, p. 674.
11. Lewis, James E., and Hurwitz, Alfred: Surgical Treat- ment of Sigmoid Diverticulitis, Surg. 33:481, 1953.
12. Lloyd-Davies, O. V. : Diverticulitis. Proc. Roy. Soc. Med. London 46:407, 1953.
13. Maingot, Rodney: Abdominal Operations, New York, Appleton Century Crofts, ed. 3, p. 1233.
14. Mayo, C. W., and Blunt, C. P.: Vesicosigmoidal Fistulas Complicating Diverticulitis, Surg., Gynec. & Obst. 91:612, 1950.
15. McGowan, Frank J., and Wolff, William I.: Diverticulitis of the Sigmoid Colon, Gastroenterol. 21:119, 1952.
16. McMillan, Foster L., and Jamieson, Robert W.: Trends in Surgical Treatment of Diverticulitis of the Colon, Surg. Clin. N. America 31:159.
17. Moore, Robert M., and Kirksey, O. T., Jr.: One-stage Resection in Selected Cases of Sigmoid Diverticulitis, Ann. Surg. 139:826, 1954.
18. Morrisey, John H.: Abstract of Discussion of “Intesti- novesical Fistulae” by Roger W. Barnes and Malcolm R. Hill. J.A.M.A. 133:458, 1947.
19. Noer, Rudolf J : Hemorrhage as a Complication of Diverticulitis, Ann. Surg. 141:674 (May) 1955.
20. Ormond, John K.; Best, John W., and Klinger, Milton E.: Vesicointestinal Fistulae, Surg., Gynec. & Obst. 89:411, 1949.
21. Ransom, Henry K.: Diverticulitis of the Colon, Gastro- enterol. 26:12 (January) 1954.
22. Rowe, Robert J., and Kollmar, George H.: Diverticulitis of the Colon, Complicated by Carcinoma, Surg., Gynec. & Obst. 94:1 (January) 1952.
23. Sanderson, Fred R., and Madigan, Howard S.: Solitary
Diverticulitis of the Colon, Current Med. Dig. 57: (January) 1955. „ ^
24. Shaiken, Joseph: Diverticulitis and Carcinoma of the Sigmoid Colon, Gastroenterol. 2 7:67 (July) 1954.
25. Welch, Claude E.; Allen, Arthur W., and Donaldson, Gordon A.: An Appraisal of Resection of the Colon for Di- verticulitis of Sigmoind, Ann. Surg. 138:332 (September) 1953.
26. Wilson, Edward: Colon Resection for Diverticulitis.
Austral. -N. Zealand J. Surg. 24:36, 1954.
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35
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Special Article
The Social Security Bill, H. R. 7225
Representative THOMAS B. CURTIS, St. Louis
I am glad to be here to discuss with you the pro- posals to further extend the Federal Social Secu- rity System now pending in this Congress.
As you may be aware, the House of Representa- tives passed a bill this last session (the first session of the 84th Congress) extending the Federal Social Security System in various ways, the most impor- tant of which was the provision to make payment
Rep. Thomas B. Curtis
to disabled persons beyond a certain age. It does not specify the age itself because, once the theory is adopted by the Congress, the lowering of the age to include all disabled persons is simply a mat- ter of time.
Before I go into the details of this new proposal to provide disability payments, I would like to pause briefly to pay some attention to the pro- cedures under which this new step in Social Se- curity was taken. Regrettably, the people of this country no longer seem to care about the proced- ures under which legislation is written. At least,
Representative (Rep.) Second Missouri District.
Presented before the American Medical Association, No- vember 28, 1955, at Boston, Massachusetts.
my colleagues in the Congress seem to think that the people no longer care about this fundamental phase of our government and, to date, regrettably, their thinking seems to be based upon reason.
Indeed, I wonder what the A.M.A. thinks about orderly and proper procedures? Or any of our many, many groups concerned with Federal legis- lation? The rotten (that is the adjective I used on the floor of the House) procedures followed by the House of Representatives in considering legis- lation that would add two billion dollars a year to our Federal expenditures, met with little or no comment around the Nation.
I want to read to you the speech I made on the floor of the House on this matter. It may seem to veer off the subject of Social Security occasionally, but I think you will agree, on analysis, that it re- mains on the point.
“Mr. Speaker, of course, it is impossible to dis- cuss the proposed liberalization of the social secu- rity program and the proposed financing of it in the time allotted under suspension of the rules. The Speaker knows this and upon his shoulders rests the responsibility of proceeding in such a fashion.
“Here I am opposed to this bill. I am opposed to these procedures, and I have been given three min- utes to try to explain to this House just how rot- ten— and I use that word advisedly — how rotten the procedures were that we have followed in con- sidering this piece of proposed legislation. I could not possibly explain it to this body in the time allotted — I trust the Members will give considera- tion to the procedures followed and determine for themselves whether they have the required sound- ness to produce good legislation.
“Hereafter follows the speech I wanted to make so that this body would have some idea of the un- soundness of the proposed legislation as well as the procedures followed. The speech would have taken ten minutes. As a matter of fact, less than ten minutes was available to the three Members of the committee opposing the suspension of the rules.
“The bill before us will cost around $2 billion a year for the next twenty years, after which it prob- ably will cost $2.5 billion, assuming our present estimates are anywhere near correct. This is a gross assumption, I might add, because the very person making these assumptions warned the Ways and Means Committee in executive session that there was little to go on in making estimates concerning disability costs.
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H. R. 7225— CURTIS
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“The matter before us today is just incidentally the subject of social security. The real matter be- fore us is the reputation of the Ways and Means Committee and the reputation of the House of Representatives. Judging from the experience I have just gone through as a member of the Ways and Means Committee, where all tried and true methods of procedure required for properly and adequately considering legislation were shoved aside by the power of the majority caucus, I have just a slight hope that the House will be any more concerned than it was about proper procedures.
“The issue facing the membership of this body is quite simple. Let me illustrate. A couple of days ago I was stopped outside the Chamber by two CIO leaders. One said: ‘Well, I see you voted against social security.’ I said, ‘No, I did not vote against social security and you know it.’ He said: ‘Well, you voted against passing the bill out of committee.’ I said: ‘I certainly did, and I will vote against the bill on the floor of the House. But I am not against social security.’ In fact, I believe I probably have done as much as any member of the committee to try to help the program and cer- tainly have done considerably more than those Members of the majority — which was a majority of them — wrho attended no executive sessions, other than cursorily, to try to work out the prob- lems as best we could under bad procedures.
“Certainly, anyone voting against the suspen- sion of the rules here today will be branded by a vicious group of politicians as being against social security. That is the whole plan of what has been going on. Everyone here in the House knows it. But the fact that will be done neither makes it the truth nor does it mean that the people of this coun- try or the people of any given congressional dis- trict will believe it, if the Congressman of that dis- trict will explain the true picture.
“Last year, my colleagues, certain members of the Democratic Party, including the Speaker, took the floor to object to certain remarks which they interpreted to mean that the Democratic Party had been called a party of treason or a party that coddled communism. I added my small voice to this discussion, by condemning the actions of any- one who so stated or so intimated, because I felt that patriotism was a feature of a man’s integrity and that there was no basis at all for attacking the integrity of the Democratic Party or any individ- ual in it by such generalities.
“I took that position feeling deeply that for years certain leaders of the Democratic Party had been guilty of a grevious sin, for which they still do not apologize or desist from pursuing, the sin of at- tacking the Republican Party and members of it by alleging a defect in integrity, which transcends even the virtue of patriotism. I refer to the virtue which is the essence of all Christian religion and of the Jewish faith — love of one’s fellow man.
“Now here today, if you please, supposedly I am
jockeyed into the position of either voting for this improperly conceived and studied bill in its en- tirety or of being branded as one not interested in the welfare of my fellow man. Now does any- one here deny that that is the essence of the pro- cedures followed by our leftwing political element who have so long and too long, in my judgment, dominated American political thinking. Either you agree with their brand of government or you are against the people, against the little man.
“Now briefly to the bill itself that comes before us without any committee hearings to guide us, without the committee itself having called either in executive session or public hearings experts and others familiar with the various facets of this complicated proposal.
“What are the dangers and inadequacies? You can read the minority views in the committee re- port and get a brief resume. I will only point up a few.
“First, reducing the age of women workers from 65 to 62 will create pressures to force women work- ers to retire earlier than at the present when the advancements of medicine have been such that our people can be gainfully employed longer, not shorter. And, in fact, for their very health they should be permitted the feeling of being economi- cally valuable to their society.
“Both parties have endorsed the proposed equal rights for women provision of the Constitution. I am probably one of the few members of this body who has refused to sign a resolution following out this endorsement, because I feel that men and women are different — not one superior over the other — just different and yet in the area of re- tirement from work I see no difference. We are doing the women a disfavor, not a favor in this provision. Mind you, I am not talking about widows or wives of retired workers — the problems are different, and in these fields there are differ- ences between men and women.
“Second, the proposed disability benefits have not been carefully considered. Our states and pri- vate enterprise, and, indeed, the Federal govern- ment, have made tremendous strides in the field of rehabilitation. Any disability program must be carefully geared into the rehabilitation programs or else the rehabilitation programs can be seri- ously damaged. No person in the rehabilitation field was even called before our committee to dis- cuss the matter. In fact, in our committee were lengthy academic discussions of what the term “totally disabled” meant. I suggested we call some people from the Labor Department and from the rehabilitation field to go over this matter with us. because the term “totally disabled" is a term we are today beginning to feel applies to very few people. But our committee procedures were to hear no one, record nothing, pass all previously decided in the know-nothing caucus of my Democrat friends of the committee.
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H. R. 7225— CURTIS
Missouri Medicine January, 1956
“Third. The proposal to make share-croppers self employed instead of employees as is now the law. How did that little gimmick slip into this liberaliza- tion bill? What discussion was had on it? What testimony? What is its effect? Well, I’ll tell you what its effect is — thousands of southern share- croppers will probably no longer be included in social security. The owner running the operation will be relieved of his 2V2 per cent tax. The share- cropper will be responsible for a 3% per cent tax. The owner will no longer be responsible for seeing that a return is made. The responsibility will rest on the share-cropper.
“Yes, indeed; it is important that this bill be brought out under a gag rule with no chance of amending. I wonder who in the CIO and A. F. of L. is responsible for this being in the bill or is this something that was needed to cement a deal?
“There are many good features in this bill. One of the best is the new fiscal responsibility. If we are going to increase benefits we must provide payment for the increase. But, as I said in debate last year on the extension of social security, do not let us kid the people about this program being either actuarially sound, fiscally responsible, or something that the people are paying for. The actuarial soundness, the fiscal responsibility, such as it is, is all based upon our children and our grandchildren — when we are the beneficiaries of the program — being willing to tax themselves 9 per cent of gross wages, 41/2 for employer and 41/2 for employee, 63/4 for the self employed, as we so considerately say they shall in our present legisla- tion.
“But they are the ones who pay the bill. Not the people of today. We pay in our $1 and get out $3, our children and their children make up the $2 difference; that is, if the Congresses they elect go along with this program. I wonder if the Con- gresses they elect will have the courage to let these tax increases come about? Certainly judging by the recent Congresses since social security has been in effect the answer is an emphatic ‘No.’ And yet these Congresses have been representing peo- ple who got $10 for every $1 put in and more.
“And, finally, and fortunately for the country in one sense, and tragic in another, what we do to- day will not become the law of the land. All we are engaged in today is making a mockery of the House of Representatives and confirming the mock- ery already made of itself by the Ways and Means Committee. The Senate leaders have already an- nounced that they intend to hold hearings on this bill. They have already stated that they are not going to abandon, just yet, at any rate, the time tested procedures that produce good legislation and protect against bad legislation.
“I am hopeful that there are in this body at least one third who feel the integrity of the House of Representatives and its committees is of suffi-
cient importance to a free society that they will lay aside partisanship, will take their courage in their hands and vote against this gag procedure, and then take up the burden, and it is a burden, of explaining to their people just what the issues were on the floor today.”
Now gentlemen, the Senate will take this Bill up next session beginning in January 1956, because there were not one third of the members of the House of Representatives who saw this issue as I did. I understand a real study will be made of the serious problems — aside from financing, that are involved in this seemingly simple matter of dis- ability payments.
May I give this great organization some advice which I think is sound and basic? As you approach this problem, be certain that you make it quite clear that you are interested in and desirous of solving the problems that confront our disabled people. Otherwise you will soon find yourselves pictured — as have other groups on other subjects — as a group uninterested in human and social welfare unless you adopt the detailed program which these artists are promoting. In these days I am so reminded of the basic plot in the play of King Lear — the Tragedy of King Lear as it is properly titled. It is a simple plot. An old man was getting ready to retire and settle his estate on his three daughters. Before doing so, he asked the three how much they loved him. The first two had eloquent tongues and little integrity and told the old man what he wished to hear. The third daugh- ter, perhaps a little disgusted with the outpourings of her sisters, was factual about her love and pointed out that she expected to get married some day and she would owe some of her love to her husband. We all know the sequel to this story, why it was a tragedy; the promises of the older two proved false and the disinherited third daugh- ter, due to her banishment, was unable to save her father.
I suggest that this plot is an allegory. It is easy to tell the people of this present and voting genera- tion how much we love them and all the things we will do for them. It is another thing to get up and say, but wait, we owe some love and allegiance to the coming inarticulate generation and we can- not pass all our love and consideration on to you. Will we, the American society, end up in tragedy because, like King Lear, we banish the thoughts and those who think and express them because we do not like to hear them? And banish them with a feeling of righteous indignation because we have not heard the words we wanted to hear of all en- compassing love for our own selfish generation? Banish them with a tinge of hatred in our souls because we choose to believe that those who ex- press them have no love for the people, the little man, the common man?
It is hard today to get a message out to the
Volume 53 Number 1
H. R. 7225— CURTIS
39
American people. That message must be carried above the din and the shouting of those who say they have all the answers; that these problems are not difficult to solve; that those who say there are difficulties in solving these problems are persons who are trying to thwart the will of the people and are setting up imaginary difficulties.
I could talk here today about the detailed prob- lems of the Social Security System and we could have a serious consideration of them and, through this exchange of ideas, we would arrive at some correct solutions. But any discussion here is of no avail if the people believe that the American Medi- cal Association is not interested in the welfare of the people — that the American Medical Associa- tion is not interested in solving the problems many of our people face in getting adequate health and hospital care — that the American Medical Associa- tion is not interested in moving on ahead to solve the still existing problems in the rehabilitation field and in the field of geriatrics, one of ever increas- ing significance.
Many Doctors say to me, “But surely you are wrong in thinking that the people of this country think the medical profession is uninterested in advancing the health and well-being of our people. Look at the advancements in medical care and treatment in this society of ours in the last dec- ades.” It is true that never in the history of the world has so much advancement been made in such a short space of time in the health and well- being of a people; it is certainly true that that ad- vancement came through the efforts of our great medical profession and the system of political eco- nomics that exists in our society. Yet the people are listening to this wooing voice of professed love which says it is not enough. Let’s get all the gold at once, let’s kill the goose; those who keep the goose and want to preserve its life are merely try- ing to keep you from getting the gold. They are your enemies.
Where, indeed, has this world-turned-upside-
down philosophy stemmed from? Where we find ourselves in an atmosphere where we cannot dis- cuss things as honest human beings differing from each other, because our integrity has been attacked and we are branded as dishonest men?
Gentlemen, I do not believe I am overstating the case. Because of the forces set loose in our society, it becomes very important that you and other groups whose integrity has been cleverly attacked and smeared get the message to the peo- ple as fast as you can, that you do indeed love them, not a hypocritical statement, but an honest one like Cordelia’s, but chasten yours by eliminat- ing any feeling of annoyance you may have with the statements of the demagogues which have put you in the position of having to defend yourselves.
Not only will Social Security snowball beyond our powers to halt its running away, but it can start an avalanche in the over-all powers of the Federal government which may overwhelm us.
This Nation conceived in liberty and dedicated to the proposition that all men are created equal is by no means endowed with immortality. Abra- ham Lincoln was fearful that any nation so con- ceived and so dedicated could long survive, know- ing full well that the cynical political philosophers had always maintained that such a nation given its own purse strings would spend itself to death. But in Lincoln’s day political leaders would make their own decisions on the basis of the facts and arguments surrounding a problem and then report to the people the reasons for their decisions. Today the top political leaders devote their energies, not to leadership, but to trying to figure out what the people are thinking today on the immediate to- morrow. I have great faith, however, that when the American people begin to understand, as I see signs they are beginning to understand, the im- portance of representatives, not delegates, being in the Halls of Congress, they will act accordingly. Then I, with Lincoln, will assert my faith that this Nation under God shall not perish from the earth.
Have you marked your calendar?
NINETY-EIGHTH ANNUAL SESSION MISSOURI STATE MEDICAL ASSOCIATION
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MISSOURI MEDICINE
President’s Page
A paper delivered at the annual meeting of the American Public Health Association, held in Kansas City in mid November, by Dr. Earl L. Koos, professor of sociology at Florida State University, presented some interest- ing thoughts regarding patient care. Dr. Koos found as a result of a survey
that only 19 per cent of persons interviewed believe that medical care costs too much; 81 per cent be- lieved that costs are not out of line with general costs of living.
Physicians were criticized by 51 per cent for unwillingness to make house calls and for keeping patients waiting far beyond appointment time in the office; 64 per cent of persons were critical of doctors and hospital care because they have become too impersonal and lack the human touch. One per- son among those interviewed stated: “I don’t say our hospitals don’t turn you out alive but they cer- tainly don’t do anything to help a person psychologically to get well. I think what I am trying to say is, nobody gave a darn about me as a person. I was just somebody filling a bed.”
“The responses generally indicated,” according to Dr. Koos, “that the patient feels he has been somewhat forgotten in the course of medical and hospital progress. The aura of impersonality said to prevade highly technical care is viewed adversely by patients. The technics of human relations seem- ingly should go with scientific technics.
“An old question in the world of doctoring is: How much should the people know about medicine? We need only look at any popular magazine to realize people are being offered information on medical developments, sometimes in an unduly optimistic fashion. It seems inconsistent for the medical world to withhold from the role of teaching the public.”
We have heard complaints like these quoted from many sources — failure to make house calls; making patients wait for hours in our offices even though they have definite appointments; lack of warmth in our handling of sick people; impersonal hospital handling.
Surely we can do something to correct our own habits in order to im- prove patient-physician relations.
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EDITORIALS
From Football to Medicine
No greater or more beloved coach ever coached a football team than Don Faurot, head football coach at the University of Missouri. Famous as the originator of the “Split T,” and author of “Foot- ball: Secrets of the ‘Split T’ Formation,” Don is probably as well known for his Missouri Plan in college athletic competition. Essentially this plan limits the recruiting of college athletes to within his own state. It has had its good years and its lean years. Everything that lives follows the same rule, and, to be sure, the Missouri Plan lives and breathes as you and I.
With the kind permission of Don Faurot, we should like to borrow his Missouri Plan for Mis- souri medicine.
The program of a four year Medical School at the University of Missouri did not materialize through a sudden spontaneous effort on the part of its sponsors. It required more than a quarter of a century of concentrated study and planning. It required an informative educational program for the people of our state to convince them of the value of such a school. It was finally achieved on a promise. Let us not forget this promise repeated- ly pledged to the people of Missouri. The promise was evidenced in the campaign slogan: “A State Medical School for Missouri Doctors — General Practitioners for the Whole State of Missouri.”
What differentiates a general practitioner from a specialist? His medical education is essentially the same up to the date of graduation from medi- cal school. The differentiation begins with his in- ternship. A good rotating internship makes for a good general practitioner, preferably in a non-Uni- versity connected hospital. It is a well-known fact that university controlled hospitals, even with ro- tating internships, tend to produce specialists.
Let us follow our plan with the same sincerity that Coach Don Faurot follows his.
Our boys must have rotating internships in good non-University controlled teaching hospitals with- in our own state to produce general practitioners for the whole State of Missouri.
Martyn Schattyn, M.D.
Ninety-Eighth Annual Session
The Ninety -Eighth Annual Session of the Mis- souri State Medical Association will be held at the Jefferson Hotel, St. Louis, April 8 to 11, 1956.
Plans and the program for the session are pro- gressing and indications are that it will be a well attended and valuable session. The session will open on Sunday, April 8, with a meeting of the House of Delegates at 1:30 p.m. Other sessions of the House will be held Monday afternoon, at 4:00 p.m., and the final session on Wednesday after- noon, at 1:30 p.m.
The scientific program will begin at 9:00 a.m. on Monday, April 9, and will include symposia, panels and round table luncheons as well as formal presentations. On Monday morning sym- posia on “Surgery” and on “Pediatrics” will be presented following individual speakers. On Tues- day morning, symposia on “Obstetrics” and on “Medicine” will be given. The afternoon session on Tuesday will close with a panel on “Acute Surgical Emergencies.” The Wednesday morning program will include a panel on “What’s New in Medicine” covering many phases of practice today. Round table luncheons will offer opportunity for questions and answers on Monday and Tuesday.
Speakers from out of the state who have accept- ed invitations to present papers in the general meetings include Tom D. Spies, M.D., Birming- ham, Alabama, who will speak on “Strengthening the Nutritional Processes During Aging”; Wil- liam D. Holden, M.D., Cleveland, on “Manage- ment of Severe Metabolic Deficits in the Surgical Patient”; Henry L. Barnett, M.D., New York, on “Kidney Disease in Children”; Claude Starr Wright, M.D., Augusta, Ga., on “Victories or Vic- tims: A Critique of Advances in Anemia”; Mel- vin A. Casberg, M.D., Solvang, Calif., on “The Adequacy of Medical Education”; Leonard H. Biskind, M.D., Cleveland, on “Functional Uterine Bleeding”; T. Leon Howard, M.D., Denver, on “Renal Vicissitudes”; Herbert C. Lee, M.D., Rich- mond, Va., on “Advances in Surgery of the Pan- creas.”
Members of the St. Louis Medical Society and the St. Louis County Medical Society will serve as hosts during the session.
Both technical exhibits and scientific exhibits will add to the value of the session. All will be located on the mezzanine floor and the Ivory Room of Hotel Jefferson and will be open Mon- day, Tuesday and until after the House convenes on Wednesday afternoon.
It is planned that the complete program will be published in the February issue of Missouri Medicine.
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“Meal Planning for the Sick and Convalescent"’ has been designed to relieve you of the need for repeating over and over again essential dietary facts. This new Knox booklet presents in layman’s language the latest nutritional applications of proteins, vitamins and min- erals, gives practical hints on serving food to adults and children, suggests ways to stimulate appetite and describes diets from clear liquid to full convalescent. Best of all it offers the homemaker for the first time detailed daily suggested menus for each type of diet,
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Missouri Medical Meetings
American Academy of Allergy, Chase Hotel, St. Louis; post- graduate review, Feb. 4-5; scientific session, Feb. 6-7-8, 1956.
Missouri State Medical Association, St. Louis, April 8-11, 1956.
St. Louis Pediatric Society — second Thursday of each month, September through May at Medart’s Restaurant, 8:00 p.m.
Component Society Meeting Dates
Audrain County Medical Society — third Monday of each month.
Barton-Dade County Medical Society — third Wednesday of each month.
Benton County Medical Society — meets only on call.
Boone County Medical Society — first Tuesday of each month.
Buchanan County Medical Socitey — first Wednesday of each month.
Butler-Ripley- Wayne County Medical Society — first Wednes- day of each month.
Callaway County Medical Society — third Thursday of each month.
Cape Girardeau County Medical Society — first Monday of each month.
Chariton-Macon-Monroe-Randolph County Medical Society — second Thursday of each month September through May.
Clay County Medical Society — last Tuesday of each month.
Clinton County Medical Society — meets only on call.
Cole County Medical Society — first Monday of each month.
Cooper County Medical Society — first Monday after the 15th of each month.
Dallas-Hickory-Polk County Medical Society— first Wednes- day of each month.
Dunklin County Medical Society — third Tuesday of each month.
Franklin-Gasconade-Warren County Medical Society — last Tuesday of each month at the St. Francis Hospital, Wash- ington, at 12:30 p.m.
Grand River Medical Society (Caldwell-Carroll-Livingston, Grundy-Daviess, Harrison, Linn, Mercer, DeKalb) — second Thursday of each month.
Greene County Medical Society — fourth Friday of each month.
Henry County Medical Society — meets only on call.
Holt County Medical Society — meets only on call.
Howard County Medical Society — meets only on call.
Jackson County Medical Society — fourth Tuesday of each month execpt June, July and August, at auditorium of General Hospital No. 1.
Jasper County Medical Society — second Tuesday of each month, September through May.
Jefferson County Medical Society — meets only on call.
Johnson County Medical Society — meets only on call.
Laclede County Medical Society — second Monday of each month at 6:00 p.m., at the Louise Wallace Hospital, Lebanon.
Lafayette-Ray County Medical Society — second Tuesday of each month at 7:30 p.m., at the Victory Cafe, Lexington.
Lewis-Clark Scotland County Medical Society — meets only on call.
Lincoln-St. Charles County Medical Society — third Thurs- day of each month.
Marion-Ralls-Shelby County Medical Society — fourth Tues- day of each month. 7:30 p.m.
Miller County Medical Society — meets only on call.
Mineral Area County Medical Society (St. Francois-Iron- Madison-Washington-Reynolds-Ste. G e n e v i e v e) — f o u r th Thursday of each month.
Moniteau County Medical Society — second Thursday of each month.
Newton County Medical Society — meets only on call.
Nodaway-Atchison-Gentry-Worth County Medical Society — first Monday in February, April, October and December.
North Central Counties Medical Society ( Adair-Schuyler- Knox-Sullivan-Putnam) — meets only on call.
Ozarks Medical Society (Barry-Lawrence-Stone-Christian- Taney) — second Tuesday of each month September through June.
Pemiscot County Medical Society — third Thursday of each month.
Perry County Medical Society — second Thursday of each month.
Pettis County Medical Society — third Monday each month September through May.
Phelps-Crawford-Dent-Pulaski-Maries County Medical Soci- ety— fourth Thursday of each month.
Pike County Medical Society — third Tuesday of each month.
Platte County Medical Society — meets only on call.
St. Louis County Medical Society — second and fourth Wednesday of each month.
St. Louis Medical Society — first, third and fifth Tuesday of each month October through May.
Semo County Medical Society (Stoddard, New Madrid, Mis- sissippi, Scott) — third Wednesday of each month September through May.
South Central Counties Medical Society (Howell- Oregon- Texas-Wright-Douglas-Ozark) — fourth Wednesday of each month.
Vernon-Cedar County Medical Society — meets only on call.
Webster County Medical Society — meets only on call.
West Central Missouri Society — second Thursday of each month.
Musings of the Field Secretary
A number of physicians in greater St. Louis, these days, are taking one of their own prescriptions and, seemingly, enjoying the reaction. They are enthu- siastically engaging in a recreational activity, often advised for patients, as a restful and relaxing hobby. These doctors, with the aid of numbers of allied professions, are “blowing and fiddling,” at least some of their cares away, in the St. Louis Physicians’ Orchestra.
The orchestra was started in the fall of 1954, hav- ing its first rehearsal and meeting at the home of Walter J. Siebert, M.D., in September. The sparkplug and prime continuing motivator of the orchestra is a committee composed of Dr. Ben G. Mannis, chair- man, who plays first trumpet, Dr. Mary E. Morris, pianist and cellist, secretary-treasurer, Dr. Byron Mc- Ginnis, trumpet and Dr. Walter J. Siebert, violin. At present, there are thirty active members of the orchestra. This number includes fifteen physicians of
St. Louis Physicians’ Orchestra at a practice session on November 14.
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For Blue Cross and Blue Shield, 1956 is also a year ot new horizons. In this year, the particular type of health care prepayment these Plans pioneered enters its second quarter-century of service to the nation . . . protecting patients from worry, from anxiety, from financial insecurity in the face of medical bills . . . assuring the doctor and hospital of prompt and direct payment.
Just an idea twenty-five years ago, today Blue Cross protects nearly fifty million Americans . . . Blue Shield, over thirty-two million. Last year alone, the Plans paid doctors and hospitals over a billion dollars for care and treatment of these members.
Doctors' foresight and leadership helped achieve this record . . . will assure even greater accomplishments in the future.
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ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
whom ten are members of St. Louis Medical Society and five are members of St. Louis County Medical Society. The other fifteen members represent other professions with a doctor’s wife or two in the count. Practice sessions are held on Monday nights in the banquet hall of the St. Louis Medical Society Build- ing. The first public appearance was a concert, as part of a hobby show, December 16, 1954, at the St. Louis Medical Society; and they have been going strong ever since. During this last summer, a breather was taken with reorganization and rehearsals getting underway again in September.
The director and musicians work diligently.
The director, who so ably puts the orchestra through its paces, is Mr. Edward Ormond of the St. Louis Symphony. He plays regularly in the symphony but finds time on Monday nights to direct the musical interlude at St. Louis Medical Society. Usually, Mr. Ormond and members of the orchestra begin re- hearsals in the usual dress of the day but as the musical tempo and concentration increases, shirt sleeves and loosened collars appear spontaneously.
Much credit is due Mr. Ormond and the orchestra
Practice was for a concert given on December 5.
committee for their devoted efforts in making this St. Louis Physicians’ Orchestra click. The orchestra committee is a subcommittee of the Public Relations Committee of the St. Louis Medical Society and is fostering a project which has fine concrete, potential public relations value, in addition to individual partic- ipating enjoyment and benefit.
Oh doctor! Where is your fiddle or maybe it’s a horn?
Incidentally, another entertaining concert was pre- sented by the orchestra at the St. Louis Medical Building on Monday night, December 5.
AMERICAN ACADEMY OF ALLERGY TO MEET IN ST. LOUIS
The American Academy of Allergy will hold its 12th annual meeting February 4 to 8 at the Chase and Park Plaza hotels, St. Louis.
“Indications and Contraindications for Therapy in Bronchial Asthma” will be presented as a panel at 9:00 a.m., on February 4, with Leo H. Criep, M.D., Pittsburgh, as moderator, and panelists will be Harry
L. Alexander, M.D., St. Louis; Alvan L. Barach, M.D., New York; Samuel C. Bukantz, M.D., St. Louis; T. S. Danowski, M.D., Pittsburgh; John C. Krants, Jr., Ph.D., Baltimore, and Louis Weinstein, M.D., Boston.
At 2:00 p.m., a panel on “Immunological and Clin- ical Aspects of Antigen Therapy” will be presented with Oscar Swineford, M.D., Charlottesville, Va., as moderator, and J. Harvey Black, M.D., Dallas; Samuel
M. Feinberg, M.D., Chicago, and William B. Sherman, M.D., New York, as participants.
On Sunday morning, February 5, the Association of Allergists for Mycological Investigations, will present a program on research problems currently under study and phases of clinical mold allergy. In the afternoon, the Academy will present a panel discus- sion on “Pediatric Allergy” with Charles A. Janeway, M.D., Boston, as moderator, and participants will be Harry S. Bernton, M.D., Washington; Ralph Bowen, M.D., Houston; Vincent J. Derbes, M.D., New Orleans; Harry L. Mueller, M.D., Boston; James C. Overall, M.D., Nashville, and Donald L. Thurston, M.D., St. Louis.
The remainder of the session will include pres- entations by Charles A. Janeway, M.D., Boston, on “The Gamma Globulins”; Sidney Raffel, M.D., Stan- ford, Calif., on “Bacterial Hypersensitivity”; Carl V. Moore, M.D., St. Louis, on “Immunohematology”; Herman N. Eisen, M.D., St. Louis, on “Pathogenesis of Allergic Contact Dermatitis,” and Irvin Kerlan, M.D., Washington, on “Allergy and the Food and Drug Administration.”
Physicians are invited to attend the session and there is no registration fee.
DEATHS
Willis, John Buren, M.D., Mayview, a graduate of Barnes Medical College, 1897; honor member of the Lafayette-Ray County Medical Society; aged 81; died October 25.
Blair, Vilray P., M.D., Florissant, a graduate of Washington University School of Medicine, 1893; hon- or member of the St. Louis Medical Society; aged 84; died November 24.
NEW MEMBERS
Cook, Thomas B., M.D., 112V2 West Main, Richmond. Lafayette-Ray County.
Jones, Keith D., M.D., Warrensburg Medical Center, Warrensburg. Johnson County.
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News
The Cass County Democrat, on November 24, car- ried an article with pictures about J. S. Triplett, M.D., Harrisonville, announcing his ninetieth birthday on December 2, and telling the story of his life.
“Tuberculosis” was the topic of the Buchanan County Medical Society broadcast on December 4. Herbert C. Senne, M.D., was moderator, and partic- ipants were John R. Forgrave, M.D., Edsel S. Reed, M.D., Irwin I. Rosenthal, M.D., and Donald J. Stallard, M.D., all of St. Joseph.
The annual pilgrimage of the St. Louis Medical Society to the grave of Dr. William Beaumont was made on November 21. The address was presented
by Daniel L. Sexton, M.D., St. Louis, president of the Society.
Word has been received by H. G. Frame, M.D., Mountain Grove, of the death of Flagge Philip Wesley, M.D., Alexandria, Va., on November 6. Dr. Wesley was a graduate of Washington University School of Medicine in 1902 and was a roommate of Dr. Frame’s, who graduated that same year.
St. Mary’s Hospital in Jefferson City will honor the memory of Walter L. Leslie, M.D., by hanging his picture in the hospital.
At a county medical societies civil defense con-
TELEVISION AWARD MADE TO ST- LOUIS UNIVERSITY
Dr. Joseph C. Peden (right), delegate of the Missouri State Medical Association to the American Medical Association, presents a television award for the Saint Louis University School of Medicine to Dr. James W. Colbert, Jr. (center), Dean, in ceremonies held at the Chase Hotel October 31. On the left is Dr. William T. Strauss, Coordinator of Television for Ciba Pharmaceutical Products, Inc., Summit, New Jersey. The presentation followed a nationwide television show, “The Hot Box,” telecast direct from the School’s Physiology Department over thirty-nine TV stations. The program, the eighth in the “Medical Horizons” series was presented by the pharmaceutical firm in cooperation with the A.M.A. The award was for “an outstanding contribution to the public understanding of medicine.”
50
ADVERTISEMENTS
51
Pork in the Human Dietary
Pork may be looked upon as an im- portant factor in America’s general health and well-being. The average in- take of pork in America is about 46 pounds of lean pork and 20 pounds of bacon and salt pork per person each year.1 But America’s demand for pork goes further than taste appeal and deeper than mere statistics. Pork makes a valuable contribution to day-in-and- day-out nutrition.
Pork rates among the foremost sources of thiamine. As a source of all other B vitamins and many essential minerals, such as iron and phosphorus, pork meat is considered an important dietary con- stituent.
Lean pork is virtually completely di- gestible. Its protein serves to promote growth and aid in the maintenance of tissue cells. Like all high quality pro- tein, that of pork aids in the elaboration of protein hormones, enzymes, and anti- bodies.
Pork constitutes a valuable part of the daily diet (Table I), and also contrib- utes importantly to the nutrition of the pregnant woman (Table II).
Pork and pork products have won America’s favor by their unique com- bination of economy, palatability, and nutritional value.
1. Consumption of Food in the United States, 1909-1952, Washington, D.C., United States Department of Agri- culture, Bureau of Agricultural Economics, Agricultural Handbook No. 62, September, 1953.
2. Watt, B.K., and Merrill, A.L.: Composition of Foods — Raw, Processed, Prepared, Washington, D.C., United States Department of Agriculture, Agricultural Handbook No. 8, 1950.
3. Bowes, A. deP., and Church, C.F.: Food Values of Portions Commonly Used, ed. 7, Philadelphia, Anna dePlanter Bowes, 1951.
4. Uheldelin, V.H., and Williams, R.J.: Studies on the Vitamin Content of Tissues, II, Houston, Texas, Univer- sity of Texas Publication No. 4237, 1942.
5. Schweigert, "B.S.; Nielsen, E.; "Mclntire, J.N., and Elvehjem, C.A.: Biotin Content of Meat and Meat Prod- ucts, J. Nutrition 26:65 (July) 1943.
6. Scheid, H.E., and Schweigert, B.S.: The Vitamin Bu Content of Meat, Annual Report, An Outline of Research During the Fiscal Year 1953-54, Chicago, American Meat Institute Foundation, Bull. 22, 1955.
7. Estimated on basis of protein content of meats. Sherman, H.C.: Food Products, ed. 4, New York, The Macmillan Company, 1948 p. 155.
8. Recommended Dietary Allowances, Washington, D.C., National Academy of Sciences— National Research Coun- cil, "Publication 302, 1953.
Cooked Pork Chops, Ham, and Pork Sausage
|
Nutrients and Calories Provided by 3-Ounce Portions |
|||||||
|
TABLE 1 |
Protein Gm. |
Thiamine mg. |
Niacin mg. |
Riboflavin mg. |
Iron mg. |
Phosphorus mg. |
Calories |
|
Pork Chops, without bone, cooked, 3 oz.2 |
20 |
0.71 |
4.3 |
0.20 |
2.6 |
200 |
284 |
|
Ham, without bone, cooked, 3 oz.2 |
20 |
0.45 |
4.0 |
0.20 |
2.6 |
202 |
338 |
|
Pork Sausage, cooked, 3 oz.3 |
14 |
0.42 |
2.8 |
0.20 |
2.1 |
139 |
396 |
|
3.5 ounces of fresh pork loin, equivalent to approximately 3 ounces of cooked loin, contains 0.47 mg. pantothenic acid;4 0.10 mg. pyridoxine;4 0.005 mg. biotin;5 36 mg. inositol;4 0.08 mg. folic acid;4 0.0027 mg. vitamin B12;6 63 mg. chlorine;7 0.1 mg. copper;7 20 mg magnesium;7 280 mg. potas- sium;7 70 mg. sodium;7 and 0.01 mg. manganese.7 |
|||||||
|
Nutrients and Calories of Cooked Pork Chops (3 ounces) Expressed TABLE 1 1 as Percentages of Recommended Daily Dietary Allowances8 |
|||||||
|
Percentages of Allowances for: |
Protein Thiamine |
Niacin |
Riboflavin |
Iron |
Phosphorus |
Calories |
|
|
Girls, 13-15 years of age; weight, 108 lb.; height, 63 inches. |
25% |
LO LO |
33% |
10% |
17% |
15% |
11% |
|
Women, 25 years of age; weight, 121 lb.; height, 62 inches. |
31% |
59% |
36% |
14% |
22% |
17% |
12% |
|
Pregnant Women (3rd trimester) |
L O CNJ |
47% |
29% |
10% |
17% |
13% |
11% |
The nutritional statements made in this advertisement have been reviewed by the Council on Foods and Nutrition of the American Medical Associa- tion and found consistent with current authoritative medical opinion.
American Meat Institute
Main Office, Chicago... Members Throughout the United States
52
ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
ference held at the American Medical Association on November 12 and 13, Carroll P. Hungate, M.D., Kansas City, was one of the moderators.
Among speakers at a pharmacy seminar at the Uni- versity of Kansas City on November 10 was Jesse D. Rising, M.D., Kansas City.
For being the oldest graduate of the University of Missouri medical alumni present at Homecoming recently, A. J. Campbell, M.D., Sedalia, was presented a University of Missouri serving tray. Frank G. Mays, M.D., Washington, president of the Medical Alumni, made the presentation.
The November issue of the Missouri Alumnus carries a picture of Ralph R. Coffey, M.D., Kansas City, as a former president of the M Men. The picture was taken at a reunion luncheon of ex-athletes at Home- coming of the University.
Participating in dedication ceremonies of the Jack- son Clinic at Madison, Wis., on October 26, was Claude J. Hunt, M.D., Kansas City.
“Professional Aspects of Preparation for Marriage and Family Planning” was the subject of an in- stitute for graduate nurses at the University of Kan- sas Medical Center on November 17. Participating in the institute were Albert Preston, Jr., M.D., Drury M. Love, M.D., Robert F. Lamar, M.D., Andrew D. Mitchell, M.D., J. Milton Singleton, M.D., Louis H. Forman, M.D., Dan L. Berger, M.D., Sylvia Allen, M.D., W. J. Stelmach, M.D., Jacob Zellermayer, M.D., and Bela K. Kent, M.D., all of Kansas City.
“Medical Aspects of Disaster” was the subject pre- sented by Carroll P. Hungate, M.D., Kansas City, at a meeting sponsored by the Woman’s Auxiliary to the Buchanan County Medical Society on November 21.
Presentation of the William P. Howe award for promoting school health by the American School Health Association was made by Guy N. Magness, M.D., University City, to Dr. Cyrus H. Maxwell, Washington, D. C., at a recent meeting of the as- sociation in Kansas City.
The Buchanan County Mental Health Society re- cently elected H. Ewing Wachter, M.D., St. Joseph, as its president.
Appearing on the program of a postgraduate neu- rosurgery meeting of the University of Oklahoma School of Medicine at Oklahoma City on December 8, Leonard T. Furlow, M.D., St. Louis, discussed “Trigeminal Neuralgia.”
The Kansas City Area Hospital Association had named Miss Susan Jenkins as executive director.
Miss Jenkins has been with the Blue Cross-Blue Shield plans in Kansas City.
The American College of Surgeons has reelected William J. Stewart, M.D., Columbia, for a three year term as Missouri representative on its board of gov- ernors.
COURSE IN COMMON NEUROLOGICAL SYNDROMES
A course in the more common neurological prob- lems will be presented for general practitioners by the American Academy of Neurology in St. Louis, on April 25. This one day course has been authorized by and has the wholehearted support of the American Acad- emy of General Practice. It has been evaluated at six hours credit in Category II.
Diseases of the nervous system implicated a large segment of the population and there has been a tre- mendous accumulation of literature, most of it pub- lished only in neurological journals, covering some of the newer aspects of the diagnosis and treatment. “Common Neurological Syndromes” will cover most of the problems with which the general practitioner is confronted and emphasis will be on the clinical and therapeutic aspects. The formal lectures will cover such subjects as headaches, strokes, convulsive states, the Parkinsonian state, neurological emergencies, metastatic carcinoma to the central nervous system, common disorders of muscles, peripheral nerve lesions, weakness of the lower limbs, neurosyphilis in the post penicillin era, neurological manifestations of the blood dyscrasias, and treatment of infections of the central nervous system. Recognized authorities on these sub- jects will be selected, as lecturers, from the member- ship of the American Academy of Neurology. The evening will be reserved for two question periods, one devoted to the subjects presented during the day, and the other to any neurological subject.
The enrollment fee for Common Neurological Syn- dromes is $10.00 and application for membership should be directed to Mrs. J. C. McKinley, executive secre- tary, American Academy of Neurology, 3501 East 54th Street, Minneapolis 17, Minnesota. The fee should ac- company the application. Refund of fees, for those who later discover they cannot attend, is possible up to April 1. To provide adequate seating and acoustic fa- cilities, it is necessary for the committee on arrange- ments to have reasonably early knowledge of the num- ber that will attend. It is therefore important that those who intend to enroll do so as early as possible.
In addition to the course on Common Neurological Syndromes, which is oriented for the general practi- tioner, the American Academy of Neurology will pre- sent nine one day courses April 23 to 25 inclusive. These courses, neuropathology, neurochemistry, neuro- physiology, electrodiagnosis, neurological diseases of infancy and childhood, injuries to the central nervous system, extra-pyramidal disorders, infections of the nervous system and convulsive disorders, though still emphasizing clinical and therapeutic aspects, will go into greater detail and will be oriented for the neurol- ogist. Any general practitioner wishing to do so, may enroll for attendance in any one or more of these courses. For further information about these courses, write the executive secretary.
ADVERTISEMENTS
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Councilor District News
FIRST COUNCILOR DISTRICT
DONALD M. DOWELL, CHILLICOTHE, COUNCILOR
Grand River Medical Society
The Grand River Medical Society met November 10, at the Strand Hotel, Chillicothe. Twenty-nine mem- bers, twenty Auxiliary members and ten guests were present. About sixty enjoyed the fine dinner. After introduction of visitors and guests, among them Dr. and Mrs. Willard Ellsworth, formerly of New York City and now located at Cainsville, Missouri, the Auxiliary retired to their meeting, and the scientific program was presented.
The speakers were Drs. Paul Scheele, Charles Kromer and James P. Murphy, from the St. Louis University Medical School, St. Louis, who discussed “Bedside Diagnosis and Treatment of the Arrhyth- mias.” This was an interesting presentation followed by discussion and questions.
The minutes of the last meeting were read and approved.
This being time for the annual election, President Watkins A. Broyles appointed an Election Committee, Drs. Donald M. Dowell, John H. Platz and E. A. Duffy.
After their report, it was with a unanimous vote
that the following officers were elected for 1956: Pres- ident, Dr. Charles M. Grace, Chillicothe, and Sec-
ident, Dr. Frank R. Daley, Hamilton; 2nd Vice Pres- ident Dr. Charles M. Grace, Chillicothe, and Sec-
retary and Treasurer, Dr. E. A. Duffy, Trenton.
There being no further business, the meeting adjourned.
E. A. Duffy, M.D., Secretary
Clay County Medical Society
The Clay County Medical Society held its Annual Clinical Conference at the Elms Hotel in Excelsior Springs on Thursday, November 3.
The conference got underway with a noon luncheon at which Dr. Roscoe Pullen, Dean of the School of Medical, University of Missouri, spoke on “The Uni- versity of Missouri Medical School.”
Dr. Pullen showed slides to indicate the progress on the new medical school building program. He also
The conference opened with a luncheon meeting.
mentioned additions to the new hospital faculty and discussed briefly the present set-up at the medical school for training of medical students.
Missouri speakers giving clinical talks on the after- noon program of the Conference were: Dr. Victor B. Buhler, Kansas City, President of the Missouri
Speakers were seated at a head table.
State Medical Association, “Presentation of Patholog- ical Specimens,” and Dr. Robert L. Jackson, Professor and Chairman, Department of Pediatrics, School of Medicine, University of Missouri, Columbia, “Common Pediatric Problems.”
The Conference dinner in the evening was attended by some 100 doctors and their wives who were privileged to hear a discussion on “Highlights of Medical Civil Defense Planning and Requirements.”
Discussions were not limited to sessions.
Taking part in this discussion were Dr. Carroll P. Hun- gate, Kansas City, Chairman, Committee on Civil De- fense, Missouri State Medical Association, and Dr. Curtis H. Lohr, Clayton, Superintendent and Medical Director of St. Louis County Hospital.
As a part of this discussion, Dr. Lohr explained the plan that has been worked out for evacuating patients and personnel from the St. Louis County Hospital westward into rural St. Louis County in view
54
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56
ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
of bombing attacks in case of war. He then showed movies of a test run on such an evacuation.
This was a most interesting presentation and a highlight of the Clinical Conference.
The Woman’s Auxiliary of the Clay County Med- ical Society acted as hostesses to the wives of the doctors who attended the Conference.
A full program was arranged for the ladies during the afternoon and then both doctors and wives at- tended the evening banquet and program.
Some eighty-five physicians registered for the Con- ference.
S. R. McCracken, M.D., Secretary
SECOND COUNCILOR DISTRICT
W. F. FRANCKA, HANNIBAL, COUNCILOR Pike County Medical Society
A meeting of the Pike County Medical Society was held on Tuesday night, November 22, at the Pike County Hospital, Louisiana.
Guests present at the meeting were Dr. W. F. Franc- ka, Hannibal, Councilor of the Second District, Mis- souri State Medical Association; Dr. B. L. Murphy,
Those present posed for group picture.
Hannibal, and Ray McIntyre, Field Secretary of the Missouri State Medical Association.
A number of matters affecting the practice of med- icine were discussed at the meeting.
Eight members of the medical society were in at- tendance in addition to the three guests.
J. W. Middleton, M.D., Secretary
Chariton-Macon-Monroe-Randolph County Medical Society
A dinner meeting of the Chariton-Macon-Monroe- Randolph County Medical Society was held at the Woodland Hospital in Moberly on Thursday night, November 10.
Dr. Spencer L. Freeman, of Kirksville, gave the principle address of the evening and spoke on “Oph- thalmology for the General Practitioner.” He ef- fectively illustrated many pathologic conditions of the eye with colored slides.
County Society officers for 1956 were elected at this meeting and are as follows: President, Dr.
C. C. Cohrs, Moberly; Vice President, Dr. Daniel
D. Stuart, Brunswick, and Secretary and Treasurer, Dr. R. H. Young, Moberly.
Sixteen doctors attended this meeting.
W. D. Chute, M.D., Secretary
FOURTH COUNCILOR DISTRICT
JOSEPH C. CREECH, TROY, COUNCILOR Jefferson County Medical Society
A luncheon meeting of the Jefferson County Med- ical Society was held Tuesday noon, November 1, at the Harman House, just north of Crystal City and Festus on U. S. Highways 61 and 67.
Dr. Thomas Thale, St. Louis, Chairman, Committee on Mental Health, Missouri State Medical Association, and staff member of St. Louis State Hospital, discussed plans for mobile psychiatric clinics for this area as called for in legislation passed by the Missouri as- sembly last spring.
J. F. Rutledge, M.D., Secretary
Franklin-Gasconade- Warren County Medical Society
A luncheon meeting of the Franklin-Gasconade- Warren County Medical Society was held at the St. Francis Hospital in Washington, on Tuesday, Novem- ber 29.
Twenty-five members and guests were present to hear the Honorable Clarence Cannon, Congressman
Congressman Cannon was the speaker.
from the 9th Missouri District, discuss “Medical Legislation on the National Level.”
Mr. Cannon said that, from a recent trip to Eng- land, he found many people with whom he talked unhappy over the socialized medicine program in that country. He further said that, in his opinion, it is unlikely that such a program will ever be adopted in this country.
He discussed the tremendous expenditures by the Federal government today and the need for balancing the budget. Among these expenditures, he talked about large sums of money being spent by the Fed- eral government in the various fields of medical re- search.
He pointed out that Federal spending needs to be cut down to what can be afforded from the stand-
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58
ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
Close attention was held by the speaker.
point of paying for as we go along. He brought out an interesting point by stating that rarely did he ever receive from any of his constituents a letter sug- gesting cutting down of Federal expenditures but, on the other hand, he did receive many letters re- questing something calling for the expenditure of more Federal funds.
H. D. Steinbeck, M.D., Secretary
FIFTH COUNCILOR DISTRICT
J. LOREN WASHBURN, VERSAILLES, COUNCILOR Audrain County Medical Society
A dinner meeting of the Audrain County Medical Society was held in the cafeteria of the County Hos- pital at Mexico on Monday night, November 21.
The scientific program for the evening, under the auspices of the Missouri Academy of General Prac- tice, was presented by C. M. Waggoner, M.D., roent- genologist, Columbia, who discussed “Clinical Evalua- tion of X-ray Therapy.”
Following the scientific program, a number of business matters were discussed.
The Society voted to assist in anyway they could to help carry out the extended polio vaccine pro- gram in the State of Missouri.
The following doctors attended the meeting: Harry F. O’Brien, M.D.; Ben Jolly, M.D.; Glen Kallenbach, M.D.; Henry J. Ector, M.D.; Leonard Davis, M.D.; Charles Garcia, M.D.; J. Frank Jolley, M.D.; Thomas L. Dwyer, M.D.; Harold Lankford, M.D., and James Moss, Administrator, Audrain County Hospital."
The meeting adjourned at 10:00 p.m.
T. L. Dwyer, M.D., Secretary
Postgraduate Course at Missouri University
Thirty-seven physicians attended the first of a series of Postgraduate Medical Education Meeting to be held at the University of Missouri this fall and winter under the joint sponsorship of the University of Missouri Medical School and the Missouri Academy of General Practice.
The program for this meeting was presented by Dr. Walter J, Burdette, Professor of Surgery, and Dr. Samuel P. W. Black, Associate Professor of Surgery of the University. Dr. Burdette discussed “Manage-
ment of Chest Trauma,” and Dr. Black spoke on “Management of Acute Head Injuries.”
Members of the Missouri Academy of General
The Academy held its first meeting of the year at Columbia.
Practice who attended this meeting received two hours of category one postgraduate credit toward their Academy requirements.
J. Loren Washburn, M.D., Secretary
SIXTH COUNCILOR DISTRICT
C. G. STAUFFACHER, SEDALIA, COUNCILOR
Henry, Johnson, Pettis, Saline and Adjacent County Medical Societies
Sixty-six people, including doctors, their wives and guests, attended a joint dinner meeting of the Henry, Johnson, Pettis, Saline and adjacent County Medical Societies, Wednesday night, November 16, at the Pacific Cafe in Sedalia.
An enjoyable social hour preceded the dinner and program.
The scientific presentation of the evening was given by Dr. Robert Jackson, Professor of Pediatrics
Dinner preceded the scientific program.
and Head of the Department, at the University of Missouri Medical School in Columbia.
He spoke on “The General Medical Supervision of a Healthy Child.” He slanted a part of his talk toward
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REFERENCE: 1. Silcox, L. E., A.M.A. Arch. Otolaryng. 60:431, Oct. 1954.
60
ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
the lay membership of his audience and the remainder toward the physicians present.
Following Dr. Jackson’s well-received talk, all those in attendance were privileged to hear a discussion by Mr. Esser, a jeweler of Marshall, speak on the subject
Judge Flanigan was the speaker.
Ozarks Medical Society
A smorgasbord dinner meeting of the Ozarks Med- ical Society and its ladies was held at the Bank
Lawyers and dentists were guests at the meeting.
The meeting was well attended.
“Valuable Gems.” In addition to his talk, he showed various types of such gems.
This fine two phased program made a well-spent evening.
Ray Hollingsworth, M.D., Chairman for the meeting,
Henry County Medical Society
West Central Missouri Medical Society
A “get together” of the members of the West Cen- tral Missouri Medical Society, with the dentists and lawyers of the five counties composing the Society was held at the Country Club in Nevada on Thurs- day night, November 10, with thirty-eight present.
given by Dr. R. Emmett Kane of St. Louis before a meeting of the Missouri Bar a few years back.
The occasion of this meeting presented a most practical opportunity for the promoting of friendships and good relationships among the three professions in the area.
A. L. Hansen, M.D., Secretary
EIGHTH COUNCILOR DISTRICT
W. S. SEWELL, SPRINGFIELD, COUNCILOR Jasper County Medical Society
The Jasper County Medical Society held a dinner meeting at Kunzie’s Kitchen, Carthage, on Tuesday night, November 8.
Dr. George J. L. Wulff, Jr., St. Louis, Associate Pro- fessor of Obstetrics and Gynecology at Washington University Medical School, was the guest speaker.
Dr. Wulff spoke on “Problems of Sterility and Re- lated Matters.”
Following a social hour and dinner, Dr. Wulff was introduced by Dr. John D. Maddox of Joplin, a long time friend.
L. S. Crispell, M.D., Secretary
After an enjoyable social hour and consumption of a swell steak dinner, those present were privileged to hear Judge John H. Flanigan of Carthage speak on “Moments With the Masters.”
In his talk, the Judge read many interesting pas- sages from English prose and poetry. He finished his splendid performance by reading a speech which was
The Society’s president talks with the speakers.
ADVERTISEMENTS
61
~tli L(M^uumlJ)kt jjot a loinA
Imagination is essential to this diet since your patient may have to follow it for many years. These diet "do’s” can show him how to use eggs, cheese, and milk — a trio of almost purine-free foods — to supply the major portion of his protein.
In these , the trio plays a solo —
Eggs baked in pimiento-flecked cheese sauce are hard to resist. Or, if your patient prefers, the sauce can be poured over hard-cooked eggs.
A casserole of eggplant and tomatoes layered alternately with ricotta or cottage cheese makes a satisfying entree. Add a sprinkle of grated parmesan with a fine Italian hand.
Your patient may like his eggs poached in tomato juice. Then serve them in a soup bowl with a frill of chopped parsley on top.
In these , the trio plays accompaniment —
Ham ’n’ egg rolls come hot or cold. For hot, roll a warm slice of ham around eggs that have been scrambled with a pinch of savory. For cold, roll ham around egg salad mixed with cottage cheese.
Oyster stew can be creamy without cream when the milk is bolstered with dry skim milk powder. A pinch of thyme and some chopped parsley add savor.
Broiled salmon or tuna-burgers nestle nicely in a nest of noodles. A slice of cheese on top adds color and broils to a bubbling brown.
These suggestions are only a few of the possible combinations of this versatile trio. And the adequate protein nutrition they make possible, plus a liberal intake of fluids, may help establish a regimen that will please you both.
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62
ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
Hotel in Aurora on Tuesday night, November 8. There were thirty-five doctors, wives and guests present.
Following dinner, the ladies adjourned to hold a separate meeting.
The scientific program presented to the physicians
The speakers had an attentive audience.
was in the form of a panel discussion on “Bedside Diagnosis and Treatment of the Arrhythmias.”
The physicians on the panel were: Drs. James
G. Janney, John Meyers and Donald W. Bussman, all of St. Louis, and members of the Department of Cardiology of St. Louis University Medical School.
Members of the audience were requested by the panel to enter into the discussion at any time dur- ing the panel presentation.
This program was jointly sponsored by the Mis- souri Academy of General Practice and St. Louis University.
L. T. Taylor, M.D., Secretary
NINTH COUNCILOR DISTRICT
J. H. SUMMERS, LEBANON, COUNCILOR Mid-Missouri Medical Society
Thirty -eight persons including doctors and their wives attended a meeting of the Mid-Missouri Med- ical Society in Rolla on Thursday night, November 17.
Following dinner, the ladies held a separate meet- ing and were privileged to hear an address by Mrs. Frank B. Leitz of Kansas City, President of the Woman’s Auxiliary to the Missouri State Medical Association.
The doctors were treated to a fine panel discussion on “Peptic Ulcer” presented by C. Rollins Hanlon, M.D., Professor of Surgery and Director of the De- partment, St. Louis University Medical School; Sher- wood Peartree, M.D., Assistant in Radiology, St. Louis University, and Edward D. Kinsella, M.D., Instructor in Internal Medicine, St. Louis University.
Members of the audience participated in the dis- cussion which added to the interest value of the pro- gram.
M. K. Underwood, M.D., Secretary
TENTH COUNCILOR DISTRICT
BEN M. BULL, IRONTON, COUNCILOR
Dunklin, Pemiscot, Butler-Ripley-Wayne and the Semo County Medical Societies
A joint dinner meeting of the Dunklin, Pemiscot, Butler-Ripley-Wayne and Semo County Medical Soci- eties was held Tuesday night, November 15, at the Cotton Boll Hotel in Kennett.
The evening festivities began with social refresh- ments, dinner and then the scientific program.
The twenty-five doctors attending the meeting were privileged to hear an interesting and informative
Discussion did not end with the formal meeting.
Speakers answered questions following the meeting.
panel discussion on “Bedside Diagnosis and Treatment of the Arrhythmias,” by Drs. John Nuetzel, C. G. Vour- nas and John J. Ingley of the Cardiovascular Section of St. Louis University Medical School.
In addition to the comments among the members of the panel, the audience participated in the discussion. The informality of the program added much to its value. ' r
E. L. Spence, M.D., Secretary
Butler-Ripley-Wayne County Medical Society
The Butler-Ripley-Wayne County Medical Society and its Woman’s Auxiliary held a dinner meeting
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ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
WE CORDIALLY INVITE YOUR INQUIRY for application for membership which affords protection against loss of income from accident and sickness (accidental death, too) as well as benefits for hospital expenses for you and all your eligible dependents.
at the Northwold Tourist Court Restaurant Tuesday night, October 18.
An interesting discussion on “Peptic Ulcers” was con- ducted by Dr. C. W. Gaskins, Chief Surgeon at the Poplar Bluff V. A. Hospital; Dr. A. L. May of the Lucy Lee Hospital staff, and Dr. Fred J. Biggs of the Doctors Hospital Staff.
A guest at the meeting was Dr. Warren A. Henkel, Chief Area Consultant for the Veterans Administra- tion Surgical Service.
The meeting was well attended.
J. R. Loughead, M.D., Secretary
C orrespondence
THE AMERICAN ACADEMY OF ALLERGY
208 E. Wisconsin Avenue Milwaukee 2, Wisconsin November 28, 1955
Mr. T. R. O’Brien, Executive Secretary Missouri State Medical Association 634 North Grand Boulevard St. Louis 3, Missouri
Dear Mr. O’Brien:
The American Academy of Allergy will hold its 12th Annual Meeting at the Chase Hotel, St. Louis, Mis- souri, February 6, 7 and 8, 1956. Preceding the An- nual Meeting on February 4 and 5 a Pre-Convention Scientific Assembly will be held.
Panel discussions, scientific papers and exhibits cover- ing all fields of Allergy will be presented at this meeting. All meetings are open to interested phy- sicians. There is no registration fee.
On behalf of the entire membership of the American Academy of Allergy we want to send a sincere in- vitation to the officers, directors and members of the Missouri State Medical Association to attend any of the sessions of our Annual Meeting.
Sincerely yours,
Stanley F. Hampton, M.D.
President, The American Academy of Allergy.
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A. M. E. F.
Your Contribution Is Tax Deductible
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A.M.A. DELEGATES APPROVE OPPOSITION TO DISABILITY PAYMENTS
The program of alerting physicians to the im- plications of the House passed bill for disability cash payments at age 50 is being stepped up. The American Medical Association’s Hospital of Delegates has given its approval to a program including the mailing to all AMA members of a letter from President Elmer Hess, plus a fact sheet on the Social Security amend- ments.
A Board of Trustees report on the amendments notes that AMA’s concern is with two parts of the bill (H. R. 7225) : extension of OASI benefits for totally and permanently disabled children beyond age 18, and provision of OASI retirement benefits for the disabled at age 50, instead of the present statutory re- quirement of age 65.
The board declared: “This bill clearly is another step in the extension of government over the medical profession.” This is the way it would come about: By providing a disability benefit as a right through the OASI system, it would subject doctors to govern- ment regulations in making disability determinations and rendering rehabilitation services. In addition, “con- stant pressures from government, administrators and patients seeking disability certifications would cause increasing harassment of the . . . profession.”
The board report then goes on to note that the bill’s threat to the profession “is only significant if it conflicts with our ability to discharge our obligations to those we serve. It would classify and certify as hopeless many of those to whom adjustment to a new way of life offers the only hope of recovery and rehabilitation.”
IMPROVEMENTS FORECAST IN ADMINSTRATION HEALTH PROPOSALS
Roswell Perkins, Assistant Secretary of the De- partment of Health, Education and Welfare, says the administration’s health program for next year will contain revisions and improvements over the pro- gram submitted to Congress during the last session. Addressing the District of Columbia League of Re- publican Women on November 15, Mr. Perkins noted that 88 per cent of hospital beds in the United States are taken up by the chronically ill and that “we should plan ahead” in this field. He also declared: “While hearings were held on a few of these measures, most were given no consideration. Our program for next year, which is not finalized, will contain re- visions and improvements in the total program. But the question will again be squarely presented as to whether this Congress will enact the bulk of the President’s health program.”
VA LAUNCHES NEW PROGRAM FOR LONG TERM PATIENTS
The Veterans Administration has begun what it describes as “an advanced concept in the care of chronically ill veterans” in thirty VA hospitals. The program will be expanded to other hospitals as rapidly as they qualify. Dr. William S. Middleton, VA med- ical chief, explained the program provides “active
rather than custodial care for those long term patients in the VA hospital system who no longer need de- finitive hospital treatment, cannot return home, and lack the capabilities necessary for the new planned- living program in VA domiciliaries.”
Dr. Middleton outlines these points in the newest program: (1) concentration of long term patients in
special sections of hospitals, manned by specially qualified staffs, (2) for each patient, a planned main- tenance rehabilitation to retain benefits of hospital care already given and to prevent development of any further disabilities, (3) section staff to gear a planned activity program to each patient’s need for recreation and spiritual and social activities, and (4) periodic reviews of each patient’s progress with the goal of eventual discharge.
VA estimates the average age of some 110,000 veterans in VA hospitals is 48, in comparison with 38 in the veteran population as a whole. Currently there are 584,000 veterans age 65, while five years from now this group is expected, by VA estimates, to exceed 1,780,000.
SALK VACCINE PRODUCTION TO INCREASE SOON
Lagging production of the Salk poliomyelitis vaccine should start picking up in December and reach normal production rate probably in February, Surgeon Gen- eral Scheele predicted November 17. He blamed the recent drop in production on major changes made last May in vaccine production and testing, and on continuing refinements since then. Dr. Scheele made the estimates in submitting to HEW Secretary Marion Folsom an interim report of the Public Health Serv- ice’s Technical Committee on Poliomyelitis Vaccine. The committee reported the following:
1. New filtration techniques remove clumps of virus particles which were large enough to shield some virus from the action of formaldehyde, and now ex- pose all the virus to formaldehyde inactivation.
2. Monkey safety tests have been modified to in- crease sensitivity, and the monkey potency test has been revised so that it serves as an additional safety test. Points 1 and 2, along with continuous review of plant production records, assure the safety of re- leased vaccine and should make more supplies avail- able, according to the report.
3. Vaccine properly made by the Mahoney strain, while especially virulent, provides “an entirely safe immunizing agent.” Research is continuing in the hope of finding a less virulent strain.
THE DOCTOR DRAFT
Dr. Frank B. Berry, assistant Defense Secretary for Health and Medical matters, in his annual report warns that the doctor procurement problem again may become acute, despite last summer’s two-year exten- sion of the act. He said the Department may not be able to obtain all the older physicians it needs because of the amendment barring the drafting of men over 35 if they have applied for a medical com- mission and been rejected on purely physical grounds. Also, Dr. Berry thinks the ratio of 3 physicians per 1,000 of troops may be too narrow a margin for safety.
63
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News From the Medical Schools
WASHINGTON UNIVERSITY Honors
Dr. William B. Kountz, assistant professor of clin- ical medicine at Washington University School of Medicine, was installed as president of the American Gerontological Society, October 28, in Baltimore, dur- ing the eighth annual meeting of the Society. Dr. Kountz, who was elected to the office at a meeting last December in Florida, will serve a one year term.
Dr. Carl A. Moyer, Bixby professor of surgery and head of the department, recently was named to a five member advisory Committee on Research to the Veterans Administration. Dr. William S. Middleton, VA chief medical director, said the committee will “be concerned particularly with the professional and administrative aspects of research activities conducted with VA stations and with the research activities con- ducted by VA employees.”
Dr. John R. Smith, associate professor of medicine and director of medical service at Homer G. Phillips Hospital, has been elected president of the St. Louis Heart Association.
Dr. M. Hayward Post, professor emeritus of clin- ical ophthalmology, recently was elected first vice president of the American Academy of Ophthalmology and Otolaryngology at a Chicago meeting. He will serve a one year term.
Grants
A total of $366,282 in research grants has been awarded to Washington University School of Med- icine by the United States Public Health Service, Dean Oliver H. Lowry announced recently. Of this amount, $94,549 provides for new grants, with the remainder for continuation of grants previously received by faculty members at the medical school. New grants were received by Dr. Charles Eckert, associate pro- fessor of surgery and director of the division of tu- mor services, $21,509; Dr. Arthur Kornberg, professor of microbiology and head of the department, $18,975; Dr. William M. Landau, assistant professor of neurol- ogy, and Dr. Robert B. King, assistant professor of neurosurgery and Markle fellow in neurosurgery, $17,782; Dr. Robert Elman, professor of clinical sur- gery, and Dr. T. E. Weichselbaum, assistant professor of experimental surgery, $16,732; Dr. David S. Hog- ness, instructor in microbiology, $9,754; Dr. King, $7,561; and Dr. Lawrence W. O’Neal, assistant in clin- ical surgery, $2,236.
Dr. Martin Kamen, associate professor of radio- chemistry, has received a five year, $32,500 grant from the National Science Foundation for work on “Photo- Activation and Electron Transfer in Bacteria.”
A grant of $13,612 has been awarded by the Muscular Dystrophy Associations of America to Dr. Amoz I. Chernoff, assistant professor of medicine. He will work on the abnormalities of myoglobin in muscular dystrophies and the hereditary hemolytic syndrome and their relationships to the disease. The grant, which covers one year, began November 1.
Lectures, Meetings
Dr. Nathan A. Womack, professor of surgery and head of the department at the University of North
Carolina, Chapel Hill, delivered the seventh annual Major G. Seelig lecture November 23 at the medical school. He spoke on “Chronic Cystic Mastitis and Its Relation to Cancer.” Dr. Womack, a medical graduate of Washington University, is well known for his work in surgical pathology. Of special note are his con- tributions to the pathology of the tumors of the lung and to the field of cancer in general. The lecture honors the late Dr. Seelig who was professor of clin- ical surgery at the medical school and director of research at Barnard Free Skin and Cancer Hospital for many years.
Four research papers were presented at a meeting of the Washington University Medical Society on December 8. The papers were: “Enzyme Activity of Burned and Normal Skin,” by Dr. Falls B. Hershey, assistant professor of surgery, and Barry M. Kayes, research assistant in surgery; “The Effect of Growth Hormone on the Uptake of S35-Sulfate by Cartilage,” by Dr. William H. Daughaday, assistant professor of medicine; Dr. William R. Murphy, assistant in pathol- ogy; and Carolyn Hartnett, research assistant in med- icine; “Renal Juxtaglomerular Cells, Electrolyte Bal- ance and the Adrenal Cortex,” by Dr. Phyllis Hart- roft, research assistant in pathology; and Dr. W. Stan- ley Hartroft, Mallinckrodt professor of pathology and head of the department; and “E. coli Diarrhea: The Relationship of Certain Serotypes of Escherichia coli to Sporadic and Epidemic Cases of Infantile Gastroen- teritis,” by Dr. John C. Herweg, assistant professor of pediatrics and assistant dean of the school of med- icine; Dr. J. Neal Middelkamp, instructor in pediatrics; and Dr. Helen Thornton, research fellow in bacteriol- ogy in pediatrics.
Twenty-two faculty members of Washington Uni- versity School of Medicine participated in the various panels, symposia, television, cine clinics and post- graduate courses at the 41st annual clinical congress of the American College of Surgeons held October 31 to November 4 in Chicago. Participants were: Drs. Carl A. Moyer, Lauren V. Ackerman, Eugene M. Bricker, Willard M. Allen, Minot P. Fryer, Louis T. Byars, Evarts A. Graham, Harvey R. Butcher, Jr., James Barrett Brown, Henry R. McCarroll, William Sleator, James Chamness, Falls B. Hershey, Harry C. Morgan, Maurice J. Jurkiewicz, Richard P. An- drews, Charles Eckert, T. E. Weichselbaum, Harry W. Margraf, Joseph C. Penden, Jr., Tillman M. Moore and Lawrence W. O’Neal.
Three staff members presented papers at the 28th annual meeting of the Central Society for Clinical Research held November 4 and 5 in Chicago. Par- ticipants were: Dr. Phillip Comens, fellow in med- icine; Dr. Lillian Recant, assistant professor of med- icine and of preventive medicine; and Dr. Seymour Reichlin, instructor in medicine and Lowell M. Palmer senior fellow in neuropsychiatry. About forty house staff members of the department of medicine also attended the meeting.
Dr. Justin J. Cordonnier, professor of urology, par- ticipated in a panel discussion on “Urinary Diversion” at the annual meeting of the South Central Branch of the American Urological Association held October 17 to 20 in Dallas.
Dr. Edmund V. Cowdry, professor emeritus and lec- turer in anatomy and director of the Wernse Lab-
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ORGANIZATION AND ECONOMICS
69
oratory of Cancer Research, recently has given lectures at the University of Toronto, the meeting of the Southern Society of Cancer Cytology held in Hous- ton, the American Public Health Association meeting at Kansas City and the University of Kansas. He also has attended scientific committee meetings at Miami, Fla., and Duarte, Calif.
Dean Oliver H. Lowry; Dr. Robert Glaser, associate dean, and W. Bahlmann Parker, registrar, represented the medical school at the 66th annual meeting of the Association of American Medical Colleges held October 24 to 26 in Swampscott, Mass.
Examination
The American Board of Surgery examination Part I for certification was held October 26 at the medical school. There were eleven candidates from Missouri and Illinois. The second part of the examination was held December 12 and 13 at the medical school.
Visitors
Dr. Erik Lindgren, professor of radiology at the Serafimerlasarettet Hospital in Stockholm, Sweden, spoke on “Neuroradiology” November 15 at the med- ical school. The lecture was sponsored by the depart- ments of radiology, neurosurgery and neurology. In addition to his academic position Dr. Lindgren is editor of the Swedish radiological journal, Acta Radiologica, and the author of a recent textbook on radiology. He is in the United States on a lecture tour. Another recent visitor and speaker was Dr. Salvador Zubiran, Mexico City, who spoke to the house staff of the department of medicine November
17 on “The Role of Stress in the Ulcer Problem.” Dr. Mitsuteru Ishikawa, professor at the Tokyo Jikeikai School of Medicine, visited members of the faculty November 21. Dr. Ishikawa, who studied in the de- partment of bacteriology at the medical school from 1926 to 1928, is working on allergy, immunity and related subjects. Dr. Herman Kalckar, of the National Institute of Health, Bethesda, gave a biochemistry seminar and a speech for the department of pediatrics recently. A recent guest from the Institute of Nutri- tion of Central America and Panama, located at Guatemala City, was Dr. Guillermo Arroyave who visited with Dr. Martin Kamen, of the department of radiology, and other staff members.
Mr. John Hutchison, a surgeon at the University of Glasgow, Scotland, visited in the department of surgery for a week to observe new surgical methods.
UNIVERSITY OF MISSOURI Trips and Talks
Dr. William A. Sodeman, professor and chairman of the department of medicine, addressed the Cooper County Teachers Association on October 17 at Boon- ville, regarding the topic “Medical School and Heart Disease.” On November 10, Dr. Sodeman was in To- ledo, Ohio, attending the St. Vincent’s Hospital Cen- tennial. At that time, Dr. Sodeman spoke on “Ath- erosclerosis.” The Practical Nurses Association in Columbia heard Dr. Sodeman’s talk entitled “Practical Nursing in Internal Medicine,” on November 14. Then, on November 15, Dr. Sodeman was guest speaker at the Pettis County Health Forum in Sedalia where he spoke on “Nerve Pills and Sleeping Medicine.”
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70
ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
Staff members of the Department of Microbiology attended a meeting of the Eastern Missouri Branch of the Society of American Bacteriologists held in St. Louis on October 29. Dr. F. B. Engley, professor and chairman of the department, presented a paper at the meeting entitled “Evaluation of Antiseptic Toxicity in Tissue Culture.” Dr. Herbert S. Goldberg, assistant professor of microbiology, traveled to Washington, D.C., for the Third Annual Antibiotic Symposium of the Department of Health, Education and Welfare, held November 1 to 5. Approximately one thousand were present. The Symposium was concerned pri- marily with two important points regarding antibiotics. More information was given on the increase in the number of toxic reactions to antibiotics and prelim- inary information was reported on new antibiotics. Dr. Engley, Dr. V. J. Cabelli, Dr. R. Keller and Dean R. L. Pullen attended a meeting of the American Public Health Association in Kansas City on Novem- ber 14 to 18.
Dr. Clarence D. Davis, professor and chairman of the department of obstetrics and gynecology, partic- ipated in a panel entitled “Cancer of the Cervix and Uterus” as part of the activities of the Missouri Academy of General Practice at a recent meeting in Jefferson City.
On October 31, Dr. E. T. Standley, assistant pro- fessor of pathology, delivered a talk entitled “Recent Advances in Clinical Pathology” to the University Hospitals staff nurses in connection with the educa- tion program being conducted for them.
Dr. Robert L. Jackson, professor and chairman of the department of pediatrics, delivered a lecture on “Common Pediatric Problems” as part of the Clinical Conference sponsored by the Clay County Medical Society held in Excelsior Springs on November 3. Dr. Jackson was guest speaker on November 7 at a series of meetings in Nebraska sponsored by the Lincoln General Hospital, the Education Division of the University of Nebraska, and the Lincoln Public Schools. Dr. Jackson spoke on the use of growth charts in school health programs and the evaluation of growth in children. On November 10, Dr. Jackson was in Camdenton at a meeting sponsored by the Missouri Heart Association. This was the second ses- sion in the postgraduate course on “Cardiology.” Ap- proximately fifty doctors heard Dr. Jackson’s lecture on “Heart Failure in Children.”
Dr. W. R. Hepner, Jr., associate professor of pediat- rics, was one of nearly seven hundred who attended the annual meeting of the Central Society for Clin- ical Research held in Chicago, November 3 to 6. Re- ports on recent advances in biological research were given and regular business was conducted.
Dr. Clement E. Brooke, of the department of pediat- rics, continues with a joint program in cooperation with the University of Kansas whereby clinical stu- dents from the School of Medicine of the University of Missouri travel to Children’s Mercy Hospital in Kansas City to make rounds with the staff and stu- dents from the University of Kansas.
Dr. Walter J. Burdette, professor and chairman of the department of surgery, attended the annual meet- ing of the American College of Surgeons held in Chicago, November 3 to 5. On November 12 Dr. Burdette delivered a talk entitled “Studies on In- termediary Metabolism of Cardiac Muscle” at a meet- ing sponsored by the Society of Clinical Surgery held in New Orleans. At the same time, the Louisiana
Division of the American Cancer Society presented him with a scroll bearing a resolution of appreciation and commendation for his work as chairman of the executive committee and vice president of the Louisiana Division of the American Cancer Society from 1949 to 1955.
Dean Roscoe L. Pullen and Miss Dorothy L. Vorhies, associate professor of dietetics, apprised a group of heme economists of the progress of the University of Missouri School of Medicine and University Hos- pital, in connection with Agriculture Forum Day held at the University on October 31. Dr. Pullen was also guest speaker at the Clay County Medical Society Clinical Conference in Excelsior Springs on November 3.
As part of the Capping Exercises held on November 6 in Jesse Auditorium at the University of Missouri, Dr. Pullen delivered an address entitled “Nursing in Modern Society.” Twenty-eight nurses received their caps from Mrs. Katherine A. Mason, assistant director of the School of Nursing, at this colorful ceremony.
Dr. Pullen continued his attempts to apprise in- terested persons of the progress of the School of Med- icine at a meeting of Pi Lambda Theta, Christian College, held on November 10.
Postgraduate Activities
Postgraduate medical education programs are well underway, with enthusiastic participation and gratify- ing attendance. On October 19, Dr. William T. Ellis, assistant professor of obstetrics and gynecology, and Dr. Samuel P. W. Black, associate professor of sur- gery, were guest speakers on the program in Spring- field, sponsored by the University of Missouri School of Medicine and the Greene County Medical Society. Dr. Ellis spoke on “Management of Hypertensive Dis- orders of Pregnancy” and “Diabetes in Pregnancy.” Dr. Black’s topics were “Management of Acute Head Injuries” and “Pain in the Lower Back.” Drs. Ellis and Black also delivered these lectures the following evening in Joplin, under the joint sponsorship of the School of Medicine and the Jasper County Medical Society.
Dr. Thomas W. Burns, assistant professor of med- icine, and Dr. Walter R. Hepner, Jr., associate profes- sor of pediatrics, presented the program for Novem- ber. Dr. Burns delivered lectures entitled “Diagnosis and Management of Rheumatic Fever in Adults” and “The Use and Abuse of Thyroid and Anti-Thyroid Agents.” Dr. Hepner presented ideas on the man- agement of difficulties in the newborn child. His sec- ond lecture dealt with the management of diarrhea and vomiting.
In addition to these programs being held in Joplin and Springfield, the School of Medicine is also present- ing a series of meetings in Columbia, sponsored by the Missouri Academy of General Practice. The first such meeting was held on November 17 with Dr. Walter J. Burdette, professor and chairman of the depart- ment of surgery, and Dr. Samuel Black presenting two lectures on the management of chest trauma and acute head injuries.
Appointments
Dr. Gwilym S. Lodwick, associate professor of Radiology, State University of Iowa College of Med- icine, has been appointed professor and chairman of the department of radiology at the University of
Volume 53 Number 1
ORGANIZATION AND ECONOMICS
71
Missouri School of Medicine, effective July 1, 1956. Doctor Lodwick, a native of Mystic, Iowa, received his medical and postgraduate training in radiology at the University of Iowa. Doctor Milton E. Kirkpatrick, executive director of the Greater Kansas City Mental Health Foundation, has been appointed clinical as- sociate in medicine (psychiatry). Doctor Kirkpatrick will give biweekly lectures in child psychiatry and child guidance to the medical students.
Doctor Barbara Randall of Columbia has been ap- pointed instructor in physical medicine. Doctor Ran- dall received a Master’s degree in physiology (physical medicine) at the University of Iowa and formerly taught at Ohio State University before coming to the University of Missouri.
Doctor Constantine Anast, currently instructor in pediatrics, State University of New York College of Medicine at Syracuse, has been appointed instructor in pediatrics effective February 1, 1956.
Grants
Dr. L. E. Thomas, associate professor of biochem- istry, is the recipient of a grant for cancer study in the amount of $5956.53 from the United States Public Health Service. This grant is a renewal for study he has made for over five years on the subject “Isolation of Characterization of Cellular Proteins.”
The United States Public Health Service has re- newed the undergraduate cancer teaching grant of $25,000 for the year beginning January 1, 1956. The grant will be administered under the direction of Dr. Joseph E. Flynn, professor and chairman of the de-
partment of pathology and cancer coordinator for the School of Medicine.
Honors
Doctor Clarence D. Davis, professor and chairman of the department of obstetrics and gynecology, and Doctor Samuel P. W. Black, associate professor of surgery, were initiated into the American College of Surgeons at the meeting held in Chicago, November 3 to 5.
Doctor Edward L. Washington, clinical associate in pediatrics, was a recent initiate into the American Academy of Pediatrics.
Lectureships
The University of Missouri School of Medicine was honored to have Dr. Harry E. Morton, professor of bacteriology at the University of Pennsylvania School of Medicine, as a guest lecturer on November 18. Dr. Morton addressed members of the faculty and student body on the subject “Pleuropneumonia- like Organisms.”
Dr. John Adriani, director of the department of anesthesia, Charity Hospital of Louisiana, New Or- leans, addressed a general assembly of the faculty and student body on October 8 on the subject of “New Drugs.”
SAINT LOUIS UNIVERSITY
Dr. Ralph A. Kinsella, Senior, Professor of Internal Medicine and Director Emeritus of the Department, Saint Louis University School of Medicine, was
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ORGANIZATION AND ECONOMICS
Missouri Medicine January, 1956
awarded one of the University’s first Alumni Merit Awards at the Student Convocation held November 15 which opened the University’s two day Founders’ Day Celebration. The awards were presented to twelve graduates of the University representing various schools. The event marked the 137th anniversary of the founding of Saint Louis University.
The Very Rev. Paul C. Reinert, S.J., President, presented Dr. Kinsella the award which read in part: He qualifies par excellence as an exemplar of our President’s definition of a “distinguished Alumnus”
Dr. Kinsella receives award
of Saint Louis University. His three degrees — the Bachelor’s, the Master’s, and the Doctor’s — were all earned in Saint Louis University in 1906, 1910 and 1911, respectively. For thirty-one years, he guided the Department of Internal Medicine as teacher and administrator. Except for his prehigh school life, the ten years of his absence from Saint Louis University for advanced study, and service in three other fac- ulties of Medicine, and the three years of his Army service, he spent forty-one years of his life in Saint Louis University.
As a scientist, he was ever the uncompromising lover of the stark truth; as an investigator, he opened many of nature’s jealously guarded secrets concerning endocarditis, rheumatic fever, and the cel- lular mechanisms of infection; as an author some of the most distinguished monographs in world wide- ly known compilations and published numerous papers on his research. He has received every honor which his profession in our country could bring to him as a physician and internist.
Dr. Edmond F. Sassin, assistant professor of clin- ical neurology and psychiatry, was the discussion leader at a two day Work Shop held at the National Conference of Catholic Charities held at Grand Rap- ids, Michigan, November 7 and 8.
Dr. Grayson Carroll, associate professor of clinical urology, gave a series of lectures on “Cancer of the Prostate” at Duke University and the Veterans Admin- istration Hospital in Durham, North Carolina on November 4 and 5. Dr. Carroll was also the guest speaker at the Iowa Urological Society in Iowa City, Iowa, on December 10.
Dr. Jack R. Eidelman, senior instructor in neurology and psychiatry, lectured on “The New Drugs in Psychiatry and Their Practical Applications” at Vet- erans Hospital in Muskogee, Oklahoma, November 18.
Dr. Otakar Machek, instructor in orthopedic sur- gery, took part in a panel discussion at the Missouri State Nursing and Allied Homes Association Meet- ing held at the Hotel Jefferson December 13. His discussion was titled, “Should Nursing Homes Attempt Rehabilitation.”
BOOK REVIEW
Fifty Years of Medicine, by Lord Horder. Philosoph- ical Library, New York. 1954. Price $2.50.
This little volume consists of the Harben Lectures delivered before the Royal Institute of Public Health and Hygiene. It is to some extent autobiographic in nature. He describes briefly the advances in clinical pathology, chemotherapy, surgery, x-ray, endocrinol- ogy, industrial medicine and nursing. He discusses with critical remarks some modem trends in social and psychosomatic medicine. He reviews the develop- ments in the fields of nutrition and foods, and phys- ical medicine and rehabilitation, especially in rela- tion to Great Britain and the recent war. There is an amusing section on noise abatement.
One would suggest that the most interesting part of the book is his consideration of medicine and the state; illuminating statements of his views of the British National Health Service Act. Errors emphasized are precipitancy and attempting too much in too short a time. It was a blunder to base the new scheme primarily on the hospital and not on the family physician. Many hospitals were closed to general prac- titioners so he could no longer follow his patient into the wards, take part in the diagnosis and treatment while there, and resume effective care when the pa- tient returns home. There is a segregation of the general practitioner from the specialist. In the process of developing the hospitals the Service has tended to accentuate this division of the profession into special- ists and general practitioners. It would be dangerous if the intellectual contacts of the two branches of the profession were diminished. Much more “welfare” was embarked upon than the country could afford. The economic consideration of the work of the general practitioner is important. Every case which the doctor refers to the State hospital, when he could himself diagnosis and treat it, either in his office or at the patient’s home, costs the country more money. Add to this the fact of the long waiting lists at the hospitals of both out and in patients, and the consequent absenteeism involved, and the expense of short cir- cuiting the general practitioner and his normal func- tion becomes obvious. The lowering of the status of the general practitioner has sapped this most impor- tant branch of practice of its spirit of initiative and adventure. Young physicians have therefore been at- tracted to the specialist and consultant branches, en- couraged thereto still further by subsides and prom- ises, to find later they were not needed. H. A. B.
Hair Permanently Removed by Electrolysis
DOROTHY WORRELL R.N.
233 N. Vandeventer, St. Louis Telephone, Jefferson 3-9436
Work Done on Prescription of Physicians Only
Curiosa et Trivia
William B. McCunniff, M.D.
The current price of 100,000 units of penicillin is less than 1 per cent of the cost in 1942. Procaine penicillin cost fifteen times as much in 1948 as it does now; and insulin is sold for about 10 per cent of its cost in 1923.
Because of complaints from French dentists, citizens returning from Belgium must have their dentures checked. If they are new, the proud pos- sessor of the “store teeth” must pay a 35 per cent duty for importing the cheaper Belgian teeth.
One person in the United States goes blind every twenty-four minutes. The blind population of the United States is now approximately equal to that of Buffalo, New York.
Note to a pharmacist: . . will you send me a
medicen for my stomach I have sour stomach
and acidity after eating offle bad and send me two bottles alka seltzer and send my bill how much I owen. . .
Advertising manager and vice president of the Maiden Form Brassiere Company (“. . . I dreamed I went ... in my Maidenform Bra”) is Dr. Jo- seph A. Coleman. After two years practice and five in the Army, E.N.T. man Coleman went into the lingerie business. Dr. Coleman also holds a half dozen patents in brassiere design.
About one half of professional boxers show urinary turbidity after a fight.
Almost within the shadow of a well known and great medical center in Cleveland, is another healing institution. Located at 10828 Carnegie is the Mayo Animal Clinic and Hospital.
Capsule Clinics
I. A. Wien, M.D.
• It appears that about 4 per cent of subjects with intracranial aneurysm have polycystic kidneys
and about 15 per cent of those with polycystic kid- neys have intracranial aneurysms. Hazard, J. B., and McCormack, L. J.: Med. Clin. North America 39 (July) 1955.
• Actually, there is little understanding of the exact physiology of the parathyroid hormone;
however hyperphosphaturia with the resultant de- crease in serum phosphate is the initial sign of hyperparathyroidism. Greenwood, J. H., et al: Med. Clin. North America 39 (July) 1955.
• Dihydrotachysterol(A.T. 10) mimics the action of parathyroid hormone in causing a rise in
the serum calcium. It is one of our best drugs, for the patient apparently does not build up a toler- ance against it. Greenwood, J. H., et al: Med. Clin. North America 39 (July) 1955.
• Protection against hyperthermia is very effec- tively accomplished by two mechanisms — pe- ripheral vasodilation and active sweat secretion. Major physiologic adaptations resulting in an improved ability to work during the early days of acclimatization to heat are probably cardio- vascular in nature. The kidney “conserves'
sodium and chloride in excess of amounts re- quired to compensate for sweat losses, with the result that plasma and interstitial fluid volumes are “isotonically” expanded. Bass, D. E., et al.: Medicine 34 (September) 1955.
• In 520 cases of hyperthyroidism treated with 1-131 over a ten year experience, 75 per cent
responded to a single dose, no true recurrence of hyperthyroidism has been observed, and no cancer of the thyroid attributable to radioactive iodine has been demonstrated. Chapman, E. M., and Maloof, F.: Medicine 34 (September) 1955.
• Neoplastic disease of the heart is seldom recog- nized even though it is not longer considered
unusual. Myxomas make up 50 per cent of the primary tumors of the heart and 75 per cent of them are located in the left atrium. Hurst, J. W., and Cooper, H. R.: Am. Heart J. 50 (November) 1955.
• Diamox can exert a powerful effect in lowering intra-ocular pressure. It is particularly valu- able in cases of secondary and congestive glau- coma; however in chronic glaucoma its effect is only temporary. Drance, S. M.: Brit. J. Ophth. 24 (November) 1955.
85
Missouri Medicine in Review
Leo H. Pollock, M.D.
FORTY YEARS AGO
Suit against the board of education of St. Louis has been filed in the circuit court by several cit- izens, among them three physicians, one of whom was recently expelled from membership in the St. Louis Medical Society. The instigators of the suit
are seeking to restrain the board of education from us- ing the school funds to main- tain the department of hy- giene which conducts the medical examination of school children. The peti- tion alleges such use of the school funds is not sanc- tioned by law.
Dr. J. Shelton Horsley, Richmond, Virginia, was the guest of the St. Louis Medical Society, January 2, and read a paper on “Blood-Vessel Surgery.”
S. C. Young, a chiropractor at Cape Girardeau, was fined $50 for practicing medicine without a license, January 17. The deposition of a licensed practitioner now deceased was read in court stat- ing that Young was working for the physician.
Grundy County Medical Society has secured quarters in the board of directors’ room of the Trenton Trust Co. for their regular meetings. The members are proud of their new meeting place, as it is steam heated, electric lighted and alto- gether very attractive.
Dr. David R. Hill, Commissioner of Health of Joplin, has consented to stand for reelection under the commission form of government which Joplin adopted a year ago.
Dr. Julius Rotter, formerly of Parsons, Kansas, was recently convicted of wife abandonment in St. Louis and sentenced to six months in the work- house. The publicity given the occurrence has caused Dr. Julius Charles Rotter, St. Louis, con- siderable embarrassment on account of the sim- ilarity of names. Dr. Julius Charles Rotter is a member of the St. Louis Medical Society and in no way related to the convicted man.
Dr. James R. Smith, Warsaw, secretary of Ben- ton County Medical Society, was so unfortunate as to lose his office and contents during a fire December 23. Unfortunately no insurance had been placed on the doctor’s possessions, and he is now sorely in need of office furniture, operating table and cases.
The wife of Dr. William Harrison, Marshall, died December 15. Mrs. Harrison was a daughter of the late Col. Vincent Marmaduke and granddaugh- ter of former Governor M. M. Marmaduke.
Dr. W. D. Fulkerson, Trenton, has been confined
86
to his home with a severe attack of erysipelas, but is better now and will be out in a short time.
TWENTY FIVE YEARS AGO
The business corporation that would encroach on individual practice comes before the physician often and came before the St. Louis Medical Soci- ety in the form of a proposition by a company organized to furnish medical, surgical and roent- gen ray service to policy holders for one half the usual charge, the policy holder to pay the sum of 15 cents a week for this cheap medical service and in addition at his death receive “a swell $300 funeral.” The promoters evidently believed physi- cians would grab at the chance of having “5,000 families allotted to them,” which was the bait dangled before them. No member of the society was inveigled into the scheme.
There are approximately 143,000 physicians in the United States and about 32,000 other practi- tioners who care for the sick.
Dr. O. E. Kiessling, Washington, D. C., has been appointed chief economist and W. W. Adams chief statistician of the newly created demographical division of the United States Bureau of Mines, Department of Commerce. Their duties will be to conduct statistical studies relative to the health, safety and welfare of persons employed in mineral and related industries.
The New York Polyclinic Medical School and Hospital, New York City, dedicated a new twelve story addition to the institution December 29, 1930. The addition was constructed at a cost of $1,500,000 and will provide more space for clinics, teaching, private rooms and operating rooms.
Dr. Charles E. Hyndman, St. Louis, was installed as president of the St. Louis Medical Society, Jan- uary 6, 1931.
Dr. Edward H. Skinner, Kansas City, was in- stalled as president of the Jackson County Med- ical Society at the meeting of the society, Jan- uary 6, succeeding Dr. Frank C. Neff. The presi- dent-elect is Dr. A. J. Welch who will become president in January, 1932.
Dr. L. C. Chenoweth, Joplin, was elected presi- dent of the Jasper County Medical Society at the annual meeting of the society, December 2.
Dr. L. H. Fuson, St. Joseph, was elected presi- dent of the Buchanan County Medical Society, December 3, 1930. Dr. Fuson was vice president in 1930 and he succeeds Dr. E. M. Shores as presi- dent.
Dr. Otto C. Horst, Springfield, was elected pres- ident of the Greene County Medical Society at the meeting of December 12, 1930.
A compound, tri-ortho cresyl phosphate, has ( Continued on page 90)
Upjohn
Ulcer protection that
lasts all night:
Pamine-Phenobarbital
BROMIDE
Tablets
Each FULL-STRENGTH tablet contains:
Phenobarbital 15.0 mg. (^4 gr.)
Methscopolamine bromide 2.5 mg.
Dosage :
One tablet one-half hour before meals, and 1 to 2 tablets at bedtime.
Each HALF -STRENGTH tablet contains:
Phenobarbital 8.0 mg. (% gr.)
Methscopolamine bromide 1.25 mg.
Dosage :
While the dosage and indications are the same as for the full-strength tablets, this tablet allows greater flexibility in regulating the individual dose, and may be employed in less severe gastrointestinal conditions.
Supplied:
Both strengths in bottles of 100 tablets.
*REaiSTEREO TRADEMARK FOR THE UPJOHN GRAND OF METHSCOPOLAMINE
Tlie Upjohn Company, Kalamazoo, Michigan
Missouri Academy of General Practice
J. H. Trolinger, M.D.
of General Practice
American Academy
The medical event of the year for most Missouri General Practitioners occurs March 19 to 22, 1956, in Washington, D. C.; it is the eighth Annual Sci- entific Assembly of the American Academy of General Practice. Final plans for this major meet- ing were completed October 24, 1955. They show every promise of culminating in the biggest and best yet. All Missouri physicians are invited and urged to attend this meeting which is now gener- ally regarded as the most instructive and clin- ically practical four day gathering offered any- where.
Aside from the wealth of educational and pleas- urable opportunities to be afforded, it is antici- pated that much further progress will be made by the organizational meeting of the American Academy of General Practice in its efforts to improve American medicine. The American Acad- emy of General Practice has attained a member- ship of some twenty thousand since its inception just eight years ago. Its component state chapters have made impressive strides toward improving skill and competence of generalists throughout the country; however, too many pressing (even threatening) problems remain unsolved to per- mit the luxury of even the briefest complacency.
The current keen and capable leaders of the American Academy of General Practice are at- tacking these problems chiefly as they affect the family physician — but always with the primary objective of improving American medicine and American health.
Stronger, more militant exertions are being properly made through the American Medical Association, since a large majority of our parent organization’s membership is comprised of general practitioners. It is anticipated that much will be accomplished this coming year by the parental strength, facilities and various councils of the American Medical Association in solving the more pressing problems of the family physician; prob- lems which are by the very nature of things as well as by definition those of American medicine.
Many of our general practice problems are but signs of more profound and serious trends that threaten the integrity and reputation of our entire national medical body; e.g., the rash of articles in lay magazines of recent years casting doubts and often aspersions upon the entire profession. Major specialty groups quarreling with each other through popular magazines may be an unwhole- some manifestation of something more dangerous than a superabundance of superspecialists. They might well be construed as evidence of disunity and beginning disintegration of the American
88
Medical Association — such a development to be inexorably followed by governmental domination of all phases of medicine.
Among the more pressing problems which would seem to warrant action by the American Medical Association is the arbitrary restrictions in many sections of the country on hospital prac- tice. Many of us are viewing with alarm the grow- ing trend of hospitals to practice medicine; such hospital restrictions deprive many competent fam- ily physicians of the privilege to practice med- icine, for without available hospital facilities no modern physician can give the American people the excellent care they deserve.
The influence of the American Medical Associ- ation through its House of Delegates can do much to improve the education of medical students, interns and residents for the practice of general medicine.
The Council on Medical Education and Hos- pitalization can do much to implement the estab- lishment of a Department of General Practice in more (if not all) medical schools. This would serve to increase interest as well as competence in general practice. The present day medical student is taught entirely by specialists who rouse his interest in first one and then the other specialty. Following graduation he likely as not interns in a hospital unfairly and unreasonably restricting privileges of the generalist. He naturally con- cludes that if he is to enjoy the now indispensable right