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Full text of ' fAAR2J 1954 ^sity“of kN library Founded 1813 2^L of MED G^ Digitized by the Internet Archive in 2016 JME 46 BER 1 INDIANAPOLIS, INDIANA, JANUARY, 1953 Single Copy, 50 Cents Per Year, $5.00 1 ' I: I 1 I i SCIENTIFIC ARTICLES Cost Allocations of Overtreatment Dermatitis. Edward Gaul, M.D., and G. Underwood, M.D., Evansville • 17 The Carotid Sinus Reflex. Urschel, M.D., Mentone 21 Clinical Observations on Pancreatic Malignancies. Malinowski, M.D., M.C., U.S.A. 25 EDITORIALS Robert M.

Moore - — — - 31 American Legion — — — 32 Answer the Call - — — 32 Editorial Notes - - — 33 SPECIAL ARTICLES Medical Panorama. Cavins, M.D., Terre Haute 34 County Society Officers to Meet January 11 —. 35 President's Page.

Crimm, M.D., Evansville 36 The Fourth Estate Looks at Medicine — 37 New Spray On Plastic Dressing May Prove Effective for General Use. — - 39 Emergency Medical Care in Tippecanoe County. Dubois, M.D., D. Jones, M.D., P. Rothrock, M.D., Lafayette 40 Three Associate Editors Assume Duties on Staff of THE JOURNAL.

43 Serving the Child Effectively Through the School Health Program 44 State Nurses' Association to Ask Legislature for Scholarship Funds 47 State Board Annual Registration Law: Provision for Licensees in Service 48 MISCELLANEOUS Nows Notes Deaths A.M.A. Washington Office News — Society Reports: I.S.M.A. Executive Committee.

Ccuncilor District Meeting Local Society Reports Indiana State Board of Health — Division of Communicable Disease Control. Advertisers' Index... 50 55 56 58 60 60 64 66 86 Entered as Second Class Matter* January 25* 1933* at the Postoifice at Iiidianapolis* Indiana, under the Act of Congress of March 3* 1879. Accepted for mailing at special rate of postage provided for in Section 1103. Act of October 3* 1917, authorized October 18* 1918. Copyrighted 1953 by The Indiana State Medical Association.

Published monthly. Office of publication: 1017 Hume Mansur Bldg.* Indianapolis 4, Ind. In the hands of the physician often the critical evaluation of the drug to be administered is as important to the patient’s recovery as is the diagnosis of his con- dition. In each case correct procedures can be determined only by the physician. CHLOROMYCETIN is eminent among drugs at the disposal of the medical profession. Clinical findings attest that, in the hands of the physician, this widely used, broad spectrum antibiotic has proved invaluable against a great variety of infectious disorders. Notably effective, well tolerated, broad spectrum antibiotic The many hundreds of clinical reports on CHLOROMYCETIN emphasize repeatedly its exceptional tolerance as demonstrated by the infrequent occurrence of even mild signs and symptoms of gastrointestinal distress and other side effects in patients receiving the drug.

Similarly, the broad clinical effectiveness of CHLOROMYCETIN has been established, and serious blood disorders following its use are rare. However, it is a potent therapeutic agent, and should not be used indiscriminately or for minor infections— and, as with certain other drugs, adequate blood studies should be made when the patient requires prolonged or intermittent therapy.

Januai'y, 1953 The Journal of The Indiana State Medical Association 7 COOK COUNTY GRADUATE SCHOOL OF MEDICINE Posfgroduafe Courses— W/nfer 1952-53 SURGERY — Intensive Course in Surgical Technic. Two Weeks, starting lanuary 19, February 2. Surgical Technic, Surgical Anatomy & Clinical Surgery, Four Weeks, starting March 2. Surgical Anatomy & Clinical Surgery, Two Weeks, starting March 16. Basic Principles in General Surgery, Two Weeks, starting March 30. Gallbladder Surgery.

Ten Hours, starting April 20. Surgery of Colon &. One Week, starting March 2. General Surgery, One Week, starting February 9. General Surgery.

Two Weeks, starting April 20. Fractures & Traumatic Surgery.

Two Weeks, starting March 2. GYNECOLOGY — Intensive Course, Two Weeks, starting Febru- ary 16. Vaginal Approach to Pelvic Surgery. One Week, starting March 2.

OBSTETRICS — Intensive Course. Two Weeks, starting March 2. PEDIATRICS — Intensive Course.

Two Weeks, starting April 6. MEDICINE — Intensive General Course.

Two Weeks, starting May 4. Electrocardiography & Heart Disease. Two Weeks, starting March 16. Allergy, One Month and Six Months, by appointment.

UROLOGY — Intensive Course — Two Weeks, starting April 13. Ten- Day Practical Course in Cystoscopy starting every two weeks. DERMATOLOGY— Intensive Course.

Two Weeks, starting May II. TEACHING FACULTY— ATTENDING STAFF OF COOK COUNTY HOSPITAL Address: Registrar, 707 S. Wood St., Chicago 12, III. Known as Kryptok. Were patented in Philo- delphio in 1899 They represented the first major improvement in bifocals since Fronklin's split lenses.

Kryptok bifocals ore still being produced. Development of fused and one-piece bi- focols and trifocals is keeping pace with the demand for better vision. Ouolity lenses such os Ponoptic. Ond Korectol ‘ D*’.

Ore ovolloble through Blue Ribbon Service THE *T0Aite-5^«iMe OPTICAl COMPANY j INDIANAPOLIS. SOUTH BEND = and TERRE HAUTE = GENERAL OFFICES; COLUMBUS. OHIO r 0 Convalescence is associated with protein loss of serious magnitude, yet little is known of the funda- mental nature of the loss.^ Loss of nitrogen cannot be prevented; however, nitrogen balance can be maintained, wound healing enhanced, and conva- lescence shortened, by a high protein diet.- Ottierwise the patient uses his own ‘‘available’' nitrogen stores to accomplish the healing defect.'

The patient “is better off before his nitrogen stores have been wasted than after. Surgeons have long noted that chronically debilitated patients are poor operative risks.”' Decubitus ulcers heal quickly in heavily protein-fed patients.* These facts are clear, as is also the fact that Knox Gelatine, which is pure protein, offers a useful method of supplementing the ordinary dietary protein. Knox Gelatine is easy to digest, while its supple- mentary dietary nitrogen will furnish protein with- out other substances, especially salts of potassium which are retained during convalescence; without excess fat and carbohydrate, which are not needed especially; and without a food volume which may interfere with intake. Protein MetatMlism During Convalescence After Trauma. 50:166, 1945. Co Tui, Minutes of the Conference on Metabolism Aspects of Convalescence Including Bone and Wound Healing. Josiah Macy, Jr- Foundation, Fifth Meeting Oct.

And Madden, S. Hemoglobin, Plasma Protein and Cell Pro- tein: Their Interchange and Construction in Emergencies. Medicine 23:215, 1944. Mulholland, J. H., Co Tui, Wright, A.

M., Vinci, V., and Shafiroft, B. Protein Metabolism and Bed Sores. 118:i015, i943. AVAIIAUE AT GROCERY STORES IN 4-ENVBOI>E FAMaT SUE AND ai-ENVELOFE KONOMV SIZE PACKAGES Write today for your free copy 'Feeding the Sick and Convalescent.' Knoz Gelatine, Johnstown, N. IS KNOX GELATINE U.S.P. ALL PROTEIN NO SUGAR Patronize Your Advertisers 8 The Journal of The Indiana State Medical Association January, 1953 THE INDIANA STATE MEDICAL ASSOCIATION OFFICERS FOR 1952-53 President — Paul D.

Crimm, M.D., Boehne Hospital, Evansville. Delete A File From The Ifstream. President-elect — William H. Howard, M.D., 5231 Hoh- man Avenue, Hammond.

Treasurer — Roy V. Myers, M.D., 1904 N.

Rural Street, Indianapolis. Assistant Treasurer — James W.

Denny, M.D., 5504 East Washington Street, Indianapolis. Executive Secretary — Mr. Waggener, 1021 Hume Mansur Building, Indianapolis. (Home Telephone: Franklin, Indiana, 587) Assistant Executive Secretary — Miss Lucille Kribs, 1021 Hume Mansur Building, Indianapolis. Field Secretary — Mr. Amick, 448 S. Bond St., Scottsburg.

Legal Counselor — Mr. Albert Stump, 1058 Consolidat- ed Building, Indianapolis. SECTION OmCERS 1952-53 Section on Surgery: Chairman, Karl M. Koons, M.D., Indianapolis. Vice-chairman, Thomas C. Haller, M.D., Crawfords- ville. Secretary, Truman Caylor, M.D., Bluffton.

Section on Medicine: Chairman, Richard M. Nay, M.D., Indianapolis. Vice-chairman, Paul L.

Stier, M.D., Fort Wayne. Secretary, Jack L. Eisaman, M.D., Bluffton. Section on Ophthalmology and Otolaryngology: Chairman, Edwin W.

Dyar, Indianapolis. Vice-chairman, Kenneth L. Craft, M.D., Indianapolis. Secretary, Marvin P. Cuthbert, M.D., Indianapolis.

Section on Anesthesiology: Chairman, George N. Love, M.D., Indianapolis. Vice-chairman, Meredith B. Flanigan, M.D., India- napolis. Secretary, V.

Stoelting, M.D., Indianapolis. Section on General Practice: Chairman, Bernard E. Edwards, M.D., South Bend. Vice-chairman, Norman R.

Booher, M.D., India- napolis. Secretary, Frank H. Green, Jr., M.D., Rushville.

Section on Obstetrics and Gynecology: Chairman, Robert W. Wilkins, M.D., Fort Wayne. Vice-chairman, Pierce MacKenzie, M.D., Evansville.

Secretary, Floyd T. Romberger, Jr., M.D., India- napolis. Section on Public Health and Preventive Medicine: Chairman, Marvin McClain, M.D., Scottsburg. Vice-chairman, Minor Miller, M.D., Evansville. Secretary, L.

Renbarger, M.D., Marion. DELEGATES TO THE A.M.A. For One Year (terms expire December 31, 1953): Karl Ruddell, M.D., Indianapolis, and Wendell C. Stover, Boonville. Alternates: Robert H. Rang, M.D., Wash- ington, and Lall G. Montgomery, M.D., Muncie.

For Two Years (terms expire December 31, 1954): Cleon A. Nafe, M.D., Indianapolis, and E. Jones, M.D., Hammond. Alternates: Alfred Ellison, M.D., South Bend, and William C. Wright, Fort Wayne.

COUNCILORS District Councilor Term Expires 1 — Herman T. Coombs, Evansville..Dec.

31,1953 2 — Arthur G. Blazey, Washington Dec. 31, 1954 3 — William H. Garner, New Albany Dec.

31, 1955 4 — Charles Overpeck, Greensburg. 31,1953 5 — M. Topping, Terre Haute.—Dec. 31, 1954 6 — W. Kennedy, New Castle Dec. 31,1955 7 — Roy A.

Geider, Indianapolis Dec. 31, 1953 8 — F. Keeling, Portland Dec. 31, 1954 9 — Wemple Dodds (Chairman), Crawfordsville Dec. 31, 1955 10 — J. Doty, Gary Dec.

31, 1953 11 — Elton R. Clarke, Kokomo.Dec. 31, 1954 12 — M. Catlett, Fort Wayne.

31, 1955 13 — Kenneth L. Olson, South Bend.Dec. 31, 1953 1951-52 DISTRICT MEDICAL SOCIETY OmCERS District President 1. Huggins, M.D., Evansville. Ramsey, M.D., Bloomington. Dusard, M.D., Bedford 4.

Carpenter, M.D., Columbus 5. Rhea, M.D., Greencastle. Ross, M.D., Richmond. Everly, M.D., Indianapolis.

Wilder, M.D., Anderson 9. Miller, M.D., Lafayette 10. Lee Hickman, Hammond 11.

Good, Kokomo 12. Gerding, M.D., Fort Wayne 13. Luzzader, New Carlisle Secretary Place and date of meeting -Chas. Schneider, M.D., Evansville..J. Brown, M.D., Carlisle.Eli Goodman, M.D., Charlestown -H. Rothring, M.D., Columbus.Columbus, 1953.Stuart R.

Coombs, M.D., Terre Haute.John E. Fisher, M.D., New Castle.Connersville, April 30, 1953 -T. Petronoff, M.D., Indianapolis.Warren Fisher, M.D., Anderson.- -Hugh B. McAdams, M.D., Lafayette. Noblesville, 1953.Leo Cooper, Gary.,C.

Herd, M.D., Peru Delphi, May 20, 1953.James M. Burke, M.D., Decatur.O.

Wilson, M.D., Elkhart INFORMATION FOR CONTRIBUTORS TO THE JOURNAL All articles must be typewritten, double-spaced, on one side of white paper, with margins of at least one inch. Photographs should be printed on glossy paper. Negatives are not acceptable.

Only a limited number of illustrations can be used with each original article. If an excessive number are submitted for publication, the cost of extra illustrations must be borne by the author. Contributors are responsible for all statements made in their articles.

The editor and eidtorial board members may not be in agreement with various views expressed by authors, but it is desired to allow authors as great latitude as possible. However, the right is reserved to reduce in length or reject any article. Articles are accepted for publication only with the understanding that they are submitted for exclusive publication in THE JOURNAL of the Indiana State Medical Association.

All communications regarding advertising and subscrip- tions should be sent to THE JOURNAL of the Indiana State Medical Association, 1017 Hume Mansur Building, Indian- apolis 4, Indiana. Communications dealing with editorial natters should be sent to Frank B. Ramsey, M.D., Editor, 201 Hume Mansur Building, Indianapolis 4, Indiana. January, 1953 The Journal of The Indiana State Medical Association 9 eP^thers will tKaak, “^ou ^ CHILDREN’S SIZE BAYER ASPIRIN IT e will be pleased to send samples on request THE BAYER COMPANY DIVISION of Sterling Drug Inc.

1450 Broadway, New York 18, N. Dissolved on Tongue • The Best Tasting Aspirin You Can Prescribe. • The Flavor Remains Stable Down to the last Tablet in the Bottle. • 24 Tablet Bottle... Each 15^ 2'/2gr.

(JD OlD Grooved Tablets — Easily Halved. Patronize Your Advertisers 10 The Journal of The Indiana State Medical Association January, 1953 Indiana State Medical Association Committees for 1952-53 STANDING COMMITTEES EXECUTIVE (1952-53) — C. Clark, Indianapolis, chairman; W. Portteus, Franklin; Paul D.

Crimra, Evansville, president; W. Howard, Hammond, president-elect; Roy V. Myers, Indian- apolis, treasurer; Wemple Dodds, Crawfordsville, chairman of the Council. BOARD OF APPEALS ON PATIENT-PHYSICIAN RELATIONS — Augustus P. Hauss, New Albany (2 years); Minor Miller, Evans- ville (3 years); Clifford M. Jones, Whiting (2 years); C.

Black, Warren (1 year); William C. Reed, Bloomington (1 year); Harry P. Ross, Richmond (1 year); R. Calvert, Lafayette (3 years); C. McCaskey, Indianapolis (2 years); R.

Wilkins, Fort Wayne (3 years). COUNTY MEDICAL SOCIETY OFFICERS’ CONFERENCE— R. Ploughe, Ehvood, chairman: L. Montgomery, Muncie; R.

Lavengood, Marion; H. Ramsey, Bloomington; Albert M. Mitchell, Terre Haute; Claude D.

Holmes, Sr., Frankfort; Francis P. Jones, Indianapolis; J. Gilliatt, Salem; Fred D. Houston, Lawrenceburg. CONSTITUTION AND BY-LAWS — W.

Garner, New Albany, chairman; Paul R. Tindall, Slielbyville; A. Blazey, Washington; Walter K.

Robinson, Gary; Donald G. Mason, Angola; 1. Barclay, Evansville; Louis C. Bixler, South Bend; George S. CONVENTION ARRANGEMENTS — E. Fitzsimmons, Evans- ville, chairman; J. Neill Garber, Indianapolis; Keith Hammond, Paoli; J.

Davis, Flat Rock; Wendell C. Stover, Boonville; R. Hansell, Indianapolis; Henry G. Backer, Ferdinand; James 11. Crawford, Evansville.

INDUSTRIAL HEALTH — ^E. Jones, Hammond, chairman; C. Powell Van Meter, Indianapolis; E. Lamb, Indianapolis; J. Clevenger, Muncie; Coen L.

Luckett, Terre Haute; Richard Carl Swan, Anderson; B. Fitzgerald, Logansport; Gan'cy B. Bowers, Kokomo; H.

Holmen, South Bend; Edgar H. Weber, Evansville; L. Spolvar, Indianapolis. MEDICAL EDUCATION AND HOSPITALS— James W. Denny, Indianapolis, chairman; D. I'aris, Kokomo; Edwin A. Lawrence, Indianapolis; Harry E.

Klepinger, I>iifayette; John A. Shively, Bluffton: Alfred Ellison. South Bend; Maurice E. Glock, Fort Wavne; Irvin H. Scott, Sullivan.

PUBLIC POLICY AND LEGISLATION — Harold C. Ochsner and J. Wright, Indianapolis, co-cliairmen; Lester D.

Bibler, In- dianapolis; W. Howard, Hammond; Dillon Geiger, Blooming- ton; Harold J.

Ilalleck, Winamac; James i. Wyatt 111, Fort Wayne; W. Kennedy, New Castle; R. KleimloiTer, Evansville. PUBLIC RELATIONS — Earl W.

Mericle, Indianapolis, chair- man; F. Mitrnan, Huntington; 0. Alexander, Terre Haute; Davis W. Ellis, Rushville; Charles P.

Schneider, Evansville; Jerome A. Graf, Bloomfield. PUBLICITY — E. Clauser, Muncie, chairman; I). Megen- hardt, Indianapolis; Norbert M. Welch, Vincennes; A.

Gregg, Connersville; J. Ritchey, Indianapolis; R. MacDonald, South Bend; Homer G. Hamer, Indianapolis. RURAL HEALTH — J.

E, Dudding, Hope, chairman; Paul B. Casebeer, (’linton; Sam I.

Rotm.:n, Jasonville; John M. Bretz, Huntingburg; Robert W. Kuhn, Wilkinson; Raymond G. Geick, Fort Branch; Eli Goodman, Charlestown; Louis E.

How, Lakeville; L. Vore, Plymouth: Milton Omstoad. SUBCOMMITtEE ON PRECEPTORSHIPS — Lester D.

Bibler, Indianapolis, chairman; M. Kahler, Indianapolis; Walter L. Portteus, Franklin; Charles R.

Alvey, Muncie; Joseph E. Dudding, Hope (cliairman.

Rural Health); James W. Denny, Indianapolis, (chairman, Medical Education & Hospitals); John D. Van Nujs, Indianapolis. SCIENTIFIC EXHIBITS — John L. Arbogast, Indianapolis, cliair- man; Samuel L. Adair, Jelfersonville; Fred R.

Malott, Converse; J. Frank Maurer, Brazil; Dallas Fickas, Evansville; Byron Nixon, Farmland; C. Toney Dutchess, Galveston; J. Oyer, Fort Wayne; L. Mason, Terre Haute. SCIENTIFIC WORK — Clyde G.

Indianapolis, chair- man; H. Caylor, BIuH'ton; Clarence H. Rommel, West Lafa- yette; A.

Ratcliffe, Evansville; E, C. Singer, Fort Wayne; Neal Baxter, Bloomington; Richard P. Good, Kokomo. SPECIAL COMMITTEES ALCOHOLICS STUDY — L.

Beggs, Columbus, chairman; Paul Loiig, Anderson; Howard W. Beaver, Indianapolis; C. Washington; C. Cullnane, Evansville; Carl M. Hostetler, Goshen; Kenneth Broshoars. ANTI-NATIONAL HEALTH INSURANCE COMMITTEE — Elton R. Clarke, Kokomo, chairman; V.

Earle Wiseman, Gre encastle; G. Larson, LaPorte; W. Portteus, Franklin; J. Doty, (iary; L. Baile.v, Zionsville; Cleon A. Nafe, Indianapolis; T. Hayes, Muncie; Herman M.

Baker, Evansville. AUDITING — Wemple Dodds, Crawfordsville, chairman; Roy V. Myers, Indianapolis; Thomas C.

Brown, Delphi; F. Messer, Kendallville; Roy A. Geider, Indianapolis; Charles Overpeck, Greensburg.

CANCER — Parvin M. Davis, New Albany, chairman; R. Stout, Elkhart; George A.

May, Madison; L. Fort Wayne; W. Gatch, Indianapolis; David A. Bickel, South Bend; Mell B. Evansville; F. K^einmaii, Hebron. CHRONIC ILLNESS— Charles N.

Manley, Rising Sun, chairman: Warren C. Hastings, Fort Wayne; Justin R. Nash, Albion; R. Webster, Brazil; Marvin McClain, Scottsburg; Paul A. Clouse, Evansville; A..T. Steffen, Wabash; W. Nance, Vincennes; Indn E.

Huckleberry, Salem. CIVIL DEFENSE — Glenn Ward Lee, Richmond, chairman; T. Armstrong, Michigan City; W. Baldridge, Terre Haute; Jamerf M. Leffel, Indianapolis; E.

Bailey, Logansport; Claude D. Holmes, Sr., Frankfortj, Paul V. Sparks, Winchester; James E. Jobes, Indianapolis; K. Olson, South Bend; Walter R. Spring- stun, Evansville; Jean V. Carter, Tipton.

CONSERVATION OF VISION — Richard Good, Kokomo, chair- man: Carl J. Rudoljjh, Souili Bend; Noel McBride, Terre Haute; E. Dyar, Indianapolis; Edward U. Murphy, Evansville. CRIPPLED CHILDREN SERVICES — Leo K.

Cooper, Gary, chair- m.n; John W. Ripley, Seymour; Wayne R. Glock, Fort Wayne; I.

Brown, Muncie; Edward ’J'. Stahl, Lafayette; John S. Brown, Carlisle; L. Ensminger, Indianapolis.

DIABETES — D. Dickson, Gi'eensburg, chairman; L.

Gwaltney, Roachdale; S. Bryan, Evansville; James P. Vye, Gary; Frederic M. Dukes, Dugger: Ray Elledge, Hammond. FOOT HYGIENE — Richard W. Ilalfast, Kokomo, chairman; M. Topping, Terre Haute; Robert B.

Acker, South Bend; Frank W. Teague, Indianapolis; Willis L.

Pugh, Evansville; W. Ferguson, West L fayetle; Frederic W. Brown, Fort Wayne. HARD OF HEARING — Hugh A. Kuhn, Hammond, chairman; C. McCaskey, Indianai)olis; Carroll O’Rourke, Fort Wayne; Robert W.

Turgi, Gar; Robert A. Sniitii, New Castle; Guy W. Owsley, Hartford City; J. Begley, Evansville; W. Stewart, Terre Haute.

HEART DISEASE — Stuart R. Combs, Terre Haute, chairman; C. Clark, Ind.anapolis; Ualpii C. Fades, Val])araiso; Philip W. Rothrock, Lafayette; Patrick j.

Corcoran, Evansville; Walter S. Fisher, Columbus; Dan L. Urschel, Mentone; John F. Ling, Richmond. INDIANA INTER-PROFESSIONAL HEALTH COUNCIL— M.

Catlett, Fort Wayne, chairm, n; David A. Dukes, Tell City; George M. Ellis, Connersville; Marion E. Clark, Cambridge City; Ward Laramore, Indianapolis. INFANTILE PARALYSIS — William C.

Vance, Richmond, chair- man; Leroy E. Buniey, Indianapolis; Herbert O. Chattin, Vin- cennes: James M. Kirtley, Crawfordsville; James F.

Peck, Prince- ton; Kenneth T. Knode, South Bend. INSTRUCTIONAL COURSES— Seth W. Ellis, Anderson, chair- man; Edwin A.

Lawrence, Indianapolis; Eugene L. Bulson, Fort Wayne: M. Gevirtz, Hammond; Russell A. Sage, Indianapolis; Sleplien L. Evansville; Raymond E. South Bend; James M.

Burk, Decatur; John A. Larson, Logansport. MATERNAL AND CHILD HEALTH— A. Cavins, Terre Haute, chairman; Reuben Craig, Kokomo; G, W. Gustafson, Indianapolis; II.

Hammond; Malilon F. Miller, Fort Wayne; Russell A. Gardner, Michigan City; J. Stoelting, Terre Haute; Wilfred Brockmmi. Curtis Young, Ev.insville. MEDICAL CARE INSURANCE — Wm.

Reed, Bloomington, chairman: D. South Bend; H. Stimson, Gary; M. Kahler, Indianapolis; Francis B.

Mountain, Connersville; F. Napper, Scottsburg; George Willison, Evansville; Joseph G.

Weber, Terre Haute; C. Jones, Wliiting; Raymond O. Beeler, Indianapolis.

MENTAL HEALTH — L. Harsliman, Fort Wayne, chairman; John E. F'isher, New Castle; V. Beam, East Chicago; C.

Williams, Intlianapolis; E. Vernon Hahn, Indianapolis; F. Farghor, Michigan City: James F. Reilly, Vincennes.

MILITARY MANPOWER — John E. Owen, Indianapolis, chair- man; G. Thomas, Lafayette; John M. Palm, Brazil; Carl 0. Fort Wavne: Gayle J. Hunt, Richmond; Erwin Blackl>nrn, South Bend: Wm.

Cockrum, EvanfniHe; H. English, Gary. NECROLOGY —.bnnes B. Maple, Sullivan. PHYSICIAN-HOSPITAL RELATIONSHIPS — K.

Olson, South Bond, chairman; Jess E. Burks, Crawfordsville; Kenneth E. Comer, Mooresville; C. Ilorzer, Evansville; Justus M.

Lkiiart: Thomas M. Conley, Kokomo; R. Beeler, Indianapolis; Ilenrv W. Conrad, Milan. SCHOOL HEALTH AND PHYSICAL EDUCATION — Harold D. Lynch, Evansville, chairman; N. Salon, Fort Wayne; Clarence V.

Roselle, Anderson; S. Hammond, Portland; C.

Richard- son. Rocliester; Carl A. Attica; Owen Johnson, Peru; W. Winchester; Flwnrd T. Edwards, Jr., Vincennes.

STATE FAIR — Malcolm 0. Scamahorn, Pittsboro, chairman; W. Bloomington; Myron L.

Llabeggor, Berne; M. Mount, Bloomfield: 'I'homas R. Owens, Muncie; Donald M. Kerr, Bedford; Philip W. Hedrick, Indianapolis. TRAFFIC SAFETY — 0. Wilson, Elkhart, chiiirman; Ralph C.

Eades, Valparaiso; Arthur C. Vandevert, Sellersburg; Robert E. Moses, Worthington; Richard Schantz, Remington; Robert Rang, Washington. TUBERCULOSIS — J. Strayer, Lafayette, chairman; E. C ister, South Bend: R.

Meyer, Vincennes; Robert A. Staff, Rockville; J. Nelson Ewbank, Richmond; On'a T. Kidder, Fort Wayne; James Spigler, TeiTe Haute; James H. Stygall, Indianap- olis: 1‘hilin II. Crown Point; T.

Owens, Muncie. VENEREAL DISEASES — George W. Bowman, Indianapolis, chairman; Wm. Sigmuml, Col imhus; Ernest 0.

Nay, Terre Haute; Frank J. Kendrick, Gary: W. Barnhart, Evansvdlle; Paul P. Bailev, Fort Wa ne: Donald L. Lishlev, Tell City.

VETERANS AFFAIRS AND REHABILITATION — Jack E. Brownstown, chairman; Wm. Challman, Mt. Vernon; Herman T. Combs, Evansville; James L.

Lamey, Anderson; Nelson B. Combs, Mulberry: Norman R. Booher, Indianapolis; Dan E. Talbott, Indianapolis; L. Bailey, Zionsville; John M. Palm, Brazil. OpmJonA, 3etter then worse.

When I irsed the fourth tube of salve there on the table, it seemed to do a lot of good at fir.st; and then all at once it got worse.” i’ast-treatment patch test reactions ])roved that in 27 per cent of patients with contact dermatitis, minor or severe complications were produced by topical treatments, hdnir patients with olndons evidence of overtreatment refused patch tests. Including these cases would have increased the inciilence to,i() ])er cent., n organome.rcurial was the etiology in 4 cases: I’ontocaine and Xupcrcainal, 1 case: Calgesic, o cases: Khulitol, 2 cases; Ivy Dry. 1 case; ammoniated mercury, 1 case; Jer- gens l.otion and Alede-X, 1 case; and unknown prescri )tions, 4 cases. The histories in the 17 o -ertreated cases showed the usual series of events '■ Wi -es or husbands, fathers or mothers, rela- tives and friends, and mere ac( uaintances, and lay-diagnosticians, including hawkers, treat the skin.

Some of the remedies ])r(jducing over- treatment have been ])rescribed by physicians which is jiroof that skin ])re])arations, particularly anti])ruritics, are marketed with insufficient ])harmacologic study. Recently a jibysician re- ferred a i)atient for a Imllous dermatitis on the arm. Wdien he called he stated that he had prescribed an antihistaminic cream that had made the ]iatient much worse.

Pa.st-treatment patch tests showed no reacticjn to the cream, hut an organomercurial produced a l,)ullous re- action. The patient was tiying to keep down the infection at home with a free use of a red antise[)tic. “Between treatments” that patients try at home are frerpient causes of cutaneous flare ups. Physicians are not told about these treatments. Every patient with an acute der- matitis should be i)atch tested with all topical remedies as soon as feasible. The tests will pro- tect both physician and patient. The proof that information reaching the ])nhlic about the skin is misleading is furnished by the fact that the 17 overtreated cases used a total of 83 different skin remedies containing several hundred dififer- ent chemicals, f fermatologically speaking, treat- ment of the skin is still tied to the era in medi- cine when oral potions were swallowed, hit or miss.

Distribution of Cost Liability ( )rdinarily, it is th.ought that skin patients ar-e not ])eo[)le who fre( uent the hospitals. ^Vs of today, they are often lied patients. I'he house- wife with her hands a weeping dermatitis is help- less. An explosi 'e, generalized dermatitis in- cajiacitates the individual. Seven of the 17 over- treated cases cxjierienced this coiujilication from remedies alleged to heal and relieve itching.

If the buttocks is the site of a pustular dermatitis, the person cannot sit down. V severe pedal dermatitis places the patient in bed or on crutches.

It is not unusual for a therapeutic der- matitis to close the eyelids. Seven jiatients re- ( uired hos[iitalization. D'hev did not go to collect insurance benefits; they went liecause an organ ol their body had been stricken by too much treatment to a iioint where it could uo longer carry on its vital I unctions. D'he total ci.ist for the seven hospital cases was well over $2,000.

The distrihntion of this liahil- it ' is shown in Table 1. Table 1 — PER CENT LIABILITY DISTRIBUTION OE OVERTREATAlEXr DERAIATITIS Personal Insurance Liability Liability Huspital Cost _ _ 21 79 Medical Eees 70 30 Wages Lost 47 53 It is aiiparent that insurance companies pay a good portion of the cost of overtreatment. In Table 2 is shown the per cent distrihntion of the total overtreatment cost for the seven hospital cases. Medical fees are a minor item in the cost of overtreatment dermatitis; notwithstanding the ALLOCATIONS OF OVERTREATMENT DERMATITIS— GAVL-UNDERV'OOD 19 fact that we shoulder all the responsildlity and work to restore these patients to health. Table 2— PER CENT COST DIS'I RIBUTION OF OVERTREATMENT DERMATITI S Hospital Cost Wages Lost Medical Fees 4(1 45 15 'I'hese tables should alert physicians to the im- portance of secptela fr(.)iu injudicious therapy of the skin.

We should condemn lay-treatments of the skin hecause, unknowingly, we assume re- sponsihility for it when the patients iinally come under our care. Prevention of Overtreatment by Patient Education Seldom a week passes that an old ])atient does not telephone the following ( ueries: '1 hurned the hack of my hand on the stove. I put some cornstarch on it.

Was that alright?” “ Ve were on an outing several days ago and this morning my little boy has a ra.sh on his leg. 1 bathed it in oatmeal water and applied some cornstarch.

Was that all right?' These experiences are ade- ( uate evidence that people are clamoring for safe methods of caring for their minor skin troubles. Patient education is a form ol ]iuhlic relations in dermatology that [)revents dermatitis, needless suffering and catastrojihic drains on the family budget. The following report ol a case is typical of this program: Ca.se C. II., a white housewife aged 55, was seen for the hrst time in May, 1951. She was susce])til)le to rhus and had noticed for a num- ber of years that after working in the garden, especially when the weather was hot and humid, little blisters would ap])ear on the sides and hacks of her fingers.

The ])resent attack appeared on Sunday. Monday was wash day. Cnmindful of the lesions, her hands were placed in detergent suds with bleach added. The wash tubs were cleaned out with a scour- ing ])owder. That afternoon her hands felt irritated. The little blisters had become red and a few oozed. Some itching was present.

She recalled that two years ago she had used a salve for itching that was said to he won- derful. It was found in the medicine chest with the label stained and disfigured. A liberal amount was squeezed out and thoroughly rublied in. Supper dishes were done in the evening, and later she fled (led to sham] )oo her hair and take a bath.

After these duties were finished, her hands were fire-red and itched severely. More of the same salve was rubbed in.

During the night she was up and down. To (juote, “My hands were driving me crazy. They itched so I thought 1 would tear them off.” In the early morning a soda hath was tried. Lysol was added to jirevent infection and kill any stray fungi. A medicated soap was lathered on, and after rinsing and drying, her daughter applied a healing balm. Early Tuesday morning she was sitting in the office.

The odor of Lysol filled the room, mingled with that of camphor and menthol. The hands and forearms were co -ered with large turkish towels. The right hand ^vas swollen twice its normal size. Bullae were breaking; the contents staining the towels. With her left hand she jiointed to her face and legs, “Look, I am breaking out all over.”, t this moment she would have been a shock- ing lesson to anyone interested in the pharma- cology of cutaneous medications.

Caution would circumvent their enthusiasm, d'he hus- liand and daughter helped her out on her way to the hos])ital..^he had a jirivate rfioin in the hosjiital for 5 days, reipiired 8 ho.spital visits and 12 follow up office visits. Past-treatment ])atch test reactions to the remedies are shown in h'igure 1. During the follow up visits she was given instructions on the judicious use of soap, cos- metics. After she was well, sjiecial warnings were given on the importance of keeping all these agents away from minor skin injuries. She was told that the skin has a re- markable alarm mechanism to warn of danger. Itching, most commonly, warns of a chemical injury. Ignoring this warning is like running a red light.

Trouble may be close at hand..Vny eruption was to be covered with gauze; and if it was not l)ctter in 24 hours, she should A’isit the office. Nine months later she was seen. The right hand was covered with a white cotton glove. She related this story. The night before, her grandson complained of his ankle hurting. She rubbed it with Baume Ben-Gay.

An hour or so later her hand started to itch and burn. She bathed her hand in some oatmeal water, dusted on some cornstarch and covered it with a cotton glove. She knew it was the Bauine Ben-Gav that had produced the symptoms. 20 ALLOCATIONS OF OVERTREATMENT DERMATITIS— GAVL-VNDERWOOD Kimu’t* I. Nieiit patoli tost roa(‘tioiis to 'I'opa mi iiic*. A; C'iiti4*iii*a Soap..*>% soiiitioii.

K; Itlne Wliito..*>Vr solution 'I'opa in i ii io oiHitains niotlia- p>rilono li>droohloriilo, on/;olatoH ineta4‘i‘osol. It is allo^oil t 14* anti tliorapoiitit* at ox4»noratotl Uy tlio liiilltpus patii tt>this roinotl.

The right hand itched, and this was the one that had ap])Iied the analgesic'. Teaching her to recognize dermatologic sym])tonis and heed their warning can l>e translated into the data shown in d'ahle d. In-^tead of trying to relieve them h ' something in the medicine chest, she sought their meaning and readily discovered their cause. The expense before education was over $200. Ta1)le 3— COST DISTRIHUTK )i OF OVF.R- TRliATAlEXT DERMA'ITITS IN CASE C.H.

Tn'forc Ldiicahoit After liducation Hospital Cost (>4% Hospital Cost. 80% ) ( Pers. Liah, 20% ) Medical Fees*.10%. Hosi)ital isits 8 llosi)ital 'isits _ 0 ( )ffice 'isits 12 ( )tfice Visits _ 1 * Coml)ined cost of hospital and oflicc visits. Comments Lhiless dermatologic patients with contact der- matitis are jiatch tested with the topical remedies they have used, the etiology of local or general- ized exacerbations of initial entaneons lesions will he missed in approximatelv 27 per cent of cases. This diagnostic procedure protects both patient and physician. Self-diagnosis and lay- treatment of skdn diseases is a deceptive and cost!

It increases hospital costs, bur- dens insurance carriers, and.strains the family budget. Aledical tees are a minor item compared to the total cost. This fact does not prevent the agitators from tilacing the high co.st of medical care on onr doorstep. D'eaching ])atients the need to search, out the cause of itching, that dermatologic sympti.mis most commonly warn of injury to the skin, is a program that jirotects the health of patients and increases the stature of dermatology'. Daub- ing cutaneous symptoms, masking their warning calls with antipruritic chemicals is a frustrating- endeavor, in spite of the fact that these agents are intensively promoted, reprinted and sampled to even- jihysician..Professional colleagues ren- der their jiatients an injustice, delay the diag- nosis, jeopardize their health when they make snap-diagnoses of skin comjilaints and dismiss them with the remark, “Try this.' The patient believes that his surgeon or internist knows all about the skin.

I f hn.sv housewives can learn to interpret dermatologic symptoms and spare themsel -es complications, it would seem that others could do the same. Individuals, organi- zations and institutions that cr - about the short- age of physicians will see in Table 3 that pn.i- fessional skills will he more available by the exercise of greater vigilance from within our ranks.

BIBLIOGRAPHY 1. E.: ( )vertrcatn-ient Dermatitis. J.A.iM.A., 127:4.19, 1945.

G.: Therapeutic Dermatitis. HeT, 240:77, 1952. 3 Lhulerwood, (.1. E., Collins, E., Alosby, M.: ( Ivertreatment Dermatitis of the Feet. J.A.M.A., 130:249, 1946. 4 Lhiilerwood, G.

E.: (.ivertreatment der- matitis in dermatitis venenata due to plants. 1.18:570, 1948. E., Underwood, G. B.: Dermatitis of the hands residtin.g from overtreatment. & Digest of 'freatment, 3:186, (Mar.) 1952.

E., L'mlerwood, G. B.: Dermatitis venenata from organo-mercurial compounds. (With a com- parison of their pharmacologic action on normal and injured skin.) J.A.M.A., 140:860, 1949. January, 1953 THE CAROTID SINUS REFLEX—URSGHEL 21 THE CAROTID SINUS REFLEX:- II.

Use of the Normal Reflex in Bedside Diagnosis Treatment I I It so-called carotid sinus retiex is one of a number of neurovascular reflexes which act to maintain normal blood pressure and cardiac rate in humans. It is of special imercst to clinicians l.)ecause of the clinical syndrome resulting from pathologic-hy])eractivity of the reflex. The ■‘Carotid Sinus Syndrome', or 'Cardi(j-inhibi- tory Carotid Sinus S 3 mdrome” ^ ■as first compre- hensively described by Weiss and llaker’^ in 1933. Although it had been recognized in part over a century before. Tiering- had, in 1927, first described accurately and in detail the nerve areas and neurova.scnlar mechanisms involved in the reflex, normal and abnormal.

It is not our purpose at this time to discuss the carotid sinus syndrome, which has been ade- ( uately described in detail in the first pajier of this scries-’. Imstead, the author wishes to point out the wa}'S in which the normal refle.x may be used diagnostically and theraiieuticallv in clini- cal practice. Some of these uses, esiiecialh' in regard to the tachycardias, are well known, whereas others ma_ ’ not be so generally recog- nized. Technique for Eliciting the Reflex The techni( ue of eliciting the refle.x has lieen described and illustrated ])reviously-^ and need only be briefly repeated here, d'he carotid sinus is a bulbous dilatation at or near the bifurcation of the common carotid artery. In most jiatients it can be located without difficulty just below the angle of the jaw, with the head tipped uiiward and to the ojqiosite side. It can usuallv be locat- ed best by palpating the carotid lower in the neck, then carelnlly following the arter - upward to the bifurcation.

This is an important matter, as the sinus should be clearly distinguished Iie- fore pressure is a])plied. Even in experienced hands it is sometimes difficult to be sure that the pressure is Iieing applied to the sinus area, and * This is the second of a series of three articles hy Doctor Urschel. ERSCHEL, Al.D. Mentone not to an adjacent segment of the carotid. After the sinus is accurately defined it is pressed firmly against the adjacent transverse vertebral lirocess, the pressure being' maintained no longer than 30 seconds in aipv one test, e.xcept as will be mentioned later. Gentle massage of the sinus is often of aid, and pressure.should be apjilied with two or er'cn three fingers to assure even dis- tribution. Unless there is present the contrain- dication of age or advanced arteriosclerosis, the lest mav be freelv repeated without danger.

1 Si- lateral tests should never be performed simul- taneousl)-, one side being test.-d at a time. The right carotid sinus has generally been more re- active in the author's e.xperience, though there tire manv exceptions.

1 lowe -er, in almost all cases, one side is more sensitive than the other. Transient or permanent cerebro-vascular dam- age has been occasionally reported as occurring following carotid sinus pressure. In almost all in- stances these accidents occurred in elderly ar-- teriosclerotic individuals, and I'ecause of this the test in such patients should be )erformed only when absolutely necessary, and then with s])ecial precautions regarding duration of [iressure, care- ful delineation of the carotid sinus, needless rep- etition of the test, et cetera. The test can usually be carried out with the patient in the recumbent position, as the cardim inhibitory effect (with which we are principally concerned in this pa])er ) can be elicited as readily in the recumljent as in the erect position. The vasodepressor (or hypotensive) effect is best demonstrated with the patient sitting or standing. Finally, it is to be emphasized again that in most of this paj-ier we are dealing with the nor- mal reflex mechanism and not with the al)normal carotid sinus syndrome. I’ressure on the carotid sinus sends impulses by way of the carotid sinus nerve, a branch of the glosso])haryngeal, to the vasodepre.ssor and vagus ( cardio-inhibitory ) centers in the I)rain.

Efferent impulses pass out through the sympathetics to the vascular system. 22 THE CAROTID SINUS REFLEX— URSCHEL January, 1953 ])roducing peripheral vasodilatation and lowering of the systemic blood pressure, and through the vagus to the heart, producing cardiac slowing of varying degree by inhibiting the SA node or by delaying conduction through the AV node. These two effects (lowering of the blood pressure and slowing the cardiac rate ) can be demonstrated to some degree in almost all normal individuals, and are the basis for the various therapeutic and diagnostic procedures described in this paper. Use in the Arrhythmias This is the most common and best defined use of the carotid sinus reflex, and the effects in the various rate and rhythm almormalities have been summarized in Tal)les I and It. 'Idle iirincipal value here lies in diagnosis, as only in paroxysmal auricular tachycardia is there predictable thera])eutic response to carotid sinus pressure. ( Stellar-* has recently reported two cases of nodal paroxysmal tachycardia in which T.^HLE 1.

THE EFFECT OF CAROdTU SINUS PRESSURE UPON THE ARRH YTHMI.A.S WITH RAPID REGULAR RATE. Effect of Carotid Sinus Type of jlrrhytluiiia Ercssiirc Paroxysmal Auricular Two ixis.sibilitics — either an Tachycardia abrupt cessation of the tachy- cardia with brief asystole and resumption of normal rhythm; or no response at all. Paroxysmal Ventricular No response. Tachycardia Auricular Flutter Sexeral ])ossibilities, one of which is diagnostic — an ab- rupt reduction, usually by half, in the apical rate, with resumption of the previous rate when pressure is re- leased. Another characteristic re- sponse is brief total ventric- ular asystole, with resump- tion of rapid rhythm. (The cardiogram during this in- terval will show the typical flutter waves.) I here ma - he no response. This is more common than the above diag- nostic changes, unfortunately.

Sinus I'achycardia Moderate slowing during period of pressure, with gradual return to rate ap- proximating previous one. THE EFFECT OF CAROTID SINUS PRESSURE UPON THE ARRHYTHMIAS WLIH RAPID IRREGULAR RATE. Type of Arrhythmia Effect of Carotid Sinus Pressure Auricular Fibrillation Non-diagnostic and incon- stant slowing of the apical rate.

'entricular F'ihrillation No response. Sinus I'achycardia with The extrasystoles are not af- extrasystoles fected, but the basic ventric- ular rate may be reduced sufficiently to enable the ob- server to distinguish the ir- regularity from auricular fibrillation with which it may be confused. Normal rhythm was restored by this method.) We are here dealing with the carclio-inhibitory, or vagotonic, effect, and it must also be empha- sized that the carotid sinus reflex is not the sole means by which increased vagus tone may be elicited. Kyeball jiressure, breath-holding, in- duced vomiting, or the X'ahsalva maneuver may all have a similar effect, and one or more of these may be n-iore effective th;in carotid sinus ]>res- sure in certain individuals, so that all should be tried in indicated circumstances.

In younger in- dividuals with paroxysmal auricular tachycardia or flutter there appears no contraindication to ])ressure of more than,1U seexmds duration if it api)cars that ])rolonged stimulation will achieve the desired result. Careful auscultation during the test may demonstrate brief periods of re- sponse which can he made permanent (in par- oxysmal auricular tachycardia) by more pro- longed pressure. In sinus tachycardia the mechanism producing cardiac slowing is inhibition of the S. Node, but in the other arrhythmias it is the production of varying degrees of AV block.

A thorough un- derstanding of these j)hysiologic responses will enable the ])hvsician to make an accurate bedside diagnosis in a high percentage of patients with tachycardia. In Angina Levine and 1 larvey*’ have reported relief of acute anginal pain in almost every patient in whom carotid sinus pressure produced cardiac slowing. This resi)Ouse occurred in a few sec- onds, being more rapid than with nitroglycerine. January, 1953 THE CAROTID SINUS REFLEX— URSCHEL 23 The only failures were in 5 patients (of 50 ob- served ) who had no reduction in cardiac rate. Of the remaining 45, 70 per cent had total relief from distress, 30 per cent partial relief.

The test was also used in 60 patients with other causes for pain, and onl - 7 of these reported any change in distress. This control grou]) in- cluded many diti’crent causes of pain, including several j)atients with acute myocardial infarc- tion.

'I'his maneuver has proven usefid in a numher of cases (jf angina in the author's experience and in one case the patient has been taught to a])])ly carotid sinus pressure to relieve his attacks of pain. In Auscultation of the Heart 'idle accurate timing and identification of car- diac murmurs is often difficult or impossible in the presence of a rapid cardiac rate, hi such patients temporal'}' slowing hy the use of carotid sinus stimulation may clarify the problem.

This may be true even in tachycardia of only moder- ate degree, and the author uses the maneuver repeatedly in auscultation of the heart. The amount of sinus pressure necessary is often mini- mal, and of no danger to the patient. Also, as was noted in the discussion of the arrhythmias, most of these patients are young adults or chil- dren, in whom the contraindications to sinus pressure are of lesser importance. '1 his is a valuable aid often neglected in e.xaniination of the heart. In the Differential Diagnosis of Syncope, Unconsciousness, or Convulsive States Here we are dealing with the carotid sinus syndrome, or pathologic carotid sinus relfex, which has been repeatedly described and is gen- erally well knowifk We need say little about it at this time except to reemphasize the jjoint that the carotid sinus syndrome should alwavs be con- sidered in the differential diagnosis of patients presenting these complaints, 'foo many “incur- alde epileptics” have been cured by therapy for their carotid sinus syndrome to allow us to neglect this diagnostic aid. This is especially true in elderly, arteriosclerotic, or hypertensive pa- tients, those in whom the carotid sinus syndrome is most common.

One point is particularly worthy of em])hasis — carotid sinus pressure must not onh' ])roducc bradycardia or hypoten- sion, hut it must reproduce the patient’s sym- tom complex in order to make the diagnosis of carotid sinus syndrome. As we have repeatedly emphasized, bradycardia and hy[)Otension are normal resi)onses in man}' patients and do not alone constitute the carotid sinus syndrome. In Differential Diagnosis of Meniere’s Disease 'fhe carotid sinus s}ndrome may produce sym[)toms similar to those resulting from organic disease of the vestibular ai)j)aratus. As in the conditions li.sted in the preceding [)aragraph, awareness of the possibility cd' carotid sinus dis- ease is of great imi)ortance.

In Differential Diagnosis of Organic Cardiac Disease The carotid sinus syndrome frequently leads to a diagnosis of organic heart disease, occurring as it does in patients who are in the age group where arteriosclerotic heart disease is common. 'I'he diflerential diagnosis may be difficult, as in the.Stokes-Adams seizures'’', because of the co- existence of coronary sclerosis. L’alpitation and vague chest distress often ft)llow the attacks of carotid sinus syndrome, and apprehension is al- most always itrominent. Correct diagnosis is ital here because of the entirely different prog- nostic implications of the carotid sinus syndrome and of organic cardiac disease.

Also, digitalis sensitizes the refle.x, and if incorrectly given, mav aggravate the patient's difficulty. In the Diagnosis of Arteriosclerosis Goodnian and WassermaniT have suggested that the pure vasode[)ressor reaction, without associated brad}'cardia (or hypotension lasting more than 3 minutes after the l)radycardia has ended), is diagnostic of atherosclerosis of the ‘ffiroximal arteries”, i. E., the aorta, innominate, subclavian, aiul carotids. They feel that the atheromatous deposits in the aorta disturb the chemoreceptors which act as a pressor mechan- ism in opposing the carotid sinus depressor effect. It has been well known for years that older arteriosclerotic individuals are much more prone to a [)ath(jlogic hyper- reactivity of the carotid sinus mechanism, but it appears doubtful that the test can be used to diagnose the presence 24 THE CAROTID SINUS REFLEX— URSCHEL January, 1953 of “))roximal” atherosclerosis, as Goodman and ^^'assernlann suggest.

Adequate control studies are lacking in their presentation, and other fac- tors are known to affect the sensitivity of thie carotid sinns mechanism. Carotid Sinus Sensitivity in Anesthesia Kovenstine and Cullen have ])(hnted out the dangers involved in anesthesia in patients with a hyperactir’e carotid sinns mechanism.

1'he_ ’ have pointed out the sensitizing effects of various pre-()];)erative medications, such as digitalis, cer- tain harhiturates, and. Cyclo])ropane was their anesthetic of choice, with mor])hine as the only ])re-operative medication. Atroi)ine eliminates the vagal ( cardio-inhihitory ) response and may he used in i)atients who have this ty])e of reaction only. Ether, X’inethene, and chloro- form sensitize the reflex in light ane.sthesia. De- press it as the narcosis deepens. Ror'enstine and Cullen also point out the pos- sihilitv of the anesthetist inadvertently stimukit- ing the reflex mechanism hy jiressure beneath the angles of the jaw.

This aii])ears to he a real danger, especialh in earl ' induction of anesthe- sia vhen the patient may he struggling and the level of the anesthetic is such as to.sensitize the reflex. Summary and Conclusions 1. The carotid sinus reflex has been reviewed, with emi'hasis on the techni(iue for eliciting the mechanism, and on the diagnostic and thera- ])eutic uses ol the test. Jn diiif/iiusis it is important in the arrhyth- mias with rapid cardiac rate.

Es])ecially those with regular rhythm; in the differential diag- nosis of conditions causing sy ncope, unconscious- ness, and convulsions; in Meniere’s syndrome; in certain types ol organic heart disease such as total AV block with.Rtokes-Adams seizures; as au aid to auscultation when reducing the cardiac rate is imjjortant; to some extent in the differen- tial diagnosis of chest pain; and possibly in the diagnosis of aortic arteriosclerosis. VT In therapy the carotid sinus reflex is prin- cipally useful ill paroxysmal auricular tachycar- dia, where proper jiressure often restores normal rhythm. Nodal tach 'cardia has lieen likewise afl'ected, but the other types of rapid regular or irregular arrhythmias are not helped. In acute paroxysms of angina the reflex is of value in relieving distress, if the cardiac rate can be slowed. 'Fhe ini )ortance of the refle.x in anesthesia has been reviewed, with precautions to be fol- lowed in patients with a hv >eractive reflex who require surgery.

HIHLIOGR.RPHV 1. M'fiss,.S., and Itaker, J. 1’.: The Carotid Sinus Refle.x in Health and Disease, Medicine 12: 297, 1933. E.: Die Karotissinusreflexe auf Herz und Gelasse, Tli.

Steinkoiift, Dresden und Leipzig, 1927. L.; l lie Carotid Sinus Reflex. Clini- cal Manifestations of the Hyperactive Reflex. 45: 1237, 1952. 1.: Xodal 'I'achycardia Following Digi- talis (Iverdosage, ( Sto )i)ed by Carotid Sinus Pres- sure): Report of 1 wo Cases,.4nn. 32: 717, 1951). A., and Harvey, W.

P.: Temporary Re- lief of. Nginal Pain hy Carotid Sinus Stimulation, Tr.

P’h_ sicians 60: 255, 1947. L., and Kraning, K. Lx.: The Carotid Sinus Refle.x. Spontaneous and Induced Stokes.- dams.Attacks in a Patient with the Hyperactive Refle.x, to he published. And M'assermann.

S.: Carotid Sinus Pressure as an.Aid in the Diagnosis of Atheroscle- rosis, J. Gerontology 3: 196, 1939. Rovenstine, E..A., and Cullen, S..A.: '1 he Anes- thetic.Management of Patients with Hyperactive Carotid Sinus Reflex, Surgery 6: 137, 1939. January, 1953 OBSERVATIONS ON PANCREATIC MALIGNANCIES — MALINOWSKI 25 Clinical Observations On Pancreatic Malignancies TMI^OIX )R]£ S.

AIALIN( )WSKr-' IJ. LINiCAL ex])triences with carcinoma of the ijancreas at thi>Medical Center are conii)ar- al)le to those rejxirted hy otlier.^ in that the diag- nostic difficulties along with the high niorhidity and mortality rates add to the discouraging ami dark picture.

Despite all this, the overall picture ap])ears to he a little hrighter, in light of the in- tensive studies and rei)orts r)ii carcinoma ol the pancreas that are a]>pearing in the literature. Interest in pancreatic malignancies has increased and more ca.ses are being detected earlier he- canse mau}^ jdiysicians are not forgetting that the i)atient also has a pancreas.

It only has been during the last few years that we have begun to study intensively the problem of [)ancreatic ma- lignancies and to date our.studies are ])redomi- nantly clinical, with interest in the early diag- nosis by means of )ancreatic function studies. I’ertinent observations, as well as studies con- ducted at this hospital on carcinoma of the i)an- creas, form the basis of this report. The incidence of carcinoma of the pancreas, in regard to all cancers of the abdomen is 6 per cent; the over-all mortality rate, even after sur- gery, is reported as a]:>proximiitely cS5 per cent’. This high mortality rate appears to he directly related to the dela}’ on the ])atient's )art in seek- ing medical attention early in the course of the illness and to delay in establishing the diagnosis. Our observations conclusively indicate that pa- tients who were seen for the first time at this hospital after being jaundiced f(,)r two months or longer had a mortality rate of 100 per cent, and lived only for four to si.x months.

Those who had been jaundiced less than one month had a better prognosis. The need for early diagnosis is urgent and undeniable if we are to imi)rove the mortality rate in this disease. The dilemma that frecpient- ly confronts the clinician ui)on seeing such a patient who has been jaundiced for several weeks tO' a month, is to differentiate hetw'een the so- called 'medical jaundice” due to liver cell dam- * From the Department of Medicine, Indiana Uni- versity Medical Center.

Age and “surgical jaundice' due to interference to bile flow on the basis of extra-hepatic obstruc- tion. In the latter, with long standing olrstruc- tive jaundice on the basis of a malignancy, the liver cells are invarialily damaged, and biliary hepatitis or cirrhosis is evident. This perplexing jtrohlem freijuenth’ c(.)iil routed tts, inasmuch as a majoritv of our patients were jaundiced tor several weeks ] trior to admission to this hospital. It is h()]ie) 6 (20%) 3(11%)? 'Tail (1 1 0 p Ampulla Gall 0 1 0 p Bladder 3 0 0? All three cases of carcinoma of the gallbladder had cholelithiasis.

Various reports reveal an associated cholelithiasis with carcinoma of the gallbladder to be from 75 to 100 per cent'^’^. Our small series sujiports the latter incidence. It has lieen fretjuently observed that the presence of gallstones must he related to the origin of carci- noma of the gallbladder and exjierimental studies have shown that derivatives of cholic acid are among the most powerful of carcinogens. The role of diabetes or insufficiency of insulin per sc appears to be of no etiological signifi- cance. (fine patient had mild diabetes for 10 years, but of diagnostic significance is the fact that two patients develo]ied diabetes three and six months respectively Ijefore the onset of their jaundice. The role of alcoholism was studied in- asmuch as alcohol stimulates the pancreas to secrete a highly concentrated pancreatic juice.

An incidence of 20 per cent appears to be of etiological significance. The questionable role of food, food products and dietary habits still re- mains unanswered and should l)e further investi- gated. Clinical Features. Onl}’ the significant clinical features are presented in Table 3. The TABLE 3 SIGNIFICANT CLINICAL FE.4TURES OF PANCREATIC AND BILIARY TRACT jM ALIGN ANCIES Location Jaundice I'ain I'alpable Mass Hepa- tomegaly Metastases to Liver 11 tad 24 (9.1%) 21 (S2%) 13 (46%) 20 (71%) 8 (40%) Tail 1 3 0 O 3 Ampulla 3 2 0 3 0 Gall Bladder 3 - 1 3 1 striking feature in these cases was the associa- tion of ])ain with the jaundice.

This is in agree- ment with the re])orts of others’”’-'. The old con- cept of jiainless jaundice being diagnostic of ma- lignancy of the head of the pancreas must be discarded for not only is it erroneous, hut also misleading.

In our series of 28 cases of carci- noma of the head, 82 ])er cent had j>ain and 5 cases had jxiinless jaundice. Two cases had pain without jaundice. In analyzing the duration of jaundice prior to admission to this hosjfital, it was found that the majority of the cases of car- January, 1953 OBSERVATIONS ON PANCREATIC MALIGN ANCIES— MALINOWSKI 27 cinonia of the head were jaundiced for four weeks or longer, while those of the ampulla less than four weeks. A pal])able hrm mass in the e[)igastrium was found in 46 per cent of the cases of carcinoma of the head, and less than one-third of the cases had a palpable gallbladder to physical examina- tion; however, on surgical exploration or au- tops}’, approximately 65 per cent of the cases had a distended gallbladder. The pain, in practically all cases of carcinoma of the head, preceded the jaundice, and in 90 per cent of the cases the pain was described as boring in character and localized high in the abdomen, usually iu the right e])igastrium. ^ p- proximately two-thirds of the patients described the pain as dull, constant and boring, while one- third described it as sharp, severe and boring. In the cases of malignancy of the tail, one had pain in the left xyphoid and lower thoracic regions; one had persistent, dull gnawing epigastric pain, and the other had generalized abdominal pain.

The presence of hepatomegaly in 71 per cent of the cases with malignancy of the head of the pancreas was of significance, as well as freciuent- l}' confusing to the clinical picture. This clinical finding was also characteristic of the other malig- nancies. The ([uestion arose if the hepatomegaly could have resulted from metastases to the liver. Pathological findings revealed metastases to the liver in 40 per cent of the cases with carcinoma of the head; 100 per cent in those of the tail, and in one case of carcinoma of the gallbladder and this by direct extension into the liver.

Laboratory Findings. Th.e significant as well as useful laboratory tests that frecjueutly were of value in establishing the diagnosis in these cases are presented in Table 4.

IMalignan- cies of the tail have been excluded since the tests were of no diagnostic value, uor suggestive of pancreatic malignancy. In 24 cases of carcinoma of the head with jaundice it was of interest to note that the degree of jaundice was complete in 46 per cent and incomplete in 54 per cent. L'ldnary urobilinogen was significantly reduced to absent in the former group, while iu the latter group, the urinary urobilinogen frequentlv was within normal values; however, it was found to he elevated in three cases and highly suggestive of “medical jaundice”. Alkaline phosphatase TABLE 4 LABORATORY FINDINGS IN CARCTNOM.Y OF THE PANCREAS AND BILIARY TRACT Finding Head Tail Ampulla Gall Bladder.Yneniia 60% 1 0 1 Degree Complete of 46% 0 2 2 Jaundice Incomplete Reduced or absent 54% 1 1 1 Urinary f’robilin Elevated Alkaline b2% ■ 1 — I’hosphatase Abnormal 92% 1 0 2 Liver I'rotile Abnormal 57% 1 0 1 Serum Proteins 32% 0 0 1 Hypoprothrombinemia 537c 0 1 1 (Jccult blood in stools 437c 0 1 1 and blood cholesterol levels were invariably found to be elevated iu malignancy of the head. In view of the diagnostic difficulties encount- ered because of the jaundice, all cases were thoroughly studied for evidence of liver cell damage.

The tests utilized were cephalin-cho- lesterol flocculation, thymol turbidity and brom- sul])halein retention. These tests, in combination of two or three were indicative of liver cell dam- age in 37 ])er cent of the cases. If we include the cases with hvpoproteinemia and an abnormal ^V/G rati(j, then 69 per cent of the cases studied showed evidence of liver cell damage which would tend to mislead the clinician into think- ing in terms of medical jaundice. Ilowerer, when one considers that these patients had long- standing jaundice, the biliary hepatitis or cirrho- sis that results is apparent. The last case seen had this secondary diagnosis confirmed b}’ a needle biop.sy of the liver. Prothrombin time determinations in essence were non-contributory, for abnormalities in this test, as is well known, depend upon the absence of bile from the intestine or liver cell damage, both of hich were present in many cases. One simple and informative test in these ma- lignancies is for the presence of blood in the feces.

The test for occult blood was positive in 43 per cent of the cases with carcinoma of the head, while only one patient with carcinoma of the ampulla had his stool tested for blood, and the result was positive. The hy])oprothrom- 28 OBSERVAriONS ON PANCREATIC W1 ALIGN AN Cl ES— MALINOWSKI January, 1953 Ijinemia ajiparentK' is not the basis for the posi- tive test for occult Ijlood, for only in two cases was it at the critical level (13 and 21 ]:>er cent of normal), while the remainder had prothrom- bin time levels above the critical level (40 to 60 ])er cent of normal). It appears that the basis for the presence of blood in the feces is bleed- ing or oozing of the malignant lesion itself or ]n-obablv also de.striictive changes of adjacent tissues and blood vessels. Kecentlv studies were undertaken to determine if any deviations from normal pancreatic func- tion existed in cases of ])ancreatic malignancies, and if so, could such deviations be of diagnostic value. Studies on jiancreatic function have l>een intensivelv utilized for several years at this hos- pital in jjancreatic diseases other than malignant, and have ju'oren to be (piite hclplul.

4'he problem of di flerentiating between oh- slrnctive jaundice resulting from carcinoma and that resulting from common duct stone is fre- (juentlv difficult. ( )ur a )proach to this jirohlem namely was along the lollowing lines; In malig- nancies of the pancreas or the ampulla ol ater, we reasoned that some degree of jiancreatic duct or ductal obstruction usually existed, and follow- ing stimulation of the ])ancreas, the imjiairment of How of enz_ ’mes would he rellected by a sig- nificant rise in serial serum amylase levels. Along the same line, we reasoned that there would he no rise in serum am_ 'lase alnes in obstructive jaundice due to non-malignant lesions, such as common duct stones, ])licaiiou to the early diagnosis of pancreatic cancer.

1 lowex’er, for the present, jirompt iin-estiga- tiou into the tyi>e of jaundice, ajipreciation of the fact that the patient has a pancreas, utiliza- tion and critical interpretation of hejiatic and ]>ancreatic function studies should increa.se the number of cases diagnosed earl ’ and substantial- ly ini])rove the ])resent surgical results in terms of five }ear cures. REFERENCES 1..^rkin, and Weisberg, S. T '.: Carcinoma of the pancreas; a clinical and pathologic study of seventy-five cases. Gastroenterology 13:118, 1949. W., Lichenstein.

And Fischer, S. M.: Carcinoma of the gall bladder.

Gastroenterology 1.3:084, 1950. W, and Brown. H,; Primary car- cinoma of the gall Wadder,.A.nn. 132:121, 1950.

J.: Carcinoma of the gall Ijladder: Re- port of 50 cases,.4nn. 132:110, 1950.

30 OBSERVATIONS ON PANCREATIC M ALIGN ANCIES— MALINOWSKI January, 1953 7. And Klinge, F. W'.: Pain and hyper- ani 'lasemia as an early sign of carcinoma of the head of the pancreas and of the ampulla of Vater, Gastroenterology 12:204, 1949. And Steigmann, F.: Differential diag- nosis between medical and surgical jaundice by lab- oratory tests, Ann. 29:469, ' 1948.

STATE AMEF CHAIRMEN TO MEET American Afedical Education Foundation state chairmen will kick oft the 1953 fund-raising drive with a meeting Sunday, January 25, at the Sheraton Hotel in Chicago. This second annual meeting will launch officially the medical profession’s concerted eft'ort during the coming year to raise voluntary funds to assist the country's medical schools.

Keynote speaker will he T. TlcGuire, f l.D., AIMEF chairman for Nel)ra.ska. Chief alue of the meeting u ill he to exchange experiences and ideas on local fund-raising jiromotions. Representatives from every state will he on hand for the one-day session. LAUNCH 5 MILLION DOLLAR MEDICAL EDUCATION CAMPAIGN The National hTmd for IMedical Education, with offices in New York, is launching a five million dollar industry-wide solicitation campaign in support of medical education in the United States. Chester, newlv-a])pointed chairman of the fund’s Committee of.

Merican Industry, will direct a nation-wide organization to mol.)ilize business concerns hehind the nation’s hard-pressed medical schools. Chester is honorary chairman of the hoard of General Foods Corporation. The National F'und for Medical Education is a lay organization which is working in conjunction with the American Aledical Education Foundation, founded hy the. American Aledical.Association two years ago.

The AAlEF’s goal for 1953 is included in the five million dollars. The National I'und’s Committee of American Industry, which will spear- head the caiu])aign, will he composed of 100 ranking lousiness leaders from every segment of industry. Their task will he to educate industry as to the critical needs of the medical schools.

The committee contem])lates solicitation of 25,000 American husiness concerns during 1953. Chester plans to appoint a vice- chairman, an advisory council, and di ’ision chairmen, who will direct the activities of more than 50 industrial committees. Ade, New A.T)rk, has been ai)pointed fund-raising director for the campaign. And Palmer, AAA L.: Carcinoma of the pancreas: Diagnostic criteria.

81:173, 1948. Malinowski, T. S.: Serum am Iase response to pancreatic stimulation as a test of pancreatic dis- ease, Amer.

222:440, 1951. January, 1953 EDITORIALS 31 THE JOURNAL OF THE Indiana State Medical Association IJEA'OTEI) TO THE lIVTEHESTS OF THE MEDICAI, PROFESSION’ OF INDIANA Copyright Iiii1i:iii:i Stiite Aledical Association Office of Piiblicntioii: 1017 Hume Mansur Riiildiiip,' Indiaiiapolis A.

Indiana Editor Emeritus: E. Shanklin, M.D., Hamiiiond, Indiana Editor: Frank B.

Ramsey, M.D., 201 Hume Mansur Building', Indianapolis 4, Indiana. Associate Editors: A. Cavins, M.D., 221 South Sixtli Street, Terre Haute, Indiana; Ball O. Montg'omery, M.D., Ball Memorial Hos- pital, Muncie, Indiana; David A. M.D., 515 Odd Fellows Building, South Bend, Indiana; Stephen L. Johnson, M,l., 521 Sycamore Street, Evansville, Indiana.

Editorial Board: Term-Expires Thomas M. Conley, M.D., Kokomo Clyde G.

Culbertson, M.D., Indianapolis Richard H. Il.D., Fort Wayne George M. Cook, M.D., Hammond, Harold D. Lynch, M.D., Evansville. Culbertson, South Bend.. 31, 1953 Dec. 31, 1953 Dec.

31, 1954 Dec. 31, 1954 Dec. 31, 1955 Dec. 31, 1955 Business Manager: James A. Waggener, 1017 Hume Mansur Building, Indianapolis 4, Indiana. Home telephone: Franklin. Indiana, 587.

Editorial Secretary: Jeanne S. Grover, 1017 Hume Mansur Building, Indianapolis 4, Indiana. MOORE MEN the Indiana Heart Foundation dedicates the Heart Clinic of the In(liana])olis General Hospital to the memory of Ur. Moore it will honor an ont.standino' teacher and beloved physician. No more fitting- tribute conld he ])aid to Boh Moore’s skdll as a teacher than to have the clinic, to which he gave so liherallv of his time, named in his honor.

IMr many years of his active ]>rofessional life the weekly meetings of the clinic were graced by Doctor iUoore’s presence, and as a result the clinic was always hlled with a mnltitiide of patients and students. Although the clinic was held at midday on Saturday — jirohahly the most inconvenient time of the week — it was attended by many stu- dents, and usually by several active practitioners who came to learn at the feet of a master. Roll call was not necessary. Students were punctual, and man)' students from other classes were regular participants. The clinic ex )erienced its share of obstacles and vicissitudes through the years but survived these difficulties under Dr.

Moore’s leadership. At one time it was the most popular teaching clinic at the Indianapolis City Elospital. The most freqnentlv heard item of conversation among students of those days on Saturday morning was “Let’s he sure and get to Bob -Moore’s heart clinic.” Teaching came naturally to Doctor Moore. Me loved to teach and whether the day’s work found him on the ward or with private patients he was always accomjianied liy undergraduate or graduate students. He would have been a great teacher even without his academic rank, or without his teach- ing clinic. Blowever the clinic itself will be remembered h - hundreds of physicians as one of the most enjoyable experiences in their med- ical education.

The dedication of the Robert M. Moore Heart Clinic will he joined in the hearts of countless doctors who will not be able to attend the formal ceremonies. 32 EDITORIALS January, 1953 AMERICAN LEGION MCI^NTLY the Indiana Department of the American T.ettion requested the formation of a liaison committee for the consideration of ])rol)lems common to tlie Letfion and the Indi- ana State Medical Association.. Mple precedent for this t 'i)e of cooi)erative et'lort is afforded on the national level. The Xational 1 lead( narters of the Let;ion has for many years utilized its own Xational Medical. D dsory Hoard, formc(l from its memhershi]) for the investigation and discussion of medical matters.

More recentK- the liai.son committee of the A.M.. Has met with a similar national l.et^ion committee. Ssociation's liaison committee has been formed and has met with its Legion counter- part together with rei)resei'tati ves of the Indiana Dental Association and the Indiana lIos]dtal. 'This was the first such meeting' on a state level. It was also attended by re])resen- tatives of the T.eyion National 1 lead( uarters, the A.M.A., the American Dental Association and the American lIos])ital Association..

T the ])re.sent time the actual Inisiness which was transacted is of lesser importance than the fact of the meeting itself. It is a well known fact that any and all problems are better solved when the solution is achieved on a plane nearest the grass rof)ts. Some of the biggest arguments are based on misunderstanding on one or both sides.

Merican Legion and the medical profession have been on the.same side of several big issues, ddiere is iio reason wbv differences cannot be com])osed by cooperative effort. Discussion of tbe.se same problems at the December meeting of tbe American Medical Association in Deiwer resulted in the adoj)tion of a resolution in which the 1 louse of Delegates suggested that all states follow the Indiana i)lan in forming a liai.son committee from interested grou )s to discuss and. It is ho])ed, eventnallv sol -e their common ]iroblems. ANSWER THE CALL dfl A' month in the vear thousands of ]!eo])le in need or distress reach out to the Led Cross for the hel]) they must have, hel]) that comes from the generous efforts and su])i)ort of housewives, businessmen, industrial workers, school children. ])rofessional workers — your nextdoor neighbors — and countless others who serve their fellow man through the Red Cross.

In a time of tension and cynicism it is well to be reminded of the inherent goodness of )eo])le. To call attention to their constant volun- tary effmrts to make life a little better for tbe men and women in tbe armed forces, for hos- ])italized r’eterans, for disaster sufferers, and for those in need in other lands.. Lthough the heart and hands of the Red Cross are ])rovided by hundreds of thousands of volunteers, money is also needed to collect blood; to ])rovide financial assistance for service- men, veterans, and tbeir de])endents: to furnish emergenev aid and rehabilitation tracti- tioner for a town which otherwise might not have attractefl a doctor. 'I'he Tdfe Insurance Medical Research h'und which is suj)ported by the majority of life insur- ance com])anies of Ihiited.States and Canada, six of whom are Indiana com )anies, has just pub- lished its seventh annual re])ort. The fund con- tributed almost $81)0,000 in 1052 to medical schools and research workers. The seven-vear total is close to live million dollars. Leach ol the insurance ctnnpanies contributes t(.) the fund in proportion to its ’ohime of busi- ness.

( irants are made for research on diseases of the heart and arteries on the recommenda- tions of an ad ’isor_ - council whose members are chosen from the taculties of medical schools.. T the ])resent 8t>research ])rograms are be- ing supported linancially, as well as 35 research fellowshi j)s. Arteriosclerosis, hypertension and rheumatic heart disease are the princii)al re- search subjects. The National Safety Council recently con- ferred an.Vward of Honor on the U. S..Naval ( Irdnance Plant, IndianaiHilis, for the operation of its facilities for a total of 4,094, 0‘)9 man- hours from March 20, 1951, to Jauuarv 5, 1952, without a disabling injury.

34 MEDICAL PANORAMA January, 1953 SMOG,— AND THE LIKE We 1 i(j 1(1 these rights to be inalienal>le; the rights to life, liberty and the pursuit of happi- ness. D'his being' granted, it follows that as air- breathing animals our right to an atmosphere of sufficient ])urity is also inalienable, otherwise our right to life is threatened. In this age of vast pollution of the air by industrial and com- bustive b}’-products, man, through lack of any natural power of aeroscepsis except detection of odors, is at a disadvantage in protecting himself against many of these noxious agents. The ex- tent of this as a public health problem is dis- cussed by Robert B. Alarin, i I.D., in The Jour- nal of the Medical Society of Neze Jersey, November, 1952, some extracts from which fol- low: While John Q. Public has long accepted smoky air as part of urban living, rebellion is in the offing. Poor visibility, grime and smell are no longer welcomed as signs of economic wealth and well being.

Disasters such as those in the kleuse ^alley of Belgium in 1930, and Donora, Pennsylvania, in 1948, have focused public attention on air pollution and the danger which lurks in the haze. Mills, i reports that pollution of city atmosphere constitutes a health problem of the first magnitude and completely over-shadows such factors as inadequate housing, over-crowding, and poor nutrition. Health-giving sunshine is lost, fogs intensified, buildings soot-streaked, clothing and furni- ture soiled, and lungs blackened. The attitude and the efficiency of the individual are impaired. The amount of ill health among people subject to air pollution for prolonged periods is significantly greater than the amount of ill health among people living in areas relatively free from air pollution. The control of air pollution is complicated lyv its cnmple.xity of cause.

No longer is smoke control enough. Serious consideration must be given both to visual pollutants such as fly ash and soot, and to in- visible pollutants such as nitrogen o.xides, sulfur oxides, hydro-carbons, aldehydes, acids and radio-ac- tive contaminants.

He:Jc Jis Just where the medical profession fits this picture is frequently a tender point with a slowly arousing 1 Dr. Clarence Alills is Professor of Experimental Medicine at the Uniwrsity of Cincinnati. Right t>r wrong, there is a getieral feeling that leadership in a prol)lera so intimately connected with public health should develop among those most interested in its preservation: the doctors.

It is heart- ening to report that in scattered areas throughout the United States the profession has already made sig- nificant contrilnitions. Research in many of the prob- lems is being actively conducted by local and national groups, as rvell as b}' public health teams from various states.

A solution will come about onh- from a co- operative civilian and professional effort. How^ high we value public health may dictate the course.

In the meantime, the people, as they should, look to the medical profession on all levels, local, state, and na- tional, to dedicate their efforts to the solution of one of the most pressing problems in public health that tins nation has ever faced. R-r-R-R-R-r— CRASH!

The JJrginia Medical Monthly tor November. Calls attention to an evil which no doubt has Iteen discussed in county medical societies any numlter of times, usuallv with the result that some society representative has a little talk with the jnirveyors of aml)ulance service, after which there is »'reat impr(jvement, — for a while.

Then the temiffation to make sensational runs over- comes prudence and we’re off again in a cloud of dust with one foot on the siren and the other on the accelerator. Somehow it reminds one of Kenneth Grahame’s famous Toad.

As in In- diana, even so in fair Verg'inny: HASTE BY AMBULANCE MAKES WASTE The recent accident at R)land and Grace Streets in Richmond in which a private car driven by a lady marine was totally destroyed, a city ambulance was overturned, and a w^ater plug broken off causing a flooding of the street and great inconvenience to a number of citizens on their w'ay to w’ork, poses the question of how fast should an amlmlance go? For- tunately no one was injured in this accident. The ])roperty damage amounted to $2,300. A second am- bulance found the patient pacing the sidewalk in front of his house.

His only complaint w'as a headache. He was taken to the emergency room of the hospital and given a couple of aspirin tablets. The difference between safe driving and reckless driving amounts to probably 5 minutes, or at the most January, 1953 MEDICAL PANORAMA 35 10 minutes, in readiing the destination if all goes well. We can imagine cases of stah wounds, deep razor wounds of the throat, asphyxia from gas poisoning in which minutes could make a difference in the outcome.

As a matter of fact the gre^t majority of injuries can be liandled very well b_v a neighbor or bystander, now that first aid training by the Red Cross has be- come well nigh universal. In cases of asphyxia, gas poisoning, and electric shock, there is no need of rush treatment l)v ambulances, since they are best treated by the local fireman who has the training and equip- ment, including pulmometer and antidotes for poisons, for emergency treatment. Jtist how many injuries would he well handled hy a neighhor might provoke air argument; Imt certainly the time saved on short runs in the city hy driving more than 40 miles an hour can amount to very little in 95 jier cent of cases, — • possibly we should say in 99.44 per cent, h'igure it out yourself: 2 miles at “60 jier” takes 2 minutes, at “40 per,” only 3 minutes. Less thrill- ing, yes, l)Ut also less damaging, mv friend. County Society Officers to Meet January 11 Highlighted by the luncheon address of William L. McGrath, Cincinnati, the 28th Annual Conference of County Medical Society Officers promises to be one of the most outstanding programs of this representative group of the Indiana State Medical Association. The morning and afternoon session will convene in the Riley room of the Claypool hotel on Sunday, January 11.

Registration opens at 9 o’clock. An address of welcome will be given by Paul D.

Crimm, M.D., president of ISMA, at 9:30. William Wright and Dr. Ochsner of the Committee on Public Policy and Legislation will conduct a discussion on the coming session of the Indiana General Assembly after which the executive secretary, James A. Waggener, will talk on “Association Procedures.” A social hour will precede the noon luncheon.

The speaker, Mr. McGrath, has had an unusual business career over a period of 32 years with the Williamson Heater Company and is now its president. He has served as president of Cincinnati Cham- ber of Commerce, president of Cincinnati Industrial Association, has been national president of the Society for the Advancement of Management, president of the National Warm Air Heating and Air Conditioning Association.

In 1949 he was appointed employer member of the American delegation to the Interna- tional Labor Organization Conference at Geneva, Switzerland. As vice-chairman of this employer delegation he participated in four yearly conferences, the last in May and June, 1952. He will discuss the possible influences of this organization on the medical profession and his address is informative and in some respects startling. A discussion of all phases of press and professional public relations practices will be con- ducted at the afternoon session by Lawrence Rember, AMA public relations field service director. There will be ample time for everyone to participate in discussion of each subject during the day and the meeting is open to all doctors. The program will be concluded by mid-afternoon with the presentation of a brief comic program.

36 PRESIDENT’S PAGE January, 1953 fijiMidetdiu S^axfSL ^ FELLOW MEMBERS OF THE I.S.M.A.: A lthough the earth is round, frequently it is considered to be in a h of a shape. This vernacular deduction has been oracled by many from the time Magel- lan sailed around the world. The moral and economic levels, which are the vogue, influence opinion to the extent that, at times, the world does seem to be in such a state of shapelessness, especially if you cannot stomach inhuman totalitarianism.

People of today retain the same anatomical pattern as those who lived in the world of yesteryears, but their lives are molded by centuries of civilization and shaped by the struggle for existence. All of us are delivered on earth naked and void of everything except potential essentials. All are born selfish and non-cooperative but thanks to the processes of education we attain varying degrees of unselfishness and cooperation. Likewise, we acquire a certain am.ount of brotherly love which often is not more than skin deep or too often dependent upon remuneration of filthy lucre or upon a friendship of 'Til scratch your back if you scratch mine.' And whether born poor or rich, the essay 'to stay off relief' acquires us substance, which ultimately van- ishes through the medium of taxes and death. With a lethal exodus in the offing for all, folks continue to harangue and to hate and to hoard.

Although one hesitates to esti- mate the number of persons who are in search of pelf purely for self, certainly too few carry on a livelihood always mindful of a quotation from the Sermon on the Mount 'Whatsoever ye would that men should do to you, do ye even so to them.' Undoubtedly this quotation is responsible in part for the effort put forth to convert the world into One World. Theoretically the idea has merit but practically it cannot be achieved until more people adhere to the Golden Rule; until Christian, Jew, Moslem, et al, live up to their religious tenets every day in the week, instead of just on Sunday; until every race strives to preserve the identity of every other race; until each nation is capable of settling its own domestic problems. 'Peace on Earth, Good Will Toward Men' will never be universal until we either educate or we exterminate those who desire to control where we live, where we work, and where we worship. In the meantime, no group of citizens are in a better position to improve the Amer- ican Way of Living and the American Way of Doctoring than the practitioner of the healing art.

We must, by example, show our patients and fellow practitioners the ethical way to practice medicine. We must continue our prime objective of getting the patient well. We must answer the call of the sick by day or by night, in order to prevent patients from saying 'Last night I could not locate a physician and had to call a chiro- practor.' We must stick to issues and not indulge in personalities. We must avoid professional backbiting and remember that 'the wise man holds himself in check while the fool runs on ahead.'

All of which adds up to the fact that organized medicine has been, is, and always will be duty bound to practice the Golden Rule in order to do its share in designing the destinies of the practice of medicine whether it be in One World or in a divided world. And may nineteen hundred and fifty-three find us reconsecrating those resolutions which will make America strong regardless of the shape of the world. Once upon a time an old Indian prayed 'Oh, Spirit, help me not to criti- cize my friend until I have walked in his moccasins two weeks.' January, 1953 CURRENT EDITORIAL COMMENT 37 The Fourth Estate Looks At Medicine This section of THE JOURNAL is devoted to the presentation of opinions which appear on the editorial pages of the public press, and which are of interest to the medical profession. Its function is to review comments which may be favorable or unfavorable to medicine.

Members are invited to submit editorial clippings for this column. YOl It HEAl.TH Are you one of the people who take better care of your machinery and your livestock than you do of your own personal health? Maylie your face gets red as you ponder this ipies- tion.

'Idle editor’s face got red when he wrote it. It is a fact, suhstantiated hy tlic Indiana State iNfed- ical Association, that most Hoosiers — just like Amer- icans in general — refuse to take their health seriously until they are carried into a hospital or forced to call their physician. Health is the most precious )osses- sion any of us have, and it is very hard tf) fully regain when we lose it or start losing it, 'I he seriousness of our apathy tow-ard health care was pointed out recently hy Dr. William Wright, Sr,, president of the state association, when he testified before the President’s Commission on Health Xeeds of the Nation, He vigorously opposed the “insiilious propaganda' for compulsory health insurance and urged instead that efforts he directed toward encouraging local health programs, local initiative and local volun- tary etf'orts to awaken the people to the ease and low- cost with which they can meet their own health or medical problems, d'he Guide is in thorough accord with Dr. W'e suggest that many readers might like to have a copy of his statement liefore the President’s Commis- sion in Detroit last Sept. This can he obtained by writing to the State Aledical Association, 1021 Hume Mansur Building, Indianapolis 4, Ind, — The Indiana fanners Ciiide IN HEt OliM’I’ION OE HIGH SEUf lCE George A, Ball’s record of selfless service in the cause of better medical care and education makes the endowment of a chair in his honor at the In- diana University School of Medicine a most fitting- tribute. The James Whitcomb Riley Memorial Associa- tion has joined with Indiana University in estab- lishing a George A.

Ball Visiting Professorship In Surgery in recognition of the Muncie philan- thropist’s many years of effort and personal gen- erosity in behalf of the Riley Hospital for Chil- dren, Indiana University and medical education in general. Appropriately, he was notified of the endowment yesterday, his 90th birthday, by mem- bers of the Riley Memorial Association board of governors and representatives of the I.U. School of Medicine. Ball, the lone survivor of the five brothers who founded the famous Ball Brothers Company, was one of a group of persons who more than 30 years ago conceived the idea of a children’s hos- pital in memory of James Whitcomb Riley.

He is charter member of the memorial association and an original member of the board of governors. He has done much invaluable work in behalf of the hospital and the medical school, and he and his family have made large contributions to both. The chair in surgery is, indeed, a merited recog- nition of Mr.

Ball’s continuing services, as is the fact that more than 100,000 children have bene- fited from his good woik for Riley Hospital. — Indianapolis Star.

W HEN ONE I.s IA 0-'l'IIIUl).S 'file other day we referred to a pamphlet by Frank K. Holman, former president of the American Bar association, demonstrating the need of a constitutic.mal amendment to protect Americans against United Na- tions 'treat)' law.' Holman makes the point that the United States is unique in that the Constitution makes treaties 'the supreme law of the land' without further iniplementing legislation. “The state department,' he says, 'suggests that the President would not recommend and the senate would not ratify a treaty which adverseh' affected American rights.

Can we risk this in view of what has been going on?’’ Mr. Holman's answer is that we cannot, and he t)ffers, among other examples of the slipshod, casual, and almost jocular treatment accorded treaties in the senate, an amazing incident which occurred last June 13. On that day, because no one had denianded a roll call, only two senators were present. John Sparkman of Alabama, recentl ' Adlai Stevenson’s Democratic running mate in the Presidential election, was presid- ing. The only other senator present was Kdward J, I'liye of Alinnesota, a New Deal Repulilican. 38 CURRENT EDITORIAL COMMENT January, 1953 Sparkman announced to Tliye that, without objec- tion, the senate would proceed to the consideration oi executive business.

As the Congressional Record puts it, Sparkman then “laid before the senate messages from the President,' referring to various nominations, which Sparkman then referred to appro]iriate com- mittees. Sparkman then called up two conventions and one treaty, relating to consular con -entions be- tween the United States and Ireland and the United States and Britain. The texts of these various under- takings cover 11 pages of fine print in that day's rec- ord of proceedings. Sparkman, presiding, cast the only vote on these three instruments, then ruled that “in the opinion of the chair, two-thirds of the senators present' had con- curred and tlie undertakings had been duly ratified. Thye said nothing.

He conceded later, “1 did not ohject.' Here we have the ludicrous situation in which the presiding officer of the senate casts a lone vote on an important international instrument and then rules that he, in his own person, represents a majority and con- stitutes two-thirds of the senators present and voting. M’heii treaties and similar undertakings are dealt with thus frivolously in the senate, it behooves the people of the United States to exercise great caution in determining the character of treaties and interna- tional conventions that reach the senate. Especially is this true when United Nations conventions would have the effect of overturning the basic law of the land. — Chicago Tribune rKNSIO.V AM) IIKAI/I'II General Eisenhower’s endorsement just before the election of a pension plan for self-employed workers pointed up one of the inequities of the income tax laws. But there are others. The proposition that a doctor, lawyer, dentist,, writer, grocer or druggist or anyone else who is professionally or in a business way outside the Government’s “security” programs ought to be able to put something aside for his later and less productive days seems to us to be a fair one.

Most of the arguments we have heard against it aren’t very convincing. Some say that it will dis- criminate against workei's who can’t deduct so- cial security payments fi-om their taxes. It seems to us this sort of argument is easily answei’ed; all these pension plans suggest is deferment of in- come and deferment of taxes upon that income until it is to be used. Workers covered by social security could be granted the same sort of tax relief. Drafters of the planned economy are, of course, against such ideas because they make people less dependent upon the Government. The planners like the inequities in the income tax laws because such inequities are aids to more and more Gov- ernment control.

Among the inequities in the income tax law is one which sooner or later reaches all taxpayers. It also has helped provide arguments for socialized medicine. The administration defeated at the polls last week favored socialized medicine, and the income tax laws, whether designed to do so or not, pro- vided bait for its fishing among the voters. Medical attention is costly and to offer it “free” is to make a very attractive offer — even though more and more people are learning that nothing is “free” when dispensed by a government which must tax its citizens to provide services. Under the present law, a taxpayer cannot de- duct medical expenses such as doctor’s bills, dental costs, pills, platters. X-rays or treatments of any kind unless the costs are in excess of 5 percent of the taxpayers’ adjusted gross income.

As an example, a man whose income taxes are figured on a gross income of $3,600 a year finds that during that year he has had to pay out $190 in medical costs. The Government will allow him to deduct but $10, and he must pay a tax on the $180. Good use of the taxes on that $180 could be made by any man whose adjusted gross in- come is $3,600 annually, and there ai'e millions of taxpayers in that class.

General Eisenhower is as much against the idea of socialized medicine as the Truman Ad- ministiation was for it. But just being against it isn’t enough.

Positive treatment can cure the evils of socialized medicine’s false appeal. One way to cure it would be to allow all taxpayers to deduct all expenses attached to health.

This would also cure one of the inequities of the income tax law, for it seems to us to be an unfair burden to have to pay taxes for trying to get well. — ir«// Street Journal.

January, 1953 SPECIAL ARTICLE 39 NEW SPRAY ON PLASTIC DRESSING MAY PROVE EEEECTIVE EOR GENERAL USE Official Air Force Photos, released ha Department of Defense III the photo^raiih alu>e, left, tftie huriied area ol' a Iiaiid is re:idy lor spraying' >vitU tlio new “aeroplast’'. Center plioto^rapli shows hand sprayed wHIi “aeroplasC’ to a thiekiiess of approximately live thousaiiiil hs of an ineh. Diiriiisr healin;;, the ^ve needed for similar treatment. It consists of 2 ]>ounds of oiiiliiient.

OO yards ol' handa.ues, y:irds of adhesive tape,:tiilan for furnishing emergency medical care to the ])eo])le of La- fayette and the surrounding area. 'I'he ])lan which seemed to lie the one that would best handle the situation was worked out bv the committee and ado])ted hy the society. 'I'he workings of the ]»lan are ex])lained in the following letter which was sent to eacli memher of the Ti])])Ccanoe Countv Medical Society. Xew,s])aper ad size 2 columns nOJ/ Inches NOTICE THi: ■IIHI’ECAXOE COUNTY MEDICAL SOCIEIA' WI.SHES TO ANNOUNCE 'I'HE Ol'ENlNC OF TWO NEW SERXMCES. EMERGENCY MI'.DICAL SKRXICE If you cannot locate your physician or have no physician and need emergency medical service; DIAL 2-3323 PHYSICIANS' EXCHANGE Eor help in locating your physician: DIAL 2.I375 CONSULT YOUR NEW PHONE BOOK E(.)R THE LISTING OF THESE TELE- PHONE NUMBERS. To ^Members of the Tippecanoe Countv Medical Society: Two new services are being installed l)v the County Medical.Society, namely: THE PHY- STCI.VNS' EXCHANGE and the EMER- GlfXCY ^IICDICAL SlfRVTCh. These services will go into effect on Decemher 12.

'Fhere will be two telejihones installed. A signout sheet will be kept at the hospital at the Home Hosi)ital switch board: PHYSICIANS’ EXCHANGE— DIAL 2-3375 and EMERGENCY MEDICAL SER HCE— DIAL 2-3323 riiere will be four newspaiter ads announcing this new service. They will run in the Lafayette journal and Courier on Dec.

2, PCSvl, and Jan. The new phone hook will contain an ad that will ai)pear in the }'ellow section, advertising these two services.

I'he tele )hone hooks will he distrihuted Jan. 'rdciihone ad JG column EMERGENCY klEDICAL SERVICE If yon cannot locate your )hysician or have no ihysician and need emergency medical service: DIAL 2-3.123 PH YS IC I ANS’ ICNCH ANGE F()i' help in locatin.g your physician: DIAL 2.I375 The ahine services furnished by the Tiiipecanoe County Medical Society.

January, 1953 SPECIAL ARTICLE 41 Placards for display in doctors' offices will l)e sent to each doctor. Placards will be posted on the bulletin Ixiards in all chart rooms of both hosi)itals. W'lien Placard fur chart r(;oms WHEN YOU WISH 'fO LOCATE A DOC- TOR BUT HIS OFFICE OK HOME PHONE DOES NO'l' ANSWER, PLEASE PHONE PHYSICIANS' EXCHANGE. THEY WILL 'FELL ^T)U WHERI-: TO REACH HIM OR WHO IS TAKING HIS CALLS. P H Y S I C I A N S • E X C H A N G E DIAL 2-3375 A signout sheet will he ke])t at the hospital switchboard and all doctors must notify the switchboard whenever their ihone is uncovered: (Where they may he located, when they will he back, who is taking their calls.) Two doctors will he assigned each week for emergency medical service to serve from (Mon- day S:00 A.jM. T(t the following (Monday at 8:00 A.(M. All members of the Tippecanoe County Medical Society will Ite expected to serve on this service with the exception of ( 1 ) (Members of Purdue Health Service, (2) Those retired from active i)ractice, (3) Those to be excused because of j)oor health, and (4) Those members whose offices are located outside of Lafayette and ¥est Lafayette.

Physicians will Ije notihed ■ on the A ’ednesday before their service starts on (Monday. In case of previously made plans to be out of the city, your week of service can be assigned upon your return. The girls at the llome Hospital will have definite instructions as to how to answer the two phones. The puldic is to be informed of the services. To make it a success, the DOCTORS MLkST KEEP THE GIRLS INFORMED OF THEIR WHEREABOUTS. MFAIBER OF DOCTOR'S EXCHANGE Wlien you are unable to locate me by phoning my office or my home, please dial PHYSI- CIANS' EXCHANGE 2-,3375 and they will tell you where to reach me or who is taking my calls.

Instructions for girls at switchboard for Emergenc}' (Medical Service Phone. ANSWER THIS PHONE: 'EMERGENCY MEDICAL SERA’ICE.' Ask the person call- ing whether he has tried to k)cate his own phy- sician. If he is unable to locate his own phy- sician or has no physician and needs emergency medical treatment, give him the names and ])hone numbers (office and home) of the two physicians on call. Instructions for Physicians’ Exchange Phone ANSAVER THIS PHONE: 'PH YSICLANS' EXCHANGE.’’ Ask what doctor they are try- ing to locate. Refer to the 'Sigh Out' sheet and tell the person where he can locate his doctor or who is taking his calls.

All doctors who have clinical ])ractices will have an extra listing of the jthysicians’ exchange telejthone number in the white section of the phone hook. Between October 6 and ( Jctober 17 a re[)re- sentative of the directory company will contact all doctors in order to ascertain how he wishes to l)e listed in the YELLOAA' section of the phone book — listings in the YELLOAA section are at the individual doctor's own expense. The directory comi)any recommends that the doct(jrs 42 SPECIAL ARTICLE January, 1953 list the exchange number under the individual names in the yellow section. The emergency medical service phone will he listed on the front page of the phone bo()k along with FIRE, POLICE, and FBI. ASSOCrATP:D TELEPHONE CORPORATION EMERGENCIES FIRE POLICE FBI EMERGENCY MEDICAL SERVICE 2-3323 cian’s Exchange number in the white section of the ])hone book, will be billed for $19.00 per year.

Doctors who are members of the Tippe- canoe County Medical Society and who have their offices outside the city limits of I^fayette and West Lafayette will be billed for $12.50 per year. On or about December 15, 1952, you will be billed by Mr.

Berg, Manager of the Home Hospital, for either $25, $19, or $12.50. Please pay this promptl}'. Berg will handle all of the finances and if there is monev left over at the end of 1953, you will he lulled for less for 1954. The cost of running this sendee, will be in the neighborhood of $1600 for the first year. BREAKDOWN Listings in white section $354.00 Physicians' E.xchange Phone 141.50 Emergency Medical Phone 141.50 ■Advertising in yellow section 159.00 Newspaper ads 120.00 Bonuses for Home Hospital Switchljoard girls_ 720.00 Placards for offices.

(Not determined)? Placards for chart rooms.

(Not determined)? Estimated Tc'tal $1035.00 Doctors who have active clinical practices and have their offices in Lafayette or ^ ’est Lafayette will be billed for $25.00 a year. Doctors wdiose liractices do not re( tiire a listing of the I’hysi- The committee felt that the success of the plan would require the cooperation of the doctors' wives and the doctors' secretaries. With this in mind, a cop}' of the letter exj)laining the plan was sent to each doctor's wife and to each doctor's secretary. The establishment of the ])lan was made pos- sible by the co-operation of the representatives of the telephone comi)any, and the willingness of 31r.

Manager of the Home Hosi)ital, to allow the use of the hospital fa- cilities. It is felt that the ])lan will work in our com- munity.

It has been received well by the mem- bers of the society and with their help in running it, it is believed that public relations in this community will be definitely benefited. January, 1953 SPECIAL ARTICLE 43 THREE ASSOCIATE EDITORS ASSUME DUTIES ON STAEE OF THE JOURNAL Dr, Dr. Nickel ri'll lliis issue of The Journal of the Indiana State Medical Association the editorial staff is increased hy the addition of three recently named associate editors whose wide experi- ence makes them ])articnlarly valuable in the assembling and presentation of scientific material for The jouRNAf.

All have been members of the editorial board. Johnson, IM.D., hivansville, left, si)ccializes in internal medicine, certified by the American Board of Internal Aledicine. Lie is a 19d3 graduate of the Indiana University School of Medicine. During World War 11, Doctor Johnson was one of the 39 Indiana physicians who staffed the 32nd (leneral Hospital s])onsored by the Indiana University School of Aledicine.

Montgomery, Al.D., Aluncie, center, is a graduate of the Uiuversity of iManitoba Faculty of Medicine, in Winnipeg, 192S. He is certified hy the American Hoard of Pathology, is a member of the College of American Pathologists and of the American Society of Clinical Pathologists.

Doctor Montgomery has been a resident of Indiana since 1935 coming to this state from Rochesder, IMinnesota. He is pathologist at Ball Memorial hospital, Muncie. Bickel, M.D., South Bend, right, is a native Pfoosier, attended Indiana University, then graduated from the 1.

Ph School of iMedicine in 1921. He served internship and residency at W estern Reserve University hospitals.

Doctor Bickel is certified by the American Board of Oljstetrics and Gynecology and is a member of the Central Association of Obstetricians and Gyn- ecologists. He is a member of the Board of Governors of the American P'ollege of Surgeons, is chief of staff of iMemorial Hospital, South Bend, and vice-president of the South Bend Medical boundation. Doctor Bickel has contrilnited several articles to The Journal and to national medical pulrlications. 44 SPECIAL ARTICLE January, 1953 SERVING THE CHILD EFEECTIVELY THROUGH THE SCHOOL HEALTH PROGRAM DOXALD A. ILIX* Chicago V IS easy to develop a school health prot that what we arc o is not a x^hool health ])rogram. Hut a program for the im])rovement of a whole generation, collectively and individually.

We glibly divide the school health program up into ])ieces and assign those pieces to in- dixiduals. We assign what we call health teach- ing or health education to the teacher. Kmdron- ment or healthful school li -ing. We assign to the rulministrator and the custodian and possibly thi.se who o])erate the lunchroom and the locker rooms,. Nother area called health services, is the domain of the nurse and the physician. W'e trv verv hard to Ixeep these separate. It would he undesirable if a ])hysician should teach or if a teacher shotdd serve in the area which is normallv served hv the custodian.

If a nurse should enter the classroom or a teacher should *('onsunaiU in Health and Fitness, r.ureau of Health lOduca tion,.American Medical Association. 'I’his i)aper was presented befoi'e the Kesional School He 1th Cl. 11 1’erences at Han iver Colletre, Indiana, Ocloher S and Franklin (hdleg-e, Indiana, Xoveni- her 12. Advise a child on health jiractices, it would he a serious usurjiation of the other's prerogative. This, of course, is an exaggeration.

I have intentionally e.xaggerated in order to make the ]H)int. We are dealing with chiklren and chil- dren cannot be di ’ided into exclusive categories and classiheations, Thev cannot he phvsical one minute, emotional another, intellectual a third; e must talxe children as thev come, we must serve their health needs as they arise, we must make use of the “teachable moments' when the ’ occur and ve must do all of this in an environment which lends itself as an example of what we are trying to teach.

Books, Experience Both Needed I’atterns of healthful living in our children must he based on sound health instruction which gives these children fundamental concepts which thev can use in nri'dng discriminating iudg- ments regarding- healih matters Ixith now and in the future. Many of these concepts must he taught out of the hook- or out of the experi- ence of the teacher.

( )thers of them can he illustrated hv incidents that occur in the class- room, such as the near-sighted youngster who must sit in a front seat, the child who is hard-of-hearing, the habit of eating at lunch time and between meals, courtesy and safety practices on the ])layground, the cut finger, and the bruised knee, the cold, measles and all of the other thou.sand and one instances that pro- 'ide an o])portunity to jjoint out a lesson. These “teachable moments' should include the contacts the child has with the nurse serving the school, vith the visiting teacher, with the faiuily ])hysician and dentist and their associates or with, the school ])h_ -sician. The child can soon develo]) the habit of making use of most of these instances as learning exjjeriences, because he will utilize for his own infc rmation, those January, 1953 SPECIAL ARTICLE 45 teachable moments which may not happen to have an adult associated with them. As you can see, health instruction, the estahlishment of hahit ])atterns, and the deveh)])ment of attitudes go far heyond what hapjiens in school hours in the classroom under the immediate supervision of the classroom teacher. 1 lealthful school living permeates a good deal of the child's experience. IMany of the schools, particularly in the rural districts, are not at- tractive.

Thev are old, they are in i)oor repair, and thev lU'e not well designed. Nevertheless, a little effort on the ])art of an inspired teacher can mahe a considerahle dift'erence in both the phvsical and the emotional atmosphere that exists in and around that school. Simi^le soap and water cleanliness, a few flowers, orderly grounds, a clean playground and a ])leasant ])er- sonality, all hel]) to develop that appreciation for property which, in time, leads to apprecia- tion of )erson and ultimately to hahits of clean- liness, of self -protection and of interest in the rights of others that make for healthful living.

Tn the school room the most constant factor in the environment of children is the teacher. The emotionallv stable teacher who has a mature personality, will have a well-ordered, happy, emotional atmos])here in his classroom, flood ])hysical health in addition produces an ideal example for children t(j follow. This can he contrasted with the frinstrated, emotionally im- mature individual who is constantly enjoying poor health, and setting anything hut a good exani])le of ])hysical and mental health for the children in his class. It is (juite imi)ortant for administrators and boards of education to he alert to the emotional climate in the classrooms and to help those unfortunate individuals whose physical or mental health is less than adequate. This is the least that can he done for the pro- tection of the children who must he exposed to these health conditions for the better part of that sch.ool year.

The home, also, is an inqjortant factor in the environment of the child and it also determines, to some extent, the environment of the.school because the school is what the parents demand. ^^’here there is a ])redominance of substandard homes with j)arents who are uninformed or dis- interested in school matters, one is likely to find an inadequate school, because such families will not sup]iort a better one.

When such a situation exists, the adult education program must be in- tensified in order that the school environment as well as the other factors of the school health program udll he improved. “Service” Misunderstood rV third area is health service. Too fre( uent- Iv. This area is misunderstood because of the word “service.” The usual connotation of “serv- ice” is something that is done to or for another. Tn our health service programs in the school we fre( uently make the mistake of doing a lot of things “to” and “for” children, instead of helping children to do things for themselves..^'chools often have physicians come into the school to examine the children.

This is done hecau.se it is easier, the children are all in one ]?lace and do not have to l)e gotten to offices about the town, the school has a more comj)lete control over the services that will lie rendered by the ])hvsician, there is a record of the exam- ination at the school and a number of other factors, all of which make it seem to be very desirable. Ilowever, in school systems where this is carried to the logical conclusion, we find chiklren udio have no memory of being in a [ilivsician's nr a dentist’s office, who know noth- ing about the services that are normallv ofifered by the ]irivate practitioner, who have no idea of what these services might cost, or how to go about attaining them, all because the school has )rovided these children with their health serv- ices u ) to graduation. Tt seems very important that children learn about the community’s resources in the field of health service. Thev should know something about iihysicians, how ])hysicians practice, the kinds of services that they olT'er, aliout what those services cost, what the hospitals do and whv, what arc dentists, how are they consulted and for what jiurposes, and the cost of their services. Tt may lie necessary for a school.svstem to emiiloy a ]ihysician or to appoint a ])hysician to advise the school on health matters.

The school mav want to supplement the health services of family physicians with a consultation for cvhich thev are responsible. Tt would seem however, that wherever possible, the services of the family jihysician should he utilized for in- dividual ]iupil care in order to teach the child the normal health service resources that are found in each community. A ’here, for financial or other reasons, a family does not have a 46 SPECIAL. ARTICLE January, 1953 family physician, services that simulate those of the famih’ jiliysician can l>e provided through the local social agencies or ]>hysicians designated In' the county medical society to ])erform these services. I’ut the ])hysicians and the dentists are not the only ones concerned with health service.

The nurse serving the school is certainly an ally of the physician. She is able to interpret to him her ol)servations of the home and school problems of individual children. She can inter- pret the physicians’ findings and recommenda- tions to the home and the school. The teacher likewise is an im]')ortant ])erson in the health service field Ijecause of his continuous daily observations of children. It is he who is in the strategic jxisition to oliserve the changes in ap- ]>earance and in l)ehavior that may he the l)egin- ning of illness or the development of chronic deficiencies that a physician might miss unless he had a suggestion of the slow change that is taking place over a period of weeks or even months. It is also the teacher, working under the direction of the nur.se, who does the screen- ing tests for vision and hearing and the measurements of height and weight that are im )ortant laboratory ex])eriences in education, hut at the.same time are important information on health status. Quite frecpiently the bus driver and the custodian ])erform health serv- ices, particularly in the form of mental liealth.

D'hey are the only males in the lives of some fatlierless children and are looked to and re- spected 1)V some as substitute fathers. They, too, should he alert to the part that they are ]>laying in molding tlie health and emotional atti- tudes of children that the ' contact. Coordinate Services e have been talking about serving the child effectively. So far it has been neces.sary to discuss areas of service and individuals per- lorming that service one at a time.

This mast now be molded into a unified program with a unified objective in order to reach the higher levels of effectiveness. The ]jhysician, the den- tist, the health officer, the nurse, the adminis- trator, the teacher, the bus driver and the cus- todian each, in his own way, helps the school health program to he effective.

The school, the health department, the medical society, the dental society and the interested voluntary health agencies each operate their own school health programs. To do the job effectively recjuires a coordination of all of the ai'eas of service in the school health program. Also each person and agency must be ready to help the other in those areas where the professional field of one closely touches the ])rofessional field of another. Cfhviously, the physician will want to advise the nurse and the teacher on the observation of children and on the channels for referral.

Obviously, the teacher will want to counsel with the jjhysician, the nurse and the family and many of the agencies on effective methods of health teaching. Certainly the cus- todian and the bus driver, as well as the admin- istrator, will he getting ideas on environment from many people in the community. With all of these people working together it is sometimes Avise to bring children into the picture and learn from them their hoi)CS and ambitions and in- terests in order that all of this may more effec- tively l)ecome a ]xu't of their lives. ( )ne method used by many to improve the co- ordination of the various ])rofessions and agen- cies concerned with school health is the develop- ment of school health councils, or school health committees in community health councils.

These serve as a forum for the exchange of opinion, as a nucleus for interprofessional cooperation and as the center for ])lanning future develop- ments that contain the influence of all who are interested..‘summarizing, it might he said that the effec- tiveness of the school health jirogram will he improved when that ])rogram is child centered rather than adult centered and is designed less to serve the child than to help the child learn how to serve himself. The effectiveness can he increased when the various ])rofessions and agencies concerned learn to work together, to consult with each other, and to fit the contribu- tion each can make to those of the others in such a way that there is a unified school health ])rogram rather than one for each agency and each profession. Furthermore, this working to- gether can he made easy when a forum, by whatever name vou may wish to call it,* is estab- lished in which there can he this exchange of opinion, this basic planning that leads to effec- tive execution of programs, well designed to accomplish the objectives for which they were intended. January, 1953 SPECIAL ARTICLE 47 STATE NURSES’ ASSOCIATION TO ASK LEGISLATURE EOR SCHOLARSHIP EUNDS A ])ill sponsored by the Indiana State Xnrses Association has been [jrepared and will he intro- duced in the 1953 General Assembly. The hill provides for a scholarship fund through which Indiana registered nurses may secure scholar- ships to prepare themselves for positions in teaching, supen’ision, or administration in nursing.

It is believed that Indiana needs a scholar- ship hill for the following reasons: 1. 'I'he Indiana Nursing Survey, published ill 1952 and sujiported financially by the Indiana State Medical Association, shows that instruc- tors in most of Indiana's schools of nursing are not educationally prepared for their jobs. Only one of Indiana’s 24 schools of nurs- ing now has full national accreditation. Only 14 have temporary accreditation.

National accreditation has fre([uently been withheld from our schools because of the scarc- ity of full time faculty personnel, too heavy faculty load, etc. In many Indiana schools of nursing there is also a marked failure to provide for all students the clinical experiences long- regarded as essential to basic preparation. In Indiana, in the four basic clinical areas — medi- cal, surgical, obstetric and pediatric nursing — only a third of the supervisors have had addi- tional preparation beyond their basic nursing- programs; among clinical instructors in these areas only 24% have had preparation for their specialized jobs. Student nurses can only per- form in a manner in which the}^ are taught hence good instruction is essential if our schools are to prepare good nurses. Dramatic evidence of the need to improve schools of nursing is also found in the per- formance of Indiana student nurses in the na- tional test-pool examinations.

These are as follows: a. Medical nursing — 37 states rate higher than Indiana 1). Surgical nursing — 22 states rate higher than Indiana c. Obstetric nursing — 29 states rate higher than Indiana d. Nursing of children — 34 states rate higher than Indiana e.

Communicable disease nursing — 28 states rate bigher than Indiana f. I’sycbiatric nursing — 37 states rate higher than Indiana 4. It is recognized that poor schools cannot attract qualified teaching personnel until a nucleus of qualified faculty is availaWe to pro- vide a working- hasis for educational programs; in this respect, Indiana's.schools cannot hope to secure faculty personnel from outside the state t(j any ap[)reciable degree. Hospitals which own and operate the majority of Indiana nursing schools cannot offer scholarships to faculty personnel because of increasing hospital costs. Other states are securing scholarshi[) aid which is pror-iding prepared faculty with the result that nursing education is concurrentlv being upgraded in other states which will in turn place Ii-idiana even lower on the compara- tive national level ui-iless immediate action is taken.

The contents of the proposed bill are as follows: 1. It jjrovides for $100,000 annuallv to be ar-ailable for the Nursing Scholarship Fund which is to be administered by Indi- ana University. Tbe Indiana State Nurses Association is to create a scholarship con-imittec which will determine the eligibility of the scholar- ship applicants.

Any Indiana registered nurse who is a resident of this state and lacks funds to pursue her education in teaching, super- vision or administration of nursing will be eligible to apply for such scholarship. The nurse must agree upon receipt of such scholarship to accept a position in Indiana for two years following completion of the course of study. Up to $3,000 niay be granted for each scholarship and such scholarship may be used in any educational institution offering a course in nursing education that is ap- proved by Indiana University. 48 SPECIAL ARTICLE January, 1953 STATE BOARD ANNUAL REGISTRATION LAW: PROVISION EOR LICENSEES IN SERVICE Chapter 254 — Acts of 1947 Section 1.