Search

The symptomatology of carotid artery occlusive disease has always been of great interest to clinicians and has been well described in the past. 1-5 It has been emphasized that the patterns and potential course of the disease are numerous and complex. Since the development of therapeutic measures which have been advocated for this condition, it has become essential to study carefully a group of patients with documented carotid occlusive disease. This is particularly so in view of the need for early diagnosis, for the earlier a therapeutic measure is applied the less certain can one be of its effect on the future course of the syndrome. Transient ischemic attacks can occur for a year or more without any residual neurologic deficit being found. In addition, a single stroke may completely resolve without any treatment, and there may be no further difficulty for a few years. The clinical picture in 57

MANIFESTATIONS of pulmonary disease in patients with systemic lupus erythematosus reflect a spectrum of etiologic processes ranging from collagen vascular pneumonitis to bacterial, tuberculous, and fungal pneumonitis. 1-3 The use of chronic adrenocorticoid therapy predisposes to uncommon infectious pneumonitides which are difficult to distinguish clinically from the primary pulmonary disease of lupus. This case report illustrates the association of systemic lupus erythematosus with an infrequently encountered pathogen, Nocardia asteroides . Previous reports have noted this association on only three occasions. 4-6 Report of Case A 27-year-old man entering the New York Hospital on Sept 16, 1965, had a nine-year history of Raynaud's phenomenon, and a persistent malar erythematous rash for five years. In July 1965, he developed malaise, generalized lymphadenopathy, anemia, and albuminuria. No diagnosis was ascertained during hospitalization elsewhere. One week after discharge on July 2, 1965, a high fever and pleuritic pain in the right side of the

The statement quoted in Dr Barach's letter was obtained from Dr William B. Kannel and confirmed by the Atherosclerosis Committees of the American Heart Association and the Inter-Society Commission for Heart Disease Resources. Dr Frederickson's position in this matter is well known. While the evidence is not conclusive beyond any question, the statement in my article does represent the opinion of many authorities in this field based on the total information available as of this time.

THE PROBLEM of what constitutes average, normal, and optimal levels of serum cholesterol and how the results of tests to determine these levels should be applied to clinical practice still bedevils us. High levels of serum cholesterol are associated with an increased incidence of atherosclerosis and death, and a constantly low serum cholesterol level appears protective in this regard. The risk of complications associated with elevated cholesterol levels is increased when other risk factors such as hereditary premature atherosclerosis, hypertension, smoking, and diabetes occur concomitantly. Average levels vary substantially with different ethnic and geographic populations, specific hereditary traits, a number of diseases, and a wide range of dietary habits. This statement is directed to the situation as it exists in the United States today. Leading investigators are now widely recommending that the uppermost acceptable level should be 240 mg/100 ml, based on the standard Abell-Kendall method. This is consistent with

Dr Abramson has provided a primer of peripheral vascular diseases for students and general physicians. While most of the patients with peripheral vascular disease do not require surgery, those patients who do, present the more exciting and sensational material for publication, and, therefore the literature, both in journals and book form, is somewhat preponderated by surgical examples and techniques. These are useful for the skilled vascular surgeon but fail to help the student and general physician with day-to-day problems. While many vascular diseases are not agerelated, the majority of patients with these problems do have conditions either related or aggravated with the passage of years. This volume makes no pretense of being encyclopedic but contains solid advice for those not expert in the field on diagnosis and initiates the best conservative therapy when it is possible to avoid a surgical approach. Chapters are devoted to the collecting of diagnostic clinical

These proceedings represent a condensed review of the present thinking of a group of distinguished investigators and clinicians who gathered together under the sponsorship of the University of St. Andrews to discuss thrombosis and anticoagulant therapy. The views expressed represent a good cross section of those held by informed students of cardiovascular and hematological problems of Great Britain and continental Europe. In most respects, these coincide with the accepted concepts in the United States, but there are enough differences in details to warrant careful study of this volume by all who are interested in this area. The subjects covered were many, but they could be grouped in the following general categories: current concepts of blood coagulation in relation to vascular disease; the organization and laboratory control of anticoagulant therapy; the use of anticoagulants in myocardial infarction in peripheral and cerebral vascular disease and in prophylaxis; the heparinoids and their place

T IS presently fashionable in scientific circles to regard basic research as the high-priestess of the new era, and certainly no one can challenge this general position. However, the definition as to what basic research really consists of and who is doing it varies, depending on the spokesman. In the medical field the pathologists, the biochemists, and the anatomists consider themselves to be the basic scientists. But in broader scientific circles the physical chemists, the physicists, and the mathematicians, with the many ancillary branches of these disciplines, are not unanimous in accepting the biochemists or the pathologists into their fold as true basic scientists. Even within the medical field, it seems to make a difference whether the investigator works with an electronic computer, test tubes, mice, guinea pigs, or human beings—the implication in some quarters being that man working with man as his subject is in some way a lesser

In 1933, Harris, Ray and Ward 1 demonstrated the excretion of vitamin C in the urine and established a relationship between the excretion and the intake of this vitamin. Since that time, a number of chemical methods for the determination of the state of vitamin C nutrition in man have been presented. The determination of the twenty-four hour "resting level" of urinary excretion presented many technical disadvantages and was impractical in the study of ambulatory patients. The content of ascorbic acid in the fasting blood was observed to vary considerably with the recent dietary intake of vitamin C and gave only a rough index of the actual state of saturation. 2 The test dose method, in which a given dose of ascorbic acid is administered and the output in the urine is used as an index of saturation, was found to have many advantages. Oral test doses of 300 to

This paper is the second 1 in which the results of experiments having a two-fold object are presented. The experiments were made to determine (1) the action of several of the more frequently used antiseptics on some of the more common pathogenic organisms and (2) the reliability of the present standard of evaluating antiseptics as a means of correct appraisal of their practical value. A more detailed report may be expected in a later communication. In May, 1927, Leonard and Feirer 2 described a new antiseptic known as S.T. 37. It is a practically colorless, odorless, limpid fluid with a warm, sweetish taste, containing 1 mg. of crystalline hexylresorcinol per cubic centimeter of solvent, consisting of 30 per cent glycerin and 70 per cent water. This solution is claimed 3 to be bactericidal to viable bacterial suspensions in fifteen seconds or less. It is further stated to be nontoxic, nonirritating

The response in terms of urinary excretion to a large dose of vitamin C administered orally has been widely used during the past few years as an indication of vitamin C saturation of the body. 1 The amounts and the mediums (i. e., orange juice, tomato juice and crystalline vitamin C) have varied, but the method of administration has been by mouth. The possibility of error in such a test is now known to be great, owing to the variation in absorption and utilization of vitamin C from the gastro-intestinal tract as a result of varying degrees of acidity (anacidity), inflammation, the introduction of laxatives and other less understood factors. We have found this to be the case frequently. 2 The same objection holds for tests which involve studies of the blood level after the oral administration of this substance. Moreover, the level of excretion at which continued daily doses

The steady increase in the number of clinics where internists and surgeons are cooperating closely in an attempt to solve the many problems associated with peripheral vascular diseases constitutes an encouraging index of the care which patients suffering from these conditions will receive in the future. Although the object of all internists and surgeons may be conceded to be the ultimate benefit of the patient and his restoration to a life as nearly normal as possible, the training of the two groups tends toward different philosophic and technical approaches to this objective. This gulf is widened by isolation and narrowed by close association. The problems involved will receive sounder consideration as a result of continuous interplay of surgical and medical opinion, and no clinic devoted to this field can be considered adequate which does not make this inevitable. In general, medical care of the extreme forms (ulceration and gangrene) of

To the Editor.— Your editorial, "Is Rheumatic Fever Necessary?" ( 214: 361, 1970), commenting on the recent report of the Study Group on Rheumatic Fever and Rheumatic Heart Disease of the Inter-Society Commission for Heart Disease Resources was appreciated. It was heartening to have your support in the urgent need for applying a proved preventive measure for the eradication of this disease. However, your comments on the paucity of emphasis on research needs suggested a lack of understanding of the objectives of this Commission and of the recognition that this report was only one of approximately 30 sections which will be published, first serially in Circulation and finally in volume form. As stated in the Introduction to the Commission's report ( Circulation 41, May 1970, p A-1 to A-15), the objective of this Commission can be epitomized as "research to application"—the development of a guide to medical facilities, communities, and regions for

Cases of purpura haemorrhagica after the use of sedormid (allyl-isopropyl-acetyl-carbamide) have been reported with increasing frequency since 1933. Joekes 1 reviewed the literature on this subject and stated that there were to date thirty-seven reported cases of purpura haemorrhagica due to sedormid. Since the period covered by his recent survey, seven more cases have been added to the literature. 2 It is interesting to note that on March 5, 1938, the Council on Pharmacy and Chemistry of the American Medical Association 3 declared sedormid not acceptable for New and Nonofficial Remedies. Also of the twenty recorded observers, only four are Americans. 4 In view of this we feel that it might be pertinent to describe a recent case of severe purpura haemorrhagica with two separate episodes due to this sedative. REPORT OF CASE A white woman aged 57 complained of multiple subcutaneous hemorrhages, which she had noticed on finishing her

Records of 1,400 patients with the diagnosis of venous thrombosis or thrombophlebitis were reviewed. Eighty-one had associated cancer. In 61, the thrombophlebitis was diagnosed clinically; in 20, at autopsy. Fifty-one had carcinoma. Thrombophlebitis was recognized in 31 prior to the carcinoma. Other types of malignancy also showed this relationship. The lungs, female reproductive tract, and the pancreas were most frequent sites for the primary lesion. The resistance to anticoagulant therapy used in the treatment of thrombophlebitis was striking. Phlebitis sometimes persists or recurs over long periods of time before the cancer is discovered. These characteristics should be regarded as warning signs indicating a comprehensive survey for occult cancer.

Chronic ulcers, associated either with varicose veins or with the occlusions following phlebitis of the deep veins, constitute one of the most severe and disabling conditions affecting the lower extremities. Despite the numerous forms of treatment, including vein injection, recommended during the past fifty years, certain of these ulcers fail to heal. This is a report of the results of a new method of treatment of these ulcers, which appears to be more satisfactory than any hitherto suggested. The formation of varicose ulcers is now generally accepted as being the result of venous stasis, secondary to the dilatation of the veins and weakening of venous valves. This produces an increasing backpressure into the capillary bed, with the development of pressure edema and the waterlogging of the tissues. With the associated anoxemia, impaired nutrition and accumulation of toxic waste products of metabolism, the resistance of the tissues to trauma and infection

The problems presented by the development of arteriosclerosis are of overwhelming magnitude both medically and socially. Their potential significance is, nevertheless, for the most part hopelessly underestimated. Yet, unless satisfactory solutions are found for the varied facets of this massive loadstone, it may prove too heavy for our present civilization. Once before when our civilization was threatened by the weight of a great problem, a then little known man, Abraham Lincoln, suggested a mental approach which appears equally applicable to the present: "If we could first know where we are and whither we are tending, we could better judge what to do and how to do it." For centuries men have sought the secret of longevity. The alchemists, soothsayers and astrologers flourished in the courts of many dynasties that they might prolong the lives of the rulers. The search for this secret drove men such as Ponce de Leon to

THROUGHOUT his entire existence, man is poised delicately and dangerously as on the two-faced escarpment of a mountain; on one side there is the risk of hemorrhage and on the other side the deadly threat of thrombosis. By a remarkable and complex combination of chemical and physical processes, both hemorrhage and thrombosis occur almost incessantly and simultaneously in different parts of his vascular tree; yet only rarely in his lifetime does he slip off his precarious perch to a catastrophic injury or death. And, of the two, the risk of death or disability due to thrombosis or embolism is far greater than that due to hemorrhage. This article will discuss these aspects of occlusive arterial disease. The most common causes of arterial occlusion are thrombosis at the site of an atherosclerotic plaque and embolism due to a fibrillating or infarcted heart. These episodes may be acute, the critical phase

The long-term effects of anticoagulant therapy have been studied in 100 patients with evidence of cerebral vascular thrombosis or embolism. During 2,842 patient-months without anticoagulant therapy there were 229 thromboembolic episodes (67 being cerebral) as compared with 20 thromboembolic episodes (5 being cerebral) that occurred during 2,291 patient-months on anticoagulant therapy. Similar data permitted comparison of continuous with interrupted anticoagulant therapy, and it was found that 48 thromboembolic episodes occurred during 1,311 patient-months on interrupted therapy as compared with 15 episodes during 957 patient-months on continuous therapy. The dosages of anticoagulant (usually bishydroxycoumarin) were aimed to keep the prothrombin time for the undiluted plasma between 20 and 40 seconds. Hemorrhagic complications occurred in 30 of the 100 patients; there were three fatal cerebral hemorrhages, occurring over a period of 2,532 patient-months of anticoagulant therapy. The results are interpreted to mean that anticoagulant therapy is effective in reducing the danger of recurrent thromboembolic episodes if contraindications are observed and prothrombin times are pains-takingly controlled.

It may safely be inferred that the use of antiseptics antedates the earliest existing record of mankind. The preservation of foods in times of plenty for the periods of scarcity was a lesson learned early by prehistoric races. They preserved their foods by dyeing, smoking, salting or spicing. Spices, volatile oils, and balsams were early used by priests and healers in the care of wounds, although antisepsis was undreamed of. Later certain preparations of mercury and other heavy metals came into common usage. Distilled liquors, potions made from herbs, and even the cautery were listed in the armamentarium of our forebears devoted to the healing of wounds. Throughout the ages, and until the work of Lister in the latter third of the nineteenth century, the term "antiseptic," however, was associated exclusively with the preservation of foodstuffs. Following his epoch-making discoveries, new and different terms with distinct meanings came into being.

It has long been realized by thoughtful teachers and practitioners of medicine that the wide variations noted in blood pressure 1 records of the same individual were due not only to changes in the pressure from time to time under different conditions but also to differences in the methods and interpretation used by the observers. A recent survey 2 revealed a serious lack of agreement among physicians as to the correct technic for taking and interpreting the blood pressure. Equally confusing was the situation among insurance companies as to what they should require of their examiners in this regard. Experiments with multiaural stethoscopes demonstrated that recent years have brought little if any improvement in this situation, since the variations among the recently qualified were as great as those among attending physicians, and the range of error was too great among all groups tested. The committees for the standardization of methods

Aortocoronary vein bypass is the most recent and promising of the surgical procedures for revascularizing the heart. At present there is a wide range of opinion regarding indications for this operation and the environment in which it should be carried out. Many physicians now feel under pressure to recommend the procedure for increasing numbers of patients and this in turn has resulted in pressure on hospitals for new and expanded cardiac surgical programs. Therefore, the time is right for an authoritative statement on the current status of this operation with guidelines for establishing quality surgical programs for these patients. The recent statement of the Inter-Society Commission for Heart Disease Resources (ICHD)1does much to fill this need. The ICHD was created three years ago under a grant from the Regional Medical Programs Service to develop guidelines for optimal medical resources for the prevention and care of patients with cardiovascular

IN RECENT YEARS the subject of biological telemetry, the transmission of biological data electrically from a patient to a geographically distant point, has received increasing attention and investigation. Einthoven1in 1906 was the first to explore the transmission of electrocardiograms by telephone. This system has been refined and is now in use in several hospital centers and communities. Radio has also been used for intercontinental land-to-land transmission of ECGs and other biologic data. The advantages of telemetric electrocardiography in patient care are beginning to be appreciated.2-5However, transmission of such data with accuracy from ship to shore over distances of 1,000 miles or more has been retarded by interference associated with the ship, by other man-produced interferences, and by atmospheric conditions which frequently interfere with radio transmission. Any one of these factors may produce distortion in the ECG configuration. These difficulties have now been overcome, and the purpose

This study, evaluating anticoagulant therapy in the treatment of cerebrovascular disease, was begun in 1956, using patients from the Cornell Medical College and Columbia University Medical College, medical services at Bellevue Hospital. Shortly after the onset of the study it was found that we would need to limit our evaluation to those patients with an already established stroke, as we saw very few patients with "transient ischemic attacks" or "progressing strokes." This was due to the fact that in our patient population patients with cerebrovascular disease tend to avoid hospitalization until a stroke is clearly evident with a hemiplegia or hemiparesis. The study was therefore designed to test the thesis that anticoagulant therapy is of value in the prevention of further thrombo-embolic phenomena such as second strokes, pulmonary emboli, and myocardial infarction in patients with an established stroke. Two previous reports of this study have been published.1,2The first

INFLAMMATION in and around a vein in which there is clot formation is known as thrombophlebitis. When the inflammation primarily involves the outer walls of the vein without the development of thrombosis, we term this condition "periphlebitis." Usually, after a short time, a clot does form and the diagnosis then is thrombophlebitis. However, if a clot forms first due to stasis, as in a postoperative condition, and little or no inflammation of the wall occurs, the condition may be termed phlebothrombosis during the early phase. Usually, as time passes, the venous wall will be involved and thus the diagnosis is thrombophlebitis. It is often difficult to determine the exact stage of development by clinical observation alone. In fact, several stages of this process may be present simultaneously, and, at present, our feeling is that the treatment should be essentially the same. Classification and Etiology There are many causes of

The work described in this article was undertaken following the observation in a neighboring hospital that B. pyocyaneus was found, in several contemporary cases, growing in dressings of mercurochrome220 soluble after the first twenty-four hours' applications to a wound. The questions arising for solution concerned the unusual frequency of infections by B. pyocyaneus—Pseudomonas aeruginosa (Schroeter)—usually an infrequent invader, and the specific value of mercurochrome as an antiseptic in infections with this microbe. Pus was chosen as a medium for growth in an endeavor to imitate to some degree the conditions in the body, especially in infected surgical incisions. The pus used was sterile, having been drawn from a shoulder bursitis and having failed to produce any growth on blood agar plates or in dextrose broth. It was thick and creamy and on microscopic examination showed countless pus cells and ropey, mucus-like shreds, but no bacteria. The cultures of B.

The effect of safflower oil emulsion given as a supplement to the usual diet was studied in 24 young men, weekly samples of blood being taken and analyzed for total cholesterol. After an initial period of five weeks, the subjects were divided into two groups who received either safflower oil emulsion or a placebo for seven weeks. At the end of that time the two groups were reversed, so that those who had received the placebo now received emulsion and vice versa. Neither the subjects nor the supervising physicians knew which preparation a given subject was receiving at a given time. The emulsion, containing 65% safflower oil, was given in 15-cc. doses five times daily to a total of 75 cc. each day. Used as a supplement to the usual diet under these conditions, it had no demonstrable depressant effect on the total serum cholesterol levels.

There appears to be emerging a remarkable unanimity from both professional and public sources that medical service must be reorganized in the immediate future. The simple approach which first occurs to some is to provide more funds in the hopes of quickly producing medical facilities and personnel and greatly improved medical service. Those who are experienced in this problem recognize that funding is indeed essential but that instant results are not to be expected. It takes years and not months to train physicians, nurses, and technical personnel. It also takes many months, often several years, to plan, fund, and develop new or renovated facilities and to assemble and pretest the rather complex equipment and units now considered essential for modern medical care. In order to provide quality care for large numbers of our population, considerable restructuring of the use of our resources will be essential. For the past three years

The discovery and study of the substances that play a part in the coagulation of the blood have, as in many other areas in science, progressed in a rather strange and irregular manner. Workers in many laboratories have prepared or described the action of what they have considered to be new factors that contribute to this process, and unfortunately have given them names without knowledge or consideration of the work of others who preceded them. Some factors are now known by from 10 to 14 different names. As reports appear from various laboratories, the use of these terms is confusing to the experienced investigator. A scientific Tower of Babel has thus been erected. The situation appears discouraging, if not chaotic, to the physician who is not a specialist in this field, and even more so to the medical student. While there is widespread agreement on the meaning of prothrombin, thrombin

Oral and parenteral anticoagulants are available and effective in the treatment of thromboembolic diseases. Discontinuing therapy is inviting recurrence in certain cases. Reports on anticoagulant therapy should include answers to pertinent questions: 1. How were the patients selected? 2. Were "control" and "treated" series selected by unbiased random sampling? 3. Who actively controlled the anticoagulant therapy?

The exact mechanism by which bishydroxycoumarin (dicumarol®) affects the blood coagulation system is still unknown. The similarity in the chemical structure of 3-substituted 4-hydroxycoumarins to vitamin K led the original workers1to suggest that bishydroxycoumarin might act by blocking or competing with vitamin K in maintaining prothrombin activity. This hypothesis was supported by animal experiments which demonstrated the similarity of vitamin K deficiency to the biologic response to bishydroxycoumarin2and the ability of vitamin K to reverse the action of this drug.3However, it was clearly shown that the levels of 2-methyl-1, 4-naphthoquinone necessary to counteract the action of the anticoagulant are considerably larger

The present study was undertaken with the primary objective of developing data which might throw further light on our understanding of the production of arteriosclerosis. It was appreciated that certain other facts of interest might be uncovered as the investigation progressed. Although years of study by numerous workers have been devoted to this great enigma of biology, it can be fairly stated that today it is not known whether arteriosclerosis should be considered as a disease or as a purely degenerative process. The fundamental importance of diet, climate, infection, metabolism, race, heredity and many other factors is yet to be finally evaluated. Age alone does not appear to be responsible, since arteriosclerosis may be present in some persons at 30 years or less, whereas others may show practically none at the age of 70. A popular hypothesis has been that arteriosclerosis is related to prolonged stress and strain on the

Although the capillaries as a group exercise the most profound influence on the functions of the living body, their activity, especially in man, has been susceptible of direct study for only a short era in the history of medical science. A great volume of instructive work has since been produced, much of which has been confined to animals other than man. My purpose in this discussion, however, will be to outline briefly some of the more recent observations concerning the activities of the minor vessels of the skin in man which appear to have some value clinically, either (1) in adding evidence which results in changes in certain conceptions of physiology in normals, or pathologic variations in disease processes, or (2) in giving information of direct value in the study of single patients or groups of patients with similar diseases. It should be clearly stated at the outset that although

One of the most interesting and challenging developments in the field of the biologic sciences in recent years has been the recognition, isolation and, finally, synthesis of the substance causing hemorrhagic sweet clover disease in cattle, the dicoumarin 3,3′-methylene-bis-(4-hydroxycoumarin). We must give full credit for this contribution to two keen students of veterinary medicine, Schofield 1 and Roderick, 2 and to an outstanding agricultural chemist, Karl Paul Link. Schofield in Canada and Roderick at the North Dakota Agricultural Experimental Station studied and quite accurately analyzed the factors responsible for this phenomenon in cattle and rabbits. They pointed out that, whereas normal sweet clover silage produced no damage, spoiled sweet clover resulted in hemorrhagic tendencies and often in death. In 1934 Prof. Karl Paul Link and his associates at the Wisconsin Agricultural Experimental station of the University of Wisconsin undertook thetask of identifying the hemorrhagic factor in spoiled sweet clover.

The capillaries constitute a most essential unit of the circulatory system,1the part about which least is known. Technical improvements have greatly facilitated capillary studies. The apparatus used for our studies was recently described in detail.2 NORMAL CAPILLARIES OF THE SKIN The first impression one gains in a study of the capillaries is that even when normal they are subject to a wide range of variation. not only in different persons, but within the same person. This is true of all anatomic parts. One must therefore guard against drawing conclusions from small differences in structure or in reaction. Appearance. —It is known that the capillaries are the finest terminal connecting loops between the arterioles and the venules. Each capillary is divided into a narrow, constricted arterial limb and a wider, more dilated venous limb. The diameter of the arterial side may be less than the diameter of a

On the basis of clinical and experimental observations, it has been recorded by many authors 1 that the use of tobacco produces definite effects on the vascular system, which are particularly important in certain disease conditions, such as thrombo-angiitis obliterans and angina pectoris. In spite of this widely recognized association, the available evidence has tended to show that the smoking of tobacco must be looked on as an aggravating rather than an etiologic factor. Following the work of Maddock and Coller, 2 experiments have been reported by Barker, 3 Johnson 4 and Wright, 5 proving that the smoking of cigarets will produce in the great majority of normal individuals, under certain conditions, a marked change in the surface temperature of the extremities. This can be measured at the tips of the fingers and toes. We noted that in many instances slowing and even stoppage of the blood flow occurred in

On the completion of hostilities with Japan it was inevitable that a large number of allied prisoners of war would be released from Japanese prison camps. Approximately one third of these were American. The period of captivity had ranged from three and one-half years to a few days. The conditions under which most of them had lived were those of starvation, filth and lack of suitable clothing, with periods of definite torture. Thousands died as a result of these hardships. It was believed that a careful health survey of those who survived might be of value in helping to determine the best future care for them, the possibility of the prevention of the spread of communicable conditions in their families and communities, and a better understanding of the changes which take place in man after exposure to such living conditions. To achieve these objectives a board was established by the

The state of medical education, as it exists in Germany and Austria today, may appear to have only a remote relation to the health of other portions of the world, and in particular to the problems of medical care in the United States. A moderate degree of reflection, however, will clearly demonstrate that the health of any large nation in the center of the continent reflects quickly on the health of all surrounding countries. Furthermore, those who have been familiar with the problems of medical licensure of foreign physicians during the past two decades will anticipate that this experience will be repeated as soon as it is possible for physicians of Germany and Austria to migrate to the United States. Inevitably, pressure will be brought to bear on the various licensure bodies to pass on the qualifications of the graduates of the German and Austrian medical schools, in order that