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JournaMGantet
A Monthly Medical Journal
Index to
VOLUME LVI
New Series
January 1936 - December 1936
Represents the Medical Profession of
Minnesota, North Dakota, South Dakota and Montana
The Official Journal of the
North Dakota State Medical Association South Dakota State Medical Association Montana State Medical Association
Minnesota Academy of Medicine Minneapolis Clinical Club
Sioux Valley Medical Association American Students’ Health Association
w Great Northern Railway Surgeons’ Association
Minneapolis, Minn.
Lancet Publishing Co., Publishers
1936
6-3-4
THE J
INDEX OF AUTHORS A
Abramson, Milton
Cases Given Contraception at the Birth ControP League Clinic.
Adams, C. G. -
Tuberculous Meningitis in Children.
Adams, J. M. 270
Tuberculous Meningitis in Children.
Alexander, H. L. - - - - - - 131
Interpretation of the Skin Test Used in Allergic Disorders.
Amberson, J. B., Jr. - - - - - - 189
The Significance of Tuberculosis in the College Age Group.
Anderson, J. K.
Case of Prolapse of the Rectum Treated by Con- stricted Band.
B
Baehr, George -------
The Role of the Private Physician in the Control of Venereal Diseases.
Bailey, Richard J. ----- -
Contact Dermatitis.
Bierring, Walter L. -
Trend of Modern Diagnosis as Related to Medical Specialism.
Bond, Earl D. -
The Wish to Fall 111.
Borland, V. G. ------
Case of Prolapse of the Rectum Treated by Con- stricted Band.
Bradshaw, R. W. ------
Trends in Student Health.
Bru nsting, Louis A. -
Ulcers of the Legs; Diagnosis and Treatment.
Bullard, Mattie J. ----- -
Anemias in College Women.
Bunker, Paul G.
Practical Laboratory Aids for the Otolaryngologist.
Burrell, L. S. T.
The Prevention of Tuberculosis.
Cardie, A. E. - - - - - - 18
The Treatment of Diabetes Mellitus among Rail- road Employees.
Chaddock, Charles Gilbert - 38
Some Cutaneous and Deep Reflexes of the Arm and Hand.
Collins, Arthur N. - - - - - - 139
Trauma and the Malignant Testis.
Cook, J. F. D. - - - - - - 65
Samuel B. McGlumphy, First President of the North Dakota State Medical Association.
Cowern, E. W. ------- 590
Further Observations on the Relationship between Herpes Zoster and Chicke.ipox.
Crafts, Leo M. - 539
Reflections on Sexology.
Cueto, A. A. - - - - - - 571
A New Treatment for Baldness.
D
DeWeese, A. O. - - - - - 575
A Study of the Organization and Administration of College Hygiene.
Diehl, H. S. 295, 533
Venereal Diseases among College Students.
Studies of the Treatment of Colds.
Dill, D. B. 313
Blood Changes in Exercise.
Dixon, C. F. - - - - - - 380
General Considerations Regarding Lesions of the Colon.
DuBois, Julian F. ----- - 70
History of Medical' Licensure in Minnesota.
Dyson, R. E. - - - - - - - 245
Abdominal Surgery in Children.
Eisenstadt', Da vicV/H.
Most frequenZ/reactions in Treatment of Syphilis. Emersor_ _
Health Preparation of Students, ntroduction (Tuberculosis Number).
Fopeano, J. V. ------
Active Pulmonary Tuberculosis in Students at the University of Michigan.
Forsy
rSve^ffumronary Tuberculosis in Students at the
/Michigan.
’o\s, 1)4** KT - / / - \ -
Manifestations of Allergy in General Practice.
Fox, Lawrence K. w
Development of Legal Requirements for the Prac- tice of Medicine in South Dakota.
French, H. E. - - ji
Medical Education in North Dakota.
E. N. C ^
Gerrish, W. A.
Presidential Address, North Dakota Number. Goodman, Joseph ------
Description of a Technic for the Study of Allergy in Eczematous and Eczematoid Dermatoses. Grassick, James ------
Joseph G. Millspaugh, M. D., First President of the North Dakota State Medical Association.
H
Hill, H. W.
Tuberculosis Insusceptibles, An Epidemiological Note.
Hill, L. F.
Tuberculosis in Children.
Hitchcock, E. D. -
History of the Medical Association of Montana.
Hoskins, R. G. -
Endocrine Factors in Behavior.
Hudson, G. E. -
Endocrine Theraphy in Gynecology.
Hyman, O. W. ......
Student Health Service as a Part of the Medical College.
I
Illge, Alfred H.
Granuloma Fissuratum.
Jackson, Wilbur ......
Medical Care in Social Security.
Jacobs, S. .......
Fallacies in Interpreting the Tuberculin Reaction.
James, H. H. -
Treatment of Uterine Hemorrhage of Benign Origin with Radium.
Jennings, Frank L.
The Problem of Increase in Exercise in Pulmonary Tuberculosis.
Jordan, L. S. - The Teacher.
K
Kelly, E. F. - -
An Address, The Integration of Pharmacy and Medicine.
King, Garnet -------
Anesthesia With Highly Volatilized Ether Vapor.
Kingery, Lyle B. - - -
Granuloma Fissuratum.
Kneeland, Yale, Jr. -
The Problem of Cold Prevention.
Knight, Ralph T. ----- -
Obstetrical Analgesia.
481
149
175
566
566
522
69
527
427
134
65
206
183
80
249
587
585
485
543
176
1
92
187
- 580
536
485
532
608
THE JOURNAL-LANCET
635
L
Lanza, A. J. - - - - - - 519
Response to Address of Welcome (Montana Number) .
Larson, Lawrence M. - 622
The Injection Treatment of Large External Ingui- nal Rings Without Hernia.
Laymon, Carl W. - - - - - 7, 472
Contact Dermatitis, A Summary of Various Causes.
Cancer of the Face.
Levine, Ida - - - - - - - 601
Some Complications Attending Artificial Pneumo- thorax.
Lindberg, D. O. N. - - - - - 180
The Role of the Chest Roentgenogram in Tuber- culosis— An Evaluation of the Various Diagnostic Factors.
Lyon, E. P. - - - - - - 372
I Am Automatic.
Me
McCoy, G. W. 81
Communicable Disease Control.
McGlumphy, S. B. - - - - - 73
Our Professional Likes and Dislikes.
McQuarrie, I. - - - - - - - 254
The Physiological Roles and the Clinical Signifi- cance of the Endocrine Glands.
M
Madden, John F. ----- - 478
An Ambulant Type of Fever Treatment for Syphi- lis of the Nervous System.
Michelson, Henry E. - - - - - 463, 564
Relationship of Tuberculosis to the Tuberculo- dermas
Cancer of the Skin.
Montgomery, Hamilton ..... 473
Pigmentation of the Skin.
Moody, Robert O. - - - - - - 613
Determining Appropriate Body Weight in Relation to Body Build.
Myers, J. Arthur ..... 24, 601
Treatment. Prognosis and Prevention of First In- fection Type of Tuberculosis.
Some Complications Attending Artificial Pneumo- thorax.
Mytinger, W. H. ..... 195
The Control of Tuberculosis.
o
O’Connor, R. ------ - 583
Management of Strabismus.
O’Donoghue, Arch. F. - - - - - 487
The Problem of Malposture and Visceroptosis.
O’Leary, P. A. - - - - - 303, 464
Criteria of Cure of Syphilis.
Wassermann Fastness.
P
Parsons, L. R. - - - - - - - 547
Use of X-Ray in Kidney Conditions.
Pastor, J. R. - - - - - - 199
The Fight Against Tubercidosis in Puerto Rico.
Pelouze, P. S. - - - - - - - 307
The Treatment and Criteria of Cure of Gonococcal Infections in the Male.
Platou, E. S. - - - - - - . 283
Epidemic Meningitis.
Pryor, Helen B. - - - - . . 613
Determining Appropriate Body Weight in Relation to Body Bu’ld.
R
Randall, O. Samuel ..... 88
The Present Status of Irradiation Treatment of Cancer.
Rankin, A. B. - - - - - . . 592
Gastric Tetany (Case Report).
Raycroft, Joseph E. . 95
Health Service in Educational Institutions.
Rice, Carl O. ...... 622
The Injection Treatment of Large External Ingui- nal Rings Without Hernia.
Rider, A. S. ------ - 86
The Tuberculosis Facilities at Sanator.
Riley, W. A.
The Tropical, or Oriental. Rat Flea, Xenopsylla Cheopsis Established in Minnesota.
Rosenthal, Theodore -
Acne and Its Relation to the Endocrines.
Rowe, Albert H. ----- -
Gastro-Intestinal Allergy.
Rusten, Elmer M. .....
Treatment of Lumphogranuloma Inguinale.
s
Scott, Walter -------
The Problem of Malposture and Visceroptosis.
Shannon, W. R. ----- -
The Use of Calcium in the Control of Convulsions in Infancy and Childhood.
Sharp, David V. ----- -
The Problem of Increase in Exercise in Pulmonary T uberculosis.
Shepard, Charles E. -
Determining Appropriate Body Weight in Relation to Body Build.
Shuman, John W. ------
History of California Medicine.
Smith, M. - - - . -
Bronchitis or Tuberculosis?
Snow, W. F.
Individual Prophylaxis in Theory and Practice as Applied to Syphilis and Gonococcal Infections.
Stiehm, R. H. -
Tuberculosis and Physical Activity.
Sulzberger, Marion B. - - - -
Description of a Technic for the Study of Allergy in Eczematous and Eczematoid Dermatoses.
Sweitzer, S. E. ......
Scabies: Further Observations on Its Treatment
with Pyrethrum Ointment.
T
Tanquist, E. J. ......
Case of Thrombosis of Heart.
Thompson, W. H. ......
Influenzal Meningitis.
u
Unverricht, W. ......
The Importance of Thoracic Cautery in the Man- agement of Pulmonary Tuberculosis.
Urner, John A. ----- -
Obstetrical Analgesia.
Vasko, J. R. -
The Treatment of Foot
V
Ailments.
Vaughn, Warren T. ....
Modern Methods in the Study of Migraine.
Vonderlehr, R. A.
Syphilis and Gonorrhea as a Major Public Health Problem.
w
Wakefield, E. G.
The Physiology of the Colon and Clinical Con- sideration of Carcinoma.
Wallgren, Arvid - -
From Childhood Infection to Adult Type of Pul- monary Tuberculosis.
Walzer, Matthew ......
The Mechanism of the Paroxysm in Bronchial Asthma.
Wangensteen, Owen H. - - - - -
Memorial Tribute to Dr. E. Starr Judd.
Watkins, F. L.
No History Is More Interesting than That of Public Health Itself.
Wilce, J. W.
Athletic Heart — Modern Conceptions and a Recent Investigation.
Williamson, G. M. - - - - -
Early State Requirements of the North Dakota State Board of Medical Examiners.
Winer, L. H.
Skin Biopsies.
Wise, Fred .......
The Therapy of Eczema.
Wolf, Jack -
The Therapy of Eczema.
591
496
120
479
487
278
92
613
76
207
299
315
134
467
87
273
205
608
322
127
291
618
237
1 17
570
521
557
67
471
441
441
636
THE JOURNAL-LANCET
INDEX OF EDITORIALS A
Age of Indiscretion, The -
Ambulance Hubbub ------
Annual Meetings ------
Are Physicians Educated? -
C
Certification of Specialists in Internal Medicine Chaddock Reflexes, The -
Chicago Passes a Fracture Ordinance Cleanliness of Biologicals - - - -
Cup Bearers to the Gods -
D
Delicate Child and Tuberculosis, The Dermatologic Symposium, A - - - -
Diagnosis and Treatment of Allergic Disease Doctor and Politics, The -
Domestic Disease Dissemination -
E
Editor of the Journal of The American Medical Association, The ------
F
Fact Versus Opinion -
Fatigue and Automobile Accidents
Flick Out Candles With a Clean Napkin
G
Gall Tract Surgery ------
Growing Significance of Lipid Metabolism
I
Inter-State Postgraduate Assembly Ivan Petrovitch Pavlov, 1849-1936
L
Liability Insurance -
M
Medical History Par Excellence Medical Solidarity - Medicine and Politics Medicine Marches On Minneapolis Surgical Society Minnesota Meeting .... Montana Meeting .... More Information Needed Concerning Fever Causes ....
Mr. Soule and the Tuberculin Test -
New Year’s Greetings Nurses Not Overpaid
o
Our Medical Future
P
Physics Self-Administered Dangerous Placating and Pleasing the Public Politics ......
Poverty and Patience
Practice of Preventive Medicine, The
Q
Question of Ethics, A - - -
S
Salesmanship in Medicine Silent Disease, The State Medicine - Surgeon and Educator
T
Three Great G Men Toward More Accurate Diagnoses Tuberculosis and Immigration Tuberculosis in the Cattle Herds
u
Hay
505
451
286
505
504
42
43 595 3 84
596
504
152
43
551
154
44
328
214
153
287
550
214
383
286
98
451
215
153
328
383
551
384
41
629
42
154
630
595
98
452
452
550 213
551 42
596
42
215
99
384
V
Venereal Diseases in the Practice of Medicine 3 27 W
We Are Appreciated - - - - - 631
Worthy Organization, A .... 629
INDEX OF ARTICLES A
Abdominal Surgery in Children - - - 245
Acne and Its Relation to the Endocrines - 496
Allergic Disorders, Interpretation of the Skin
Test Used in - - - - - - 131
Allergy, Description of a Technic for the Study
of, Eczematous and Ezematoid Dermatoses - 134
Allergy, Gastro-Intestinal - - - - 120
Allergy, Manifestations of, in General Practice 5 22 American College of Surgeons’ Sectional Meet- ing at Omaha, Nebr. - - - - 156
American Congress of Physical Therapy, The 156 American Student Health Association, Fifth
Annual Report ...... 492
Anemias in College Women .... 623
Anesthesia With Highly Volatilized Ether Vapor 536
Analgesia, Obstetrical ..... 608
Arm and Hand, Some Cutaneous and Deep
Reflexes of the ...... 38
Asthma, Bronchial, The Mechanism of the
Paroxysm in - - - - - - 117
Automatic, I Am ...... 372
B
Baldness, A New Treatment for - - - 571
Behavior, Endocrine Factors in ... 24?
Birth Control League Clinic, Cases Given Con- traception at the ..... 446
Birth Control Organizations - - - - 553
Blood Changes in Exercise - - - - 313
Body Weight in Relation to Body Build, Deter- mining Appropriate, ..... 613
Book Notices 39, 97, 210, 325, 449, 503, 552, 593, 628 Bronchitis or Tuberculosis? .... 207
C
Calcium, The Use of, in the Control of Convul- sions in Infancy and Childhood - - - 278
California Medicine, History of 76
Cancer of the Face - - - - - - 472
Cancer of the Skin ..... 564
Cancer, The Present Status of Irradiation Treat- ment of ....... 88
Case Report: Gastric Tetany .... 592
Chickenpox, Further Observations on the Re- lationship Between Herpes Zoster and - 590
Cold Prevention, The Problem of - - - 53 2
Colds, Studies of the Treatment of - - - 533
Colon, General Considerations Regarding Lesions
of the -------- 380
Colon, The Physiology of, and Clinical Con- sideration of Carcinoma - - - - 618
Communicable Disease Control - - - 81
Contraception, Cases Given, at the Minnesota
Birth Control League Clinic - - - 446
Convulsions, The Use of Calcium in the Control
of, in Infancy and Childhood - - - 278
D
Dermatitis, Contact — A Summary of Various Causes .......
Dermatitis, Contact ------ 475
Dermatoses, Eczematous and Eczematoid, Des- cription of a Technic for the Study of Allergy
in 134
Development of Medicine in the Northwest, The 62
Diabetes Mellitus, The Treatment of. Among
Railroad Employees - - - - - 18
Dislikes and Likes, Our Professional - - 73
Unfair to Doctors
THE JOURNAL-LANCET
E
Eczema, The Therapy of - - - - 441
Eczematous and Eczematoid Dermatoses, Des- cription of a Technic for the Study of Allergy in ........ 134
Endocrine Factors in Behavior - - - - 249
Endocrine Glands, The Physiological Roles and
the Clinical Significance of the - - - 254
Endocrine Therapy in Gynecology - - - 587
Endocrines, Acne and Its Relation to the - - 496
Ether Vapor, Anesthesia With Highly Volati- lized - - - - - - - - 536
F
Flea, Rat, The Tropical, or Oriental, Xenopsylla
Cheopis Established in Minnesota - - 591
Foot Ailments, The Treatment of - - - 322
G
Gonococcal Infections in the Male - - - 307
Gonococcal Infections, Individual Prophylaxis in Theory and Practice As Applied to Syphilis and ........ 299
Gonorrhea, Syphilis and. As a Major Public
Health Problem - - - - - - 291
Granuloma Fissuratum ..... 485
Gynecology, Endocrine Therapy in - - - 587
H
Hand and Arm, Some Cutaneous and Deep Re- flexes of the ...... 38
Health, Preparation of Pre-College Students - 149
Health Service in Educational Institutions - 95
Heart, Athletic — Modern Conceptions and a Re- cent Investigation ..... 557
Heart, Case of Thrombosis of ... 87
Herpes Zoster and Chickenpox, Further Obser- vations on the Relationship Between - - 590
Hygiene, College, A Study of the Organization
and Administration of - - - - - 575
I
I Am Automatic ...... 372
Inguinal Rings, The Injection Treatment of
Large External, Without Hernia - - 622
International Medical Assembly - - - 506
Inter-State Postgraduate Medical Association of
North America 598
Introduction (Tuberculosis Number) - - 175
Irradiation Treatment of Cancer, The Present
Status of ------ - 88
J
Judd, Dr. E. Starr, Memorial Tribute to - - 570
K
Kidney Conditions, Use of X-Ray in - - 547
L
Laboratory Aids, Practical, for the Otolaryn- gologist - - - - - - - 32
Legal Requirements, Development of, for the
Practice of Medicine in South Dakota - - 69
Likes and Dislikes, Our Professional - - 73
Lymphogranuloma Inguinale, Treatment of - 479
Me
McGlumphy, Samuel B., M. D., First President
of the North Dakota State Medical Association 65
M
Malignant Testis, Trauma and the - - - 139
Malposture and Visceroptosis, The Problem of 487 Medical Education in North Dakota - - 527
Medical Examiners, Early State Requirements of
the North Dakota State Board of - - 67
Medical Licensure, History of in Minnesota - 70
Medical Specialism, Trend of Modern Diagnosis
As Related to ----- - 499
Medicine, An Address, The Integration of Phar- macy and ....... 580
Medicine in the Northwest, The Development of 62
Meningitis, Epidemic ..... 283
Meningitis, Influenzal ..... 273
Meningitis, Tuberculous, in Children - - 270
Migraine, Modern Methods in the Study of - 127
Mdlspaugh, Joseph G., M. D., First President of
the North Dakota State Medical Association 65 Minneapolis Clinical Club - 102, 157, 221, 331, 386
Minnesota Academy of Medicine - 45, 1 12, 227, 393
Minnesota, Northern Medical Association 453, 552
Minnesota State Board of Medical Examiners,
List of Physicians Licensed by the - - 462
Minnesota State Medical Association, Tentative
Program of Annual Meeting - - - 216
Minnesota State Medical Association, The - 3 38
Minnesota State Sanatorium Clinics 49, 159, 338, 454 Montana, Fifty-eighth Annual Meeting of the
Medical Association of - - 511-517
President’s Address - - - - - 517
Response to Address of Welcome - - 519
Montana, History of the Medical Association of 80
Montana, Medical Association of, Fifty-eighth
Annual Program ------ 386
N
North Dakota, Medical Education in - - 5 27
North Dakota State Board of Medical Exam- iners, Early State Requirements of the - - 67
North Dakota State Medical Association Forty-
Ninth Annual Meeting of the - - - 288
North Dakota State Medical Association, Tenta- tive Program of Annual Meeting - - 221
North Dakota, Transactions of the State Medical
Association Session — 1936 .... 399
Obituary
Beard, Richard Oldfhg, M. D. - - - 506
Eggers, August, M. D. - - - - - 597
Lundquist, C. Gilbert, M. D. - - - - 45 3
Ohage, Justus, M. D. - - - - - 101
Van Valkenburg, Frederick W., M. D. - - 155
Workman, Harper M., M. D. - - - - 597
Woutat, Henry Gustav, M. D. - - - - 100
O
Organized Medicine in the United States - 59'
P
Paroxysm, The Mechanism of the, in Bronchial
Asthma - - - - - - - 11 7
Petrositis, Chronic - - - - - - 319
Pharmacy and Medicine, An Address, The Inte- gration of ------ - 580
Pneumothorax, Artificial, Some Complications
Attending - - - - - - - 601
Pneumonia, Newer Methods of Diagnosis and
Treatment of - - - - - - 519
Potts, Thomas R., M. D., First President of the
Minnesota State Medical Association - - 66
Prophylaxis, Individual, in Theory and Practice as Applied to Syphilis and Gonococcal In- fections ....... 299
Public Health Itself, No History Is More In- teresting Than That of - - - - 521
R
Rat Flea, The Tropical, or Oriental, Xenopsylla
Cheopis Established in Minnesota - - 591
Rectum, Case of Prolapse of the, Treated by
Constricted Band ..... 382
Roentgenogram, Chest, The Role of the, in Tuberculosis — An Evaluation of the Various Diagnostic Factors - - - - - 180
658
THE JOURNAL-LANCET
s
Sanator, The Tuberculosis Facilities at - 86
Scabies: Further Observations on Its Treatment
with Pyrethrum Ointment .... 467
Sexology, Reflections on ..... 539
Skin Biopsies - - - - - - - 471
Skin, Pigmentation of the - - - - 473
Skin Test, Interpretation of the, Used in Allergic
Disorders - - - - - - - 131
Social Security, Medical Care in 543
South Dakota, Development of Legal Require- ments for the Practice of Medicine in - - 69
South Dakota State Inter-Allied Professional
Council, The - - - - - - 219
South Dakota State Medical Association, Tenta- tive Program of Annual Meeting - - - 218
South Dakota State Medical Association, Trans- actions of the Fifty-fifth Annual Session — 1936 349
Presidential Address, A. S. Rider, M. D.,
F. A. C. S., Flandreau, S. D. - - - 363
President-elect Address, J. L. Stewart, M. D.,
Nemo, S. D. 3 65
Alphabetical and District Society Roster - 368
State Requirements, Early, of the North Dakota
State Board of Medical Examiners - - 67
Strabismus, Management of .... 583
Student Health Service as a Part of the Medical
College - - - - - - - 585
Student Health, Trends in 147
Students, Pre-College Health Preparation of - 149
Syphilis, An Ambulant Type of Fever Treatment
for, of the Nervous System - - - - 478
Syphilis and Gonococcal Infections, Individual Prophylaxis in Theory and Practice As Ap- plied to ....... 299
Syphil is and Gonorrhea As a Major Public
Health Problem - - - - - - 291
Syphilis, Criteria of Cure of - - - - 303
Syphilis, Most Frequent Reactions in Treatment
of 481
T
Teacher, The - - - - - - - 187
Testis, Trauma and the Malignant - - - 139
Tetany, Gastric: (Case Report) - - - 592
Thrombosis of Heart, Case of - 87
Tuberculin Reaction, Fallacies in Interpreting
the 176
Tuberculodermas, Relationship of Tuberculosis
to the ........ 463
Tuberculosis, Active Pulmonary, in Students at
the University of Michigan .... 566
Tuberculosis and Physical Activity - - - 315
Tuberculosis Facilities at Sanator, The - 86
Tuberculosis in Children - - - - - 183
Tuberculosis Insusceptibles, An Epidemiological
Note ........ 206
Tuberculosis, or Bronchitis? .... 207
Tuberculosis, Pulmonary, From Childhood In- fection to Adult Type of 237
Tuberculosis, Pulmonary, The Importance of
Thoracic Cautery in the Management of - 205
Tuberculosis, Pulmonary, The Problem of In- crease in Exercise in 92
Tuberculosis, Relationship of, to the Tuberculo- dermas ....... 463
Tuberculosis, The Control of - - - - 195
Tuberculosis, The Fight Against, in Puerto Rico 199 Tuberculosis, The Prevention of 193
Tuberculosis, The Role of the Chest Roentgeno- gram in — An Evaluation of the Various Diagnostic Factors - - - - - 180
Tuberculosis, The Significance of, in the College
Age Group - - - - - - - 189
Tuberculosis, Treatment, Prognosis and Preven- tion of First Infection Type of 24
Tuberculous Meningitis in Children ... 270
U
Ulcers of the Legs; Diagnosis and Treatment - 468
Uterine Hemorrhage of Benign Origin, Treat- ment of, with Radium ..... 1
V
Venereal Diseases Among College Students - 295
Venereal Diseases, The Role of the Private Phy- sician in the Control of - - - - 311
Visceroptosis, The Problem of Malposture and 487
W
Wassermann Fastness ..... 464
Wish to Fall 111, The 377
X
X-Ray, Use of in Kidney Conditions - - 547
Treatment of Uterine Hemorrhage of Benign Origin with Radium*
H. H. James, M.D., F.A.C.S.
Butte, Mont.
THIS paper is concerned with the treatment of simple menorrhagia, uterine myoma, and myopathetic hemorrhage with radium ; the indications for treatment ; the technique employed ; and the results.
This is one field in which treatment by radium is of the greatest value, and with proper judg- ment in the selection of patients and with careful technique, the results often surpass those of any other form of treatment. It is interesting to note that this is the first pelvic condition in which radium was applied as a therapeutic agent. The trial was carried out in France, the birthplace of knowledge of the element. In 1906 Oudin and Verchere reported having treated uterine hemor- rhage due to benign lesions by the introduction of 11 mg. of radium element into the uterine cavity, and allowing it to remain in place for fifteen minutes, repeating the treatment five or six times at intervals of four or five days. Filtra- tion was not employed, except that of the glass container, and results were not happy ; the beta radiation caused much local reaction, and further work was abandoned.
In this country, Abbe in 1906, reported treat- ing one patient for simple menorrhagia with radium, and later reported two good results with fibroid tumors, in one of which treatment was given in 1905, and in one in 1909. There were
*Read before the Montana State Medical Societv, at Helena, Mont., July 3, 1935.
then many scattered reports of results, culminat- ing in the paper of Kelly and Burnam, in 1914.
From 1914 on, the literature has been volumi- nous concerning an adequate type of treatment.
In benign disease of the uterus, the indica- tion for treatment by radium is usually hemor- rhage, but the underlying cause of this symptom must be sought. The precise etiology is often obscure. According to the accumlated literature, the most common contributory conditions are hyperplasia or polyposis of the endometrium and uterine fibroid tumors ; more rarely, repeated pregnancies, chronic endometritis of low grade, hypertension, fibrosis of the uterine muscle, cervical polyps, ovarian cysts, or blood dyscrasias such as leukemia. When no physical basis for the symptom is found, endocrine imbalance is usually regarded as the causative factor. In planning treatment, the age of the patient, the presence or absence of fibromas and their size if present, the major complaints of the patient, and other con- ditions and complications associated with menor- rhagia are of importance.
In the control of uterine hemorrhage, in cases in which general examination has eliminated endocrine disturbance or blood dyscrasia as an etiologic factor, and in which curettage and microscopic study of the endometrial tissue so obtained have indicated that the disorder is benign, radium is the treatment of choice if certain con- traindications given below are respected. In some
9
THE JOURNAL-LANCET
instances, however, treatment by roentgen rays or by extrauterine applications of radium can be given. Such instances are those in which old chronic pelvic infection complicates the bleeding but in itself is not sufficient to require operation, and those in which a large uterine fibroid is present, but where there is definite contraindication to operation. Hysterectomy, hysterotomy or myo- mectomy is definitely indicated in a certain group of patients.
Fibromyomata of the uterus are frequently referred to as fibroids or myomata and are the most frequent of all gynecologic neoplasms. Myomata are present in from 4.3 percent to 20 percent of all gynecologic patients. Many small symptomless myomata are never recognized. In those statistics formulated largely from colored patients, the proportion of myomata is always high. Combined statistics of Frank, Kelly, Cul- len, and McDonald, formulated from 2,391 cases, show that 70 percent of patients are between 35 and 50 years of age.
Myomata are relatively infrequent under 30 and rarely require treatment after 55 years of age ; however, in my series the youngest individual treated was 23 and the oldest 74, the former being subjected to a hysterectomy, leaving the ovaries, and the later being treated by radium.
All myomata have their origin in the myome- trium and from this site may develop inwards and become submucous and even pedunculated ; or outwards, subperitoneal or intraligamentous. The subperitoneal variety frequently become pedunculated, and eventually the pedicle may be- come attenuated or entirely disappear and the tumor become parasitic or wandering, and receive all its nourishment through adhesions from the omentum or adjacent structures; in rare instances, the intraligamentous variety may in the same manner become separated from the uterus. I terine myomata are usually multiple, tumors of varying sizes being present.
The symptoms produced by myomata are too well known to require description. Hemorrhage and pressure symptoms and symptoms developing from complications such as salpingitis, are among the most frequent. 1 he character and severity of the symptoms are in accord with the lesions present, and as these vary greatly so also do the symptoms. All cases are symptomless in the early stage and some never cause trouble.
In an analysis of 934 cases, Kelly and Cullen found inflammatory lesion of the tubes present in 45 percent.
The diagnosis of uterine myomata is usually
not difficult, but the recognition of complications, many of which may be contraindications to ir- radiation, is often not so easy. An accurate and complete diagnosis is of much more importance if the tumor is to be treated by irradiation than if an abdominal section is to be performed; in the latter case an adnexa, the seat of an in- flammatory lesion or the presence of a small ovarian neoplasm does not greatly alter the ulti- mate outcome, whereas if irradiation is to be performed either of these complications may cause a fatal termination.
The theories which have been advanced to explain the beneficial action of radium upon uterine myomata are: (A) Action upon the
ovary and destruction of its follicle-bearing con- stituents ; (B) The production of an endarteritis of the bloodvessels of the tumor and myometrium ; (C) The increase in amount of fibrous tissue in the neoplasm and myometrium; and (D) The formation of cicatricial tissue in the endometrium. Of these we place the greatest reliance in the theory first mentioned. Doubtless, however, the production of an obliterative endarteritis is a contributing factor. The increase in amount of fibrous tissue is difficult to prove as the propor- tion of this tissue varies markedly in uteri which have not been subjected to irradiation.
We place little credence upon the theory of cicatricial tissue formation in the endometrium. We have examined several uteri which have been irradiated, and have rarely been able to demon- strate scar tissue except in recent cases. It is necessary to understand the manner in which radium acts in order to make a proper selection of cases suitable for irradiation. In the treatment of these, irradiation should be the hand-maiden to and not necessarily the competitor of surgery. The percentage of fibroid tumors that is suitable for radium varies from the low figure of 30 per- cent quoted by Miller to that of 70 to' 90 percent quoted by Ward ; probably two-thirds would be a better estimate.
As far as treatment is concerned, uterine myomata can be divided into three groups: (A) The small, uncomplicated, slow-growing or stationary symptomless myomata, which do not ordinarily require any treatment other than periodic observation; (B) the tumors which are best treated by myomectomy, or hysteromyo- mectomy, according to the individual case ; and (C) cases suitable for irradiation.
Many cases belong to the first group, a con- siderable number to the second, and about 60 or 70 percent to the third. Perhaps the easiest way
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to express our views regarding irradiation is by a process of exclusion and to state primarily the contraindications to irradiation.
FIGURE 1
Showing the intra-uterine applicator with radium intact.
The indications and contraindications to ir- radiation will be better understood if we consider the limitations of irradiation. Irradiation may be expected to check uterine bleeding resulting from myomata in practically all cases in which an adequate dosage is employed. Tumor shrinkage or even entire disappearance of the neoplasm, as far as palpable findings are concerned, may also be expected in the majority of cases. This result is not, however, so certain as is the development of amenorrhoea. Furthermore, the shrinkage is usually a slow process involving months and sometimes years. With these facts in mind the following contraindications to use of irradiation are easily explainable. Certain exceptions to these rules may occur :
1. Cases in which doubt exists as to the ac- curacy of diagnosis.
2. The presence of intraperitoneal lesions other than the myomata which requires surgical intervention.
3. Rapid growth, (usually means it is not a fibroid )
4. Associated neoplasms such as fundal carcinoma or any extra-uterine pelvic tumor such as ovarian tumor.
5. Pressure symptoms, (respond too slowly irradiation)
6. Softening or degeneration of the tumor.
7. Inflammatory lesions within the pelvis, especially inflammation of the adnexa. In- flammatory disease of long standing,
whether specific or not, may be activated by the application of radium.
8. When the tumor and uterus is larger than a four months’ pregnancy.
9. Large fibromas, with calcareous degenera- tion, are affected very little by radium.
10. Submucous tumor, especially if peduncu- lated, because of the possibility of slough- ing and secondary hemorrhage, is given by some authorities as a contraindication. In my experience, however, this has not been true.
11. Young patients, who are desirous of children, should never be given over 300 to 600 mg. hours for menorrhagia. In cases of uterine fibroid in young women, which have not been controlled by repeated small doses of radium, myomectomy, or if necessary hysterectomy, with preservation of the ovaries, is preferable, for irradia- tion may cause artificial menopause with the usual distressing sequelae.
12. Obstructing tumors or malformations which prevent the proper application of the radium.
13. If pain is associated with a pelvic tumor, exploration is advisable, for the pain indi- cates additional pelvic lesions which should be investigated.
14. Radiophobia ; in the eyes of some radium is used only for carcinoma and they shun any idea of irradiation. Strictly speaking, however, this is not a contraindication.
FIGURE 2
Photomicrograph of a uterine myoma. This shows the inter- lacing hands of muscle fibers; some cut transversely, others cut longitudinally.
From the foregoing it is evident that either myomectomy or hysteromyomectomy is the pre- ferable treatment in many cases. In others, how- ever, irradiation is the method of choice and any different treatment submits the patient to unneces- sary risks and certainly does not produce better
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if as good results. Irradiation is the advisable method in: (A) Small or medium-sized un- complicated myomata whose chief symptom is hemorrhage; (B) In myopathic hemorrhage ; (C) In all cases in which surgery is contraindicated, such as the presence of cardiac, renal or pul- monary disease or other conditions which would make operation unduly hazardous. Graves, Taussig, and others have directed attention to the complications which may follow irradiation ; the chief one of these is that there may be a re- currence or continuance of the bleeding. Patients respond differently to irradiation as incidenced by the fact that some tumors apparently disappear whereas others submitted to the same dosage and apparently similar in all respects, do not, or shrink only to a much less extent.
FIGURE 3
l terus with extensive myomatous involvement, chiefly inter- stitial and sub-mucous. Note the extreme distortion of the uterine cavity, preventing proper application of radium; con- sequently, hysteromyomectomy.
After irradiation the uterus and ovaries are still present and a recurrence of bleeding is there- fore possible. I he same, however, is true in the case of a myomectomy. Clark and Norris state that a little less than five percent of their cases have suffered a recurrence of bleeding sufficient to require a second treatment; the majority of these have been younger women in whom the ir- radiation dosage has been small. One irradiation by no means contraindicates a second treatment, and a recurrence can be usually cured in this way. Furthermore, intrauterine irradiation in no way mitigates against the success of a subsequent operation although this in my experience has never been necessary. In my series of 150 cases only one case required a second treatment because of hemorrhage.
FIGURE 4
Cervical myoma with adenocarcinoma of body. Showing the importance of diagnostic curettage in every case.
Complications
Nausea during the period of irradiation is not infrequent; we believe it is somewhat more fre- quent than following a simple dilatation and curet- tage. It is certainly not so frequent, severe or prolonged as generally occurs following a hysterectomy or other intraperitoneal operation. If present it disappears almost uniformly and immediately with the removal of the radium from the uterus. In many cases it is entirely absent and only in rare instances is it severe. Anesthesia, narcotization and the presence of a foreign body within the uterus doubtless account for the ma- jority if not all the cases. In my patients sodium luminal, 5 grs., are given hypodermatically as necessary, and serves to control the nausea and vomiting to a marked degree.
In a small proportion of cases leukorrhoea may be a post-operative complication of irradiation or more frequently a continuance of a previously present leukorrhoea may be observed. This type of leukorrhoea may continue for some weeks fol- lowing the post-irradiation amenorrhoea. Another complication which occasionally occurs is pia metria, the chief symptoms of which are severe pain in the region of the uterus, with fever and a sudden stopping of the uterine drainage. The condition usually occurs three to four weeks after the radium application, and is more prone to happen in those cases where there is cervical stenosis causing poor drainage from the uterine cavity. The treatment is dilatation and drainage.
The production of irradiation menopause may now be considered. This occurs with about the
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FIGURE 5
A high-power photomicrograph of Figure 4, showing adeno- carcinoma involving myoma. Secondary to the body of the uterus. A, B, C and D show carcinomatous cells scattered throughout the myoma.
same frequency and intensity as follows a bilateral oophorectomy.
As a general rule, the younger the patient, the more pronounced the menopausal symptoms. However, these, if severe, may be controlled nicely with amniotin or theelin in oil. One c.c. of either preparation given hypodermatically, once weekly, is usually sufficient to abate the symptoms. As the trouble subsides the injections may be given further apart.
Serial studies have shown that when a dosage of 1200 mg. hours is employed, climacteric symptoms other than the mere checking of the menstrual function in varying degrees of intensity will be produced in 60 percent of patients. In 36 percent the symptoms will be marked. As a rule they persist from a few months to two or three years and then subside. With the smaller dosage of from 300 to 400 mg. hours recommended for young women, in no case in my series has permanent amenorrhoea been induced. Our ob- servations substantiate the experimental work of Matthews and others who have found that the ovaries of young animals are more resistant to and exhibit greater regenerative powers after irradia- tion than do similar organs in older subjects.
Method of Treatment
Having decided that irradiation is indicated in any given case the usual pre-operative safeguards should be employed. In anemic patients a blood transfusion either before or at the time of irradia- tion is advisable. Five hundred c.c. is sufficient in the majority of cases.
Technique
Under anesthesia a careful pelvic examination
is performed. The size of the uterus is estimated and the depth of the endometrial cavity measured with a sound and recorded for future reference. A thorough curettage is performed and the curettings preserved for a histologic examination. The radium properly screened is inserted to the fundus of the uterus. By proper screening we mean a filter equal to at least one millimeter of platinum. Personally I use one millimeter of platinum, J4 millimeter of brass, and millimeter of aluminum. The radium, covered with one millimeter of platinum is placed inside of a metal intrauterine applicator eight cm. long and com- posed of J4 millimeter of brass for primary filtra- tion, covered with pj. millimeter of aluminum for secondary filtration. This tube can be disjointed in the middle by unscrewing, and the distal half is placed at an angle of about 130 degrees, which allows easy accessibility to the uterine opening. Fifty milligrams of radium are placed in the fundus area and 15' in the region of the cervical canal. Around the lower end of the tube is tied a No. 1 chromic suture and a linen thread. One end of the chromic suture is stitched through the cervix and tied. This insures the maintenance of the radium in the desired position. When the radium is to be removed, the chromic stitch is cut and the tube is then easily withdrawn by the linen. Fifteen hundred to 2,000 milligram hours is my standard dose, and is usually secured by applying 65 mg. of the element for the required number of hours. Except for the withdrawal of the radium the after-treatment is similar to that given to simple curettage cases. As a rule these patients remain in the hospital for five days. Some douches are administered, depending on the amount of vaginal discharge. It is unwise to permit the patient to go home earlier since the surgeon should see the patient through any possible complication arising from his surgical intervention. Our rule is that all irradiation patients return for examina- tion three and six weeks after treatment, and every four to eight weeks thereafter, covering a minimum period of one year. No special after- treatment is required in the average case other than good hygiene, regulation of bowels and an opportunity to recover from the effects of the anemia which has often been present.
Results
Not infrequently, after irradiation, one, oc- casionally two, rarely three menstrual periods occur prior to the onset of the permanent amenor- and Norris in which an end result study was pos- rhoea. Individual patients vary in this respect.
The period of the menstrual cycle in which the
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Type of Uterus and Result of Treatment
|
Fibrous Fibroid and Fibroma tous |
Menorrhagia and Metrorrhagia in Young Girls. |
|
|
Dose |
1500 - 2000 mg.hrs. |
300 - 500 mg.hrs. |
|
Age |
25 - 74 yrs . |
15 - 25 yrs. |
|
No. Cases |
140 |
Tb |
|
Failures |
1 (2nd treatment ( required |
Normal flow (3 moeJ to 1 year) |
|
Cases not heard from |
10 |
0 |
|
Grand total |
130 cases |
10 1 |
irradiation is performed has a bearing upon this point. If the irradiation is performed shortly before the expected period it is less likely to in- fluence the expected flow. Usually within four to six weeks at most, structural changes induced by the irradiation will have progressed sufficiently to check all bleeding. On this basis Gellhorn recom- mends irradiation soon after a menstrual period and this is undoubtedly the time of election.
All patients should be warned that the action of the radium is often slow, and they should not be discouraged if amenorrhoea is not produced at once. Among the 476 cases reported by Clark and Norris is which an end result study was pos- sible, 96 percent were cured either by the produc- tion of a permanent amenorrhoea, or a temporary amenorrhoea was produced followed by a return to the normal of the amount and periodicity of the menses.
Taussig collected statistics formulated from nearly 1,100 cases of myoma treated by irradia- tion, showing 95.5 percent of cures. Numerous other statistics could be quoted but we believe the above results demonstrated the average incident of cure in properly treated cases, and that further citation is therefore unnecessary.
Excellent results have also been secured in the treatment of uterine myomata by the X-ray. The disadvantage of the X-ray apart from the fact that the treatment is prolonged, lies in the fact that a curettage must be preformed as a separate procedure to exclude the possibility of overlook- ing the presence of a fundal carcinoma. If we accept the necessity for a routine diagnostic curettage, it is far easier for the patient, to irradiate at the same sitting rather than prolong the procedure over weeks or months with often no better end results. The incident of fundal carcinoma and myomata is relatively frequent. It is unlikely that the experienced surgeon will not at least suspect the presence of a fundal car- cinoma in an individual case. In large groups, however, occasionally such a mistake will be made due to the pre-existing symptoms from the myoma completely masking those of the carcinoma.
In conclusion may I say that we, therefore, believe that a curettage followed by a histologic examination of the curettings by a competent pathologist is an essential feature of every irradia- tion for hemorrhage of a supposedly benign origin. Neglect of this detail is to court trouble. The amount of irradiation generally applied for benign hemorrhage is from 1,200 to 1,500 mg. hours. In my series, however, I have given an average of from 1,500 to 2,000 mg. hours, with a maxi- mum of 4,000 in one case, which was an unusually large fibroid. I have had but one which required a second treatment because of hemorrhage, and this individual began to flow heavily eleven months after she had received an initial treatment of 2,350 mg. hours. She was accordingly given 2,000 mg. hours more, and has had no further trouble to date, it being one year since the last treatment. The heavier dosage which I have given undoubtedly accounts for the few recur- rences, which are less than are in general found in the literature. A combination of radium and X-ray irradiation may be well utilized in the treatment of large tumors in which removal is contraindicated. The contraindications to X-ray therapy are the same as for irradiation by radium.
Regarding hemorrhages of benign origin other than those caused by myomata, we may say that many pelvic and a few general conditions may result in pathologic uterine hemorrhage. It is unnecessary to enumerate these various conditions again. In the so-called myopathic hemorrhage irradiation is practically specific. These hemor- rhages are most prone to occur in women over 40 years of age, and are, therefore, especially suitable for irradiation.
There is little need for comparison between surgery and irradiation in the treatment of uterine myomata. The indications for surgery are well defined. Myomectomy and hysteromyomectomy are among the most satisfactory operations which the surgeon is called upon to perform both from the immediate and end-result standpoint. How- ever, the advantage of irradiation in certain types of cases are well proven, and the surgeon who submits these patients to operation is incurring an unwarranted risk, and will in the long run secure less successful results. Surgery is associated with an operative mortality of from two to seven per- cent, even in the most experienced and skillful hands, a clear salvage of from 1.82 to 6.82 per- cent. Markedly anemic patients are notoriously poor surgical risks and are the very type in which radium secures its most brilliant results. It is in such cases, as Kelly has phrased it, that radium is the modern medical miracle.
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Contact Dermatitis— -A Summary of Various Causes*
Carl W. Laymon, M.D., Ph.D.
Minneapolis
CONTACT dermatitis is the term common- ly used to designate the reactions of the superficial layers of skin which possesses an acquired hypersensitiveness to various external irritants. In America, eruptions belonging in this category have been called dermatitis venenata, occupational dermatitis, eczematous dermatitis, etc., while in Europe the word eczema is gen- erally used as a broad designation for the group.
Contact dermatitis seems to be distinct from the familial dermatosis known as atopic dermatitis, hay fever-eczema, or neurodermatitis dissemi- natus. The characteristics of the two conditions and the points of differentiation have been so well covered in publications by Coca ;4 2 3 Sulzberger, Spain, Sammis and Shahon,4 and others5 6 7 dur- ing the past few years that it is unnecessary to repeat them here.
Contact dermatitis is important in a multitude of industries. A surprisingly large number of occupational diseases involve the skin and of these dermatoses many are cases of contact dermatitis. Wise and Sulzberger9 brought out the fact that the number of industries which could be affected was surpassed only by the number of causative agents involved.
Dermatitis may occur within a short time or after longer periods (even years) of contact with an offending agent. Fungus infections, through interrupting' the continuity and lowering the natural resistance of the skin, are thought to be an important contributing factor in many cases. Burns, cuts, scratches, abrasions, and friction like- wise may permit the entry of an excitant which might otherwise cause no trouble if placed in con- tact with the unbroken epidermis. Experimental work has shown that the contact type of hypersen- sitiveness is in general favored through scarifying or traumatizing the skin.
Heat and moisture, which are more or less constantly present in many occupations, may also predispose to contact dermatitis. This fact is exemplified by the frequency of the condition in dishwashers, bakers, kitchen workers, housewives, etc. Any deviation from the normal condition of the integument whether it be maceration, or ex-
*From the Division of Dermatology, University of Minne- sota, H. E. Miehelson, M.D., director, and the Dermatology Clinic, Minneapolis General Hospital, S. E. Sweitzer, M.D., chief.
cessive dryness with resulting fissures, favors the development of contact dermatitis by rendering the protection of the skin inadequate.
Why a person who has been in contact with a particular substance for a long time should rela- tively suddenly develop hypersensitiveness can- not at present be satisfactorily explained. As Sulzberger5 stated, there are three developmental steps in the chronology of contact dermatitis:
1. Period of refractoriness to sensitization, which may vary from zero to many years.
2. Period of incubation of sensitivity, which Sulzberger, from studies in butesin sensitivity, be- lieves is usually from nine to 14 days.
3. Period of reaction time, or that period which elapses between contact with the excitant and the appearance of the eruption in the hypersensitive individual. This may also vary from case to case but is usually from 18 to 72 hours.
Broadly speaking, in eruptions occuring about the face and neck one must first consider as causative agents articles of clothing and cosmetics of all types (especially in women) and plants. Seasonal eruptions occuring yearly at definite times immediately suggest pollens as the etiologic factor. Dermatitis on the hands and in other areas requires most careful questioning in the search for the cause. As Anderson and Bruns- ting6 mentioned, a disabling dermatitis in a den- tist may be due to procaine or the hydroquinone X-ray developing fluid. Dermatitis in a florist may be due to any of several plants or the insec- ticide which he uses. Each case requires strict individualization and but few set rules can be applied.
In contrast to the excitants in atopic dermatitis which are proteins (foods and inhalants), the causative agents in contact dermatitis are extreme- ly varied in nature, and include a multitude of non-protein substances. In considering these, it must be remembered that the skin may react to a great number of so-called primary irritants, such as strong caustics, acids, alkalies, escharotics and rubifacients, without the existence of a state of hypersensitiveness. Certain strong cleaning powders and fluids, soaps, grease removers, etc., are included among the primary irritants.
In some cases the nature of the excitant is plainly evident while in others it is extremely
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obscure. Anderson and Brunsting® mentioned the fact that a certain Sherlock 1 Iolmes attitude is necessary in order to he successful in analyzing these cases. Sensitizations may he single or mul- tiple and may he grouped to involve related chem- ical compounds or species of plants. Generally speaking, sensitization to one excitant has a ten- dency to favor the development of polyvalent hypersensitiveness. In patients who are thought to have occupational contact dermatitis, the pos- sibility that the irritant is present in the surround- ings away from, rather than at work must not he forgotten.
An exhaustive complete list of all of the sub- stances which have been reported as causing der- matitis is practically impossible and the number is steadily increasing. In the following discussion an attempt is made to broadly group these excitants as well as possible and especially to include the causative agents which have been reported in the past few years. There is by necessity considerable overlapping. Weber,9 in 1930, compiled an ex- tensive list of cutaneous irritants, which may be referred to for specific substances. In the derma- tology clinics at the University of Minnesota and Minneapolis General Hospitals, numerous and varied causes of contact dermatitis have been found. For brevity, personal experiences will be omitted in the following discussion.
A. Plants:
The best known example of contact dermatitis is that due to poison ivy (rhus toxicodendron), the active principle of which is an oleoresin. In 1922, Spain10 showed by patch testing 80 indi- viduals with alcohol and chloroform extracts of the leaves, that 65 per cent of persons eight years of age or over were susceptible to poison ivy. In contrast, no positive reactions were obtained by the same method in 18 infants between five and 18 months of age. About the same time Coca11 obtained similar results which substantiated the findings of Spain. By patch testing 12 adults over 20 years of age, only one remained un- affected, while one of 12 children five years of age or under was found to be susceptible.
In 1928, Straus12 tested adults with the alco- holic extract of poison ivy in lanolin, and found that 75.6 per cent reacted positively, while 119 newborns showed no positive reactions. He be- lieved that the reason for this was lack of contact with poison ivy rather than lack of ability to be- come sensitized. He substantiated his views by showing that 72.9 per cent of 48 infants which had been among the 119 originally tested, gave
positive reactions on repeated patch testing after an interval of two to four weeks.
I reatment by intramuscular injections of ivy oil may be given prophylactically in highly sensi- tive patients or during the actual attacks. In some instances, it seems that susceptibility to the plant may be lessened or the duration of an individual attack shortened.
In the rhus genus of plants are the following species, any of which may cause dermatitis: Rhus toxicodendron (poisin ivy), rhus venenata (poison sumac), rhus diversaloba (poison oak), rhus vernicifera (Oriental lacquer plant).
The primrose may cause acute or chronic der- matitis with about the same ease as does poison ivy. Low13 was able to sensitize himself and two of eight others by repeated contact, who were at first not susceptible to the plant. Bloch14 15 was able to do the same thing in 100 per cent of attempts. These experiments with primrose and ivy sensitization show that in the specific instances concerned at least, cutaneous sensitization can be induced at will, which is in direct contrast to the atopic form of hypersensitiveness.
Simpson16 and Keston and Lazio17 have with- in the past few years also discussed and reported cases of primrose dermatitis.
Pollen Dermatitis — Contact dermatitis due to pollens is characterized by definite seasonal recur- rences during the particular time of pollination of the plant in question, involvement of the exposed surfaces of the body (face, neck, hands, arms and legs), and as a rule complete absence of other allergic disorders such as hay fever and asthma. Until the work of Brown, Milford and Coca18 it was generally believed that the hay fever pro- ducing portion of the pollen also caused contact dermatitis. Among the reports in recent years Sulzberger and Wise19 described a case of rag- weed dermatitis which they believed was caused by the ragweed pollen atopen. Even at that time, however, they reported that scratch tests were negative while patch tests with the same material were positive. Brown, Milford and Coca dis- covered then that a definite positive contact re- action could be obtained in patients with ragweed contact dermatitis using the oily residue of the pollen extracted with the usual fat solvents. In the same patients patch tests with pollen from which the oil had been removed were completely negative, proving that the cases of ragweed pollen contact dermatitis were not caused by the atopic water soluble excitant in the pollen. Patch, and especially scratch tests thus are negative when
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the pure form of the water soluble atopic excitant portion of the pollen is used.
Gay and Ketron20 in 1932, and Pascher and Sulzberger21 in 1933, verified the earlier findings of Brown, Milford and Coca. In the patient of Gay and Ketron a dermatitis of the exposed por- tions of the body had been present for 13 years, beginning always about August 15th. There was no history of atopic disease and intradermal tests for pollens were negative. Patch tests with raw pollen and pollen oil were positive. Pascher and Sulzberger also believed that in their two cases the causative factor was the pollen oil.
Their observations as to pollen oil apply in general to all plants which cause dermatitis. There are, however, occasional exceptions such as those which Pascher and Sulzberger mentioned : Angel- ica silvestris, in which the active principle is a lactone, and cinchona bark in which it is the water soluble alkaloid quinine.
In the case of pollen dermatitis the various indi- vidual members of the same general group will cause positive patch tests as a rule. Lor example, giant as well as westward ragweed and burweed marsh elder, which also belongs to the ragweed group, usually all cause an eczematous response in the susceptible patient. Anderson and B runsting6 noted this in one of their cases of ragweed der- matitis. This is not invariably true, however. Huber,22 and Huber and Harsh23 reported three cases of dermatitis recurring in the late summer months in which patch tests were positive only to the burweed marsh elder. Ramirez and Eller21 noted a case of summer dermatitis during June and July accompanied by hay fever from August until frost in which patch tests were positive only to timothy, while scratch tests were positive to ragweed, also illustrating the fact that contact dermatitis and atopic manifestations may occur simultaneously but separately in the same patient. In the above patient scratch tests of timothy, and patch tests of ragweed were completely negative, bearing out the fact that the excitants of the con- tact and atopic types of pollen hypersensitiveness are distinct from one another.
The same general statements made concerning the ragweed family apply to other plant groups. Some favorable results in the treatment of this condition have been reported, such as those of Ramirez and Eller,21 and Pascher and Sulz- berger,21 especially in the case of ivy, ragweed and chrysanthemum, using the concentrated plant oil diluted in almond oil and given intramuscularly in gradually ascending dosage. The method is worthy of trial for shortening the duration and
severity of individual attacks and for attempts at pre-seasonal desensitization in instances of plants pollinating or abounding during definite periods such as ragweed, sage, thistle, pigweed, timothy, etc. From their study, Ellis and Rosendahl25 26 found the following plant groups most important in Minnesota from the standpoint of pollens. The table is of value in attempting to determine the cause of seasonal pollen dermatitis in this vicinity : Group Time of Pollination
Ragweed July 28-Sept. 20
Sage-wormwood July 6-Oct. 1
Blue grass May 22-July 30
Millet June 5-Sept. 20
Timothy Mav 20-Sept. 1
Grama grass July 1-Sept. 15
Rye ■ June 1-Aug. 20
Pigweed June 15-Sept. 10
Sweet vernal grass May 8- July 20
Russian thistle June 15- Aug. 30
Only a few other reports will be mentioned here although practically any plant can cause derma- titis in a susceptible person. For an extensive list of plants reference may be made to the article by Weber,0 and for a discussion of tropical plants to the excellent work of Pardo-Castello.27
Overton,28 and Welker and Rappaport20 re- ported cases of dermatitis of the hands due to con- tact with tulip bulbs. The latter case occurred in a worker in the plant and bulb section of a depart- ment store and was seasonal, beginning in October and clearing up in January, since the store stocked the bulbs during that particular period. Patch tests of aqueous and ether extracts of tulip bulbs were positive and passive transfers using the Prausnitz-Kustner method were negative.
Geranium and chrysanthemum dermatitis is relatively common, especially among florists. J. W. Anderson30 reported an example of gera- nium dermatitis due to a house plant. Patch tests, using the leaves, were positive. C. R. Anderson and Brunsting,6 and Pilot31 have recently observed examples of chrysanthemum dermatitis. The former occurred in a female who worked with flowers a great deal. Patch tests to various plants were negative except in the case of chrysanthe- mums which caused positive reactions both with the flower and the leaf. It is usually true that the active principle of a dermatitis producing plant is contained in all portions of the plant. Anderson and Brunsting believe that the chrysanthemum, gaillardia, cineraria, snapdragon, poinsetta, gera- nium and pyrethrum are among the most impor- tant plants from the standpoint of contact derma- titis.
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Pilot’s patient was a florist who had a dermatitis of the face, neck and wrists for 10 years during the fall and early winter. Patch tests to the plant oil of chrysanthemum were strongly positive in 48 hours while the aqueous extract caused no re- action.
O’Donovan32 reported two interesting cases of dermatitis due to hops in workers in the English hop fields.
Schur33 observed an odd case which was shown to be caused by the osage or wild orange.
B . Cosmetics and Toilet Articles:
This group includes a multitude of substances such as depilatories, deodorants, mouth washes, toothpastes, and powders, face and talcum powders, creams, rouges, eye shadow, lipstick, mascara, hair and skin bleaches, hair dyes, toilet waters and perfumes. As in the plant group any individual compound may be etiologically impor- tant in the hypersensitive person and yet be innocuous to many others. Wise and Sulzberger8 brought out the fact that in eruptions about the face and neck, the patch test should be applied as near as possible to the area of actual dermatitis, since localized areas of hypersensitiveness are not uncommon.
Cole,34 in 1924 and later in 1927, 33 made exten- sive investigations of injuries caused by cosmetics, both in his own experience and from reports of many other dermatologists throughout the coun- try. He found such dermatoses to be surprisingly frequent.
Various metals and other substances enter into the composition of cosmetics. Lead is found as acetate in hair dyes, and as carbonate in face enamels and creams to give a soft "feel.” Mercury also is an ingredient in certain dyes but is more common in face creams and skin bleaches as ammoniated mercury. Mercuric chloride enters into the composition of freckle lotions and creams. Calomel is found in some toilet creams. Calcium and barium salts are contained in depilatories. Most important of all as causes of dermatitis are the paraphenylendiamin compounds which are used frequently in hair dyes as they stain numerous colors, are quick in action, easily applied, and penetrate deeply. Many other sub- stances are occasionally found in hair dyes such as silver compounds and pyrogallic acid. Resorcin, salicylic acid, menthol, quinine and wood alcohol often go to make up hair and skin "tonics,” all and any of which may cause violent dermatitis.
Sulzberger and Kerr3 reported two cases of diffuse, red, scaly eruptions on the face and neck due to powder, as well as dermatitis of the hands
and wrist due to a supposedly soothing cream. Patch tests were positive for the offending sub- stance in each case.
Engmann and Wander36 reported the case of an actress who was hypersensitive to mascara, which caused a dermatitis of the eyelids each time she used the cosmetic. Patch tests applied on the chest, however, were negative. In this type of case, tests may succeed when applied just above the eyes. The same workers also related similar cases due to cold cream and powder.
Lane and Straus37 observed a patient who suf- fered with a dermatitis of the neck following the application of toilet water. The active ingredient was found to be quinine. P>urgess and Usher38 reported 10 similar cases which were found to be due to quinine in shaving lotion. Ford39 noted a patient who at first developed an eruption on the face following the use of a hair tonic contain- ing quinine. About six months later he returned with an edematous, vesicular, dermatitis of the penis, scrotum, cheeks, ears and neck. The night previously his wife had used a vaginal contracep- tive suppository and he awoke the following morning with severe itching of the genitalia. A day later the face became affected. Investigation showed that the contraceptive contained quinine bisulphate. Enough of the drug was apparently absorbed and hematogenously carried to the areas of the previous involvement to cause an exacerba- tion of the dermatitis in those areas.
Ramirez and Eller24 reported cases of derma- titis due to egg white (contained in shampoo), flaxseed (hair tonic), alcohol (external use), orris root (powder), icthyol (in shaving cream), and human hair (wig) .
Harner,40 Bourbon,41 and Jamieson42 reported cases of severe dermatitis about the eyes accom- panied by conjunctivitis, due to eyelash dye. Jamieson's patient suffered loss of vision due to corneal opacity.
C. Clothing Material:
Included in this group are the various textiles such as cotton, wool, silk and rayon; as well as leather, furs and feathers, making it a rather heterogenous but convenient classification.
Case 4 in Lord’s43 report was apparently one of contact dermatitis due to wool, even though percutaneous as well as patch tests were positive to sheep wool. The patient, who was 42 years of age, developed an eruption six years previously on the hands, wrists, axillae and antecubital spaces, which was aggravated by contact with woolen garments. Following the holding of a wool covered electrode during the removal of
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hairs by electrolysis she developed an acute der- matitis on the palm a day later. Ramirez and Eller,24 and Sulzberger and Morse44 also men- tioned cases of contact dermatitis due to wool and lanolin (wool fat).
Ramirez and Eller24 observed dermatitis due to linen.
Anderson and Brunsting6 related the case of a male, aged 36, who developed an acute vesicular dermatitis following the wearing of a new pair of rayon hose. Wrapping one sock around the forearm duplicated the eruption.
Klauder70 described a patient who was unable to wear black silk whereas white or any other color of silk caused no eruption. Cotton or any other material, even though dyed black, caused no dif- ficulty. The dermatitis first appeared when the patient was six years of age and the degree of hypersensitiveness was just as great at the time of the report when the patient was 61 years old.
Lewis45 observed two patients with dermatitis affecting the feet and ankles, one who was hyper- sensitive to “bleached kip” (which is made from cowhide and used as a lining in shoes), and another to leather proper. Lewis brought out the fact that tanning is a complicated process which utilizes many chemicals such as tannic acid, chromium sulphate, coal tar dyes, and wood ex- tracts, all of which may cause dermatitis. Ander- son and Ayres46 observed a similar case which had been previously diagnosed eczema arid fungus infection. It was not definitely determined whether the dye or the leather was at fault. Park- hurst47 treated a male, aged 50, who was hyper- sensitive to undyed deerskin leather and developed an acute dermatitis of the hands and wrists upon wearing deerskin gloves. Sulzberger and Kerr5 related a case of dermatitis due to leather in hat bands. The patient had been treated for 17 years for seborrhea.
Cole35 mentioned the frequency of furs and fur dyes as etiologic factors in contact derma- titis. Ramirez24 and Eller noted similar cases.
Simon and Rackemann48 told of a patient who suffered repeated attacks of contact dermatitis on different parts of the body, due to various articles of clothing. The overcoat collar, garters, socks, shoes, suit linings, his wife’s dresses, furniture upholstery and other components of his attire were incriminated at one time or another.
D. Soaps and Washing Materials:
Members of this group of substances, which includes a multitude of solid, liquid and flake soaps, washing compounds, bleaches, scouring powders, water softeners and starch frequently
cause acute, subacute, or chronic eruptions espe- cially on the hands and wrists. It should be re- membered that many such compounds are primary irritants and cause dermatitis in which no phenom- ena of hypersensitiveness are involved. To be of any diagnostic significance patch tests must be applied in weak concentration (l/2 to 1 per cent). E. Foods:
In 1930, Feit49 presented a patient to the New York Academy of Medicine, who was hypersen- sitive to cake dough. The man was a baker and developed dermatitis of the hands whenever he handled dough which contained sugar such as that from which cake and cookies are made. The dough used in making bread and rolls caused no trouble.
Tulipan50 also treated a baker who was intol- erant to cinnamon. In his work he came in contact with flour, baking powder, cream of tartar and cinnamon. Only the latter gave a positive patch test.
Van Vono, Stuycken, and Bonneire51 believed that occupational dermatitis in bakers was fre- quently due to ammonium persulphate, a substance used by millers to improve the quality of the flour.
Fanburg and Kaufman52 observed a worker in a beverage factory who developed an eruption of the hands and forearms about a week following the peeling of lemons. Contact tests were negative for lemon juice but positive in 24 hours for lemon peel .
Kesten and Lyons53 reported three cases of contact dermatitis due to orange peel, and stated that it was frequent in pickers of the fruit. All of their patients encountered no difficulty on drinking orange juice. In one patient, a fruit and vegetable merchant, desensitization was accom- plished by means of subcutaneous injections of the ether and alcohol extract of orange peel, be- ginning with a 1 :10 dilution of the extract which would just give a positive patch test. These were continued four months until the dosage at the end of the treatment had been increased to one c.c. of a dilution 1,000 times the concentration of the initial dose. Patch tests with one per cent oil of orange, and orange peel were then negative, and at the time of the report the eruption had not recurred in seven months.
Rinkel and Balyeat54 reported the case of a salad maker, 43 years old, who had suffered from an acutely exacerbating' dermatitis of the hands, arms, neck and face for five years, accompanied by pruritis and occasional urticaria. There were no other allergic disorders either in the patient or her family. Scratch tests to lettuce as well as to
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danders and pollens were negative. She believed, however, that lettuce was a contributory factor and though she continued making salads she cleared up within three weeks when other workers handled the lettuce. She remained free from trouble if she neither ate nor handled lettuce. Even after eating lettuce she would develop the typical contact type of dermatitis. Latch tests with lettuce were strongly positive and surprisingly a positive reaction was later obtained in intradermal testing with lettuce extract. This in all probability was the contact rather than the atopic type of hyper- sensitiveness, and upon ingestion of the excitant enough reached the contact layers of the epidermis to produce the eruption, as is the case in the eczematous type of drug eruptions. It was not stated how much time was required before the intradermal test became positive. As the authors stated, it is difficult to evaluate this finding.
Ramirez52 and Eller experienced contact der- matitis due to grapes. Asparagus, celery, toma- toes, and many other fruits, vegetables or foods may occasionally be responsible for the production of this type of eruption.
F. Medications, Drugs, Antiseptics , Etc.:
Innumerable chemical compounds used either singly or in combinations in various types of medi- cation may cause contact dermatitis of any part of the body.
Anesthetics — One of the best known examples is the eruption frequently produced by procaine in dentists, nurses and physicians. Klauder,55 Sulzberger7 and Wise, Kesten and Lazio,17 Lane,50 Ramirez and Eller,24 James,57 and others have reported such cases. The eruption is almost always on the hands and subacute or chronic in its course. Patch tests with one per cent procaine are usually positive.
Keston and Lazio17 reported a case of hyper- sensitiveness to noval, an anesthetic related to novocaine.
Greenwood and Quest58 observed a patient with, an eruption due to butyn, and emphasized the fre- quency of dermatitis due to related substances such as stovain, apothesin and procaine.
Sulzberger and Wise,7 and Fowlkes50 noted cases of sensitization to nupercaine, prepared in ointment form for pruritic conditions, especially of the mucosae.
Dermatitis from butesin picrate, often used in the treatment of acute burns, is relatively fre- quent. Pusey and Rattner,00 Jackson,61 and Fox62 reported such cases. Sulzberger and Wise63 noted that butesin not commonly causes
a follicular eruption accompanied by edema, while picric acid gives rise to erythema and vesiculation.
Antiseptics — Keston and Lazio17 observed a nurse who complained of a dermatitis of the hands following the use of potassium mercuric iodide as an antiseptic in a contagion ward. Desensitization in this case was successful by first immersing the hands in a one to 100,000 dilution of the drug for one minute and gradually increasing the con- centration and time daily until she could tolerate a one to 5,000 dilution for five minutes. She was then able to use scrub brushes dipped in the anti- septic without further difficulty.
Pascher and Silverberg64 treated five patients who were shown by the patch test to be hyper- sensitive to mercurochrome and associated mer- curical drugs such as metaphen, ammoniated mer- cury, mercury oxide and mercuric chloride.
Cummer65 reported two cases of sensitization to hexylresorcinol ; one in which the solution (S. T. 37) was used as an antiseptic, and one in which it was contained in toothpaste. Mitchell66 also experienced a case of resorcin sensitization. The substance was contained in suppositories and caused an acute dermatitis in the anal region.
McNair and Neff67 reported dermatitis due to Dichloramin-M, an antiseptic similar to Dichlora- min-T. They stated that both substances could cause eruptions and that prevention was possible in the case of Dichloramin-M and probably in the case of Dichloramin-T by the washing of the ex- posed skin with reducing agents such as aqeous potassium iodide or sodium thiosulphate.
Sulzberger and Kerr5 reported a case of derma- titis of the hands and arms which was shown to be caused by a new proprietary ointment (mazon) which the patient had contacted in washing her daughter’s clothes. The latter was using the preparation to treat a ringworm infection. Patch tests on the mother with mazon ointment were strongly positive. The same authors also observed a case of hypersensitiveness to calmitol, another proprietary product.
In 1928, Perskv68 presented a patient to the Brooklyn Dermatological Society who had a der- matitis of the trunk due to the plaster contained in a cast which was applied for tuberculosis of the spine.
Halloran69 emphasized the wide range of pos- sibilities of arsenic as a causative agent of con- tact dermatitis (as well as dermatitis medicamen- tosa) .
Scheer,70 and Ayres and Anderson71 reported cases of contact dermatitis due to ephedrine.
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These eruptions are usually localized to the face, since the drug; is usually used in nasal sprays.
Wolfe and McLeod72 observed a patient with a severe dermatitis about the eyes due to atropine. The eruption was at first thought to be erysipelas. Patch tests were positive to atropine. Cummer73 noted a dermatitis of the eyelids which was caused by dionin (ethylmorphine hydrochloride), a drug commonly used as a lymphogogue in eye con- ditions. In this case, hypersensitiveness developed after 1 1 years’ usage of the drug. Exacerbations of the eruption were definitely associated with the use of dionin, though patch tests were negative.
Heller74 observed an eruption in which patch tests to opium were positive, due to the local appli- cation of lead and opium wash. Opium taken by mouth caused an exacerbation of the dermatitis.
Nelson75 reported a case of dermatitis of the hands which was proved by patch tests to be due to oil of cade. The tests- were positive to all con- centrations of the drug which were stronger than 0.5 per cent. There was rapid involution upon dis- continuing the drug.
Cummer76 treated a patient who had used an ointment for a burn containing, among other med- icants, Balsam of Peru. An acute dermatitis re- sulted, and of all the ingredients only Balsam of Peru reacted positively upon patch testing.
G. Insecticides and Parasiticides :
As a general rule these compounds contain as an active ingredient either pyrethrum or sodium fluoride. In instances where hypersensitiveness exists to only one type of substance a substitution may be made and thus avoid dermatitis. Keston and Lazio17 cited the case of a zoologist who had a dermatitis of the face, neck and arms which was found by patch testing to be caused by pyrethrum contained in “Black Flag” and “J. O.” insecti- cides. He changed to a sodium fluroide product and was free from trouble henceforth. Sulz- berger and Weinberg77 reported a similar case of dermatitis involving the arms, legs, neck and body in a housekeeper due to Black Flag (pyreth- rum) insect powder which was being distributed periodically in the patient’s work room. McCord, Kilker and Minster78 stated that pyrethrum der- matitis was common in makers of insect powder.
H. Woods:
Senear79 recently discussed in detail the ques- tion of dermatitis due to woods. He believes that such cases are relatively common and that woods of temperate climates give rise to reactions more often than is generally supposed. Dermatitis may develop at any time following contact, but in
general appears within a few days to a few weeks. The toxic agents are usually nonsaturated resinous acids or alkaloids, although other chemicals may be responsible in some cases. Senear reported a case of dermatitis which he treated which was due to contact with yew wood, used in making high grade archery bows.
Among the Oriental and other foreign woods which Senear found that had been reported as causes for eruptions were : Coco-bolo, satinwood, teak, lemon wood, acacia, Borneo rosewood, olive wood, cocos wood, sobica and partridge wood. In certain instances actual contact is not necessary, enough of the excitant being present in the air to cause trouble. Among the common woods which Senear mentioned were : Oak, beech, acacia, chestnut, poplar and elm.
Senear also reviewed “forest essence” derma- titis or woodcutter’s eczema, which has been described in France and Italy, and which is in reality contact dermatitis.
Wood preserving materials such as coal tar distillates, water gas tar, and zinc chloride may cause dermatitis as well as the woods themselves.
/. Metals:
Dermatitis due to nickel has been known for many years to exist quite commonly among nickel- platers and workers who handle the metal or its salts in industrial plants. Goldman80 recently re- viewed the subject of dermatitis due to nickel and reported two cases in nickel workers, both of whom developed the eruption in the first few days of contact. The author also discussed the possibility of nickel coins and nickel-plated objects as potential eczematogenic agents and suggested that these articles should be considered in studying dermatitis of the hands of hitherto unknown etiology. In Goldman's first case, patch tests were done with one per cent nickel sulphate, one per cent nickel chloride and pure nickel (metal). All were strongly positive except the latter. In the second case nickel sulphate, nickel ammonium sul- phate, nickel propionic acid and nickel lactate were used. All caused positive responses in the test areas, showing that the hypersensitiveness of the skin was to the nickel ion in combination with either organic or inorganic acids. Goldman, through further testing', found that the specificity was so strict that the skin did not react even to the most closely related chemical substance, cobalt.
Lain,81 Fox,82 McAlester and McAlester,83 and others7 have reported cases of dermatitis due probably to the nickel contained in alloys used in spectacle frames and jewelry. So-called white gold is an alloy of gold, copper and nickel and
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may cause eruptions over the bridge of the nose, sides of the face, and behind the ear due to con- tact with spectacle frames, or on the wrists and fingers due to wearing a wristwatch or ring. In these cases substitutions as to the type of spec- tacle frame or jewelry should be made.
Bronze contains copper, aluminium, lead, tin, arsenic and iron, and bronze powders are ordi- narily affixed to surfaces that are being printed by means of glues, sizes or bronzing liquids. Either the bronzing powders or the fixatives may cause dermatitis.
/. Dyes (All Types):
It has been mentioned previously that the para- phenylendiamine dyes are frequent excitants in contact dermatitis. Sulzberger and Kerr-' re- ported a case of dermatitis of the feet due to a black shoe dye of this type. Brown shoes and certain black ones caused no difficulty. Patch tests with two per cent paraphenylendiamine in vase- line were definitely positive.
Orthodichlorabenzene, methyl alcohol and ani- line black may also be contained in certain shoe dyes and potential excitants of contact dermatitis.
The reports of Ixesten and Lazio,17 Ramirez and Eller,24 and Cole35 emphasized the frequency of dermatoses due to paraphenalyendiamin and fur dyes.
Rowell84 reported a rather unusual case of der- matitis produced by a red dye in colored paper. A child, in an attempt to play “grown up’’ had used the paper as rouge to redden her cheeks with the resulting acute eruption. The exact nature of the dye was not determined.
Billington85 experienced and reported acute dermatitis in himself caused by the dye in a velour upholstered chair, which was Bindsched- ler’s green, one of the paraphenylendiamin group.
Cummer86 observed a patient who suffered a dermatitis of the buttocks due to contact with a red-stained toilet seat.
Oliver reported 15 interesting cases in which eruptions of the face, neck and eyelids appeared every Monday or Tuesday after the patients had read the rotagravure section of the Sunday news- paper. After appropriate patch testing, Oliver found that the excitant was para-red dye con- tained in the rotogravure ink.
K. Oils, Shellac, Lacquer, Varnish, Paint, Glue, Solvents, Etc.
Pusey88 and later Williams89 reported cases of dermatitis due to a type of lacquer, which is made from rhus vernicifera, the Oriental lacquer plant. Pusey ’s case occurred in a dealer of cheap lac-
quered bracelets and was successfully treated by means of rhus toxicodendron (ivy) extract, both plants being in the same genus. Williams men- tioned the frequency of lacquer dermatitis in Oriental countries and the occasional production of eruptions by mah-jong boxes and tiles.
Voukon10' observed dermatitis due to linseed oil.
Sulzberger and Wise7 mentioned kerosene and reducing fluids and inks as the causes of derma- titis in printers.
Ramirez and Eller24 listed glue as a cause of contact dermatitis. One such case occurred in a worker in furniture and another in a violin maker.
I he same authors found rosin to be the excitant in another violin maker. Dermatitis of the hands due to the varnish on an automobile steering wheel was also observed.
Turpentine is a relatively common excitant in contact dermatitis and is frequently found in paints and floor-oiling preparations. Bloch14 used turpentine as one of his standard test substances in contact dermatitis. McCord90 discussed derma- titis due to wood turpentine and reported fre- quent out-breaks in workers with the substance. Turner91, in reviewing the causes of dermatitis among painters in an industrial plant, stated that solvents such as turpentine, paint thinner, and naphtha were the most frequent.
L. Rubber Goods
Obermayer02 reported an interesting case of a physician who was unable to wear rubber gloves due to the development of acute dermatitis of the hands. He later suffered an eruption on the geni- talia which was ascribed to a rubber condom. Obermayer very skillfully determined that sul- phur monochloride which was used in the process of cold cure vulcanization, was the actual excitant rather than the rubber itself. Tbe similarity of this substance to mustard gas led to the idea of rendering it inert by the use of akali. The patient was then able to wear gloves treated with 4 per cent sodium hydroxide without further difficulty.
Niles93 observed a patient who presented a weeping eczematous patch due to a rubber bunion protector on the inner surface of each great toe. The manufacturers stated that the article was 90 per cent pure virgin rubber and 10 per cent re- claimed rubber and that sulphur was used as a vulcanizing agent. Rubber in the patient's corsets and garters, and rubber gloves had never caused trouble. It is possible that the actual excitant in this case was the same as that in Obermayer’s.
Fox94 reported an odd case of dermatitic of the eyelids due to the rubber portion of an eyelash
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curler. It was at first thought to be due to cos- metics, but continued observation proved the source of irritation, which was verified by the patch test.
M. Polishes (Shoe, Furniture, Metal, Etc.)
Substances in this group should be thought of
as occasional excitants of contact dermatitis.
N . Miscellaneous Substances
This group contains a number of compounds which are not closely related and some which cause difficulty in several industries.
Many attempts, with varying degrees of suc- cess, have been made to sensitize the skin of ani- mals and humans to chemicals of known formula. Silverberg’s95 work with mesotan, a drug intro- duced in 1902 for the percutaneous treatment of diseases which responded to salicylates, was re- ported in 1930. It had been noted that sensitization of the skin to mesotan (C6H4OH COOH'°'CsH) was quite frequent and took place usually after repeated rather than the first application. The drug is formed by the action of formaldehyde, methyl alcohol, and hydrochloric acid on sodium salicylate. It is easily split, and even with small amounts of water forms formadehyde and a small amount of salicylic acid.
Silverberg found that none of the 124 patients who had had no previous contact with mesotan, were primarily hypersensitive. Six of 11 patients who were rubbed repeatedly with the drug be- came generally hypersensitive in 1 1 to 34 days after the first application. Some reacted thus even to contact with minute amounts. In all but one case the type of hypersensitiveness was monova- lent and in none of the cases was there any urti- carial element. Passive transfers were uniformly unsuccessful.
Silverberg also cited the work of others who had successfully sensitized human skin to chem- ical compounds of known formulae, which in- cluded salicylate preparations, mustard oil. cignol- inbenzol, sodium nirvanol, arsphenamine, neoars- phenamine, and orthoform. She felt that each sub- stance in question must be studied individually and that no broad generalizations concerning skin sensitization to chemicals could be made.
Dermatitis due to chromium compounds is im- portant in blueprint workers, lithographers and photographers. Parkhurst96 reported such a case in a patient who had worked in blueprints for 6 weeks. Through patch testing the offending salt was found to be potassium bichromate. It was pos- sible to avoid difficulty by washing the hands in a saturated solution of sodium bisulphite and then water. The bisulphite acts as a reducing agent and
changes the chromium atom from the hexavalent to the trivalent state in which form it is apparently non-irritating.
McCord, Higginbotham and McGuire 97 also discussed the question of dermatitis due to chro- mium compounds, and stated that, although their irritating and toxic properties were recognized, they were still used on account of their superiority to substitutes. These investigators were able to ex- perimentally produce dermatitis in 20 to 25 litho- graphers by the cutaneous application of gauze moistened with solutions of chromic acid and po- tassium and ammonium bichromate. Smith98 also mentioned the frequency of dermatitis among chromium workers.
In photographers the skin comes in contact with numerous chemical compounds contained in de- velopers, among which are potassium bromide, sodium sulphite, amidol, metol, etc. “Amidol,” used in developer, is the trade name for diamido- phenol and is thought to be less irritating than “metol” (mono methyl-p-amido-m-cresol sul- phate). Patients who are susceptible to either me- tol or amidol may shift to the other and usually escape dermatitis. Hypersensitiveness to metol however, predisposes markedly to polyvalent sen- sitization which may include amidol.
A striking example of contact dermatitis is so called “match box dermatitis,” which was dis- cussed by O. Foerster" in 1923. This type of dermatitis first appeared about 1914 when phos- phorus sesquisulphid came into the match industry in the use of the “strike anywhere” match. In this condition sharply circumscribed areas of derma- titis appear under the pockets in clothing where matches are kept. The thigh is a common location. Removal of the cause usually effects a cure rapid- ly, though occasionally it is necessary to change the lining of the pocket.
Such compounds as bakelite, laconite, etc., oc- casionally cause dermatitis. Eller100 reported a case due to radio ear phones and stated that they were constructed from either a phenolic compound similar to bakelite, or laconite which contains shellac, rosin, marble dust, carbon, fossil gum and mica filler. Dermatitis may result from either type of compound. I. C. Sutton101 observed a patient who had an acute eruption caused by black horn- rim spectacle frames made of Zylonite, similar to bakelite. He also mentioned cases of dermatitis about the mouth from cigar holders and of the ear from ear phones of similar composition.
Beinhauer102 observed a violinist who had con- tact dermatitis due to rosin which he used on the bow. Patch tests were positive to dark rosin only.
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Crutchfield10^ reported a case of dermatitis due to the Portuguese Man-of-War. The tentacles of the animal, which is a coelenterate, contain an irri- tant which may cause an eruption in certain indi- viduals.
Johnson104 noted that ethyl gasoline might cause contact dermatitis. In a patient which he treated, patch tests with ethyl gasoline were posi- tive in dilution of 1 to 500 while tests with ordi- nary gasoline were negative.
Weber105 recorded the observation that the or- ganism brucella melitensis abortus, which causes abortion in cattle, may bring about a cutaneous eruption not due to direct infection but to a mech- anism of hypersensitiveness. He noted cases in veterinarians.
In cement workers, lime, sulphur, trioxide and calcium hydrate are capable of provoking cutane- ous reactions.
Hydrolene oil (asphaltic pitch) which is con- tained in briquettes, occasionally causes dermatitis, especially in coal drivers.
Taylor100 reported a cutaneous eruption which followed the dressing of rabbits.
As lias been mentioned earlier, this discussion does not include a complete list of cutaneous ir- ritants, but gives the most common as well as some of the rarer excitants. New ones are being reported frequently and it is not amiss to state that almost anything is capable of producing con- tact dermatitis in the hypersensitive individual. The Patch Test:
The scratch or intradermal tests which are used in atopic dermatitis are as a rule negative in con- tact dermatitis. The patch test, which is of great value in determining the cause of contact derma- titis has been described and discussed so many times recently that the method used need not be repeated here.
A positive patch test does not always indicate that the responsible substance has been found, nor does a negative test rule out the possibility that the suspected irritant is the wrong one. Polyvalent sensitizations are frequent and the first often pre- disposes to hypersensitiveness to many substances. Lalsely positive tests may result from too high a concentration of the irritant. Testing materials should in general be used in strengths of 1 to 10 per cent of the suspected irritant.
It is not difficult to understand why negative tests occur when one considers that it is almost always impossible to duplicate the exact condi- tions under which the irritant acts upon the skin naturally. As has been previously mentioned con- stant repeated contact, friction, irritation, heat and
moisture may constitute singly or together the nec- essary factors to produce the dermatitis which would not result from simple contact as occurs in the test.
It must be recalled too that only certain portions of the epidermis may manifest the hypersensitive- ness, though as a rule, especially in sensitivities of high grade, the entire skin will react to the irri- tant. I lence positive tests at times may occur only on or near affected areas. Wise and Sulzberger8 cited cases to illustrate this. In 3 women with con- tact dermatoses of the face due to powder, patch tests were negative on the arms, legs, and back but definitely positive on the \ -area on the an- terior surface of the neck. They believe that this location is most suited to patch testing in all cases of dermatitis about the head and neck. Similar examples of variations in the sensitiveness of the skin in different areas have been observed by num- erous workers.
Spontaneous desentizations may occur, hence a negative test may be due to the fact that it has been applied to an area which is no longer hyper- sensitive. Sulzberger and Wise7 stated that most of these processes seem to run in phases of ex- treme hypersensitiveness, lesser hypersensitiveness and normal non-sensitive reactions, and that pe- riods of desentivity often follow or are caused by the acute flare up in the eruption which caused the patient to seek treatment.
T rcatment:
As in other allergic conditions, the method of choice in the treatment of contact dermatitis is the avoidance of the causative agent, wdiich in many cases is entirely possible (certain plants, foods, cosmetics, materials of clothing, individual soaps and washing materials, etc.). In other in- stances, however, especially in the occupational cases, it is impossible to prevent contact with the offending substances. As Wise and Sulzberger8 stated, the shoemaker must "stick to his last” even though he is hypersensitive to leather and cob- blers' wax. Changes or substitutions of industrial irritants to other compounds to which the patient is not hvpersensitive, are occasionally possible. Some of these have been mentioned in the pre- vious discussion about excitants. When the hands are effected, the wearing of gloves and adequate washing and drying may prevent or at least alle- viate the condition. In some instances cure, with- out complete removed of the excitant, is impossible despite the best available methods of prophylaxis and logical dermatologic therapy. Desensitization which is successful in the case of certain excitants
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and unsuccessful in many others, is still more or less in the experimental stage.
LITERATURE
1. Coca, Arthur F.; Walzer, Matthew, and Thommen, August
A.: Asthma and Hay Fever, Springfield, 111., Charles C.
Thomas, 1931.
2. Coca, Arthur F. : The Grounds for an Etiologic Classifica-
tion of the Phenomena of Hypersensitiveness, J. Allergy, 1: /4,
1929. , rn
3. Coca, Arthur F. : Principles of Diagnosis and I reatment
of Allergic Diseases, J. A. M. A., 97: 1201, October 24. 19j3.
4. Sulzberger, Marion R. ; Spain, W. C. ; Sammis, Florence,
and Shahon, H. I.: Studies in Ilvpersensitiveness in Certain
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5. Sulzberger, M. B., and Kerr, Phyllis: Sensitizations of the
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6. Anderson, C. R., and Brunsting, E. A.: Contact Derma-
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7. Sulzberger, Marion B., and Wise, Fred: The ( o^tact^ or
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8. Wise, F., and Sulzberger, M. B.: Industrial Dermatoses.
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9. Weber, Leonard F. : A List of Cutaneous Irritants, Arch. Dermat. & Svph., 21: 761, 1930.
10. Spain. W. C. : Studies in Specific Ilvpersensitiveness:
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11. Coca, Arthur F. : Studies in Specific Hypersensitiveness:
The Age Incidence of Serum Disease and of Dermatitis Venenata as Compared with That of the Natural Allergies,
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12. Straus, IT. W. : Artificial Sensitization of Infants to
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13. Low, R. Cranston: Anaphylaxis and Sensitization, W.
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14. Bloch, Bruno: The Role of Idiosyncrasy and Allergy in
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15. Bloch, Bruno: Allergie. Anaphylaxie and Idiosvnkrasie in
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18. Brown, A.; Milford, E. L., and Coca, A. F. : Studies' in Contact Dermatitis. 1. The Nature and Etiology of Pollen Dermatitis, J. Allergy, 2: 301, 1931.
19. Sulzberger, M. B., and Wise, Fred: Ragweed Dermatitis:
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20. Gay, L. N., and Ketron, L. W. : A Case of Ragweed
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21. Pascher, Frances, and Su’zberger, M. B. : Ragweed
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1930.
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27. Pardo-Costello, V.: Dermatitis Venenata A Studv of the
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28. Overton, S. G. : Dermatitis from Handling Flower Bulbs,
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31. Pilot, J.: Dermatitis Venenata Due to Chrysanthemums,
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32. O’Donovan, W. J.: Hop Dermatitis, Lancet, 207: 597, 1924.
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Syph., 26: 312, 1933.
34. Cole, H. N. : The Dermatoses Due to Cosmetics, T. A.
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35. Cole, LI. N. : Investigation of Injuries Due to Hair Dyes, Dyed Furs and Cosmetics, J. A. M. A., 88: 397, February 5, 1927.
36. Engmann, J. F., and Wander, W. G. : The Application of
Cutaneous Sensitization to Diseases of the Skin, Arch. Dermat. & Syph., 3: 223, 1921.
37. Lane, T. F., and Straus, M. T. : Toilet Water Dermatitis, J. A. M. A., 95: 717, September 6/1930.
38. Burgess, J. F., and Usher, B.: On Ilypersensitiveness to
Ouinine, Canad. M. A. J., 23: 48, 1930.
~ 39. Ford, William K. : Drug Eruption Due to Quinine:
Recurrence Following Use of Contraceptive, J. A. M. A., 103: 483. August 8, 1934. . . , ^
40 Ilarner, Clyde E. : Dermato-Ophthalimtis Due to the Eye-
lash Dye Lash-Lure, J. A. M. A., 101: 558, November 1 1, 1933.
41 Bourbon, Oliver P. : Severe Eye Symptoms Due to Dye-
ing the Eyelashes, J. A. M. A., 101: 559, November 11, 1933.
42. Tamieson. R. C.: Eyelash Dye (Lash-Lure) Dermatitis
with Conjunctivitis, T. A. M. A., 101: 560, November 11. 193j.
43. Lord, Llewellyn William: Cutaneous Sensitization to
Wool, Arch. Dermat. & Syph., 26: 707, 1932.
44 Sulzberger, M. B., and Morse, J. L. : Ilypersensitiveness
to Wool Fat, 1. A. M. A., 96: 2099, 1931.
45. Lewis, George M. : Dermatitis Venenata Due to Shoe
Leather, Arch. Dermat. & Syph., 24: 597, 1931-
46. Anderson. Nelson Paul, and Ayres, Samuel, Jr.: Derma-
titis Venenata Due to Shoe Leather, J. A. M. A., 99. 2j, July 2. 1932. TT ,, „
47 Parkhurst, Howard J. : Dermatitis \ enenata Due to Deer-
skin Gloves, I. A. M. A., 98: 30, July 23, 1932.
48 Simon, Frank A., and Rackemann, Francis M.: Contact
Eczema Due to Clothing, J. A. M. A„ 102: 127 (January), 1934.
49. Feit, Hermann: Dermatitis Venenata (Cake Dough). Case Presentation, Arch. Dermat. & Syph., 22: 1148, 1930.
50 Tulipan, Louis: Dermatitis from Cinnamon, Arch. Der- mat. & Syph., 25: 921, 1932. „
51. VanVonno, N. D. ; Struycken, J., and Bonneire, P. : Con- tribution to the Knowledge of Bakers’ Eczema, Acta Dermato- Venereol., 15: 343, August, 1934.
52 Fanburg, S. L, and Kaufman, J. G. : Eczema Due to
Lemon Peel, J. A. M. A., 97: 390, August 8, 1931.
53. Kesten, B., and Lyons, R.: Dermatitis Due to Contact
with Orange Peel, J. Allergy, 3: 552, 1932.
54. Rinkel, Herbert J., and Balveat, Rav M. Occupational
55' Klauder, Joseph V.: Clinical Aspects of Allergy in Der-
matology, Arch. Dermat. & Syph., 19: 1928, 1929.
56. Lane, C. G. : Occupational Dermatitis in Dentists. Suscepti- bility to Procaine, Arch. Dermat. & Syph., 3: 235, 1921.
57. James, Bart M.: Procaine Dermatitis, J. A. M. A., 97: 440, August 15, 1931.
58. Greenwood, Arthur M., and Quest, James F.: A Case of
Butyn Dermatitis. J. A. M. A., 83: 1077, October 4, 1924.
59. Fowlkes, Richard W. : Dermatitis Due to Nupercaine,
J. A. M. A.. 100: 1171, April 15, 1933.
60. Pusey, William Allen, and Rattner, Herbert: _Dermatitis from Butesin Picrate, Arch. Dermat. & Syph., 19: 917, 1929.
61. Jackson, N. Riley: Dermatitis from Butesin Picrate Solu-
tion and Butesin Picrate Ointment, Arch. Dermat. & Syph., 21 :
40, 1930.
62. Fox, E. C. : Exfoliative Dermatitis from Butesin Picrate
Ointment, Arch. Dermat. & Syph., 26: 44, 1932.
63. Sulzberger, M. B., and Wise. Fred: Allergy in Certain
Drug Eruptions. Arch. Dermat. & Syph., 28: 461, 1933.
64. Pascher, F., and Silverberg, M. G.: Hypersensitivity to
Mercurochrome Shown by the Patch Test, Arch. Dermat. & Syph., 27: 408, 1933.
65. Cummer, Clyde L. : Dermatitis from the Use of Hexyl-
resorcinol Solution, S. T. 37; Acquired Sensitivity, J. A. M. A., 100: 884, March 25, 1933.
66. Mitchell, James M.: Resorcin Anal Dermatitis, Due to
Resorcin in Anusol Suppositories, J. A. M. A., 101: 1067,
September 30. 1933.
67. McNair, James B.. and Neff, Andrew M.: Dermatitis from Dichloramine-M. J. A. M. A., 84: 166, January 17. 1925.
68. Persky : Dermatitis Venenata (Plaster of Paris), Arch.
Dermat. & Syph., 19: 981, 1929.
69. Halloran, Chris: Dermatitis Exfoliativa Due to Arsenic
in Wall Paper, Arch. Dermat. & Svph., 20: 303, 1929.
70. Scheer, Max: A Case of Dermatitis Venenata Due to
Ephedrine, Arch. Dermat. S; Syph., 20: 641, 1929.
71. Ayres, Samuel, Jr., and Anderson, Nelson Paul: Derma- titis Medicamentosa Due to Ephedrine, J. A. M. A., 97: 437, August 15, 1931.
72. Wolfe. O. R., and McLeod, J. : Atropine Dermatitis: An
Unusual Case Associated with Erysipelas, J. A. M. A., 97: 460, August 15, 1931.
73. Cummer, Clyde L. : Dermatitis of the Eyelids Caused by
Dionin. Arch. Dermat. & Syph., 23: 68, 1931.
74. Heller, N. B.: Acute Dermatitis Due to Opium Prepara- tions, Arch. Dermat. & Syph., 24: 417, 1931.
75. Nelson, T. : Contact Dermatitis Due to Oil of Cade, J.
Allergv, 3: 319, 1932.
76. Cummer, Clyde L. : Dermatitis Caused by Balsam of Peru. Arch. Dermat. & Svph., 16: 44. 1927.
77. Sulzberger, Marion B., and Weinberg, C. Berenda: Derma- titis Due to Insect Powder. I. A. M. A., 95: 111.. July 12, 1930.
78. McCord, Carey P. ; Kilker, C. EL, and Minster. Dorothy
K. : Pyrethrum Dermatitis, J. A. M. A.. 77: 448, August 6,
1921.
79. Senear, Francis Eugene: Dermatitis Due to Woods, J. A.
M. A., 101: 1527, November 1 1. 1933.
80. Goldman, Leon: Nickel Eczema, Arch. Dermat. & Syph.,
28: 688, 1933.
81. Lain, Everett S.: Nickel Dermatitis: A New Source, J. A. M. A„ 96: 771, March 7, 1931.
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THE JOURNAL-LANCET
82. Fox, Howard: Nickel Dermatitis from Spectacle Frames
and Wrist Watch. J. A. M. A., 101: 1066, September 30, 1933.
83. McAlester, A. W., Jr., and McAlester, A. W., 3rd: Nickel Sensitization from White Cold Spectacle Frames, Am. J. Ophth., 14: 925, 1931.
84. lvowell, Hugh Grant: An Unusual Case of Dermatitis
Venenata Caused by Colored Paper, Arch. Dermat. & Syph., 7: 603, 1923.
85. Billington, Paul S. : Dermatitis from Dyes, J. A. M. A., 93: 402, August 3, 1929.
86. Cummer, Clyde L.: Toilet Seat Dermatitis Produced by a Red Stain, Arch. Dermat. & Syph., 27: 976, 1933.
87. Oliver, E. A.: Rotagravure Ink Dermatitis, J. A. M. A., 91 : 870, September 22, 1928.
88. Pusey, William Allen: I.acouer Dermatitis, Arch. Dermat. & Syph., 7: 91, 1923.
89. Williams, Charles M. : Lacquer Dermatitis, Treated with
Rhus Toxicodendron Antigen, Arch. Dermat. & Syph., 12: 851, 1925.
90. McCord, Carey P. : Occupational Dermatitis from Wood
Turpentine, J. A. M. A., 96: 1979, June 26, 1926.
91. Turner. J. A.: Acute Dermatitis Among Painters Em-
ployed in Industrial Plant, J. of Indust. Hygiene, 7: 293, 1925.
92. Obermayer, M. E. : Eczema Due to Ilypersensiliveness
to Rubber, Arch. Dermat. & Syph., 27: 25, 1933.
93. Niles, Henry 1).: Dermatitis Due to Rubber Bunion Pro-
tector. J. A. M. A., 97: 778, September 12. 1931.
94. Fox, E. C. : Dermatitis of the Eyelids Due to Rubber on an Eyelash Curler, Arch. Dermat. & Syph., 28: 222, 1933.
95. Silverberg, Mable G. : The Sensitization of the Skin to
Mesotan, Arch. Dermat. & Svph., 21: 166, 1930.
96. Parkhurst, II . J.: Dermatosis Industrials in a Blue Print Worker Due to Chromium Compounds, Arch. Dermat. & Syph., 12: 253, 1925.
97. McCord, C. P. ; Higginbotham, II. G., and McGuire, J. C. : Experimental Chromium Dermatitis, J. A. M. A., 94: 1043, April 5, 1930.
98. Smith, A. R. : Chrome Poisoning with Manifestations of
Sensitization, J. A. M. A., 97: 95, July 11, 1931.
99. Foerster, O. II.: Match and Match-Box Dermatitis, J. A.
M. A., 81: 1186, October 6, 1923.
100. Eller, Joseph Jordan: Ear Phone Dermatitis, Arch. Der- mat. & Syph., 22: 268, 1930.
101. Sutton, Irwin ('.: Acute Dermatitis from the Wearing
of “Horn Rim” Spectacles, J. A. M. A., 89: 1059, September 24, 1927.
102. Beinhauser, L. G. : Resin Dermatitis, J. A. M. A., 81:
13, July 7, 1923.
103. Crutchfield, E. D. : Dermatitis Produced by the Portu-
guese Man-of-War, Arch. Dermat. & Syph., 12: 72, 1925.
104. Johnson, I). W. : Dermatitis from Ethyl Gasoline, Arch.
Dermat. & Syph., 28: 174, 1933.
105. Weber, L. F. : Brucella Dermatitis, Arch. Dermat. & Syph., 26: 422, 1932.
106. Taylor, F. R. : Enidemic of Dermatitis Venenata Due to
a Hitherto Undescribed Cause, J. A. M. A., June 14, 1930.
107. Voukon, F. T.: Linseed Oil Dermatitis, J. A. M. A., 89: 20, July 2, 1927.
The Treatment of Diabetes Mellitus Among Railroad Employees*
A. E. Cardie, M.I).
Minneapolis
I HAVE been asked to talk to you today on the problem of the railroad diabetic and his management. ( )bviously, a diabetic railroad employee is different in no way from any other diabetic person as far as the disease is concerned, but the very nature of his work places him in a position where often times a question is raised as to his qualifications for work. Are the rail- roads justified in retaining a diabetic employee? Should he be discharged, or, should he be put in some position requiring very little responsibility? Are the railroads assuming an actual liability in retaining him ? For many years these and other questions of similar nature have arisen for dis- cussion among the railroad companies of the country. My interest was aroused in this matter when T reviewed the transactions of the American Railway Surgeons for the past ten years. They have been greatly interested in this and have given it a great deal of thought. The committee on disability and rehabilitation has made a report annually for ten years on this subject, and, in 1934, made a complete survey of the entire sub- ject. For those of you who are not familiar with the report I should like to read a part of it :
“It has been impossible to determine with any degree of accurateness the incidence of diabetes
*Presented before the Great Northern Railway Association, Glacier National Park, July 1, 1935.
among railroad employees ; perhaps the nearest to a correct estimation is that reported by one observant who claims that .05 per cent of all trainmen have diabetes and that, if considered alone the engine men will show 1.7 per cent.
“The hazard presented by the diabetic in rail- road employment presents three distinctive fea- tures: (1) The sudden onset of coma; (2) the likelihood of a prolonged disability following trivial injuries, particularly to the feet; (3) the fact that diabetics who require insulin in the man- agement of their cases are subject to the pos- sibility of a sudden insulin reaction at what may be a critical time.
“It has been found that there are a number of trainmen and enginemen, afflicted with diabetes, who maintain their physical fitness by a strict adherence to a properly prescribed diet under the surveillance of a competent medical adviser. As long as this can be accomplished without the administration of insulin it is believed that the employee may be considered as a fairly safe hazard. Failure to maintain a physical fitness by diet and the necessity of resorting to insulin, creates an unusual hazard in that a severe and sudden insulin reaction, leading even to loss of consciousness, is apt to develop, unless an abso- lutely proper balance is maintained between the carbohydrates and the intake of insulin. The com-
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mittee feels and has recommended that any man in train service who is taking insulin shall be considered as unfit for such service, or services, as long as the administration of that product is re- quired.
“While diabetes is a most important factor in the development of railroad disability, your com- mittee summarizes the result of its survey with the following recommendations :
“1. All applicants for employment in train or engine service should be subjected to a careful physical examination, including urinalysis.
“2. All re-examinations should include a uri- nalysis.
“3. The attending surgeon should make a uri- nalysis in all cases of injury.
“4. Engine and train employees suffering from diabetes and unable to maintain a physical fitness by means of diet alone, should be temporarily re- moved from service, pending a restoration to such fitness.
“5. Diabetics requiring the administration of insulin should be removed from any hazardous occupation so long as the condition requires the use of this product.
“6. Diabetics manifesting an increasing amount of sugar or any serious symptoms should be re- moved from train service until the condition is improved.
“7. Finding of acetone in any diabetic case is certainly an indication of an impending crisis.’’
You can see from the above report that the railroad diabetic is a very important problem and one in which everyone here should take a personal interest. Doubtless, at this very moment, you are asking yourself certain questions? The main question is undoubtedly whether or not the uncom- plicated diabetic taking insulin should be removed from service. Of course, there is no question in anyone’s mind that a diabetic with severe com- plications should not be permitted to work ; but should the uncomplicated diabetic be removed simply because he is taking insulin. All of you know many diabetics taking insulin and holding responsible positions which they have held for years without difficulty. You also know that dis- charging an employee because he has diabetes and is taking insulin may be the very beginning of breaking his morale and practically shutting the door as far as future work is concerned. On the other hand, any recommendation which has for its purpose efficiency of service and safety for all, is, of course, the right one. We have here a real problem and I wonder if such a recommendation will be universally adopted. It seems to me that
certain factors, such as the nature of work a man is doing, the severity of the case, the character of the individual, and the type of medical care, should exert a deciding influence. If the railroad knew that their diabetics, with or without insulin, were in the hands of competent physicians, might that not modify their attitude? Previous to this time competent men have been considered as those with special diabetic training or ones doing in- ternal medicine. The reason for this was that diabetic management was considered to be a very complicated afifair requiring too much time and energy for the busy physician. A physician com- petent to handle diabetics does not necessarily need to be a diabetic specialist. If a doctor has at his disposal a few simple principles of treatment and an intelligent co-operative patient, he should be able to treat the average diabetic in a perfectly satisfactory manner.
I noticed in the above report that the diabetic who can be properly controlled by diet is accept- able for service. This should raise a question in your mind.
Previous to the discovery of insulin the treat- ment of diabetes was by diet alone. Since the dis- covery of insulin, we have had more than ten years’ experience with its use. During that time there has been a greatly renewed interest in the treatment of diabetes. The literature has been full of articles on this subject, and we have amassed a tremendous amount of information which has given a better understanding of the disease and treatment. You are all aware of what insulin has done to improve the status of the diabetic. We know now that many diabetics are leading an ordinary life because of insulin, and appear to all intents and purposes physically normal. These people are engaged in daily occupations and assuming positions of more or less responsibility without the loss of time. If we are to derive any good from all of the work of the past ten years, it is time we assimilated our knowledge and applied it to improving the living and working conditions of the diabetics as a whole. In my mind, it is our responsibility to keep the uncom- plicated diabetic, who is employed, physically fit. This, I feel, is the great diabetic problem of today.
Why should we penalize the diabetic when we have such a drug as insulin? If all diabetic employees could be controlled by diet, I doubt if the) railroad would have much of a diabetic prob- lem. At least this is something which anyone handling a diabetic should think about.
Since it is not possible for all physicians to have special training in diabetic care, what is needed
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is a method of taking care of these people. If it is possible to have a method of treatment which will maintain the physical fitness of an uncom- plicated diabetic, we should have a result whereby this great group of diabetic patients can be con- trolled. There is no doubt that, with your routine examinations, you will discover diabetes in its uncomplicated form which will give you a group of diabetics, some of whom may be controlled by diet alone, and some of whom will need in- sulin. Regardless of what the case is you will need a simple practical method which will brings re- sults.
The selection of a method of treatment as a rule should be guided entirely by its efifect on the group as a whole and not upon one individual. Under what might be called the ideal system, a patient is sent to a hospital, where he has the advantage of institutional care. This, however, applies only to a group of selected people and is not necessarily the most practical. If he is sent to a large medical center, his family physican at home may never be advised and the patient loses the advantage of care at home, where many times it should have begun. We must remember that diabetic treatment is not for just a period of one or two weeks, but is for the life of the individual, and the best treatment is the one which produces the best and most lasting results. Many times the patient who goes to the hospital is not financially able to do so. but if he does go, he goes for what is known as intensive observation. After careful laboratory studies are made, and tolerance deter- mined, be is finally instructed by a trained dietitian in food requirements and given a diet list of elaborate proportions. He goes home with a pair of scales and good intentions of following out his instructions. After a short time, bills come in, rents come due, the scales are put away, the elaborate instructions forgotten, and he is again guessing at his diet. He goes back to his ordinary routine of life; he reverts to his former condition, and he has lost ground in spite of his ideal treat- ment. This, of course, is not always the case, but we have seen it happen so often that sometimes I wonder if it is justifiable, both in expense and loss of time from work.
On the other hand, we have what may be called the practical diabetic treatment, which results in the greatest amount of good in a large group taken at random. The more valuable treatment is not that which secures the best results in a small group, but that which obtains the best results in a large group. One cannot assume that the majority of diabetics are mentally capable or in
a position to follow the ideal treatment, and if we are able to have our diabetics master a simple, practical treatment, we have often accomplished the greatest good. The average individual will follow a prescribed treatment only in direct pro- portion to its simplicity. Simplicity is also im- portant from the viewpoint of the physician. The diabetic desires to look for advice and counsel to his own physician. 1 f he can be under the care of some one he knows at home who is interested in him, and who is guided by a few simple rules of treatment, he is often a much better treated diabetic than if he were sent away for a short period of specialized care and returned with no medical care at home.
For the past ten years we have had a diabetic out-patient department in connection with the Minneapolis General Hospital. This has grown steadily until, at the present time, 500 diabetics are under our care. We were soon struck by the fact that we could not hope to send all of our patients into the hospital for care and diabetic instruction. It was necessary to develop a method whereby these people without diabetic complica- tions could be treated in as successful a manner as was possible without hospitalization, and to allow them to goon leading normal lives, enjoying gain- ful occupations with a minimum loss of time. These diabetics come from all walks of life and are engaged in various occupations. They are a very representative group of diabetics, a cross- section of life, but. because of economic con- ditions, have needed relief medical care. I have had these people under observation for different lengths of time, some of them for the entire ten years. We have tested the various phases of diabetic treatment, and, as a result, have had the opportunity of developing a practical method of handling these people. We have been gratified to find that our plan has been successful in con- trolling the disease without loss of time and with very little effort on the part of the patient, unless the patient was not co-operative. And I would like to say right here that no diabetic treatment is of any value unless the patient co-operates.
I believe we have had some success in our treat- ment of the group as a whole, and, if this has been true, we have been using our knowledge of diabetes for the greatest good. There is nothing new or startling in our method of treatment, arid it is very similar to methods used in other out- patient departments. It may not be ideal, but it is practical and workable, and can be carried out by any physician. The simple type of treatment, to mv mind, is what is needed more and more in the
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field of medicine, for we have often been handi- capped by too complicated methods of treatment. The physician of today finds very little help from the average textbook. He has usually turned to pamphlets which have been circulated by various drug firms. The difficulty with the pamphlet form of treatment is the fact that, usually, neither the patient nor the physician reads the pamphlet unless some emergency arises and neither of them take time to sit down and go over the material to- gether. Undoubtedly, these might be of value in bringing a uniformity of thought to the physician, helping him in his treatment and aiding the patient in a better understanding of his disease, if both the doctor and patient understand what is in the pamphlet.
In treatment, nothing takes the place of instruc- tion by the physician personally. Two or three things are accomplished by this method which can never be obtained by any other method. You im- part to your patient a sincere interest in his case, a desire to be of help, and the fact that you are one who should be consulted in regard to his trouble. Furthermore, it is the fundamental rule of medicine that each patient is the most impor- tant in his own mind and the physician must make him feel that he is the most important in the physician’s mind. This applies to the diabetic as to no other case. One of the greatest troubles in the past has been the fact that the physician did not take the time and energy to assimilate a few fundamentals of treatment and, therefore, could not care for the disease properly or be interested in treatment. Nothing' can take the place of the doctor as a personal health adviser. Every effort must be made by the physician to have the patient report to him at regular intervals. This applies to all diabetics.
Thus, in a very brief and sketchy manner, I have tried to present a broader viewpoint on the diabetic question. We are faced with many hun- dreds of diabetics, people in moderate circum- stances, who must work for a living, and it is our duty to care for them. I do not see why we should discriminate against the average diabetic, if we can find a way to keep these people physically fit. I realize there are exceptions to this idea, but I must remind you again, I am speaking of the average uncomplicated diabetic. In the next few minutes I should like to tell you our simple method of treating this group of diabetics.
In the beginning, we must keep in mind that the treatment of diabetes is greatly influenced by some factors not related to the disease itself, which have a tremendous influence on the course
of the disease and its successful treatment. By that I mean such factors as home environment, economic situation, emotional instability, emo- tional reaction to their condition, and reaction to physical limitations. All these and many more serve as unforeseen and uncontrollable barriers to successful treatment. If a physician will keep these constantly in mind he will be more tolerant and charitable toward his patient, and this will help him greatly in obtaining co-operation and success. We feel that this is of such importance that we are constantly on the alert, watching for these influences.
On entrance to our clinic, a careful history is taken, a physical examination is made, and the patient weighed. May I emphasize the importance of weighing a patient. A 24-hour sample of urine is collected and tested for sugar, acetone and diacetic acid. A fasting blood sugar is taken. If these are done, one has all of the data necessary to begin treatment. It is not advisable as a rule to place the patient showing acidosis upon ambula- tory treatment, but he should be classed as a patient with complications and put on special care. I he clinical data are of as much importance as the laboratory data, and as far as the laboratory data are concerned, simple methods are all that are needed. We still believe that the basis of all diabetic treatment is the diet.
What are the requirements of an adequate diet? ( 1 ) Sufficient calories to maintain normal weight and provide energy for work; (2) sufficient pro- tein to build and repair the body tissue; (3) min- erals, vitamins, residue and water, and (4) that it conform as largely as possible with the ordinary every-day diet that the family is eating. We make no attempt to estimate the basal caloric require- ment of the individual. Our ultimate aim is to obtain normal weight and srength for the diabetic. This figure for normal weight can be obtained from any standard life insurance table.
A few words in general about diet, I feel, is appropriate at this time. During the past ten years we have seen almost every combination of carbo- hydrate, protein and fat diet tried. The ones thought of today are the high fat diet of New- burgh and Marsh, and the high carbohydrate diet as advocated by Rabinowitch and Sansum. All of these have their followers and each has pro- duced equally good results in the hands of their advocates, but, fortunately, as in every other therapeutic measure, we are swinging back into a middle ground using a diet which is moderate in carbohydrate and moderate in fat value. The im- portant thing to remember in the matter of diet is
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In obtain sufficient calorics and a balanced diet. We know that the high fat diet {jives a larger nuniher of calorics with a lower total glucose \ a 1 ux' than does the high carbohydrate diet. The high carbohydrate diet is sometimes preferred In the patient, hut we know that the high fat diet re quires a smaller number of units of insulin than does the high carbohydrate diet. I he advocates of the high carbohydrate diet are correct in the statement that insulin has a tendency to activate relatively more glucose as the carbohydrate value rises, but the fact remains that these diets require larger doses of insulin.
As I said before, we are concerned mostly with calories .and a balanced diet. We are using a diet at the present time that is not the high fat diet but which has a tendency to increase in the amount of fat. Lor we are confronted with the problem of giving the best diet with the greatest number of calories at the least cost, using the smallest amount of insulin. These factors are important to an) diabetic whose earnings are small. It con- forms as nearly as possible to the ordinary home diet and it is given in measured quantities. W e do not believe that the weighed diet is necessary and at times a pair ol scales gives a diabetic an absolute inferiority complex, since he feels he is set apart from the rest of the family. And I wish to emphasize that while we desire our diabetic to adhere to a diet we do not want him constantly reminded of his illness by any unnecessary prepa- rations of food. The error which may result in the measured diet is as a rule inconsequential in its effect on treatment.
We have four simple diets. These 1 have placed in vour hands together with a list of food substi- tutions. I ’lease notice that we have a tendency to higher fat value. This is not the high fat diet. These diets are vcr\ palatable, contain all the essentials of an adequate diet, are low in cost, and conform to the average household diet. We have found that we obtain the greatest number of calories at the least insulin cost. In starting treat- ment, a patient is given the first diet slip. Me is told how to test his urine and advised to return in from four to seven days. On his first diet he max naturally lose a little weight but nothing of am importance. At the end of that time another 24-hour specimen of urine is tested. II this speci- men show s sugar you will immediately know that insulin will be needed for his further treatment, since the caloric value is so low. Accordingly, insulin is given. W e do not determine the patient's tolerance for the ordinary treatment. As you know the tolerance of a diabetic is the maximal
number of grams of glucose from all sources that can be oxidized in 24 hours without insulin, after the subject has had full opportunity to recover from interfering factors. This is a hard thing to do in the out-patient service.
If the patient shows evidence of moderate amounts of sugar in his urine, we begin usually with ten units of insulin morning and night, 20 minutes before breakfast and 20 minutes before the evening meal. A physician should have no fear in the use of insulin if he will use it with judgment. You must remember a normal indi- vidual can take five to ten units of insulin before each meal and have no bad effects. Since this is so, the diabetic can surely start with that amount. Another lew days are allowed to elapse on this treatment when the urine is tested again. It is important that the diabetic eat the entire full diet but no more. 1 1 at the end of this time he is sugar-free, the insulin is held constant and the next diet in order is given. If he is not sugar- free, insulin is given three times a day, the dosage increased, and the diet kept the same until such time as he is sugar- free. When he is sugar-free, the insulin is kept constant and the next diet given.
Mis weight is watched, and the ultimate result to be obtained is a normal weight, sugar-free urine, adequate diet, and proper insulin dosage. If the diabetic is overweight he should be held on an inadequate diet, but sugar-free, and allowed to burn up some of his bodily tissue.
You can obtain the result desired easily if you will use one of these four diets and not be afraid to use adequate insulin. We divide our diet so that each meal is practically equal in carbohydrate, protein and fat value, and we try insofar as pos- sible to give the insulin in equally divided doses two or three times a day. It has been repeatedly shown that small doses of insulin at intervals give better results than a single large dose. Occasional- ly you will find a diabetic that is hard to control because lie seems to burn his sugar irregularly, and you may have to adjust the size of the dose. An easv wav to do this is to test single specimens just before and two hours after each meal, and von can readily determine when the larger and smaller (loses of insulin should be given. Many times the largest dose will come before breakfast. You will immediately ask what about the blood sugar. In the majority of cases, it usually runs somewhat parallel to the urinary sugar, but it may vary from day to day. 1 f any importance can be attached to it, it is of value in estimating the threshold. l*>y threshold is meant the height of
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blood sugar at the time sugar is first spilled into the urine. Occasionally one finds the condition of "high threshold.” That is most often found in the arteriosclerotic and elderly diabetic. Occa- sionally this may be found in the younger diabetic also. Be careful in giving insulin or increasing it in patients who are free from sugar in their urine just because of an elevated blood sugar. Blood sugar will vary in individuals. It may be possible for an elderly diabetic to carry a blood sugar above the normal for a young person. We have found that the elderly diabetic would appear to feel better if he were allowed to show small amounts of sugar in the urine and he is usually perfectly safe in doing so.
You will notice that in the list of substitutions the foods are divided very much as you have been used to seeing them. They are all average serv- ings. If these are used along with the diets and the amounts substituted correctly, the patient can enjoy a diet of the widest variety.
We have found that by using this method we have been able to place our patients on a dietary regime in a minimum amount of time. All patients are taught to test their own urine, using the Benedict test. They are taught to give them- selves their own insulin and instructed how to tell a reaction and what to do for it. These patients are watched at intervals checking their weight and urinary sugar. We know that if a patient will co-operate by following an adequate diet and taking the prescribed dosage of insulin he can be maintained in a satisfactory physical condition. You will be surprised how quickly the diabetic will learn his own problem and how in- terested he will be in taking care of himself. In fact, he will soon learn how to adjust his own insulin to control his urinary sugar. In any diabetic under treatment the diet will have to be varied slightly from time to time and the insulin adjusted, but usually this can be done very easily. One thing must be remembered, if a diaebtic is doing some unusual physical exertion, he may require less insulin, as work metabolizes carbohy- drates. However, as a rule, everyone’s work is a fairly constant factor, but keep this in mind.
The one great fear which everyone seems to have in the treatment of diabetics is that of insulin reaction, but I believe that this is much overrated. A diabetic soon learns his own treatment so well that he can take care of this with little difficulty.
There are also other phases of the diabetic regime, which time will not permit me to discuss, and do not relate to my subject, because I am speaking of the big problem, that of the uncom-
plicated diabetic. A railroad diabetic with com- plications is a case requiring special consideration, and I believe is more than just a railroad problem. I hese people, of course, have no place in railroad work, but it is well known that a well controlled diabetic is much less prone to these complications than an inadequately treated case. However, I cannot terminate any diabetic discussion without saying a few words in general about these com- plications. First, as regards coma — this complica- tion usually is more common before the age of 40 and not so common past that age. It is most often the result of some infectious process or care- lessness on the part of the patient. Its treatment is known to you all. We believe that small frequent doses of insulin are better than larger infrequent doses. It is well to watch the blood pressure in these cases, for they oftOn rapidly develop vas- cular collapse when the findings of coma seem to be improving; one must be constantly on the alert to support the circulation. Second, the arterio- sclerotic changes — these are usually seen after the age of 40. They manifest themselves in cardiac changes, blood vessel disorders of the extremities, and the eye complications. The chief arterio- sclerotic changes in the heart affect the coronary arteries. Nathanson has made a study of our diabetics from a coronary standpoint and has con- cluded "that coronary sclerosis is the predominat- ing cardiac lesion of diabetes mellitus. It is usually seen after the age of 50 where its inci- dence is approximately 50 per cent. Above the age of 50 the incidence of coronary disease is six and one-half times greater in diabetics than in non-diabetics. Hypertension is not a prominent feature in diabetes. Electrocardiography is sug- gested as routine diagnostic procedure in elderly diabetics. Remember also that coronary disease in the diabetic will often be aggravated if diabetes is too strictly controlled. The arteriosclerosis in the extremities produce pain, ulceration and gan- grene. You are well acquainted with these. The conservative treatment should be followed, as far as possible, massage, postural exercises, alternate foot baths and Pavaex treatment. When gangrene develops, be certain no infection exists under the black necrotic area if amputation is anticipated, and treat the infection per se before amputating. Never forget to give gas gangrene antitoxin be- fore amputation. The eye changes are those in the retina due to arteriosclerosis and hemorrhage. We believe that adequate diabetic treatment is the one to follow in these cases. We have not found that over-treatment or under-treatment gives any better success. In the lens there are definite
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T 1 1 E JOUR X A I LA NCET
changes in size due to carbohydrate content and one must remember tlu.s when patients complain of vision changes.
I have tried, in this short time, to present a few problems confronting the diabetic. I believe an improvement in the general status of the diabetic could be brought about, by giving the diabetic a better opportunity for treatment. The impres- sions I have gained have not been obtained statis- tically, for this is hardly possible, but, 1 believe, clinical impressions, after all, count for a great deal in practical therapeutics. They have been gained by watching and talking to the people month after month for a long time, and also by exchanging ideas with those associated with me. These people constitute the average diabetic patient of today. 1 lie success of the treatment de- pends upon the influence and fitness of the physi- cian, and the willingness of the patient to co- operate, and above all, on its simplicity. That, in a nutshell, is the whole diabetic problem. 1 be- lieve that the problem which confronts the rail- road is similar ; either to adopt the recommenda- tion of the committee or attempt to keep these men in service, but insisting on two things: (1) A familiarity of the various railroad physicians with the treatment of diabetics, and (2) co-operation on the part of the employee in the treatment.
If these could be obtained, I believe that certain diabetic employees could be maintained in physical
fitness with the use of insulin and kept in service. 1 1 the diabetic employee is a co-operative employee, he should be a good diabetic and a good employee. It is recognized that a co-operative diabetic is usually an outstanding person in his community. 1 f he does not co-operate he is not a good employee. 1 realize that diabetic trainmen are prone to suffer from the same complications as any diabetic. 1 hey may have insulin reactions; they may have coma ; they may have arterio- sclerotic complications, but I believe that one of our greatest factors in producing these complica- tions has been that our physicians have been con- fused by the mass of literature and figures, and they have not had a few simple rules to follow which would permit them to keep the diabetic from having a great many complications. We usually find that if complications arise, it is often the result of carelessness due to a lack of under- standing of the treatment. ( )ne reason we had so many complications in the past was because we did not have a simple method the diabetic could and would follow. We must learn that success- ful diabetic management, which previously seemed to be difficult, is in reality, simple.
BIBLIOGRAPHY
1. Trarsactions of the Association of American Physicians, Vol. XLVII, pp. 309-316.
2. Nathanson, M. II.: Cardiac Pathology of Diabetes Mellitus, Tiie Journal-Lancet, 54: 323.
3. Association of American Railroad Proceedings of the Medical and Surgical Section, 1925-1934.
Treatment, Prognosis and Prevention of First Infection Type
Of Tuberculosis*
J. Arthur Myers, M.D.
Minneapolis
Treatment
TREATMENT Unnecessary. Fifteen years ago, we were very enthusiastic about the necessity for treatment of children who had the first infection type of tuberculosis. Then we believed that it would be possible to hasten resolu- tion of the recent pneumonic lesions and to secure more permanent healing of those which already presented evidence of calcium deposits. The con- struction of special children’s buildings on sana- torium grounds, the building of preventoria, the
^Presented before the Michigan State Tuberculosis Associa- tion, Lansing, November 8, 1935, and the Sixteenth Annual Con- ference of Ohio Health Commissioners, Columbus, November 14, 1935. From the Departments of Preventive Medicine and Internal Medicine, University of Minnesota, and the Lyman- hurst Health Center, Minneapolis,
opening of special schools, the establishment of fresh-air classrooms, and the organization of summer camps, were accomplished at an expendi- ture of huge sums of money. Up to that time, no one had actually observed a group of children over a sufficiently long period of time to determine whether the course of the first infection type of disease could be altered by any form of treatment.
Since that time such studies have been made and have shown that it makes no difference whether children who have the first infection type of tuber- culosis are given strict bed rest in a sanatorium and even have collapse therapy instituted whether they are placed in a special school or whether they remain at home under the same conditions as
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normal children should have. The course of the disease is the same ; that is, lesions which can be demonstrated by X-ray film resolve in the same manner ; calcium deposits are laid down in the lung parenchyma and in the lung hilum in the same manner and at the same rate regardless of the treatment instituted. Moreover, it has been shown that no matter how long' such children are kept on strict bed rest, even with collapse therapy added, one neither alters that very dangerous factor, namely, the sensitization of tissues nor destroys the tubercle bacilli laid down in the original focus and in the regional lymph nodes. Neither is there any evidence that the foci of bacilli are more quickly, more completely or more permanently walled off when strict bed rest is employed or any of the other therapeutic pro- cedures than when the child remains at home under the ordinary conditions of life; that is in all groups treated and untreated, sensitiveness of the tissues to tuberculo-protein persists and tubercle bacilli remain alive and virulent, ever ready to produce reinfection destructive type of tuberculosis once they are set free upon sensitized tissue.
Febrile Reactions — The first infection of tuber- culosis in the pneumonic stage is rarely diagnosed when fever is present, except in the relatively few cases who have high temperature elevation. When the disease is detected in the febrile stage, it is only reasonable that the child should be treated just as when fever is caused by other infections, such as influenza. Since the febrile stage usually is of such short duration, the treatment can very well be carried out in the home, provided there are no uncontrolled sources of exposure among the associates, and other home conditions are good. The red-cell sedimentation rate has been found to be definitely elevated during the febrile stage and seme authors are strongly of the opinion that the treatment should be continued until the rate has returned to normal. However, the ulti- mate results in our cases have been equally good whether or not treatment was administered. In no case have we resorted to collapse therapy in any form. At present, we can see no indication for such treatment.
Lymanhurst Studies — When our work at Lymanhurst began in 1921, we strongly recom- mended sanatorium care for every child who was found to have a focus of first infection tubercu- losis in the pneumonic stage. Many families re- fused to carry out our recommendations because there were no outward manifestations of tuber- culosis. We then advised that their children who
25
were old enough be admitted to the Lymanhurst School. Many even refused this for the same reason and insisted upon having their children remain at home with no' treatment whatsoever. Thus, our children were divided into three groups, which have given us an unusual opportunity to observe the effects of treatment upon the first infection type of disease. The first group consists of those whom we sent to sanatoria, the second of those sent to a special school (Lymanhurst), and the third of those who remained at home with no treatment except that every effort was made to break the contact when an open case of tuber- culosis existed in the home or among other close associates. This same effort was exerted in all cases.
In fact, in a group consisting of 155 children who have been observed from the time the disease was in the acute inflammatory stage until lime or fibrous strands were deposited in sufficient quantity so that they could be visualized by the x-ray film, 19 were treated in sanatoriums ; 50 in the Lymanhurst School, while 86 remained in their homes. Of the 155 children, 136 were traced re- cently while the remainder (11, no institution, eight, Lymanhurst) have moved away or for some other reasons could not be located at this time. Among the 136 traced, we are unable to see any difference in the course of the disease, regard- less of whether the children were treated as strict bed patients, were sent to a special school, or re- mained as active as any normal child is in the home. In fact, with the exception of three who developed the reinfection type of disease, the entire group traced in 1935 are apparently per- fectly normal, healthy individuals, going about the activities of life just as other children in their communities who have not had tuberculosis.
Moreover, we have not been able to obtain any evidence to show that hospitalization, special schools, summer camps, or any other form of treatment except breaking contact with tubercle bacilli has any influence upon the later develop- ment of reinfection type of disease. In fact, our only fatal case died of tuberculous meningitis in a sanatorium after having been there many months and the two cases who later developed reinfection, chronic, pulmonary tuberculosis in adult life, were given long periods of treatment in sanatoria for the first infection type of disease when they were children. In addition to this group of children, whom we observed from the time their disease was in the pneumonic stage until the present, we have had under observation another larger group of children who had the first infection type of
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T HE JOUR X AL-I .A N'C ET
tuberculosis in the calcified stage when our obser- vations and treatment began. In this group, we have also been unable to see any difference be- tween those treated in institutions and those who remained at home.
Originally, the Lymanhurst School for Tuber- culous Children had wards, where children could be hospitalized. Observation, however, revealed the fact that, there was no real necessity for such service and, therefore, the staff members unani- mously agreed that it should be discontinued. The school was retained as the treatment division where children were carefully observed but at the end of thirteen years of such observation the med- ical staff came to the conclusion that the child with the first infection type of tuberculosis needs no special treatment, either in a hospital or a special school, such as Lymanhurst. Although many staff members were enthusiastic about the school and were very desirous of having it continued, the actual facts convinced them that it was not neces- sary and, therefore, they could not conscientiously ask that money derived from taxation be used for the maintenance of the treatment division. This resulted in a false rumor now extant that Lyman- hurst has been closed.
The staff then strongly recommended that at least a part of the funds previously used in the operation of the treatment division of the institu- tion he diverted to two activities, which observa- tion had proved would yield the most in tubercu- losis control. I he first consists of administering the tuberculin test to a much larger number of children than had previously been done to detect as many as possible who have been contaminated with tubercle bacilli ; to carefully examine and follow such children and to put forth great effort to find the source of their contamination through examination of their associates. The next pro- cedure is to treat or isolate as many as possible of the clinical cases found. This, we believe, to be the best method of treating infected children of any community. It simply consists of breaking contact with the open cases of tuberculosis, giving those already contaminated a better chance to avoid the reinfection type of disease, and prevent- ing others from becoming contaminated. The second activity consists of making frequent x-ray film examinations of all who react positively to the tuberculin test as the period of adolescence approaches and thereafter in order to detect the reinfection type of disease early when treatment may be administered most successfully. Hence, Lymanhurst is now a diagnostic and epidemiologic center.
The failure of treatment to influence the course of the first infection type of tuberculosis is being recognized by a good many tuberculosis workers with the result that already in this country some buildings constructed for children on sanatorium grounds have been closed and later re-opened for the isolation of patients with pulmonary tuber- culosis in communicable form. Such action is being contemplated by a number of other institu- tions. In Puerto Rico the institutions for children who have only the first infection type of tubercu- losis are now being used for adults with com municable disease. When it has been shown tliai treatment over a long period of time in special institutions for tuberculous children has not modified the course of the first infection type of disease, how futile it is to hope that the summer camp would be of any benefit. Nevertheless, in this country there now exist in the institutions for tuberculosis 11,647 beds for children, such as sanatoriums, tuberculosis departments in general hospitals, and preventoriums. During the year 1934, 12,629 children were admitted to these beds: 1,191 had adult type tuberculosis; 6,659 childhood type ; 824 extrapulmonary lesions ; 3,236 were non-tuberculous ; and 701 were un- classified. There is grave doubt whether any of these children except the 1,191 with adult type tuberculosis and the 824 with extrapulmonary lesions should have occupied beds in these in- stitutions, not only because of the fact that the 6,659 with childhood type disease probably would not need any treatment, as well as the 3,236 non- tuberculous cases, but also because the survey by the Council of Medical Education and Hospitals of the American Medical Association, called attention to the fact that some of these children were being exposed to adults who had open tuberculosis or to other children even in preven- toriums, who were admitted with the adult or re-infection type of disease. Moreover, sana- torium and hospital beds are too much in de- mand for patients with tuberculosis in a com- municable form to have them occupied by those only suspected of having tuberculosis or having only the first infection type of disease.
Prognosis
In childhood, as well as in infancy, the imme- diate prognosis of the first infection type of tuber- culosis is excellent. In fact, we have not yet seen a child die of this type of tuberculosis per se. However, recently developed lesions in this age period, as well as in infancy, produce a high degree of sensitization of the tissues to tuberculo- protein and in a few who have them, acute rein-
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27
lection forms of tuberculosis develop, such as meningitis, miliary disease and tuberculous pneu- monia. Therefore, one must be on the lookout for such forms of the disease among all children reacting positively to the tuberculin test and par- ticularly among those whose tissues have recently become sensitized. However, an extremely small percentage of contaminated children develop these acute highly destructive forms of tuberculosis during the period of childhood.
The remote prognosis of the first infection type of tuberculosis in childhood is also excellent, since in adult life likewise, one rarely sees the first in- fection type of lesion that has caused any illness whatsoever. However, because of the fact that the tissues of the body remain sensitive and the first infection type of lesions harbor living and virulent tubercle bacilli, there is always the possibilty that these bacilli may be liberated and find lodgment on allergic tissues where they set up reinfection and often very destructive chronic forms of disease. Bacilli may be liberated through the rup- ture of a capsule which previously has adequately imprisoned them. Such rupture may be the result of trauma. Again, there may be the burrowing through of the contents of the capsule, such as deposits of calcium with sharp edges. These de- posits in the form of pneumoliths are sometimes actually expectorated or may be aspirated into a ramification of a bronchus where they have occa- sionally been found to produce foreign body abscesses. Obviously, such cutting through of the capsule may liberate caseous tubercle bacilli con- taining material. Sweany has shown that after a time, there may be absorption of the capsules sur- rounding' the first infection foci to such an extent that tubercle bacilli are set free. This is true even when the capsule contains calcium or true bone. Thus, there are many possibilities of tubercle bacilli escaping from lesions of the first infection type. This does not affect the remote prognosis as far as the primary lesions are concerned but very materially affects it as far as new lesions of the reinfection type are concerned. Indeed, the remote prognosis of children reacting positively to the tuberculin test is not particularly good. However, the bad effects are not experienced except rarely, until the period of adolescence approaches and thereafter. Beginning with the approach of adolescence, reinfection chronic pul- monary tuberculosis begins to make its appearance much more frequently than at any previous time and increases in prevalence until it reaches its height, about twenty-five or thirty years. It then continues to be a very prevalent disease through-
out the span of life. The following case serves to illustrate this fact.
On May 31, 1921, a boy of twelve years was admitted to Lymanhurst as the first patient. His mother had died of tuberculosis and the tuberculin test showed that he had the first infection type of disease. X-ray examination of his chest showed unmistakable evidence of lime deposits in the right lung hilum. After a time he was discharged from the Lymanhurst School well immunized and vaccinated, as we thought. Approximately ten years from the time he was admitted to the School, he was taken to the Minneapolis General Hospital because of illness and examination revealed exten- sive pulmonary tuberculosis involving much of the left lung and a small portion of the right lung. This was of the adult type which later caused his death. Neither the positive tuberculin reaction nor the so-called vaccination scar, represented by cal- cium deposits in the right hilum, prevented the development of destructive tuberculosis or allayed the progress of his disease. Thus, our first Lymanhurst case for whom we had rendered such an excellent prognosis based upon opinion rather than fact, shattered our earlier teachings as many others have since done.
The children who react positively to the tuber- culin test are much more likely to develop the reinfection destructive type of disease during and after adolescence than those who react negatively. In a group whose observations began in 1921 when the average age was approximately eight years, it was found that those who reacted posi- tively were five times more likely to develop the clinical type of disease by the time they had reached their majority than those who had reacted negatively to the test. In fact, when only those examined in 1921 were considered, approximately 10 per cent who were positive to the tuberculin test had fallen ill from clinical tuberculosis by 1935, whereas, only slightly more than one per cent of those who reacted negatively to the tuber- culin test in 1921 had developed clinical tubercu- losis by 1935. Therefore, every physician, whether he be engaged in private practice or in some other phase of medical work, can readily see the sig- nificance of detecting the group of children who have the first infection type of disease through the tuberculin test. They are not ill at the time, nor will they fall ill with this type of tuberculosis, but many of them will later fall ill with the re- infection type of disease. This necessitates very careful examination of this group during the age periods when the reinfection type of disease be- comes prevalent.
TI I E JOURNAL- LAN GET
28
In fact, Opie has demonstrated calcium deposits in (J8 per cent of cases who had the reinfection type of pulmonary tuberculosis. Rathbun has shown that among' the boys and girls of high school age who develop the reinfection and fatal type of tuberculosis, old childhood lesions with evidence of calcification could he demonstrated by x-ray film in 50 per cent of the cases. From his experience which is large and his judgment which is excellent, he believes that the small percentage of girls and boys who have the first infection type of tuberculosis, furnish at least 75 per cent of the teen age girls and boys who develop the reinfec- tion type which often is fatal.
Prevention
Inasmuch as there is so little that we can do to control tubercle bacilli once they gain entrance to the tissues, the only logical procedure is to pre- vent the first infection type of disease among chil- dren through avoidance of exposure to tubercle bacilli. Already much has been accomplished as evidenced by the fact that the number of children who react positively to the tuberculin test in many parts of the country is rather rapidly becoming smaller. If this kind of work is carried to its logical conclusion, the time is not far distant when the child whose tissues have been sensitized to tuberculo-protein will be quite rare in these com- munities. In most of these communities, the vet- erinarians are already doing their part to protect children against tubercle bacilli of the bovine type.
Medical Program — The work of the medical profession consists of finding all open cases of tuberculosis in the community as well as those persons who have the disease in the pre-symptom stage but may later be spreaders of bacilli. The finding of such cases has become a very simple matter as far as examination is concerned. Nearly all of them are positive tuberculin reactors, there- fore, it is necessary to examine only this group of reactors. In communities where it is impossible to examine the entire population, there are certain leads which the physician can follow. One is the testing of all school children. This is valuable because an open case of tuberculosis cannot exist long without infecting the children of that home. Therefore, when one finds the children reacting positively to the test, one very frequently finds that some member of the family or other close associate has open tuberculosis. Where funds are limited in families or communities so that it is impossible to administer the tuberculin test to all children, it has been found very profitable, from the stand- point of finding open cases of tuberculosis, to test the youngest children in the schools ; for example,
those in the first and second grades. Usually the children of earlier ages have had less association with persons outside the home and the few who react positively are more likely to have contracted their infections from open cases in the home. When such cases of clinical tuberculosis are found they should he treated at once, or if the disease is too extensive, they should Ire isolated. In short, the spread of their tubercle bacilli should be stopped at the earliest possible moment. New sources of exposure in families will often be de- tected by periodically testing all school children who previously have reacted negatively to the test.
Examination of School Employees — While there probably is no more tuberculosis among teachers and other employees of a school system than among other groups in the same community, the fact remains that the teacher comes in intimate contact with large groups of other persons, such as fellow teachers and school children. Therefore, the danger of spreading tubercle bacilli to these contacts is not much less than when an open case of tuberculosis exists in the home. So often teach- ers have clinical tuberculosis in the pre-symptom stage. If examination is made compulsory and the disease is detected at this time, treatment is rela- tively simple. Many of them need be taken out of their work for only a short time and some not at all. In this manner, they are spared long periods of invalidism and the mental anguish of knowing that they have spread tubercle bacilli to their fellow teachers and their pupils. Again when such examinations are made compulsory, some teachers are found to have disease already in a com- municable form. Perhaps they have never been aware of its presence. Only the occasional teacher knows that the disease exists and exposes children and other associates maliciously. All such persons should be given leaves of absence until their disease has been treated so successfully that it is no longer in a communicable form. They may then be safely returned to their work provided they are kept under close observation.
The only satisfactory manner is to make exami- nations compulsory for original employment and for reappointment. Each examination should in- clude an x-ray film of the chest made by a first class technician and interpreted by a physician who is experienced not only in x-ray work but is well informed on the various clinical aspects of tuberculosis. Enough of this work has been done by such workers as Slater, Jordan and Ryan to prove that it is absolutely necessary if we are to giVe the teacher and school children of this country adequate protection. \\ hen such com-
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pulsory examinations were made in the Minne- apolis school system, 68 employees with lesions definite enough to cause shadows on the x-ray film suggestive of reinfection type of tuberculosis were discovered. Final diagnosis in each of these cases must be made by the clinician based not only upon the tuberculin test and the x-ray film, hut also upon laboratory examinations and care- ful clinical observation. Six of these employees were found to have tubercle bacilli in the sputum very soon after the compulsory examinations were made. The others are under close observation. In Decatur, Illinois, Lindberg found 1.3 per cent of the employees of the schools of Macon County had clinical tuberculosis.
In many states laws already exist requiring that teachers submit health certificates periodically. Unfortunately, such laws are not always enforced. Moreover, a health certificate made on the basis of an examination that does not include the tuber- culin test and first-class x-ray films of the chest properly interpreted is of little value, since so many clinical cases of tuberculosis have neither symptoms nor abnormal physical signs. However, it is encouraging to find that in a good many places school boards are requiring adequate exam- ination of all employees ; for example, through the excellent work of Smith during the past six months, seventeen counties in the state of Ken- tucky have become definitely interested in the examination of teachers. In five of these counties already the tuberculin test with x-ray films of the positive reactors, or in lieu of the tuberculin test x-ray films of the chest, are a definite requirement for all of the 2,400 teachers employed. In South Dakota a very recent regulation was passed by the State Board of Health requiring all teachers to present evidence to the effect that they are free from tuberculosis in a communicable form. Dr. Dyar, epidemiologist of that state, after observing the response to this regulation states that he con- siders it one of the most valuable public health measures that the state has taken in a g'ood many years. Another very encouraging fact is that the educators, themselves, have become interested and large numbers of teachers are being examined for tuberculosis by their private physicians, hollow- ing the examination of such teachers, many have become enthusiastic about having their pupils adequately examined.
In short, the prevention of tuberculosis among school children consists of avoiding contact with open cases of the disease in the homes, schools and elsewhere. Those who have already been infected will be benefited and seme cases of reinfection
type tuberculosis will be prevented from develop- ing in their bodies through the breaking of con- tact.
Institutions and Summer Camps — The develop- ment of institutions for children with malnour- ished, anemic conditions, etc., was thought to be valuable in the prevention of tuberculosis at one time. However, there is not one iota of evidence to show that the building up of a child’s body through care in these institutions, summer camps, etc., protects him in any way from infection with tubercle bacilli if he is later exposed to them. A good example is that of a child whom I observed for a number of years because of tuberculosis in the family. This child has always been overweight and her general appearance is excellent, yet in December, 1930, she developed the first infection type of tuberculosis in the pneumonic stage clearly demonstrable by the tuberculin test and the x-ray film. This came under control without the appear- ance of any symptoms. In 1934, she developed acute appendicitis and was treated surgically. In 1935, she was hospitalized for several weeks while she was desperately ill from typhoid fever. With each of these conditions it was purely a matter of infection and the excellent general condition of the child did not protect her. The use of institu- tions and summer camps for children whose tuberculin tests are already positive will not in- fluence the course of the first infection type of disease. Summer camps provide a worthwhile outing, particularly for children of the cities and such camps as are operated by religious organiza- tions, luncheon clubs, etc., are to be highly recom- mended, but the expenditure of funds derived through the sale of Christmas seals or from tax- ation in the name of tuberculosis is to he be con- demned. A survey of tuberculosis hospitals and sanatoriums in the United States by the Council of Medical Education and Hospitals of the Ameri- can Medical Association led to the following statement: "The preventorium service defeats its own purpose when it allows the admission of tuberculous contacts and childhood tuberculosis to the exclusion of open pulmonary cases."
Parsons, who has made a careful study of tuberculosis among children in England, says : “Children who can be removed from their homes should not be sent to a sanatorium unless it is one which only admits children, and in which there is rigid isolation of children with open pulmonary tuberculosis. In spite of all that is with truth claimed for sanatoria, there is in my opinion a chance that children may contract re- infections in them if for no other reason than
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that patients sometimes break rules ; furthermore, many sanatoria are even less fitted to care for children than general hospitals.’’
False Pretenses — Our great trouble is that too much sentimentalism has been allowed to enter the field and too many health workers have used the appeal which the child makes in raising funds or securing appropriations for tuberculosis work. With our present knowledge of tuberculosis among children, it is perfectly obvious that this is not a fair approach. Workers who have been prone to take advantage of sentimentalism can make a much stronger appeal in a far more honest way by pointing out to those from whom they seek funds the great importance of finding open cases of tuberculosis in a community ; of treating those cases, or having them isolated, thus, protecting not only the children, who need no treatment, but other members of the community. An illustration showing several children in the home where an open case of tuberculosis in the far advanced stage has just been detected through Christmas Seal Funds and immediately transferred to a sana- torium after which children are shown in the normal, healthy, home surroundings, would make a much stronger appeal. This would be far more reasonable, and would represent a more honest endeavor to secure funds than one showing the removal of those children to an institution, while the open case of tuberculosis remains in the com- munity to continue to infect other children, as well as adults.
Futility of Treatment to Prevent Disease — In this class, there are workers who fight for what they term “poor dear children,” whom they have gathered together in preventoria or summer camps. They frequently publish the total number of pounds gained by this group of children as though they were being- prepared for the market. They make frequent photographs of these children to show how healthy they appear ; how they have been able to tan their skin with heliotherapy, and use these photographs to convince those from whom they seek funds that their work is a great success. Their entire activities are centered upon 100 children or less, who are under their care. They have quite forgotten the many hundreds or even thousands of children, who are just as dear in their communities and who have been infected with tubercle bacilli ; they also have forgotten the much larger number of children who are uninfected but need protection. When our work was begun at Lymanhurst, it was estimated that there were 20,000 contaminated children in the city of Minne- apolis, yet our actual capacity for treatment was
only 175. In addition to the 20,000 children con- taminated, there were approximately 70,000 un- contaminated children who needed to be protected against infection. To have continued the treat- ment department of the school, which was found to be of no benefit as far as tuberculosis control is concerned, and to have provided no protection for 70,000 children and to permit possible reinfec- tion of 20,000 children, would have been absurd. These workers in their enthusiasm for the small group whom they are trying to shelter, have failed to go out and find the open cases of tuberculosis who are continuing to infect and reinfect large numbers of children. How much more reasonable it would be to close the doors of such institutions for children, use the funds available, seek more funds, and institute a true case-finding survey in the community, stimulate the interest of all physi- cians and as quickly as possible provide institu- tional care for the open cases and treat all others adequately. This would very soon create a satis- factory environment for all children in their homes.
Very frequently the question is asked as to what can be done with the child who has been made an orphan through the death of one or both parents from tuberculosis. Should not all of these children be sent to preventoria? Before answering this question in the affirmative, one should consider that these children are not in need of treatment ; usually, they are not spreaders of tubercle bacilli and, therefore, they do not need any special care so far as tuberculosis is concerned. Ordinary orphan homes are available in most communities but before recommending that a child enter either the preventorium or the orphan’s home, one must not overlook the hazards of institutional life of the child. Attention has been called to these hazards by many workers. Those who are really interested in the welfare of the child will take such hazards into consideration and will arange a more satis- factory location for these children. The most satisfactory method, and a good deal less expen- sive method in the long run, consists of finding foster homes, where good care will be provided. All members of the family in such foster homes, however, should be carefully examined and found to be free from tuberculosis in a communicable form before any child is allowed to enter.
Desensitization — Several workers, such as Rich and Fernbach, have shown that it is possible through the use of tuberculin to markedly reduce the sensitiveness of the tissues. While no method has been devised which will desensitize permanent- ly or is any practical method yet available, the
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possibilities of such a procedure are worthy of careful consideration. However, inasmuch as the reinfection type of tuberculosis in both acute and chronic forms so rarely develops during the period of childhood, there is very little need to consider desensitization until adolescence approaches and thereafter.
Vaccination with Bacillus Calmette-Guerin (BCG) — In 1908, Calmette planted a strain of bovine tubercle bacilli on ox bile-potato medium. In 1921 after this strain had been trans- planted 230 times, the bacilli were avirulent but were still capable of causing sensitiveness to tuberculo-protein of the tissues of the animal body into which they were introduced. Because of the apparent protection produced in animals, Calmette and his co-workers administered BCG by mouth to infants who were likely to be extensively exposed to tuberculosis. They gave a dose of one eg. of an emulsion on the third, fifth and seventh days of life. They always tried to have the three doses administered before the tenth day, since they were of the opinion that the intestine absorbs the bac- teria better at that time than during any sub- sequent time. They also recommended that the infant be isolated from the source of exposure to virulent human tubercle bacilli for a period of four weeks during and following the administration of BCG. In case the tissues of the infant did not become sensitized, as manifested by a positive tuberculin reaction, they administered one-twen- tieth to one-fortieth eg. of BCG subcutaneously, following which a positive tuberculin reaction was usually obtained in from six to eight weeks. In the event the sensitiveness of the tissues died out, they recommended that BCG be administered sev- eral times during the lifetime of the individual, especially during infancy. In short, an attempt was made to keep the tissues sensitive enough so that they would react definitely to tuberculin.
Since the original work of Calmette, large num- bers of animals and children have had BCG administered. In fact, in Europe alone, this material has been introduced into the bodies of more than a million human beings. The reports from different parts of the world are very con- flicting. For example, when BCG has been used to control tuberculosis among animals, some work- ers have reported excellent results ; on the other hand, in this country where it has been given ample trial, it has been condemned and the vet- erinary profession does not consider it of any par- ticular value in their tuberculosis control program among cattle. Conflicting reports also appear in the literature as to the effect of BCG when intro-
duced into the bodies of infants and children. Some authors are very enthusiastic, claiming marked reductions in the incidence of the acute fatal forms of reinfection type of disease in in- fants. Others show little or no enthusiasm for such procedure after giving it what they consider an adequate trial.
The opinion has been voiced that the Liibeck disaster was due to BCG having regained its virulence rather than the introduction of the wrong material through error. The fact is quite well established that the virulence of the tubercle bacillus can be very definitely modified by environ- ment. Indeed, this is the way Calmette reduced the virulence of BCG. It would seem quite logical that through further changes in environment virulence might be regained and even exceed that of the original bacilli. Inasmuch as first-class bac- teriologists claim to have already restored the virulence of BCG, the subject is not one to be taken lightly but one for most serious consider- ation. We know full well that virulent tubercle bacilli when introduced into the body of an infant through exposure to an open case of tuberculosis are deposited in the lymph nodes, etc., and there may remain -alive and virulent for decades, ever ready to set up destructive disease if they find lodgment upon sensitized tissues. The work of Robertson on this subject is most convincing. If this occurs so frequently with the virulent strains of tubercle bacilli, it would seem entirely logical that BCG might remain alive in the human body fully as long and that under the change of en- vironment might completely regain its virulence or even have it accentuated. Since this is a rather strong possibility, any physician who recommends the administration of BCG or introduces it into the bodies of human beings is assuming a respon- sibility of great proportions.
When Calmette began his work on BCG, our knowledge of the dangers of sensitization of tissues to tuberculo-protein was very meager. Indeed, at that time most physicians still believed that a positive tuberculin reaction indicated immunity. Much excellent research has since been conducted on the subject of sensitization, which appears to have proved conclusively that sensitiza- tion of the tissues is a very dangerous factor in the development of clinical tuberculosis. More- over it has been shown that sensitization is inde- pendent of immunity ; that one may develop in the absence of the other and that the tuberculin test is not a test for immunity but only for sensitivity.
Without sufficient knowledge of the potentiali- ties, Calmette and his collaborators started a huge
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experiment, that is, they introduced BCG into the bodies of large numbers of infants and children. I'his experiment is now in progress hut, unfor- tunately, it will require at least two more decades before one can even begin to draw conclusions concerning the ultimate result of the introduction of avirulent, living tubercle bacilli into the human body. The only place where there is the slightest evidence that BCG has been helpful is among those groups of infants said to have had a definite reduction in mortality from acute, reinfection forms of tuberculosis. How much of this reduc- tion is due to BCG and how much to isolation from sources of exposure during the first four weeks of life has not been definitely determined. However, we do know that results obtained by such workers as G rancher and Bernard through the use of certified foster homes, exceed those of any group treated by BCG. Moreover, we have the observations of Boynton, which show that where attempts have been made to protect infants against exposure in an entire state, the mortality from tuberculosis among those under one year of age decreased 88 per cent over the eighteen years preceding 1933. She calls attention further to the
fact that in this state where BCG vaccination has not been used, tuberculosis mortality rates in children are lower and have decreased at a more rapid rate than that reported by Wallgren in Sweden with the use of BCG.
Since of all infants and children infected with tubercle bacilli, only a very small percentage die or even fall ill from tuberculosis before the age of ten or twelve years, and since the mortality from tuberculosis between infancy and adolescence has always been very low, to make any claims for the apparent good health of children during this age period on the ground that BCG was administered when they were infants is not justified.
Unfortunately, we have not worked diligently enough on the fundamentals of tuberculosis con- trol as expressed by Calver : “Practically we have, as administrators, accepted defeat in the control of respiratory disease and are awaiting the dis- covery of some new vaccine, or other sure and easy process of creating an immune popu'ation that we will not have to bother about. While thus waiting for the laboratory to produce a solution, people are dying and morbidity rates do not de- crease.”
Practical Laboratory Aids for the Otolaryngologist*
Paul G. Bunker, M.D.
Aberdeen, S. I).
NOWHERE in the practice of medicine is the laboratory of greater value than to the otolaryngologist. Unfortunately the pres- ent economic situation has made it impossible to make full use of this aid to diagnosis. The pur- pose of this paper is to revive interest in this subject and to simplify the various phases of it. A text book on this subject written by a properly qualified person would prove a valuable addition to the specialty. Perhaps the most outstanding paper dealing with this subject was published by Connor1 in 1931, and frequent reference to it has been made.
Blood Studies — Kopetzky2 summarizes the Schilling differential as follows: "The Schilling test is to determine the portion of segmented (polynuclear) and unsegmented (staff) neutro- philes. The presence or absence of eosinophiles is also noted as the reappearance of these cells con- stitutes a favorable sign. A relative increase in
* Presented at the annual meeting of the South Dakota State Medical Association, Pierre, S. D., May 14, 1935.
the staff or immature cells is indicative of in- creased infection. Changes in the nuclei result from changes in the bone marrow.”
It is to be remembered that white blood cells originate from three sources:
1 . The granulocytes in the bone marrow.
2. Lymphocytes in the lymph glands.
3. Monocytes in the reticulo-endothelial system.
The role of the basophi'e is poorly understood.
The appearance of the monocytes is a defense reaction usually appearing at the crisis of the infection.
Kopetzky has well emphasized the importance of the falling hemoglobin and drop in the red blood cells. I personally feel that most of us pay too much attention to the white and differential counts and neglect the hemoglobin. Kopetzky summarizes this information as follows:
1. Continued reduction of hemoglobin and red blood cells is an indication for transfusion follow- ing operation.
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2. Continued reduction following' surgery strongly suggests a sigmoid sinus involvement in acute hemorrhagic mastoiditis.
3. Before operation is indicative of weakened resistance.
No constant rule can be laid down from the blood picture to establish surgical indications. Comparative counts are of much more value than absolute counts. For this reason complete blood studies should be made early and frequently. By doing this one is able to gauge accurately the severity and trend of the infection. We have all seen severe cases of mastoiditis with a low white count requiring surgery and other cases with high white counts subside promptly under conserv- ative treatment. In general it may be stated that intracranial complications give a rise in the white count.
The role of the laboratory probably reaches its greatest importance in involvement of the blood stream. In this connection I would like to mention my own observations as an aid in outlining the best course of treatment. Kopetzky recognizes two types of acute mastoiditis as the acute hemor- rhagic and the acute coalescent type. \\ ith the acute hemorrhagic type invasion of the blood stream may come early in the course of the disease and usually without destruction of the sinus plate. In this type of a mastoid the route of infection is through the small interosseous veins and the pathology in the sinus is usually that of sinus phlebitis rather than a frank thrombosis. This is the type of mastoid that we see so fre- quently during the influenzal epidemics. On the other hand, with the coalescent mastoiditis, the invasion of the blood stream usually occurs late in the course of the illness with actual destruction of the sinus plate and direct invasion of the sig- moid sinus from a perisinus abscess. Here the pathology is usually that of a frank thrombosis. That these two types of mastoiditis are separate entities is borne out by the blood picture. With the hemorrhagic type of mastoid infection and blood stream invasion we usually find a normal or lower white count with a rapidly falling hemo- globin and red blood count. In the coalescent type considerable elevation in the white count is found, varying somewhat with the age of the patient. In younger patients the white count reaches its highest limits. There is also diminu- tion of the hemoglobin and red blood cells but this is not as marked as in the hemorrhagic type. In the hemorrhagic type inspection of the sinus usually shows a relatively normal sinus and Tobey- Ayer test is negative, because there is no obstruct-
ing thrombosis. In the coalescent type the sinus plate is at least partly destroyed, the sinus itself is discolored and frequently covered with granula- tion tissue as a result of a peri-sinus abscess. In this type of case the Tobey-Ayer test may be posi- tive as a result of an obstructing thrombus within the sinus. My interest in this differentiation dates back to a case, a small boy, age 6, who was very sick with bilateral mastoiditis and blood stream invasion. Bilateral mastoidectomies were done, both sinuses were uncovered and appeared normal and the Tobey-Ayer test was negative. The child was very ill and I did not feel justified in doing any further surgery, particularly as I had no means of telling which sinus was involved. The white count ran regularly in the neighborhood of 4,000 cells per mm. and the hemoglobin falling to 50 per cent. Consequently we treated the boy with frequent small transfusions according to the hemoglobin and red blood cell figures, at no time allowing the hemoglobin to fall below 55 per cent. Under this treatment the boy progressed to com- pete recovery without formation of metastatic abscesses. A short time later another patient came in with evidence of metastasis in the hip but with only a unilateral mastoid infection. The mastoid and laboratory findings were practically identical with the former case, and as he already had a metastatic infection, this case was also treated with transfusion only, aside from draining the infected hip. This patient also progressed to com- plete recovery. Since that time three other cases of this type have been encountered and all have recovered to date. The chief objection to this method of treatment would probably be the danger of metastatic abscesses, but it has been shown in this type of case that ligation of the jugular and opening of the sinuses gives no positive insurance against such abscesses forming. This type of case always presents a serious surgical risk. In the acute coalescent mastoiditis with an actual throm- bosis within the sinuses and a high white count, surgery is certainly the method of choice, as it always has been. \\ bile my experience with this condition is too limited to state with certainty that surgery should not be resorted to in those blood stream infections with low white count resulting from a hemorrhagic mastoiditis, 1 am convinced that transfusion is of much greater value in this type than the usual surgical measures on the in- ternal jugular and sigmoid sinus. The value of transfusion lies in the restoration of the hemo- globin and the addition of anti-bodies. Ersner and Myers3 suggest giving the donor an injection of foreign protein about seven hours previous to the
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transfusion in order to increase the anti-bodies in the blood stream.
Blood Cultures — Blood cultures should always be taken where any suspicion of a blood stream infection exists. The proper time to take the culture is at the height of the temperature or at the termination of a chill, under absolutely sterile technique. The doctor should always carefully check the technicians on this latter point, as con- tamination is very easy. For this reason it is advisable to take several cultures at the same time, as an excessive growth on one culture and not on the others would suggest contamination. The presence of streptococci in a blood culture is rarely due to contamination and most of these blood stream infections are due to the hemolytic streptococci. One should not overlook the pos- sibility of other conditions being responsible for the positive blood culture, such as an associated erysipelas, scarlet fever, pneumonia and endocar- ditis. This is particularly true with scarlet fever. Repeated blood cultures should be taken, if neces- sary, as one negative culture by no means rules out the condition. When a positive blood culture is present the diagnosis is established but one should never wait for a positive culture before resorting to the necessary surgery, as there are many cases of blood stream invasion where it is impossible to get a positive culture. The reason for this is that the bacteria are rapidly destroyed in the blood and reticuloendothelial system. The percentage of positive blood cultures undoubtedly would be much higher if the cultures could be taken from an artery instead of a vein, according to Ballenger.4
Middle Ear Cultures — Much information is to be gained from cultures taken from the middle ear at the time of myringotomy. The best method of doing this is to thoroughly sterilize the external canal with alcohol and use the point of the myrin- gotomy knife for the culture. Wirth states that the organism in pure culture can be obtained from the nose in 7 5 per cent of all cases, while cultures from the throat almost always give a mixed growth. The value of these procedures are :
1. Type of organism can be determined, which allows the otologist to be on guard for its par- ticular infectious characteristics.
2. Many times the original infectious organism is overgrown by secondary infectious bacteria and the real organism is thus never found. Fried- lander’s bacilli and the diphtheroid bacilli are par- ticularly prone to do this.
Cultures should always be taken in the course of mastoidectomy, particularly from the antrum.
Many different types of bacteria are found, the usual ones being hemolytic strep, pneumococcus, staphlococci and strepmucosa-capsulotus. The organisms are best cultured on Dextrose brain broth, later planted out on blood agar to determine the hemolytic properties. There is some con- fusion as to whether or not the strepmucosa-cap- suloti is the same as pneumococcus type 3. I think it is generally agreed that this is the case. The organism is best recognized by the process of agglutination, its bile solubility and its unusually large capsule, which can best be brought out by the use of thionin. This large capsule probably explains why these infections are so severe, inas- much as the capsule offers more resistance to the anti-bodies in the blood. Dean states that all pneumococci type 3 are prone to develop a surgical mastoiditis, especially in children, but Page3 re- ports a large series in which 82 per cent of this type of infection recovered without operation. Tuberculosis of the ear is more common than generally recognized and should be suspected where tuberculosis exists elsewhere in the body and in those cases where there is delayed healing or excessive drum destruction or granulation tissue. At times it is difficult to recover the organ- ism and in these cases one must resort to animal inoculation. If granulation tissue is present a sec- tion of it may establish the diagnosis. Tubercu- losis of the ear is most common in infants and is usually of the bovine type. I had one such case in an 1 1 months baby in which a large aural polyp was found, completely filling the external canal, in which a co-existing miliary tuberculosis was present. Tubercular bacilli were found in the dis- charge and section of the polyp was also positive, showing giant cells and bacilli.
Brain abscess usually gives rise to an increased white count. If the percentage of neutrophiles is high the outlook is very poor, whereas with a relative lymphocytosis the outlook is much better. The reason for this is obvious when we recall that the real purpose of the neutrophile is to com- bat the infectious organism, while the lympho- cyte acts principally to remove detritus. There- fore, a return of the lymphocytes to the normal or higher, suggests that some organization is taking place, and wherever possible, it is advisable to carry an abscess case over into this stage before operating.
Spinal Fluid — Much of the information here given on the spinal fluid is taken from the article by Connor mentioned under reference one.
1. Pressure — This is roughly indicated by the rapidity of the flow through the needle or more
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accurately by the manometer reading. Any in- crease in pressure is due to increased intracranial pressure. Pressure readings are of limited value and it should be remembered that it may be de- creased in brain abscesses.
2. Color — Turbidity is caused by cells, bacteria or fibrin webs. A neutrophile count of 300 is sufficient to cause turbidity while lymphocytes will not, as is the case in tuberculosis.
3. Normal glucose is 45-85 mgs. per hundred c.c. This decreases in acute meningitis due to action of ferments resulting from cellular dis- integration.
4. The normal chlorides, 720 to 750 mgs. per 100 c.c. An increase in the chlorides is an indica- tion of renal deficiency, while a decrease means an invasion of the subarachnoid space. In tubercular meningitis this is of secondary importance only to the presence of bacillis.
The above tests may be used to determine the presence of spinal fluid in cerebral spinal rhinor- rhea or otorrhea. Another practical point in this connection is that spinal fluid will not stiffen handkerchiefs due to the absence of mucous.
5. Cytology — The normal count is less than five cells per cubic millimeter, with no neutrophiles. Lymphocytes function chiefly to remove detritus and their presence is a favorable sign, except in tuberculosis. The neutrophiles act to destroy the invading organisms and this is an unfavorable sign. A low white count in the spinal fluid points to a circumscribed process. A brain abscess may show normal fluid or findings of a circumscribed meningitis. With a generalized meningitis the count may rise to such a height as to give a yellow fluid.
6. The Spinal Fluid Culture Is Very Important — A negative culture in the presence of other positive signs of a meningitis means that we are dealing with a protective mechanism and that there is some hope for the patient’s life. The presence of the hemolytic streptococci is prac- tically always fatal as is the pneumococcus type 3 and bacillas influenza. Smears and cultures should both be made on spinal fluid, as the intra- cellular character is lost on culture.
Albumin — Excess of albumin in the spinal fluid is of no diagnostic significance. The presence of globulin is pathological and points to meningeal irritation.
Blood Dyscrasias in Ear, Nose and Throat — Many of these cases which properly come under the care of the internist are first seen by the otolaryngologist as a result of the nose and throat symptoms. For this reason it is recommended that
complete blood studies be made on all acute in- fections of the nose and throat in order to rule out any of these general conditions. By doing this, proper treatment can be instituted at once and the physician is protected in that he is able to tell the relatives of the seriousness of the case. Reference is again made to Dr. Connor’s article in the differentiation of these conditions. “We are all familiar with the tonsillar swelling in leukemia, the adenitis of Hodgkin's disease or the severe glossitis which is found in pernicious anemia, acute leukemia, hemorrhagic purpura, metallic poisoning and severe sepsis.
(a) A granulocytic angina shows an absolute diminution in both granulocytes and lymphocytes, especially the former. The total count varies be- tween 200 and 4,600 cells per cubic millimeter. The hemoglobin and red blood cells remain rela- tively normal. The seriousness of this condition, of course, is well recognized.
(b) Infectious mononucleosis — The blood pic- ture in this condition shows a moderate leukocyto- sis of 11,000 to 26,000, with a relative lymphocy- tosis, due to the large monocyte count. According to Downey this cell is a mature functioning abnor- mal lymphocyte and may be distinguished from acute lymphatic leukemia, which shows a higher white count, immature lymphocytes and secondary anemia.”
Urinalysis — Urinalysis should be done in every severe infection of the ear, nose and throat, not only as a pre-operative precaution but for the in- formation gained. Many times an infection of the genitourinary tract is discovered which may explain the fever or other symptoms present in the case. Diabetics are very immune to pain. The edematous membrane seen in the nose is frequent- ly the result of a tubular nephritis, especially in childhood.
Syphilis — Wassermann tests should always be done in any doubtful lesion of the ear, nose and throat, and particularly in those cases where there is a lesion in the larynx, abnormal scarification in the pharynx and palate, perforations of the bony nasal septum, perichondritis, perceptive deafness, delayed healing and as a pre-operative measure to radical surgery. Where a primary lesion is sus- pected dark field examination must be made.
Diphtheria — Culture should be made on every acute throat and should be repeated daily, if neces- sary, to get a positive culture. The culture is more apt to be positive if taken beneath the edge of the membrane. It is well to remember that diphtheria may be present in the absence of any form of membrane.
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Fungus Infection — The diagnosis of fungus in- fections is frequently overlooked in diseases of the ear, nose and throat. This is very unfortunate, as these infections when treated specifically respond very well, and if not, failure is very common. This is especially true in the eczemas of the external auditory meatus. The usual fungi found in the ear are mucoracea or aspergillis nigre or fumi- gatus. Mycelium may occur in the external canal and are even found in the middle ear, producing mucoid discharge. Stevenson0 reports several cases of mycotic infection in the sinuses, especially mucor-histoides, which cleared up under the usual measures of treatment. Monila albicans has been found in 31 per cent of cases of chronic bronchial asthma.
Actinomycosis is the cause for quite a few in- fections in the throat and neck. A high percentage of infections in the tongue and floor of the mouth are due to actinomycosis. The fact that Ludwig’s angina is frequently due to actinomycosis is com- monly overlooked in the care of this condition. Any suspicious lesion should be observed for the ray- fungus and sulphur granules. These are yellowish-white bodies. The granules should be mashed between slides and examined for the characteristic mycelium and spores, as it is hard to grow in cultures.
Dr. Weidman7 gives the following excellent technique in the examination of mycosis :
(a) He states that the potassium hydroxide technique stands out. A small part of material is placed on slide and a drop of 10 per cent potas- sium hydroxide added. This clears the specimen and softens it so that it flattens out into a thin film. Should be examined immediately.
(b) For smaller fungi Giemsa