Washington University Medical Alumni Quarterly, October 1948

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WASHINGTON UNIVERSITY MEDICAL ALUMNI QUARTERLY

Published in the Interest of the University and the Alumni

• Talcum Powder Granuloma — A Frequent and Serious Postoperative Complication

• Proceedings of Washington University Medical Society

• 351 Enrolled for '48-'49 Term

Vol. XII OCTOBER, 1948 No. 1 OFFICERS OF THE ALUMM ASSOCIATION OF WASHINGTON UNIVERSITY SCHOOL OF MEDICINE

President: Dr. Samuel B. Grant '20 Vice-President: Dr. Alfred Goldman '20 Vice-President Dr. P. D. Stahl '23 Secretary-Treasurer: Dr. George W. Ittner, Jr. '37

Executive Committee Term Expires 191,9 Term Expires 1950 Term Expires 1951 Dr. A. N. Arneson '28 Dr. J. W. Thompson '23 Dr. Guy Magness '28 Dr. Richard Paddock '21 Dr. Louis H. Jorstad '24 Dr. Delevan Calkins '31 Dr. David Skilling *28 Dr. Oliver Abel, Jr. '23 Dr. Sim F. Beam '32 Dr. George Wulff *33 Dr. Samuel B. Grant '24 Dr. Oscar C. Zink '21

EDITORIAL BOARD WASHINGTON UNIVERSITY MEDICAL ALUMNI QUARTERLY

Representing the University: Representing the Alumni: Dr. Robert J. Terry, '95 Dr. Louis Jorstad, '24 Dr. Alexis Hartmann, '21 Dr. James W. Bagby, '33 Dr. Paul Hageman, '34 Dr. Leo Wade, '38 Dr. Robert A. Moore, Editor

Office of the Washington University Medical Alumni Quarterly, Euclid and Kingshighway, St. Louis 10, Missouri

Published quarterly by Washington University School of Medicine, St. Louis 10, Mo. Entered as second class matter December 14, 1937, at the Post Office at St Louis, Mo., under the act of August 24, 1912. The Washington University Medical Alumni Quarterly

VOL XII OCTOBER, 1948 NO. 1

Talcum Powder Granuloma: A Frequent and Serious Postoperative Complication* Ben Eiseman, M.D., M. G. Seelig, M.D. and Nathan A. Womack, M.D. St. Louis, Missouri FROM THE DEPARTMENT OF SURGERY, WASHINGTON UNIVERSITY SCHOOL OF MEDICINE, BARNES HOSPITAL, AND THE BARNARD FREE SKIN AND CANCER HOSPITAL, SAINT LOUIS, MISSOURI

THIS STUDY of talc granuloma is be- use of this dangerous agent in the oper- ing presented in order to stress the ating room are available, it is well to seriousness and frequency of a known realize the variety and seriousness of postoperative complication and to sug- the complications that may arise from gest a way by which it may be pre- the use of talcum powder on surgical vented. gloves. During the past 14 years sporadic re- This study reviews 37 cases of talcum ports of talcum powder granulomas powder granulomas producing symp- following surgical operations have ap- toms serious enough to require admis- peared in the literature. Because some sion to the Barnes Hospital for treat- of these reports have dealt with a small ment. In each instance a previous number of cases scattered over a long operation had resulted in the leaving period of observation, many surgeons of enough talcum powder in the wound and pathologists have tended to con- to result in a severe silicotic reaction sider the problem chiefly as one of aca- with consequent serious postoperative demic interest. During the period in complications. which no apparent solution to the AntopoP in 1933 was the first to call fundamental problem was in evidence attention to the clinical and pathologic there perhaps was some excuse for this significance of Lycopodium and talcum attitude. Now that alternatives to the powder granuloma in surgery. He pre- « Read before the Meeting of the American Surgical Association, March 25-27, 1947, Wot- SnrinE"s "Vs.. •Reprinted by permission of Annals of Surgery, 227 S. Sixth St., Philadelphia, Pa., Vol. 126, No. 5 ; November, 1947 ; Copyright, 1947, by J. B. Lippincott Co. WASHINGTON UNIVERSITY

Fig. 1A Fig. 2A

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Fig. IB Fig. 2B

Fig. 1A—Talc granuloma in lumbosacral extradural space following laminectomy. The process is recent and there are numerous giant cells. (H & E x 150.)

Fig. IB—Photograph of same field seen in Fig. 1A taken with polarized light to demonstrate the massiveness of contamination, (x 150.)

Fig. 2A—Active reaction to talc in the wall of the ileum following apendectomy. This had resulted in a persistent fecal fistula. The fibrosis around the giant cells is dense and had extended deep into the intestinal wall, where it was associated with secondary infection (H & E x 150). Fig. 2B—Photograph of same field seen in Fig. 2A taken with polarized light to demonstrate the birefringent talc, (x 150.) MEDICAL ALUMNI QUARTERLY

Fig. 3A Fig. 4A •m /*

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Fig. 3B Fig. 4B

Fig. 3A—Reaction to an unusually large talc crystal. This followed appendectomy, and the resulting lesion was diagnosed roentgenologically and clinically as regional ileitis. There was a diffuse area of edema and fibrosis involving the terminal ileum. (H & E x 150.) Fig. 3B—Photograph of same field seen in Fig. 3A taken with polarized light (x 150).

Fig. 4A—Reaction to talc adherent to chromic catgut. This was a peritoneal suture and resulted in the formation of adhesions with subsequent intestinal obstruction. We have noted stenosis of enterostomy stoma as a result of such a reaction to talc contaminating suture material. Fig. 4B—Photograph of same field seen in Fig. 4A taken with polarized light to demonstrate widespread contamination with birefringent talc. WASHINGTON UNIVERSITY

sented 6 cases of granuloma caused by the reaction of the subcutaneous tissue Lycopodium spores and talcum powder to silica and that of the microscopic crystals introduced into a surgical picture in sarcoid, pointing out that wound from the surgeon's glove. He foreign body granulomas might well be pointed out the clinical similarity of confused with sarcoid. these lesions to both neoplasm and to Ten more cases were added to the tuberculosis. literature in 1941 and 1942 when Mc- Erb3 in 1935 reported 6 cases of tal- Cormick and Ramsey,11 Byron and cum powder granuloma. In 3 of these Welch,2 and Ramsey1* reported a vari- cases the granuloma was an incidental ety of manifestations of this underlying finding but in the other 3 patients, the granulomatous lesion. These authors talc granuloma was the fundamental noted the production of peritoneal cause of the postoperative complaints. granulomas, and of chronic draining One of these cases had a severe talc re- sinuses caused by the seeding of talcum action deep within the brain substance powder into the peritoneal cavity dur- following a neurosurgic procedure. ing various surgical procedures. In 1936, one other case was reported Weed and Groves 21 in an effort to by Owen.12 A year later Fienberg* re- find the mechanism of talcum powder ported five instances in which talc crys- contamination of wounds, studied sur- tals were discovered in microscopic gical gloves after their operative use. sections by the use of crossed Nicol They found that in 74.4 per cent of all prisms. Birefringent material (of which operations at least one of the gloves talc is an example) will by this method used by the operating team was torn. of examination rotate a beam of polar- Of all gloves examined 22.6 per cent ized light. The latter author reviewed showed perforation following use in the 30,000 cases and states he found but 5 operating room. This work emphasizes examples of talc granuloma. He re- the fact that simple washing of the views, however, only those cases that gloved hand would not remove the dan- had been diagnosed as foreign body re- ger of contaminating the surgical field action of an unknown type. with talcum powder. A relatively large Grieco7 in Italy reproduced talc amount of powder remains inside the granuloma in animals by injecting a glove and can easily be spilt into the fine suspension of talc crystals subcu- wound when a glove is perforated. taneously and intraperitoneally. He German6 in a subsequent report re- demonstrated that only a few crystals viewed 20 cases in which he found upon were required to incite a large mass of microscopic examination large numbers inflammatory reaction. of talc crystals within the tissue. He Ramsey and Douglass13 in 1940 required 3 or more crystals per micros- added 5 cases to the literature and cau- copic field before he would consider tioned against the use of talcum powder talc as a causative agent. From his ani- in the operating room. The same year mal experiments in the production of German5 noted the similarity between talc granuloma, he states that concom-

to MEDICAL ALUMNI QUARTERLY itant tissue trauma is necessary in the discuss the microscopic similarity be- region of talc implantation for the pro- tween the talcum lesions, sarcoid and duction of granuloma. tuberculosis. They also point out the Wells22 in 1944 noted a number of similarity between talcum powder gran- cases in which talc granuloma had uloma and some of the manifestations caused a failure of surgical wound of regional enteritis. healing. During recent years surgical speci- A number of authors have thus rec- mens showing chronic inflammatory le- ognized the dangers in the use of tal- sions have been examined by us with cum powder. Seelig, Verda and Kidd17 crossed Nicol prisms, and many clini- in 1943 were the first to offer a substi- cally unsuspected cases of talcum pow- tute for this offending material. They der reaction have been identified. The suggested the use of potassium bitar- prevalence of these lesions and their trate powder which they pointed out varied clinical manifestations prompted caused no such tissue reaction as did us to review the surgical pathologic ma- talc, and was relatively resistant to terial at the Barnes Hospital in an ef- autoclaving. They also called attention fort to correlate our experience with to the bacteriostatic properties of this this condition. Many cases coming to powder. Subsequent to their report, reoperation prior to the recognition of this material has been adopted by a the propensities of talcum powder to number of surgeons throughout the cause such granuloma had been incor- country with varying success. The rectly diagnosed, only to be discovered greatest drawback to the use of potas- upon re-examination in the light of sium bitartrate is that if autoclaved for later knowledge. It is interesting to longer than 20 minutes it tends to cara- note that in several cases the patholo- melize, making rubber gloves sticky as gist remarked upon the reaction as be- well as decreasing their elasticity. ing "similar to one around a foreign Seelig18' 19' 20 in a series of three pa- body," but talc was not incriminated pers in 1944 and the year following, until after Antopol's article in 1933. re-emphasized the dangers of talcum The fact that talc crystals are found powder in the operating room, and of- in a microscopic section does not neces- fered another more desirable substitute sarily mean that they underlie the essen- in the form of a specially treated starch tial nature of the pathologic lesion. A powder. It was felt that this new agent high percentage of cases at re-operation once available would replace both tal- show evidence of the presence of a few cum powder and potassium bitartrate. talc crystals but in most cases they are Recently Lichtman8' ° et al. have merely an incidental finding. Crystals published two papers reviewing the en- around the periphery of the section are tire problem very thoroughly. They felt to be contaminants, probably from present a large series of lesions in the examining pathologist's glove. For which the reaction to talcum was con- this reason precipitated calcium carbon- sidered to be an etiologic factor, and ate is used as a dusting powder in the WASHINGTON UNIVERSITY

TABLE I Time Between Orig. Op. Duration and No. of of Case Original Appearance Chief Operations Operations Symp- No. Operation of Symptoms Complaint Subsequent Performed toms Died Appendectomy 3 wks. Intestinal obstruction 1 Lysis adhesions 6 wks. Appendectomy 5 days Abdominal sinus 5 I&D. Curettings. lap. 2 yrs. + Suprabic prostatec- tomy 0 Abdominal sinus 2 Curettings 2 mos. Removal of wart 0 Scar on face 8 Plastic to face 2 yrs. + Appendectomy 5 days Abdominal sinus* 2 Excision sinus 17 mos. + C holecy st ect omy 0 Abdominal sinus 2 Lap. I & D. 8 mos. Salpingectomy, Urinary and fecal oophorectomy 5 days fistula 3 Closure fistulae 10 yrs. Myomectomy, appendectomy 0 Abdominal sinus 2 Excision sinus. I&D 10 mos. + 9. Appendectomy 0 Abdominal sinus 1 Excision sinus 2 mos. 10. Appendectomy, 9M yrs. oophorectomy 6 days Fecal fistula 2 Closure fistula 6 mos. 11. Laparotomy 0 Abdominal sinus 2 Lysis adhesions 6 mos. 12. Appendectomy 5 mos. Mass in RLQ 1 I&D. abscess \ mo. 13. Appendectomy 0 Fecal fistula 4 l&D. excision sinus, resection 1 yr. 14. Appendectomy 3 wks. Abdominal sinus 3 Excision sinus 2 yrs. 15. Herniorraph'y 0 Mass, sinus 2 I &D. 3 yrs. 16. Appendectomy 0 Fecal fistula 3 Closure fistula 21 yrs. 17. Laparotomy 3 mos. Intestinal obstruction 6 Lysis adhesions, colostomy, resection ileum 3 yrs. 18. Appendectomy 3 mos. Abdominal sinus 2 Excision sinus 6 mos. 19. Appendectomy 14 mos. Abdominal sinus 4 I&D. curettings 2 yrs. 20. Appendectom y 0 Abdominal sinus 4 Laparotomies, exploration 26 mos. 21. Nephrectomy 2 mos. Lumbar sinus 1 Excision sinus 2 yrs. 22. Appendectomy 7 mos. Mass in RLQ 2 I&D. 20 mos. + 23. Appendectomy 0 Abdominal sinus 3 Lysis adhesions. I&D. 7 mos. + 24. Appendectomy 0 Intestinal obstruction 5 Lysis adhesions, I ilectomy 3-yrs. + 25. Gastrectomy 1 mo. Obstruction Esophagoplasty. anastomosis 5 lysis adhesions 6 mos. 26. Abdominal Ileocecostomy, hysterectomy 1 wk. Fecal fistula 2 closure 3 mos. X 27. Laminectomy 2 mos. Sinus 1 Excision s:nus 6 mos. 28. Laparotomy lyr. Intestinal obstruction 3 Ileostomy, resection 29. Laparotomy 1 wk. Abdominal sinus 3 I & D. 30. Appendectomy 2 mos. Intestinal obstruction 3 Lysis adhesions. resections 6 mos. \ 31. Thoracotomy 0 Chest sinus 2 Curetting sinus 10 mos. *2. Appendectomy 10 yrs. Intestinal obstruction 3 Lysis adhesions. enterostomy 11 yrs. 35. Abdominoperineal Enlargement resection 2 yrs. Stenosis colostomy colostomy stoma 6 mos 34. Laminectomy 0 Pain in leg Laminectomy excision granuloma 13 mos. 35. Abdominoperineal Enlargement resection Stenosis colostomy 1 colostomy stoma 3\ Cholecystectomy 0 Intestinal obstruction 3 Lysis adhesions 2 yrs. 37 I&D. perineal abscess 0 Perineal sinus 2 Excision perineal sinus 2 mos

ta MEDICAL ALUMNI QUARTERLY surgical pathologic laboratory, it being ducing a wide fibrotic reaction. The adequate as a powder and impossible cellular reaction in these cases was to confuse with talc crystals because of identical with that resulting from talc, the inability of chalk to rotate polar- but because sufficient amount of talc ized light. could not be identified, we have not felt We have tried assiduously to avoid justified in including them in the pres- indicting talcum powder as the primary ent series. We call attention to them, etiologic agent in a case until certain however, to stress the point that the criteria have been fulfilled. These are: talc reaction in our opinion plays a prominent role in many instances in the 1. The finding of doubly refractile formation of that type of dense stenos- crystals in the microscopic section. These crystals must be within the body ing fibrosis so often associated with of the material sectioned. postoperative symptoms. 2. The crystals must have the mor- The most striking fact concerning phology of talc, as differentiated from this group of postoperative patients is lint, fibers of cotton, silk, cholesterol the diversity of the clinical syndromes crystals, etc. that they represent. The most common 3. A typical foreign body reaction must be present immediately around finding is that of a surgical wound that these crystals, which includes the pres- failed to heal postoperatively. Twenty- ence of multinucleated giant cells, three cases (62 per cent) had such a round cells, and a varying amount of manifestation: 15 had a chronic abdom- vascular fibrous connective tissue. inal sinus, 1 a lumbar sinus, 1 a sinus 4. Clinical interpretation consistent in the chest wall, and 1 a perineal si- with talcum powder granuloma. This includes a previous operation at the nus. A few of these were simple super- site of granuloma formation, and no ficial wounds and were considered clin- other evident source of origin to ex- ically to be stitch abscesses. Others plain the condition. extended deep into the peritoneal cav- Using these criteria, 37 cases have ity. been identified in which a reaction to Besides these sinuses, five fecal fis- talcum powder produced the essential tulas were found. Before including lesion. Table I summarizes the impor- these cases, ample evidence of talc deep tant data of these cases. in the sinus wall was required, for Not included in this series is a con- many doubly refractile vegetable bod- siderably larger group in which all of ies could pass into such a fistulous the criteria mentioned above could not tract from the lumen of the intestine. be satisfied. In this latter group the As in Lichtman's series8 many of these majority of the patients had undergone cases with fecal fistulae had been previous laparotomies with resulting thought clinically to have regional en- dense diffuse adhesions. As can be teritis. noted in the photomicrographs, a mi- Table II shows the frequency of the nute amount of talc is capable of pro- various clinical complaints. WASHINGTON UNIVERSITY

TABLE II CLINICAL COMPLAINTS IN 37 PATIENTS WITH POSTOPERATIVE TALCUM POWDER GRANULOMA Sinus 18 Abdominal sinus 15 Lumbar sinus .. Chest sinus Perineal sinus Fecal fistula 5 Intestinal obstruction 7 Tumor mass 3 Neurologic signs 2 Stenosis 2

Most of the patients in this series had tories, and gross examination often lent many previous operative procedures be- weight to the diagnosis. The micro- fore being seen in this hospital. Eight scopic picture was of course always patients (22 per cent) had four or slightly atypical of tuberculous infec- more operations. The average patient tion. had 2.5 operations with no assurance As previously noted, regional enter- that more procedures would not be re- itis was often suggested when small quired after discharge. In two patients bowel symptoms predominated. further surgery is known to have been Talc granuloma is a chronic condi- performed at other hospitals when tion. In this series, symptoms ranged emergency procedures were necessary. from a few months to 21 years. During The type of operation performed in this time there were long silent periods treating these complaints were varied. in which no evidence of foreign body Seventeen patients had closure or at- was seen. Then without obvious stim- tempted closure of a chronically drain- ulus there were symptoms of irritation. ing sinus. Many of these patients re- Although a few cases had their first quired multiple operations. Lysis of symptoms occur in a matter of months postoperative intestinal adhesions was after operation, most had some evi- carried out in seven cases, and a like dence of foreign body reaction during number required bowel resection. In- their immediate postoperative hospital cision and drainage, with curettage of stay. Those cases with obstructing in- sinuses was performed in 21 cases. testinal adhesive bands seemed to have The condition most often confused late evidence of their talc reaction, per- with talc granuloma clinically in this haps because it required some time for series was tuberculosis. This was due the adhesions to form and become con- to the chronicity of the signs and symp- strictive. toms and to the similarity in the gross There were two deaths in this series. between the granulomatous lesions. The primary operations during which Non-caseous tuberculosis was a re- time talc was implanted represent pro- peated suggestion in the clinical his- cedures in all branches of surgery and MEDICAL ALUMNI QUARTERLY its specialties. The most common oper- lesions as feeling shotty when rolled ation responsible for talc spillage was between the fingers. appendectomy (49 per cent), followed The largest granuloma in this series by laparotomy for unknown procedures was a sausage shaped mass involving (11 per cent). Gynecologic operations the transverse colon, measuring 14 cm. accounted for 11 per cent of the cases, in length and 8 cm. in width. (Case No. genitourinary, orthopedic, plastic, tho- 30.) Most of the granulomas, however, racic and neurosurgical procedures each were small nodules measuring about 1 were responsible for at least one exam- cm. in diameter. ple of talc spillage and subsequent re- Microscopically talc granuloma fits action. in with those agents that upon introduc- The danger of this silicotic reaction, tion into the body cause a foreign body therefore, is universal. In some areas reaction of the proliferative type.10 small granulomas may cause fewer Pulmonary silicosis has been widely symptoms than others. This prolifer- studied, and talc (Magnesium Silicate) ative process once present usually per- reaction is merely a localized form of sists for years. The part it plays in the this same condition. production of postoperative abdominal Talc crystals are seen microscopi- adhesions has been tragic and apparent. cally to be surrounded by masses of fi- The damage in other surgical proce- brous tissue in which there is excessive dures such as craniotomy, while pres- collagen production along with inflam- ent, has been less obvious. matory cells. Individual talc crystals are seen to be the nidus of the inflam- PATHOLOGY matory reaction, which has a peculiarly Upon gross examination talc granu- wild and unoriented appearance. Con- lomas are not pathognomonic. In cases nective tissue strands are mixed in where a mass was observed, the opera- whorls and cross currents as they en- tive notes almost invariably mention velop the irritating talc particles. The the hard consistency and pearly white cellular response consists of foreign or grey color of the tumor. In many body giant cells which surround (and cases biopsy of the area was made upon in the case of small crystals also in- laparotomy because of the dense con- gest) the talc particles. No evidence of sistency of the area, which suggested destruction of these non-absorbable malignancy. When small multiple, dis- particles is seen so that the reaction by crete, areas of reaction were seen at op- no means resolves the condition. The eration, the surgeon's note often men- multi-nucleated cells in some cases tions the resemblance to miliary tuber- reach tremendous proportions, gener- cle formation. Adhesive bands within ally with a clear cytoplasm in which the peritoneum were noteworthy be- numbers of small nuclei are eccentric- cause of their dense inelastic consis- ally clustered. Small round cells are tency and their vascularity. The pa- typically in evidence. No caseation is thologist usually described the smaller ever seen. 10 WASHINGTON UNIVERSITY

The microscopic similarity to a tu- From our own experience and from bercle is evident, for a focus of inflam- that of others where talcum powder is matory reaction is surrounded by lym- used on the hands and gloves or where phocytes, giant cells, and a prolifera- it is on the scrub nurse's table it is a tive connective tissue response. Identi- source of danger. The deposition of a fication of talc crystals in the center of thin layer of talc on gauze sponges, the lesions is of course the point of dif- packs, and on the instruments follows ferentiation. This can be performed on the all too frequent and vigorous pow- routine examination merely by using a dering of the hands preparatory to don- strip of polaroid material between the ning gloves. With care this hazard may light source and the microscopic slide, be lowered, but even the utilization of and other such polarizing strip between utmost care cannot completely exclude the slide and the eye arranged so as to the possibility of occasional accidental darken all but birefringent particles. contamination. Foreign body reactions from other The ability of talc to spread through- materials are often similar microscop- out a room can easily be demonstrated ically to that due to talcum powder by placing a dark piece of paper or a crystals. The reaction to suture mate- book on one side of the room, then rial is of interest in this respect. carefully powdering the hands on the Strands of cotton or silk are them- opposite side of the room. In a matter selves slightly birefringement. It was of a few minutes a thin layer of talc noticed in several cases, however, that will be seen settling on the darkened strands of such sutures were surrounded surface. by a halo of birefringent particles that It would seem to us that the best an- did not appear to be silk or cotton fi- swer to the problem is either the use of bers, but rather to be of the nature of wet gloves or the substitution of an in- talcum powder crystals. For this rea- nocuous dusting powder. As previously son, several sutures were mounted on a mentioned, potassium bitartrate has slide and examined with polarized been used as such a substitute. More light. It was found that sutures that recently, starch treated with formalde- were new and dry showed none of these hyde in order to prevent the formation birefringent particles. Suture material of a gel upon autoclaving has been from the same source was then wet in tried. Seelig has shown the lack of tis- water and run through a hand that had sue reaction to this material in a series been dusted with talcum powder. The of elaborate animal experiments. particles of talc obviously were trans- Variously treated starch compounds ferred to the wet suture, and became have been introduced into many ani- adherent. It is possible, therefore, that mals (dogs, mice, rats, and guinea much of the foreign body reaction as- pigs). In no case does the powder elicit cribed to suture material may actually a granulomatous response. The innoc- be due to the tiny talc particles that are uousness of starch in the tissue and the adherent to the thread. rapid rate of its dissolution is clearly MEDICAL ALUMNI QUARTERLY 11 evident when the powder is injected must elapse before we can be sure that into the anterior chamber of a rabbit's the aldehyde treated starch is com- eye. Examination of an animal four pletely innocuous to both the patient days after 2 mg. of formalized starch and the surgeon. In the meantime, as has been introduced into the right eye. previously stated, potassium bitartrate, and 2 mg. of talc had been injected into properly sterilized, can be used. Tal- the anterior chamber of the left eye cum must be banned from the field of shows that starch has been absorbed, surgery. leaving no reaction. Severe fibrosis and SUMMARY tissue reaction is seen, on the other hand, 1. Thirty-seven cases of postopera- in the talcum treated eye. The talc re- tive complication due to talcum powder action subsequently caused blindness. granuloma have been presented. ' Unfortunately, however, very recent 2. These cases represent a wide di- clinical experience has disclosed an un- versity of complications, ranging from expected difficulty. The formaldehyde simple wound abscesses to serious se- starch is somewhat unstable, and seems quelae such as fecal fistulae and intes- to split up on ageing, liberating free tinal obstruction. aldehyde. This, of course, can act as an 3. The clinical and pathologic nature irritant to the hands of the surgeon. of this condition has been discussed. One corporation interested in develop- 4. Emphasis has been placed upon ing the new powder seems to have used the requirements of a suitable alterna- other aldehydes, and to have added tive dusting powder for use in the oper- magnesium carbonate to increase the ating room. "flow" of the powder. We have found previously that magnesium carbonate 5. Review of our experimental and produces granulomata; moreover, the clinical trials of formalized starch com- new aldehyde-starch powder has evoked pounds as dusting agents in the operat- hand irritation in one of our resident ing room has been given. surgeons. 6. The starch compounds as now As a result of the more recent experi- produced are not completely stable, ence, we are still searching for an ade- and must be further modified before we quate substitute for talcum. More time recommend their use. 12 WASHINGTON UNIVERSITY

REFERENCES

1 Antopol, W.: Lycopodium Granulo- is Ramsey, T. L., and F. M. Douglass: ma, Arch. Path., 16: 326, 1933. Granulomatous Inflammation Produced 2 Byron, F. X., and C. S. Welch: A by Foreign Body Irritants, J. Internat. Complication from the Use of Glove Pow- Coll. Surgeons, 3: 310, 1940. der, Surgery, 10: 766, 1941. i-i Ramsey, T. L.: Magnesium Silicate 3 Erh, I. H.: Lycopodium Granuloma, Granuloma, Am. J. Clin. Path., 12: 553, Surg. Gynec. & Obst, 60: 40, 1935. 1942. * Fienberg, R.: Talcum Powder Gran- isSchulz, R. Z., and C. R. Williams: uloma, Arch. Path., 2J,: 36, 1937. Commercial Talc-Animal and Mineralog- ical Studies, J. Industrial Hyg., 24: 75, s German, "W. M.: Lupoid-Sarcoid Re- 1942. action Induced by Foreign Body (Silica), Am. J. Clin. Path., 10: 245, 1940. i6 Schmitt, F. O.: The Ultrastructure of Protoplasmic Constituents, Physiologic «German, W. M.: Dusting Powder Reviews, 19: 270, 1939. Granuloma Following Surgery, Surg. Gynec. & Obst, 76: 501, 1943. " Seelig, M. G, D. J. Verda and F. H. ? Grieco, Faust: Granuloma di Lico- Kidd: The Talcum Powder Problem in podio e da Talco in Seguito a Laparoto- Surgery and Its Solution, J. A. M. A., mia, Arch. Ital. di Chir., 42: 641, 1936. 123: 950, 1943. sLichtman, A. L., J. R. McDonald, C. is Seelig, M. G„ and D. J. Verda: Tal- Dixon and F. C. Mann: Talc Granuloma, cum Powder Problem, J. Mt. Sinai Hosp., Surg. Gynec. & Obst., S3: 531, 1946. 12: 655, 1945. s Lichtman, A. L., and J. R. McDonald: is Seelig, M. G.: Talc as an Operating Birefringence in Tissues, Arch, of Path., Room Hazard, South Med. Jour., 38: 470, J,2: 69, 1946. 1945. io Miller, J. W.: Microscopic Appear- 20 Seelig, M. G: Talc-Abdominal Sili- ance of Experimentally Produced Dust Nodules in the Peritoneum, U. S. Public cosis (Graulomas due to talcum powder) Health Serv. Reports, 1619, 1935. and Cancer, S. Clin. North America, 24: 1162, 1944. ii McCormick, E. J., and T. L. Ram- sey: Post-operative Peritoneal Granulo- 2i Weed, L. A., and J. L. Groves: Sur- matous Inflammation Caused by Magne- gical Gloves and Wound Infections, S. sium Silicate, J. A. M. A., 116: 817, 1941. G. and O., 75: 661, 1942. 12 Owen, M.: Peritoneal Response to 22 Wells, A. H.: Failure of Surgical Glove Powder, Texas State J. Med., 32: Wound Healing Due to Talc, Minn. Med. 482-485, 1936. 27: 640, 1944. MEDICAL ALUMNI QUARTERLY 13 Proceedings of the Washington University Medical Society

THE first meeting of the Washington successful meetings, and hopes to en- University Medical Society for the joy an equally successful season in school year 1948-49 was held Thurs- 1948-49. The final session last spring day, October 21, at 8 p. m. in the Au- was devoted to the presentation of pa- ditorium of the School of Medicine, pers submitted by students in the an- and the date for the second meeting was nual competition for the Borden Under- set for December 8th at a meeting of graduate Research Award, which was the Council of the Society on Septem- won by James F. Nickel, M.D., 1948. Abstracts of the three papers pre- ber 27. Following its reorganization last sented at the student meeting on May year, the Medical Society had five very 20, are published herewith:

COMPARISON OF TRANSFUSION SURVIVAL, MECHANICAL FRAGILITY AND SICKLING SUSCEPTIBILITY IN SICKLE CELL ANEMIA AND SICKLE CELL TRAIT ERYTHROCYTES By James F. Nickel, M.D. Department of Medicine

This investigation was undertaken permitted study of the mechanical fra- for three reasons: (1) to determine the gility of normal erythrocytes and of mechanism for the increased hemolysis cells from patients with sickle cell ane- in sickle cell anemia; (2) to analyze mia and the trait, under high tensions the differences in behavior of red blood of oxygen and carbon dioxide. Finally, cells from patients with sickle cell ane- a study was made of the relative ease of mia and the sickle cell trait; and (3) sickling in cells from the two types of to search for evidence that forms of patients. sickle cell disease intermediate between The results obtained indicate that the the "anemia" and the "trait" might normal hemolysis in sickle cell anemia is the result of an inherent defect in the exist. These problems were approached erythrocyte itself. The cells in their first by measuring the survival of red sickled form are abnormally sensitive blood cells transfused from patients to mechanical trauma. Red blood cells with sickle cell anemia and the trait from patients with the sickle cell trait into normal recipients, and of cells sickle less readily and for this reason transfused from normal subjects into probably withstand the trauma of cir- patients with the sickle cell trait. A culation in a more normal manner. technique was then developed which Cells from individuals with the sickle 14 WASHINGTON UNIVERSITY

cell trait survived normally when trans- of forms of sickle cell disease interme- fused into healthy recipients. No evi- diate between the sickle cell trait and dence was discovered for the existence the anemia.

GLYCOGEN IN HUMAN BLOOD CELLS By Robert P. Gibb, M.D. Department of Pathology- Three different histochemical meth- and the cytoplasm of monocytes con- ods were applied to the study of glyco- tained moderate amounts of glycogen, gen in normal and abnormal peripheral and platelets and the cytoplasm of blood and bone marrow films. The lymphocytes smaller amounts. technics employed were the chromic Examination of peripheral blood and acid-silver-methanamine procedure of bone marrow of patients with various Gomori, the periodic acid-fuchsin sul- hematologic, metabolic, and infectious furous acid technic of Hotchkiss and diseases revealed no significant differ- the Bauer-Feulgen stain. Control sec- ences in glycogen content from the nor- tions were treated with saliva to remove mal with the possible exception of poly- the glycogen. cythemia in which a suggestive increase Large amounts of glycogen were in cellular glycogen was observed in demonstrated in the cytoplasm of poly- polymorphonuclear leukocytes, plate- morphonuclear, metamyelocytic, and lets, and megakaryocytes. A moderate myelocytic neutrophilic leukocytes and amount of glycogen was observed in in the extra granular cytoplasm of multiple myeloma cells. Large cells in eosinophilic leukocytes in films from patients with infectious mononucleosis normal individuals. Megakaryocytes did not stain for glycogen.

THE EFFECT OF TETRA-ETHYL AMMOMIUM CHLORIDE ON THE RESPONSE OF THE ADRENAL GLAND TO SENSORY NERVE STIMULATION By Seymour Reichlin, M.D. Department of N euro psychiatry There is considerable evidence indi- central end of the sciatic nerve in rats cating that, in some manner, the central by using the drug tetra-ethyl ammo- nervous system may control the output nium chloride (TEA). The adrenal of adrenal cortical hormones. It re- ascorbic concentration technique of cently has been shown that epinephrine Sayers was used to indicate cortical activates the adrenal cortex. An attempt activity, and changes in blood sugar to was made to dissociate adrenal medul- indicate medullary activity. lary activity from adrenal cortical activ- In the course of the investigation it ity in the response to stimulation of the was learned that the adrenal concentra- MEDICAL ALUMNI QUARTERLY 15 tion of ascorbic acid was affected by the could not be ascribed to a specific gan- emotional stress incident upon simple glionic effect since similar doses also laboratory handling. The blocking agent prevented the effect of injected epineph- of itself activated the adrenal cortex, rine; the amounts needed for this effect and sensory stimulation in the rat pre- were very toxic. It was concluded that treated with TEA failed to lower the the use of the drug for this type of in- ascorbic acid to values obtained by sen- vestigation was sharply limited by its sory stimulation alone. This observation own harmful properties.

Dr. Elman Returns from Medical Teaching Mission in Poland and Finland

A feeling of genuine friendship and Piekary, Poland, University of Helsinki appreciation for an insight into the and University of Turku in Finland. newer concepts of medicine was engen- The mission took with it American dered by the 11-man medical teaching textbooks, medical and surgical jour- mission which visited Poland and Fin- nals, reprints, and moderate amounts land during July and August, accord- of medical supplies, particularly the ing to Dr. Robert Elman, professor of newer drugs developed in this country. clinical surgery at the School of Medi- The members helped establish blood cine. Dr. Elman was one of the mem- banks and contributed their own blood bers of this teaching team, which was a at one hospital in Poland as an ex- joint project of the World Health Or- ample to break down objections. The ganization and the Unitarian Service visiting group found that much of the Committee. hospital equipment was modern, having Truly international in character, the been donated by U. N. R. R. A. and mission was composed of seven United the Unitarian Service Committee. States doctors and one each from Dr. Elman expressed a belief that Czechoslovakia, Sweden, Switzerland, considering that 60% of the doctors in and England. These 11 men repre- Poland had been killed during war and sented specialties including internal the handicap of inadequate supplies, the medicine, anesthesiology, pediatrics, physicians there were doing a remark- psychiatry, radiology, and four types of able job in caring for the people. They surgery — general, neurological, ortho- are tremendously eager to learn of new pedic and thoracic. Activities of the methods and have an insatiable desire group were varied among formal lec- for United States medical publications, tures, round table discussions, ward so difficult to obtain there, he said. rounds, clinical conferences, operations Dr. Elman gave a lecture, using many and demonstrations at the University of of the color slides he photographed on Warsaw, University of Cracow, Univer- the trip, at the First Untarian Church sity of Poznan, Kosciuszko Hospital in of St. Louis on October 8. 16 WASHINGTON UNIVERSITY Woman Ranks First '48 Class Interning in in Class of '48 All Parts of Country A woman student, Miss Helen Es- Washington University School of telle Clark of Paris, Texas, led the 1948 Medicine is represented in hospitals all class in medicine with the highest aver- over the country through the intern- age for the entire four-year course at ships now being served by members of Washington University and was the the 1948 class in medicine. A tabula- recipient of the Alpha Omega Alpha tion according to area gave the follow- Fraternity Prize. Now Dr. Clark, she ing results: is serving a year's internship in medi- The St. Louis area leads in number cine at Barnes Hospital in St. Louis. of students serving internships, with a Miss Clark was one of nine medical total of 38. St. Louis City Hospital has students who were graduated with the 12; Barnes Hospital, 10; Jewish Hos- degree of doctor of medicine cum laude pital, 7; St. Luke's Hospital, 7; and during the Commencement Exercises of Missouri Baptist Hospital, two. One Washington University on June 8. The other graduate is interning in the state others were: Virgil R. Bleisch, Bernard of Missouri and he is in Kansas City. T. Garfinkel, Elfred H. Lampe, Daniel Chicago ranks second, having eight L. Morgan, Frank B. Norbury, Gerald members of the '48 class interning T. Perkoff, Seymour Reichlin, and Ar- there. The state of California has six, thur H. Stein, Jr. New York City claimed five, and Min- The Borden Undergraduate Research nesota has four. Following these come Award of five hundred dollars was Michigan with three, and Washington, awarded to James F. Nickel for his re- D. C, Maryland, state of Washington search on the "Comparison of Trans- and North Carolina, each with two. fusion Survival, Mechanical Fragility The states of Ohio, Connecticut, and Sickling Susceptibility in Sickle Pennsylvania, Iowa, Alabama, Indiana, Cell Anemia and Sickle Cell Trait Massachusetts, Tennessee, Utah and Erythrocytes," an abstract of which ap- Wisconsin each have one interne from pears in this issue of the QUARTERLY. Washington University. Serving out- The George F. Gill Prizes in Anatomy side the continental United States are and Pediatrics went to Myron W. one graduate at Queen's Hospital in Wheat, Jr., and Bernard T. Garfinkel, Honolulu, and one girl at the Perma- respectively. Miss Harriette Lutz won nente Foundation in Vancouver, Brit- the Howard A. McCordock Book Prize ish Columbia, Canada. for excellence in pathology, and the Sidney I. Schwab Book Prize in psy- The 1948 graduates received excellent internship appointments, according to chiatry went to Milo L. Heideman, Jr. Dr. Thomas Hunter, assistant dean, and will represent Washington University's Please notify the Medical Alumni extensive medical program in their new Office when your address changes. jobs. MEDICAL ALUMNI QUARTERLY 17 351 Enrolled in Medical Yale Publications Received as Memorial to School for '48-'49 Dr. Fred Towsley Murphy Enrollment for the four classes in the A special exhibit of 177 publications School of Medicine totaled 351 stu- of the Yale University Press which have dents, including 31 women, upon com- been received by Washington Univer- pletion of registration on September 11. sity in memory of Dr. Fred Towstey The freshman class, which registered Murphy, professor of surgery in the on September 8, numbers 86 students, School of Medicine from 1911 to 1919, while there are .83 sophomores, 86 ju- was on display in the Medical Library niors and 96 seniors. Of the 31 women from October 1 through 15. Dr. Murphy students, only two are in the first year was a graduate of Yale College, class of class, with seven in the sophomore 1897, and was the founder and first com- class, eight seniors, and 14 juniors. manding officers of Washington Univer- Other departments in the Medical sity's 21st Hospital Unit in World War School registered at various times dur- I, 1914-1918. ing the week of September 13, when The volumes in this collection are regular classes in medicine began their largely historical, medical and scien- sessions. Twenty-five students regis- tific, but a few dealing with literature tered in occupational therapy; 13 in have been included. The books on med- hospital administration; nine in physi- ical and scientific subjects will become cal therapy; and three in orthoptic a part of the Medical Library, while technology. In the long-term postgrad- those in history and literature are to be uate courses, 23 enrolled in otolaryn- added to Ridgley Library on the Uni- gology and 11 in pediatrics. The depart- versity campus. In connection with this ment of anatomy has 19 postgraduate memorial gift, a special gift book plate students. was designed by Yale University Press, All students were given the regular with reproductions of the seals of both physical examinations and, in addition, Washington and Yale Universities. Each the freshmen this year took a battery of the 177 volumes in this collection of aptitude, personality and other spe- contains one of the book plates as a cial tests as part of their orientation permanent memorial to Dr. Murphy. program.

Anatomy is now centralized in the de- Cancer Research Move from partment proper. Research activities Barnard Completed already have been initiated in the With the move of equipment and newly-remodeled laboratories on the personnel from Barnard Free Skin and third floor of the North Building, and Cancer Hospital to the School of Medi- with the concentration of work under cine completed on September 13, can- one roof, these activities can be much cer research in the Department of better integrated. 18 WASHINGTON UNIVERSITY Departmental News

Anatomy Neuropsychiatry Dr. Warren Andrew, professor of Dr. Ivan Mensh of Chicago arrived anatomy at George Washington Univer- in St. Louis August 3T)th to take over sity in Washington, D. C, has been ap- his duties as instructor in medical psy- pointed visiting professor of anatomy chology at the School of Medicine. Dr. for the six-month period beginning Sep- Mensh comes here from the department tember 1. He will substitute for Dr. of psychology at Northwestern Univer- Mildred Trotter, professor of gross sity, and recently received his Ph.D. anatomy, who is on a year's leave of degree from that school. absence as anthropologist for the U. S. Dr. Robert I. Watson, associate pro- Army in the Territory of Hawaii. fessor of medical psychology, and Mr. Dr. Theodore Rosenthal, research as- Samuel Granick, instructor in medical sociate in cancer, returned in Septem- psychology, attended the American Psy- ber after spending five months studying chological Association meeting held in at the Carlsberg Laboratory in Copen- Boston from September 6 to 11. Mr. hagen, Denmark, where he worked un- Granick gave a paper on "The Rela- der Dr. Heinz Holter and Dr. Linder- tionship between a Protective and a strom-Lang. Questionnaire-Type of Personality Test Dr. George G. Rowe has returned to in Clinical Diagnosis."' During the Washington University after two years meeting, Dr. Watson was elected to the with the army and will be instructor in Editorial Board of the Journal of Clin- gross anatomy. ical Psychology.

Biological Chemistry Ophthalmology The Francis P. Garvan Medal honor- Dr. M. Hayward Post, professor of ing women in chemistry was awarded to clinical ophthalmology, was elected Dr. Gerty T. Cori, professor of biologi- chairman of the Eye Section of the cal chemistry, at a general session of American Medical Association at the the American Chemical Society on Au- annual convention which was held in gust 31. Dr. Cornelia T. Snell of New Chicago late in June. He will hold of- York accepted the award for Dr. Cori, fice for one year. who was on vacation at the time. Dr. Paul W. Preisler, assistant pro- Pathology fessor, was elected secretary of the Di- Dr. Robert A. Moore, Dr. Margaret vision of Biological Chemistry of the G. Smith, and Dr. Barnet M. Levy at- American Chemical Society at a meet- tended the First International Polio- ing in Washington. D. C, early in Sep- myelitis Congress, which was held in tember. He succeeds Dr. John T. Edsall New York City from July 12 to 17. of Harvard University. Dr. Edmond I. Shwayri, a graduate MEDICAL ALUMNI QUARTERLY 19

Pathology (Cont.) Dr. Jean V. Cooke, professor of pediat-. of the American University of Beirut in rics, was elected president for the en- Lebanon, has joined the department suing year. with a fellowship from the Rockefeller Dr. James Goodfriend, instructor in Foundation. pediatrics and assistant physician on During the middle of September, Dr. the staff of Children's Hospital, died Robert A. Moore, professor of pathol- July 5 of heart disease at his home in ogy, attended a meeting of the Geron- Clayton. He came to Washington Uni- tology Study Section at the National versity on July 1, 1946, when he was Institute of Health in Bethesda, Md., appointed an assistant in pediatrics. He and was in Washington, D. C, for meet- was appointed instructor on July 1, ings of the Advisory Committee on Can- 1947. A graduate of the University of cer Control for the United States Pub- Missouri in 1935, Dr. Goodfriend won lic Health Service, the American Asso- a Rhodes Scholarship and attended Ox- ciation for the Advancement of Science, ford University in England, receiving and the Scientific Advisory Board of his Ph.D. degree from there in 1937. the Army Institute of Pathology. He received his M.D. degree from Northwestern University in 1940. The St. Louis Pathological Society met in the department of pathology at the School of Medicine on September Pharmacology and 24th with the members of the depart- Preventive Medicine ment giving four papers for the pro- On their return from a nutritional gram. Dr. Ruth Silberberg, instructor survey at St. John's, Newfoundland, Dr. in pathology, was in charge of the pro- Oliver Lowry, professor of pharmacol- gram, which was as follows: "Anatomic ogy, and Dr. Robert Shank, professor of Changes in Poisoning by Ethylene Gly- preventive medicine, reported that the col," by Dr. David Smith; "Experimen- group of doctors conducting the inves- tal Studies in Leptospirosis," by Dr. tigation were fortunate in being able to Parker Beamer; "Modification of the examine many of the original group Vascular Response in Experimental which were examined four years ago. Hypersensitivity," by Dr. Gustave Dam- At that time several doctors made a min and Dr. Samuel Bukantz; and survey of the physical condition of res- "Arteritis in Infancy with Aneurysm of idents there prior to the time that en- the Coronary Artery and Myocardial riched grain was inaugurated in the Infarction," by Dr. Clarence Pickard food diet. and Dr. Gustave Dammin. Many of the scientists on this recent trip were members of the original ex- Pediatrics amining group. Their general conclu- During the annual meeting of the sion was that the physical condition of American Pediatric Society, held in their subjects had improved after the Quebec, Canada, from May 24 to 26, addition of enriched grain, but final re- 20 WASHINGTON UNIVERSITY

Pharmacology and Preventive Radiology Medicine (Cont.) Dr. Wendell G. Scott, associate pro- ports are awaiting tabulation of data fessor of clinical radiology, has been and completion of chemical analyses of appointed a member of the Committee samples which were brought back. on Radiology of the Division of Medi- cal Sciences for the National Research Physiology Council. The Committee will act as ad- visor to the Veterans Administration and Dr. William Sleator has been ap- other federal agencies. During a meet- pointed assistant professor of bio- ing of the Rocky Mountain Radiological physics in the department of physiol- Society in Salt Lake City, Utah, from ogy, starting October 1. August 12 to 14, Dr. Scott presented Dr. J. W. Duyfs, professor of physi- papers on "The Importance of Early ology at the University of Leyden in Diagnosis of Carcinoma of the Colon," the Netherlands, was a visitor in the and "Low Back Pain and the Evaluation Department during August. of Radiographic Methods of Diagnosis." MEDICAL ALUMNI QUARTERLY 21 Publications of the Faculty June - September, 1948 Ackerman, L. V. Malignant melanoma of the skin. Am. J. Clin. Path. 18: 602-624, August, 1948. Alexander, H. P., Bottom, D. S., and MacBryde, C. M. Obesity hypertension diabetes and heart failure. Clinico-pathologic conference. Am. J. Med. 5: 277-287, Aug., 1948. Alexander H. L., Levy, I., and Wood, W. B., Jr. Convulsions and hepatic diseases. Clinico-pathologic conference. Am. J. Med. h: 902-910, June, 1948. Blackman, N. Sequelae of military service and their treatment in a Veterans Admin- istration mental hygiene clinic. J. Missouri Med. Assn. 45: 579-582, Aug. 1948. Brown J B., Byars, L. T., McDowell, F., and Fryer, M. P. P*^*™?*?* \°^ne C surgical house staffs. Plastic and reconstructive surg. 3: 385-406, July, 1948. Brown, J. B., and Cannon, B. Repair of major facial injuries. Trans. Am. Surg. Assn. 65: 244-252, 1947. , ™ ■*• * Brown J B and DeMere, McC. Establishing a preserved cartilage bank. Plastic and reconstructive surg. 3: 283-293. May, 1948. Brown J B McDowell, F, and Fryer, M. P. Facial paralysis supported with autog- enous fascia lata. Ann. Surg. 127: 858-862, May, 1948. Byars L T. Preservation and restoration of mandibular function and contour. Ann. Surg. 127: 863-878, May, 1948. .,♦„♦„ Conn, Mildred, and Cori, G. T. On the mechanism of action of muscle and potato nhosnhorvlase J Biol. Chem. 115: 89-93, August, 1948. Cone A J Hydraulic head holder for direct laryngoscopy, bronchoscopy and esoph- agoscopy. Trans. Am. Acad. Ophthalmol., 1948. 509. Cooke J V Holowach, J., Atkins, J. P., Jr., and Powers J. R ^t^ody formation m early infancy against diphtheria and tetanus toxoids. J. Pediatrics 33. 141-146,

U S 9 8 Cotd o nn!er! J X, and Scrivner, ^vC Supernumerary kidney with ectopic uretera, orifice. J. Mo. State Med. Assn. 45: 430-432, June, 194S. \ • T T „„H Tniw R S The effect of the ingestion of sodium acid phos- COSemoen\JnnJaVy^lciaum°^re—ncyôurnal Urology 60: 316-320, Aug., 1948. phate on u J d glmo R. L. Tne uptake of radio- C°XsôûînTh^Ssph'np^ra tion of mouse epidermis in methylcholanthrene carcinogenesis. Cancer res. 7: 642-646, October, 1947. carcmogeiie Suntzeff, V. Influence of age on the copper and

Elman R and Mantz, H. L. Rehabilitation in Missouri at the "grass roots. J. Missouri med assn. 45: 670-674, Sept., 1948. Goodfriend J., and Thurston, D. L. Experiences with streptomycin. Med. din. North Am. 32: 805-838, May, 1948. rw,tt«chalk H R and Weiss, R. S. Studies on sensitivity to plasticizers: ortho- °°nUroMpheSl, Vsopropyl benzene -^om^ -^ N*o»™pyl ortho and para toluene sulfonamide. Arch. derm, and syph. 57. 304-307, March 1948 Graham, E. A. Some aspects of bronchogemc carcinoma. Ann. Roy. Coll. Surg. Eng. 1947, 1: 248-264. Graham E. A., Burford, T. H., and Mayer, J. H. Middle lobe syndrome. Postgrad. med. \: 29-34, July, 1948. n ■ „w„ M Kamen M D. and Moore, C. V. Observation on the utilization of gly- °Xe m'toe'bfos^Thesis of hemoglobin. J. Biol. Chem. 174: 767-768, June, 1948. 22 WASHINGTON UNIVERSITY

Hansel, F. K. Allergy in otolaryngology. Laryngoscope 58: 652-672, July, 1948. Hansel, F. K. The diagnosis and treatment of hay fever with particular reference to the ragweed type. Laryngoscope. 58: 380-395, May, 1948. . Heinbecker, P. Factors limiting surgery for essential hypertension. Trans. Am Sure Assn. 65: 155-164, 1947. ' Hurt, S. P. Occupational therapy in the rehabilitation of the poliomyelitis patient Am. J. Occupational Therapy, 2: 83-87, April, 1948. Jaudon, J. C. Further observations concerning hypofunction of the adrenals during early life. J. Pediatrics, 32: 641-669, June, 1948. Joseph, H. L. False positive serologic tests for syphilis. J. Mo. State Med Assn 45 \ 434-439, June, 1948. Kamen, M. D. Assay of radioactive isotopes in biological research. Symposium on the use of isotopes in biology and medicine. Madison, University of Wisconsin press 1948, p. -41-160. Kamen, M. D. Detection of intermediates, criteria of purity. U. S. Naval med bull Supp. March-April, 1948, p. 115-121. Ke7' A' AA Complications in the treatment of fractures by external skeletal fixation J. Mo. State Med. Assn. 45: 422-425, June, 1948. Key, J. A., and Ford, L. T. Experimental intervertebral-disc lesions. J. Bone and Joint Surg. 80-A: 621-630, July, 1948. Kirk Esben and Chieffl, Margaret Vitamin studies in middle-aged and old individ- ta n total caroten T£ T'•. r. £Jl „£• e and a + b carotene concentrations in plasma. J. Nutrition 36: 315-322, August, 1948. Krahl, M. E and Park, C. R. The uptake of glucose by the isolated diaphragm of normal and hypophysectomized rats. J. Biol. Chem. 174: 939-946, July, 1948. Kriss, J. P., and Futcher, P. H. The relation between infant birthweight and subsequent development of maternal diabetes mellitus. J. Clin. Endocrinol 8- 380-389 May, 1948. d e C e f r a aS & COnS6<1Uence of growth cessati ^Actd'scY ^.•to\ 3?0, j u„e l94l. °«- *««■ Nat IuSBSiSJ^«?,S^V^ uJTof reconstructlve ■«■■* °f the *— Levy, I-, and Moore, C. V. Pteroyl glutamic acid in the treatment of pernicious anemia. Trans. Am. neurol. assn. 72nd sess. 70-74, 1947. MS?W?,lfa A19S4U8 giCal Sag f°r edentulous m°uths. Plastic and reconstructive surg. C te appHcati ns and detaiIs oi ^TAsTn.i: 5T2tVTuirW47 ° technic. J. Missouri MiJr?if£;T; A C0,mParisc;n of aniseikonic test instruments and prolonged induction of artificial aniseikoma. Am. J. Ophthalmol. 31: 687-696, June, 1948. luu<-"«" oi MOt?'%°^ V; r,Ir0,n, metabolism and hypochromic anemia. Symposia on nutrition of the Robert Gould research foundation. V. 1, pp. 117-143, 1947 numtion ot Nolan, J P., and Natali, W. Dosage measurements for various methods of intrauter ^rJmiri^ Cati°nS *" CanCe'' °f the endometrium. Am KtoTw N n F and v!fH i'0H -, Steele, J. P. Carcinoma of the cendometrium.apsuie appiicati Measurements of the srarMKr °- °< SM^S pa r k in the treatment f ear Pyo^c i£i£$g£& ssspsxssr* ° * Pa n H d SC ei 1 A EleCtr0shock thera in rd \st ^.^83 5 85, ru g. 1948. ^ ^P—ions. J. Missouri Proetz, A. W. The sphenoid sinus. Brit. Med. Jl. 2: 243-245, July 31, 1948. R0K,e'^i)' K- D ifferfn«al diagnosis, benign prostatic hypertrophy', and neuroeenic bladders. Postgrad.D i Me. 4: 140-148, August, 1948. neurogenic MEDICAL ALUMNI QUARTERLY 23

Rutledge, R. C, Jr. The spectrophotometric determination of blood pH. J. Lab. and Clin. Med. 33: 881-885, July, 1948. Sale, L. General practitioners have a place on the hospital staff. Modern hosp. 70: 98-102, May, 1948. Saslow, G.. An experiment with comprehensive medicine. Psychosomat. Med. 10: 165- 175, May-June, 1948. Schwartzmann, J. R., and Crego, C. H., Jr. Hamstring-tendon transplantation for the relief of quadriceps femoris paralysis in residual poliomyelitis. A follow-up study of 134 cases. J. Bone and Joint Surg. 30-A: 541-549; 559, July, 1948. Schroeder, H. A. The present status of the treatment of human hypertension with; renal extracts, tyrocinase, quinones, etc. In Conference on factors regulating blood pressure, 1st conf., 1947. N. Y., Josiah Macy, Jr., foundation, 1947. Scobee, R. G. Anatomic factors in the etiology of heterotropia. Am. J. Ophthalmol. 31: 781-795, July, 1948. Scobee, R. G, and Green, E. L. Size of line in the Maddox-rod test. Am. J. Ophthal- mol. 31: 697-699, June, 1948. Scott, W. G. Suggested outline for the training of radiologists at qualified United States Naval hospitals. Amer. j. roentgenol. 60: 90-95, July, 1948. Silverman, S. R., Thurlow, W. R., Walsh, T. E., and Davis, H. Improvement in the social adequacy of hearing following the fenestration operation. Laryngoscope 58: 607-631, July, 1948. Trupp, M., and Sachs, E. Vascular tumors of the brain and spinal cord and their treatment. Journal Neurosurgery 5: 354-371, July, 1948. Ulett G. and Parsons, E. H. Psychiatric aspects of carcinoma of the pancreas. J. Mo. Med. Assn. 1,5: 490-493, July, 1948. Walker H S J., and Womack, N. A. Pseudotumor of bone in hereditary pseudo- hemophilia. Arch. Surg. 56: 329-337, March, 1948. Whipple, H. O., Hornberger, C. S., Hoffman, J. G., and Nolan J. FA new photographic material for gamma-ray dosimetry. Am. J. Roentgenol. 60: 175-181, Aug., 1948. White H L and Rolf, D. Effects of exercise and of some other influences on the renal circulation in man. Am. J. Physiol. 152: 505-516, March, 1948. Wilson C L Experimental degeneration of the supraspinatus tendon. J. Bone & Joint Surg. 30-A: 769-773, July, 1948. Woo, J. K. "Anterior" and "posterior" medio-palantine bones. Am. J. Phys. Anthro- poi. 6: 209-223, June, 1948. Wooldridge W E. and Hagemann, P. O. Benign pelvic tumors with ascites and hydrothorax. American Journal of Medicine 5: 237-244, Aug., 1948. 24 WASHINGTON UNIVERSITY Alumni News

1880 Marshall Wallis writes that he has re- Porter J. Mitchell died at his home in tired from practice at the age of 70 years Rocheport, Mo., on April 21 of this year and is living on and off a citrus grove at the age of 86 years. in La Peria, Texas. 1881 1914 William G. Estill of Lawson, Mo., died The sudden death of Joseph F. Bredeck November 27, 1947. of a heart attack on October 4 stunned 1887 his family, his friends and the people of Henry R. Smith of Detroit, Texas, St. Louis, for he had been the city's passed away at his home on June 21, ac- crusading health commissioner for 15 cording to a note from his daughter. Dr. years. After receiving his medical degree Smith, who was 93, had practiced medi- here, Dr. Bredeck spent three years in cine in Detroit and Red River County for specialized study of tuberculosis, and in 66 years and was past president of the 1917 obtained a degree of doctor of public Northeast Texas Medical Society and of health from the University of Pennsyl- the Red River Medical Society. His vania. He returned to St. Louis, was a daughter writes that "He was so very medical officer in World War I, and in proud of Washington U. and its continued 1920 was appointed tuberculosis con- development." troller of St. Louis. In 1933 he was ap- 1891 pointed health commissioner for the city Funeral services for Walter E. Gibson and from that time until his death, was were held July 26 in De Soto, Mo., where a fighter for the improvement of health he had practiced medicine for 54 years. standards in St. Louis. Over bitter oppo- He served as mayor of De Soto for ten sition, he put through two major city or- years and was active in many civic af- dinances—the standard milk and clean fairs. He retired from practice two years restaurant regulations. He gave much ago. attention to venereal disease control and 1894 recently had been working on plans for George B. Tiittle recently moved from higher ice cream standards. Three sons Boonville, New York, to Arlington, Vir- survive Dr. Bredeck, who was 58 years ginia. old. Horace W. Soper was selected presi- 1923 dent-elect of the National Gastroenter- Harold F. Corson is now living at 1202 ological Association at the latest meeting Park Ave., in Richmond, Virginia. in New York City. 1925 1895 George S. Johnson of Nashville, Tenn., John M. Brooks now lives on Route 1 died May 20, 1948 in Nashville. at Diamond, Mo., and recently moved from 1926 Neosho, Mo. Caleb Stone is living at 1115 Terry 1897 Street in Seattle, Washington. E. B. Miller of Wakita, Oklahoma, Rodney Gray has moved from Brooklyn, passed away last May 13 of a heart Wisconsin, to the town of Evansville in ailment. the same state. 1905 1928 Thomas J. Jfalley recently moved from Richard D. Kepner is practicing psy- Ontario, Calif., and is now living in chiatry in Honolulu, where he has offices Riverside, Calif. in the Young Hotel Building. MEDICAL ALUMNI QUARTERLY 25

W. F. Ossenfort was transferred last City, Kansas. He was living in Magna, June by the U. S. Public Health Service Utah. to the U. S. Merchant Marine Academy Charles Oderr has moved from the at Kings Point on Long Island, New bustle of New York City to 17 Carman York, where he is now Chief Medical Rd., in Scarsdale, New York. Officer. 1937 1929 Willis Hayward recently moved to a A newspaper clipping received by the home at 3 North Main Street in Logan, Quarterly tells of the work of Brig. Gen. Utah. Crawford Sams, who as Gen. Douglas Philip Risser is now with the Olympic MacArthur's Public Health and Welfare District Health Department at Port Secretary in Japan, has been in charge Angeles, Washington. of persons who were injured and made 1938 homeless by earthquakes in Japan during James F. Nolan resigned last July as recent months. General Sams has been assistant professor of obstetrics and gyne- in Japan since the close of hostilities, and cology at W. U. School of Medicine to before that time was on General Mar- take a position on the staff of the Los shall's staff in Washington, D. C. Late in Angeles Tumor Clinic in Los Angeles, 1941 he helped direct the establishment Calif. of medical installations for the Army in the Middle Bast theater of operations and Harry H. Abrahams is now at Gallinger later became chief surgeon and directed Hospital in Washington, D. C. the operation of U. S. Army hospitals in 1939 that area. He participated in four major Robert E. Shank is back in St. Louis campaigns during 18 months on overseas as professor of preventive medicine and duty. head of the department of preventive Noka B. Hon, who formely lived in medicine and public health at W. U. Chevy Chase, Maryland, has moved to School of Medicine. He was a member Phoenix, Arizona. of a group which conducted a nutritional survey at St. John's, Newfoundland, in 1930 Robert W. Boal is now at the Univer- August. sity of Nebraska Medical School in Mark Brockbank is living at 1631 Ken- Omaha. sington Ave., in Salt Lake City, Utah. Roy W. Tandy has been transferred 1940 from the Naval Hospital in Oakland, Robert L. Garrett moved from the Calif., to the Naval Air Station at Sand Charity Hospital in New Orleans to Point, Seattle, Wash. Oakland, California, where his address 1932 is 3324 64th Avenue. John B. Grow, who was a captain on Russell J. Crider recently moved from duty at Fitzsimmons General Hospital in St. Louis, where he was an assistant in Denver, now has offices in the Metro- surgery on the School of Medicine staff, politan Building in that city. and is in Spokane, Washington. 1933 1941 Lt. Oreon Timm has been transferred Howard S. J. Walker, Jr., can be by the Veterans Administration Hospital reached at 314 South Garth Ave., in at Port Custer, Mich., to the V. A. Hos- Columbia, Mo. pital in Danville, 111. David Bachwitt's address has been Edward Grose is now with the Univer- changed to 948 Woodland Ave., in South sity of Kansas Medical Center in Kansas Charleston, West Virginia, 26 WASHINGTON UNIVERSITY

1942 from Sioux City, Iowa, to Lancaster, Herman Blumenthal is now living in Texas. Kirkwood, Mo. 1944 Wendell Jones has moved from Mis- Bruce Armstrong' can be reached at soula, Montana, to Fort Riley, Kansas. the Barton Memorial Hospital in Phila- Souther Tompkins is living now in delphia, Pa. Rochester, Minn. Marvin Pursell is living in Webster 1943 Groves, Missouri, at 971 Greeley Ave. Rymal G. Williams writes from Cedar Buford Bnrch is with the Medical Re- City, Utah, that he completed a residency search Department of Ohio State Univer- in pediatrics and also a residency in sur- sity in Columbus. gery at Denver General Hospital in July, 1947. He is now in an active-going prac- Howe Bisbee, recently at St. Luke's tice in Cedar City, with particular in- Hospital in Denver, is now in Ada, Okla- homa. terest in general surgery. John L. Cockrell has moved from Rich- Albert Eisenstein is living at 8706 mond, Mo., to St. Louis. Florence Ave., in Brentwood, Mo. P. W. Knoke has also returned to the 1945 St. Louis area from Detroit, Mich.; he Marshall Conrad has moved from Dan- is living in University City. ville, 111., to 20 South Gore in Webster H. C. Harding' has moved from Jeffer- Groves, Mo. son City, Mo., to 4160 S. W. Patrick PL, Frank J. Kelly, who was an assistant in Portland, Ore. in medicine at W. U. School of Medicine, 1943 recently moved to New Orleans, La. David Stadtner, formerly at Fresno Sanford Tuthill has moved from Alex- General Hospital in Fresno, Calif., is andria, La., to New Orleans, where he now living in Stockton, Calif. began a residency in internal medicine Margaret Meyn has moved from St. at the Ochsner Clinic and Foundation Louis to Terre Haute, Ind. Hospital on July 1. William Middleton began a residency Clarence Schulz received an appoint- in ophthalmology at the Illinois Eye ment as resident in psychiatry at St. and Ear Infirmary in July. He and his Elizabeth's Hospital in Washington, D. C, wife and their three-year-old daughter, starting last July. Anne, are living at 6542 North Richmond Norton Johnson has been separated in Chicago. from the army and has begun a residency Tom Gc. Stauffer recently announced in obstetrics and gynecology at Bethesda the opening of his office for the practice Hospital in Cincinnati, Ohio. of psychiatry at the Chateau Lafayette in On June 30, Robert Weinhaus was Scarsdale, New York. transferred from the U. S. Marine Hos- William J. Miller, a captain in the pital in Mobile, Alabama, to the Marine U. S. Army Medical Corps, is chief of Hospital in New Orleans. pediatrics at Fort Hamilton Hospital in Edward J. Twin, formerly with the Brooklyn, New York. Veterans Administration Hospital at James G. Owen is back in St. Louis Marion, Indiana, is now living in Kansas and living at 6444 Alamo Street in Clay- City, Mo., at 3838 South Benton. ton. 1946 David B. Krebs' address has changed N. Balfour Sloiiim is with the Veterans

fa MEDICAL ALUMNI QUARTERLY 27

Administration Hospital in Albuquerque, Boyd Hayward is now at 820 East 52nd New Mexico. Street in Chicago, 111. Walter Part is living at 1801 Tarson in Robert Rutledge is an assistant resi- St. Joseph, Missouri. He was formerly dent in pediatrics at St. Louis Children's at Miami Valley Hospital in Dayton, Ohio. Hospital in St. Louis.

The Medical Alumni Office is anxious to keep in touch with your whereabouts and your activities. A penny post card giving your old and new address will be appreciated whenever you move—or if your mail is incorrectly addressed in any manner. News of yourself and any Medi- cal School graduates you know is always very welcome for the Alumni News section. Your classmates want to hear about you! sss aass^s^

WASHINGTON UNIVERSITY

Arthur H. Compton, Ph.D., Sc.D., LL.D., Bridge Chancellor Charles Belknap, B.S., Vice Chancellor Edward K. Graham, Ph.D., Assistant Dean of Faculties Thomas Edward Blackwell, Ph.B., M.S., J.D., Director of Business Administration

The College of Liberal Arts Stuart A. Queen, Ph.D., Dean The School of Engineering Lawrence E. Stout, Ph.D., Dean The School of Architecture Joseph D. Murphy, Acting Dean The School of Business and Public Administration Isaac Lippincott, Ph.D., Acting Dean The George Warren Brown School of Social Work Benjamin E. Youngdahl, A.M., Dean The Henry Shaw School of Botany Henry Nathaniel Andrews, Jr., Ph.D., Acting Dean The Graduate School of Arts and Sciences Carl Tolman, Ph.D., Dean The School of Law Wayne L. Townsend, A.B., LL.B., J.S.D., Dean The School of Medicine Robert A. Moore, M.D., Ph.D., Dean The School of Dentistry Otto W. Brandhorst, D.D.S., Dean The School of Nursing Louise Knapp, R.N., B.S., A.M., Director The School of Fine Arts Kenneth E. Hudson, B.F.A., Dean University College Willis H. Reals, Ph.D., Dean The Summer School Frank L. Wright, A.M., Ed.D., Director Mary Institute, a preparatory school for girls, located at Ladue and Warson Roads, is also conducted under the charter of the University.